Factors associated with prevalent hepatitis C: differences among young adult injection drug users in lower and upper Manhattan, New York City

Childhood sexual abuse and age at initiation of injection drug use

OBJECTIVES

We examined the relation between childhood sexual abuse and injection drug use initiation among young adult injection drug users.

METHODS

We used mixed effect linear models to compare age at first injection among 2143 young injection drug users by first sexual abuse age categories.

RESULTS

The participants were predominantly male (63.3%) and White (52.8%). Mean age and age at first injection were 23.7 and 19.6 years, respectively; 307 participants (14.3%) reported childhood sexual abuse. After adjustment for gender, race/ethnicity, noninjection drug use before first injection drug use, and recruitment site, childhood sexual abuse was independently associated with younger age at first injection.

CONCLUSIONS

Childhood sexual abuse was associated with earlier initiation of injection drug use. These data emphasize the need to integrate substance abuse prevention with postvictimization services for children and adolescents.

Innovation, diffusion and safety of a medical technology: a review of the literature on injection practices

The rapid uptake of the hypodermic syringe as a medical technology by physicians in Europe and America since its introduction in the middle of the 19th century has led to a level of medical and public acceptance seldom reached by other therapeutic techniques. Presently, the developed world has clear guidelines regarding injection use and safety; in contrast, developing countries are facing the brunt of risks associated with the use of this technology, which was introduced into their societies during the early 20th century. There is now a popular demand for injections, and an alarming number of unnecessary and unsafe injections are being administered. The problem of unsafe injections is not restricted to curative injections, but includes immunizations too. The association of unsafe injections and infection transmission is quite clear, and there is an urgent need to reduce the number of required injections and make them safe. An understanding of the determinants of current injection practices in the socio-cultural-economic context is necessary in order to plan relevant and effective interventions.

A comparison of HIV seropositive and seronegative young adult heroin- and cocaine-using men who have sex with men in New York City, 2000-2003

The purpose of this analysis was to determine the prevalence and correlates of HIV infection among a street-recruited sample of heroin- and cocaine-using men who have sex with men (MSM). Injection (injecting <or=3 years) and non-injection drug users (heroin, crack, and/or cocaine use <10 years) between 18 and 40 years of age were simultaneously street-recruited into two cohort studies in New York City, 2000-2003, by using identical recruitment techniques. Baseline data collected among young adult men who either identified as gay/bisexual or reported ever having sex with a man were used for this analysis. Nonparametric statistics guided interpretation. Of 95 heroin/ cocaine-using MSM, 25.3% tested HIV seropositive with 75% reporting a previous HIV diagnosis. The majority was black (46%) or Hispanic (44%), and the median age was 28 years (range 18-40). HIV-seropositive MSM were more likely than seronegatives to be older and to have an HIV-seropositive partner but less likely to report current homelessness, illegal income, heterosexual identity, multiple sex partners, female partners, and sex for money/drug partners than seronegatives. These data indicate high HIV prevalence among street-recruited, drug-using MSM compared with other injection drug use (IDU) subgroups and drug-using MSM; however, lower risk behaviors were found among HIV seropositives compared with seronegatives. Large-scale studies among illicit drug-using MSM from more marginalized neighborhoods are warranted.

The use of electronic debit cards in longitudinal data collection with geographically mobile drug users

OBJECTIVE

To assess the use of electronic debit (ATM) cards in conducting longitudinal research with geographically mobile ("urban nomad") drug users.

METHODS

Young illicit drug users with recent travel history were street-recruited from the Lower East Side area of New York City. Multiple efforts were made to develop positive relationships between participants and the study. Honoraria were paid through electronic debit cards usable at ATMs countrywide. Participants were encouraged to complete follow-up interviews in person if they were in New York, or by telephone if elsewhere. Follow-up rates from two other recent cohort studies of young drug users in New York are used to illustrate use of the electronic debit card method.

RESULTS

One hundred and thirty-nine participants were recruited during 2001-2002. They had traveled extensively, averaging 31 trips per participant to different cities during the previous 3 years. Telephone follow-up interviews were obtained from participants in over 200 different cities/towns. Follow-up interview rates were 81% at 6 months and 71% at 12 months - substantially higher than corresponding rates in the comparison studies.

CONCLUSIONS

The use of electronic debit cards, combined with other efforts to develop positive relationships with participants, led to high rates of continued study participation. Debit cards may be very useful in conducting longitudinal research with geographically mobile populations.

Ecstasy use among Hispanic and black substance users in New York City

Surveillance data suggests that use of ecstasy in the U.S. is predominantly among white adolescent and young adults. To investigate ecstasy use among substance users in New York City we added questions to ongoing efforts to recruit heroin and cocaine users. Of 715 participants recruited, 58.3% were injection drug users (IDUs). The median age was 32 (range 17-64), 76.4% were male, 49.0% were currently homeless, 62.4% were Hispanic, 27.3% were black, and 34.5% were born outside the United States. Overall, 23.4% used ecstasy in their lifetime and 11.9% had used in the last-6 months. In multivariate logistic regression, correlates of lifetime ecstasy use included younger age, being born in the U.S., and current homelessness. We observed a significant interaction between injection drug use and race where, compared to black non-IDUs, Hispanic non-IDUs, and white IDUs were significantly more likely to have a history of lifetime ecstasy use while black IDUs were significantly less likely. These findings are limited to persons who use other drugs, but suggest that further investigation of ecstasy use in minority populations is warranted.

Injection drug use and the hepatitis C virus: considerations for a targeted treatment approach--the case study of Canada

Infection with the hepatitis C virus (HCV) is a major public health burden in Canada and globally. The literature shows that injection drug use is currently the primary transmission route for HCV, and that a majority of injection drug users (IDUs) are currently infected with HCV in Canada. This article first reviews the burden of HCV within IDU populations and the transmission risks and the treatment implications specific to IDUs. Traditionally, IDUs have been excluded from HCV treatment unless abstaining from illicit drug use. However, recent research suggests that categorical exclusion is not medically necessary. A series of key questions about the feasibility of offering HCV treatment to IDUs in the specific Canadian context are considered, including concerns related to the motivation of treatment for IDUs, treatment delivery, treatment side effects, HCV reinfection, and the social environment. The article concludes that treatment of HCV-infected illicit drug users is both feasible and may be necessary to reduce transmission and adverse outcomes in this high-risk population.

Association between injection practices and duration of injection among recently initiated injection drug users

BACKGROUND

Earlier studies suggest higher infection risk among recently initiated injection drug users (IDUs) than more experienced users. Whether IDUs' risky injection practices rise progressively with duration of injection or frequency of practices is higher near initiation and then taper remains an open question.

METHODS

Recently initiated IDUs were street recruited and interviewed between 1997 and 1999 as part of a multisite cohort study in five US urban cities. Recent risky injection practices (injecting with others and injecting on average more now) were examined across three cross-sections defined by duration of injection: 0-1 year, 2-3 years, and 4-6 years.

RESULTS

The IDU groups of <2 years duration (n = 691) and 2-3 years duration (n = 697) had higher odds than the 4-6 year group (n = 520) of reporting injecting with others (Odds Ratio, OR = 1.52, and OR = 1.47, respectively) and injecting on average more now (OR = 1.44 and OR = 1.44, respectively). The associations remained after multivariate adjustment for demographic variables.

CONCLUSIONS

These data on recently initiated IDUs suggest that risky injection practices were more frequent earlier than later within the first 6 years of initiation, emphasizing that outreach prevention needs to identify and intervene with IDUs early.

Hepatitis C and its risk management among drug injectors in London: renewing harm reduction in the context of uncertainty

AIM

Recognizing the dearth of qualitative research on hepatitis C virus (HCV) infection associated with injecting drug use in the UK, this paper summarizes qualitative insights from a study exploring the social relations of HCV risk management among drug injectors in London.

METHOD

Adopting an inductive approach to data collection and analysis, 59 depth tape-recorded qualitative interviews were undertaken in 2001 with drug injectors recruited via drug user networks.

RESULTS

While access to injecting equipment was reportedly good, needle and syringe sharing continued in exceptional circumstances and in the context of 'trust relationships'. Analyses of drug injectors' accounts of variations of 'I never share' showed that this construction denoted less a descriptor of actual risk behaviour than presentation of perceived risk status. Paraphernalia sharing, including spoons and filters, was common. There was much confusion and uncertainty concerning HCV knowledge, including its medical and transmission risks. Injectors were aware of the provisionality and partiality of their HCV knowledge. Confusion also surrounded the meaning of HCV antibody test results, with some feeling that their positive diagnosis had been 'trivialized' by their experiences of HCV testing. Injectors tended to make sense of HCV risk in relation to HIV. With most viewing HCV prevalence as high and HCV transmission as an inevitable consequence of injecting, HCV risk was perceived as ubiquitous and unavoidable.

CONCLUSIONS

There is an urgent need to renew UK policies of harm reduction in order to support perceptions that HCV is avoidable and preventable.

Hepatitis C incidence--a comparison between injection and noninjection drug users in New York City

Hepatitis C virus (HCV) burdens injection drug users (IDUs) with prevalence estimated from 60-100% compared to around 5% among noninjection drug users (non-IDUs). We present preliminary data comparing the risk for HCV among IDUs and non-IDUs to inform new avenues of HCV prevention and intervention planning. Two cohorts, new IDUs (injecting < or =3 years) and non-IDUs (smoke/sniff heroine, crack or cocaine < or =10 years), ages 15-40, were street-recruited in New York City. Participants underwent risk surveys and HCV serology at baseline and 6-month follow-up visits. Person-time analysis was used to estimate annual HCV incidence. Of 683 non-IDUs, 653 were HCV seronegative, 422 returned for at least 1 follow-up visit, and 1 became HCV seropositive. Non-IDUs contributed 246.3 person-years (PY) yielding an annual incident rate of 0.4/100 PY (95% Confidence Interval [CI]=0.0-1.2). Of 260 IDUs, 114 were HCV seronegative, 62 returned for at least 1 follow-up visit, and 13 became HCV seropositive. IDUs contributed 36.3 PY yielding an annual incidence rate of 35.9/100 PY (95%CI=19.1-61.2). Among IDUs, HCV seroconverters tended to be younger (median age 25 vs. 28, respectively), and inject more frequently (61.5% vs. 34.7%, respectively) than non-seroconverters. These interim data suggest that IDUs may have engaged in high-risk practices prior to being identified for prevention services. Preventing or at least delaying transition into injection could increase opportunity to intervene. Identifying risk factors for transition into injection could inform early prevention to reduce onset of injection and risk of HCV.

Updating the infection risk reduction hierarchy: preventing transition into injection

Current approaches to prevention of blood-borne infections in injection drug users include referral to drug abuse treatment, access to sterile syringes, bleach disinfection of injection equipment, and education about not sharing equipment. However, rates of some blood-borne infections (e.g., hepatitis C virus) remain elevated among injection drug users, especially early after initiation into injection drug use. With lower infection rates in noninjectors and transition into injection drug use occurring most commonly among these noninjectors, prevention of transition into injection drug use as an additional step to reduce risk for acquisition and transmission of blood-borne infections merits closer attention.

Poor Validity of Self‐Reported Hepatitis B Virus Infection and Vaccination Status among Young Drug Users

Self-reported hepatitis B virus (HBV) infection status and immunization status were compared with HBV serological markers among 324 young injection drug users (IDUs) and noninjection drug users (NIDUs). The overall validity of self-reported status was poor; 52% claiming to be vaccinated were actually susceptible to HBV. There was no difference in validity of self-reported HBV status between IDUs and NIDUs. Clinicians should adopt a "Don't Ask, Vaccinate" vaccination policy for young drug users.

The Dynamics of the Human Immunodeficiency Virus Epidemics in the South of Brazil: Increasing Role of Injection Drug Users

Changes in human immunodeficiency virus (HIV) infection among injection drug users (IDUs) are provoking a shift in the pattern of the HIV/AIDS epidemic in some regions of Brazil. IDUs living in 2 cities (Porto Alegre and Itajaí) in southern Brazil were contacted, interviewed, and tested for HIV. In 1998, 187 IDUs were surveyed and, in 2000, 352 IDUs. In Porto Alegre, HIV seroprevalence, age, and duration of injection history increased significantly over time. In contrast, a trend toward decline was observed in Itajaí. Homelessness, joblessness, and prison incarceration, as well as lifetime needle sharing, also increased over time in Porto Alegre. At the time of the study, at both sites, rates of needle sharing and condom use were similar, but use of syringe exchange programs, health and drug treatment, and HIV testing had increased over time. IDUs living in southern Brazil are at increased risk of HIV infection, indicating the continued need for permanent surveillance and preventive strategies.

The social course of drug injection and sexual activity among YMSM and other high-risk youth: an agenda for future research

The cumulative epidemiologic literature indicates that many injecting drug users (IDUs) initiate injection as a mode of drug administration during late adolescence or early adulthood. Recent studies have shown that IDUs are often exposed to viral infections relatively early in the course of injection, highlighting the importance of understanding this initiation process for both epidemiology and prevention. Epidemiologic evidence similarly suggests that at least some youth populations, most notably young men who have sex with men (YMSM), are at substantial risk for exposure to HIV and other sexually transmitted diseases (STDs) from early sexual activity. Despite the importance of this issue for both epidemiology and prevention, however, surprisingly little information is available on the social course of injection initiation, including the individual, social, or ecological factors that might mitigate or exacerbate transmission risks within the critical phase of early injection drug use. Similarly, we know little about the ways that YMSM and other high-risk youth understand risk, the kinds of exchanges and relationships in which they participate in the context of initiating sexual activity, or how drug use is operant in these exchanges and early sexual experiences. In this article, we explore key dimensions of the early initiation of injection and sexual risk, and discuss how a social network approach might be instrumental in understanding the social course of drug injection and sexual activities among youth and young adult populations.

Hepatitis C virus infection: prevalence, predictor variables and prevention opportunities among drug users in Italy

The study assessed rates and predictor variables of hepatitis C virus (HCV) infection among drug users receiving pharmacological treatment for opiates addiction. There was a large cohort study in 16 public centres for drug users in north-eastern Italy, with data collected by standardized face-to-face interviews between February 2001 and August 2001. Of 1095 participants, 74.2% were HCV seropositive. Anti-HCV status was independently associated with duration of drug use of over 10 years, injecting as a route of drug administration, and hepatitis B virus (HBV) and human immunodeficiency virus (HIV) seropositivity. Further statistical analysis was conducted by dividing the subjects on the basis of the duration of heroin use: more or <10 years. In the multivariate analyses, route of drug administration and HBV status were associated with HCV seropositivity among both groups. Less education was associated with HCV among the shorter term drug users. HIV status and having a sexual partner with a history of drug use were associated with HCV seropositivity among the longer term drug users. Half of the short-term heroin users were still HCV seronegative when starting treatment, suggesting opportunities for reducing new HCV infections. Remarkable was the relationship between vaccination for hepatitis B and HCV serostatus. Being HBV seropositive was strongly associated with being HCV seropositive. But heroin users who had been vaccinated for HBV were not significantly more likely to be HCV seropositive than heroin users who were HBV seronegative. HBV vaccination does not provide biological protection against HCV; however, vaccinating heroin users against HBV may help to create a stronger pro-health attitude among heroin users, leading to a reduction in HCV risk behaviour.

Neighborhood differences in patterns of syringe access, use, and discard among injection drug users: implications for HIV outreach and prevention education

The article presents results from the Syringe Access, Use, and Discard: Context in AIDS Risk research project comparing two neighborhoods by (1) socioeconomic and demographic characteristics; (2) patterns of syringe access, use, and discard; and (3) encounters with a local human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) outreach project targeted to injection drug users (IDUs). The results show that IDUs in more economically advantaged neighborhoods were more likely to acquire syringes from a single source (rather than multiple sources), more likely to inject alone in their own residence (rather than public injection locales), and more likely to dispose of syringes in private garbage cans rather alleys or dumpsters. These results are further associated with the likelihood of encountering street outreach workers, with IDUs in more affluent neighborhoods much less likely to have any such contacts. Based on the different patterns of access, use, and discard evident in each neighborhood, the results indicate that different and more carefully tailored local outreach and prevention strategies are urgently needed.

Prevalence of human immunodeficiency virus, hepatitis B, and hepatitis C among homeless persons with co-occurring severe mental illness and substance use disorders

This study was undertaken to determine the prevalence of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) among homeless persons with co-occurring severe mental illness (SMI) and substance use disorders and to determine associated risk factors. As part of a longitudinal study of the effectiveness of integrated treatment for homeless persons with SMI and substance abuse or dependence, serological testing was performed to ascertain the prevalence of HIV, HBV, and HCV. At baseline, 6.2% of participants (11/172) were HIV-positive. Nearly one third of participants (37/114) had evidence of prior exposure to HBV, and 30% (34/114) were antibody positive for HCV. About 44% of participants (50/114) had a reactive test for either HBV or HCV. Having a reactive test was strongly associated with substance use, especially with a history of injection drug use. A significant threat exists to the health and well-being of homeless person with SMI due to high prevalence of blood-borne pathogens. Mental health providers need to play a proactive role in the identification of health-related needs and to assist with access to general health services for persons with SMI.

Hepatitis C virus infection among noninjecting drug users in New York City

The prevalence of hepatitis C virus (HCV) infection among noninjecting drug users has been reported to be higher than in the general population, but the reasons for this observation remain unclear. Noninjecting drug users aged 15-40 years and who used drugs for no longer than 10 years were enrolled in the study. The participants were interviewed about risk behaviors and had specimens drawn for serological testing. Of 276 enrolled, 4.7% were infected with HCV. Drug users who had ever sniffed or snorted heroin in combination with cocaine were significantly more likely to be infected with HCV compared with those who never sniffed or snorted heroin with cocaine. No other drug use or sexual risk behaviors were found to be associated with HCV infection. These findings suggest that sniffing or snorting heroin with cocaine may explain the increase frequently found in HCV infection among noninjectors, but further studies are necessary.

Prevalence and characteristics of hepatitis C virus coinfection in a human immunodeficiency virus clinical trials group: the Terry Beirn Community Programs for Clinical Research on AIDS

The baseline prevalence of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) coinfection among 2705 patients enrolled in HIV clinical trials in the Community Programs for Clinical Research on AIDS (CPCRA) was 16.6%. For men, multivariate logistic regression showed that the baseline prevalence of HIV-HCV coinfection was positively associated with history of injection drug use, older age, antiretroviral therapy naive status, African American or Latino ethnicity, and no history of having sex with men. No association was found with baseline CD4+ cell count or HIV RNA level. The prevalence of HCV coinfection in a diverse HIV clinical trials cohort provides additional information about risk behaviors and demographic factors that can be used in the analysis of clinical and virologic outcomes.

Addressing urban health in Detroit, New York City, and Seattle through community-based participatory research partnerships

OBJECTIVE

This study describes key activities integral to the development of 3 community-based participatory research (CBPR) partnerships.

METHODS

We compared findings from individual case studies conducted at 3 urban research centers (URCs) to identify crosscutting adaptations of a CBPR approach in the first 4 years of the partnerships' development.

RESULTS

Activities critical in partnership development include sharing decision-making, defining principles of collaboration, establishing research priorities, and securing funding. Intermediate outcomes were sustained CBPR partnerships, trust within the partnerships, public health research programs, and increased capacity to conduct CBPR. Challenges included the time needed for meaningful collaboration, concerns regarding sustainable funding, and issues related to institutional racism.

CONCLUSIONS

The URC experiences suggest that CBPR can be successfully implemented in diverse settings.

Prevalence of hepatitis C in a drug using and non-using welfare population

CONTEXT

Drug use is a primary route for the transmission of the Hepatitis C virus (HCV). A substantial proportion of welfare recipients have been shown to be substance abusers. In addition, federal legislation has imposed limits on the number of months individuals may receive benefits and has mandated most recipients to participate in a 'work activity' in exchange for benefits. HCV symptoms may inhibit welfare recipients' ability to seek and maintain employment.

OBJECTIVE

To assess the prevalence of HCV in a sample of Temporary Assistance to Needy Families (TANF) recipients and the effects of HCV antibody seropositivity on employability.

DESIGN, SETTING, AND PARTICIPANTS

The sample for this study consisted of 380 individuals participating in a longitudinal study of employment patterns among TANF recipients in Houston, TX, funded by the National Institute on Drug Abuse (NIDA). Private interviews regarding welfare receipt, employment, and drug use were conducted at intake into the study and at 4-month intervals for one year. Participants agreed to a one-time blood test. Blood samples were tested for the presence of HCV antibodies by enzyme linked immunoassay.

MAIN OUTCOME MEASURE

Employment status over time by HCV antibody status.

RESULTS

Overall, 12% of all participants tested positive for the presence of HCV antibodies. A significantly greater proportion of chronic drug users (31%) than non-drug users (4%) tested positive for the presence of Hepatitis C antibodies. Those who tested positive for hepatitis C had significantly lower rates of employment.

CONCLUSIONS

Potential infection with Hepatitis C may constitute an employment barrier for many welfare recipients.

Gender differences in sexual and injection risk behavior among active young injection drug users in San Francisco (the UFO Study)

Female injection drug users (IDUs) represent a large proportion of persons infected with HIV in the United States, and women who inject drugs have a high incidence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection. Therefore, it is important to understand the role of gender in injection risk behavior and the transmission of blood-borne virus. In 2000-2002, 844 young (<30 years old) IDUs were surveyed in San Francisco. We compared self-reported risk behavior between 584 males and 260 female participants from cross-sectional baseline data. We used logistic regression to determine whether demographic, structural, and relationship variables explained increased needle borrowing, drug preparation equipment sharing, and being injected by another IDU among females compared to males. Females were significantly younger than males and were more likely to engage in needle borrowing, ancillary equipment sharing, and being injected by someone else. Females were more likely than males to report recent sexual intercourse and to have IDU sex partners. Females and males were not different with respect to education, race/ethnicity, or housing status. In logistic regression models for borrowing a used needle and sharing drug preparation equipment, increased risk in females was explained by having an injection partner who was also a sexual partner. Injecting risk was greater in the young female compared to male IDUs despite equivalent frequency of injecting. Overlapping sexual and injection partnerships were a key factor in explaining increased injection risk in females. Females were more likely to be injected by another IDU even after adjusting for years injecting, being in a relationship with another IDU, and other potential confounders. Interventions to reduce sexual and injection practices that put women at risk of contracting hepatitis and HIV are needed.

Prevalence of and risk factors for hepatitis C virus infection among STD clinic clientele in Miami, Florida

OBJECTIVES

Hepatitis C virus (HCV) is the most common chronic blood borne viral infection in the United States. We assessed the HCV prevalence, risk factors, and sensitivity of the Centers for Disease Control and Prevention's (CDC) routine screening criteria among clients of a large urban sexually transmitted disease (STD) clinic.

METHODS

Participants were recruited from a public STD clinic in Miami, Florida, and were interviewed regarding known and potential risk factors. The survey assessed CDC screening criteria, as well as other risk factors (for example, intranasal drug use, history of incarceration, exchanging sex for money, number of lifetime sex partners, and history of an STD). Testing was done by enzyme immunoassay (EIA) and confirmed by recombinant immunoblot assay (RIBA).

RESULTS

The prevalence of anti-HCV positivity was 4.7%. Four variables were significantly associated with being anti-HCV positive, independent of confounding factors. These included injection drug use (odds ratio (OR) = 31.6; 95% confidence intervals (CI) 11.0 to 90.5); history of incarceration (OR = 3.0; 95% CI 1.1 to 8.1); sexual contact with an HCV positive person (OR 12.7; 95% CI 2.5 to 64.7); and older age (OR 1.4; 95% CI 1.2, 1.6). The sensitivity of CDC's routine screening criteria was 69% and specificity was 91%.

CONCLUSIONS

The prevalence of anti-HCV in this clinic was similar to that determined in studies of comparable populations. Having sexual contact with an HCV positive person and history of incarceration were independently associated with being anti-HCV positive. CDC's screening criteria identified approximately two thirds of the anti-HCV positive participants.

Association between hepatitis C infection and other infectious diseases: a case for targeted screening?

OBJECTIVE

Hepatitis C virus (HCV) shares risk factors and routes of transmission with several other infectious agents. However, the prevalence of comorbid infectious disorders among HCV-infected patients remains unknown. To analyze the association between HCV and several categories of infectious disorders, we carried out a case-control study using information from 172 hospitals contained in the computerized databases of the Department of Veterans Affairs.

METHODS

We identified all HCV-infected patients who were hospitalized during 1992-1999. For each case, four control subjects without HCV were randomly chosen from hospitalized patients and were matched with cases on the year of admission. The frequencies of several predefined infectious disease diagnoses were compared between cases and control subjects, and the strength of these associations were assessed in multivariable logistic regression analyses.

RESULTS

We identified 34,204 HCV-infected patients (cases) and 136,816 control subjects without HCV. Patients in the case group were younger (48.4 yr vs 59.8 yr), were more frequently nonwhite (38.5% vs 26.5%), and were more likely to have served in Vietnam (68.1% vs 33.0%); all p < 0.0001. Compared with control subjects, patients with HCV had a significantly higher prevalence of other blood-borne virus infections, including HIV (14.1% vs 3.0%) and hepatitis B (22.4% vs 0.7%); immunodeficiency-related infections, including cytomegalovirus (0.6% vs 0.2%), toxoplasmosis (0.3% vs 0.1%), cryptococcosis (0.4% vs 0.1%), and tuberculosis (3.3% vs 1.3%); sexually transmitted diseases, including gonococcus (0.5% vs 0.1%), chlamydia (1.6% vs 0.7%), syphilis (2.0% vs 0.6%), and genital herpes (1.0% vs 0.3%); and bacterial infection, including peritonitis, sepsis, endocarditis, cellulitis, and carbuncles (all p < 0.0001). After excluding potentially immunocompromised patients, including those with HIV, organ transplant, and cirrhosis, HCV remained significantly associated with CMV, cryptococcus, tuberculosis, and sexually transmitted diseases. Similar results were obtained when the analyses were restricted to Vietnam-era veterans.

CONCLUSIONS

Several infectious diseases are more common among HCV-infected patients compared with those without HCV infection. These findings support an approach of targeted screening for HCV among patients with these infectious diseases.

Controlled clinical trial to assess the response of recent heroin abusers with chronic hepatitis C virus infection to treatment with interferon alpha-n2b

BACKGROUND

Chronic infection with hepatitis C virus (HCV) is the most common infectious disease among heroin abusers, but it is recommended that specific treatment with interferon be delayed until at least 6 to 12 months after the end of drug addiction.

OBJECTIVE

We investigated the response of heroin abusers to interferon treatment shortly after the end of detoxification treatment with methadone.

METHODS

We studied 2 homogeneous groups of white Italian patients with chronic HCV infection: former male heroin abusers and males without a history of drug addiction. Tumor necrosis factor, interleukin-1beta, interleukin-2, activated monocytes, anti-HCV antibodies, HCV RNA, and alanine aminotransferase levels were assessed. Standard treatment was initiated with 5 MU interferon alpha-n2b administered subcutaneously once daily for 8 weeks. Patients with negative HCV-RNA findings at the end of 8 weeks received further treatment with 5 MU TIW subcutaneously for an additional 48 weeks.

RESULTS

Thirty of 47 patients in group A (former heroin abusers) and 30 of 30 patients in group B (controls) completed the study. Heroin abusers presented a significantly enhanced response to treatment compared with the controls. After 8 weeks, HCV-RNA test results were negative in 27 of 30 patients in group A (90.0%) and in 25 of 30 in group B (83.3%) (P = NS). Onset of relapse occurred significantly later in heroin abusers (mean [SD], 53 [3] weeks) than in controls (26 [2] weeks) (P < 0.05). Cytokine levels and activated CD11 antigen-expressing monocytes were significantly (P < 0.001) higher in heroin abusers than controls.

CONCLUSION

Heroin abusers with chronic HCV infection were successfully treated with interferon alpha-n2b soon after the end of detoxification treatment.

Lack of behavior change after disclosure of hepatitis C virus infection among young injection drug users in Baltimore, Maryland

We evaluated behavior change after disclosure of a positive hepatitis C virus (HCV) antibody test result among a cohort of young injection drug users (IDUs). Participants underwent semiannual interviews, human immunodeficiency virus (HIV) and HCV antibody testing, and pretest and posttest counseling. We used chi(2) statistics to study changes in the frequencies of high-risk behaviors from baseline to a 6-month follow-up visit among 46 IDUs who had a positive HCV test result and among 60 IDUs who did not have a positive HCV test result or who were unaware of their test result. No significant differences were detected between the 2 groups. Both groups continued to share syringes, needles, and other injection paraphernalia. These findings suggest that young IDUs may not be aware of the risk of HCV infection and highlight the urgent need for post-HCV test guidelines and behavioral interventions to reduce ongoing high-risk behavior that perpetuates the risk of HCV transmission.

Drug use frequency among street-recruited heroin and cocaine users in Harlem and the Bronx before and after September 11, 2001

We determined if illicit drug use frequency changes after a disaster by comparing drug use frequency in two street-recruited samples of heroin and cocaine users, ages 15-40 years. The users were interviewed between July 11 and November 11 and divided into before- and after-September 11th groups for analysis. The before and after groups were similar in the mean number of days of drug use per month (sniff cocaine 6.8 days vs. 9.4 days, respectively, P =.17; snorted heroin 13.9 vs. 14.0, respectively, P =.96; smoked crack 16.9 vs. 15.6, respectively, P =.96; and smoked marijuana 17.5 vs. 15.3, respectively, P =.36) and in the proportion of daily users: sniffed cocaine 10% versus 17%, respectively (P =.28); snorted heroin 47% versus 40%, respectively (P =.91); smoked crack 33% versus 37%, respectively (P =.68); and smoked marijuana 47% versus 40%, respectively (P =.41). Among street-recruited heroin and cocaine users in Harlem and the Bronx, the frequency of drug use did not increase following the events of September 11, 2001.

Psychiatric disorders among veterans with hepatitis C infection

BACKGROUND & AIMS

The presence of psychiatric, drug-, and alcohol-use disorders in hepatitis C virus (HCV)-infected patients may influence their management and prognosis. The frequency and the risk for these disorders among HCV-infected patients are unknown.

METHODS

We identified all HCV-infected veteran patients who were hospitalized during 1992-1999 and searched the inpatient and outpatient computerized files for predefined psychiatric, drug-, and/or alcohol-use disorders. We then performed a case-control study among Vietnam veterans; controls without HCV were randomly chosen from hospitalized patients.

RESULTS

We identified 33,824 HCV-infected patients, in whom 86.4% had at least one past or present psychiatric, drug-, or alcohol-use disorder recorded. However, only 31% had active disorders as defined by hospitalization to psychiatric or drug-detoxification bed sections. There were 22,341 HCV-infected patients from the Vietnam period of service (cases) who were compared with 43,267 patients without HCV (controls). Cases were more likely to have depressive disorders (49.5% vs. 39.1%), posttraumatic stress disorder (PTSD) (33.5% vs. 24.5%), psychosis (23.7% vs. 20.9%), bipolar disorder (16.0% vs. 12.6%), anxiety disorders (40.8% vs. 32.9%), alcohol (77.6% vs. 45.0%), and drug-use disorders (69.4% vs. 31.1%). In multivariable regression analyses that adjust for age, sex, and ethnicity, drug use, alcohol-use, depression, PTSD, and anxiety remained strongly associated with HCV.

CONCLUSIONS

Several psychiatric, drug-, and alcohol-use disorders are commonly found among HCV-infected veterans compared with those who are not infected. At least one third of these patients have active disorders. A multidisciplinary approach to the management of HCV-infected patients is needed.

Safer and unsafe injection drug use and sex practices among injection drug users in Halifax, Nova Scotia. An exploratory look at community and interpersonal influences

OBJECTIVE

This qualitative study sought to explore the community and interpersonal (e.g., peer) influences affecting safer and unsafe injection drug use and sexual practices among injection drug users (IDUs) living in and around Halifax, Nova Scotia.

METHODS

Sixty semi-structured interviews were conducted with IDUs, and key themes were identified. Two focus groups were also conducted to obtain feedback on the findings.

RESULTS

There are key community and peer influences on drug use and sex practices. Needle exchange provides community access to clean needles, but when the needle exchange is closed, accessibility is an issue. Peers at times assist in reducing sharing by providing clean needles to friends who are without a needle or cannot access needles because of their circumstances (e.g., in prison). Peers also sometimes encourage condom use, but in certain contexts (e.g., with an intimate partner) condom use is often not supported.

INTERPRETATION

Expanded and new prevention strategies--especially those utilizing peers--are urgently needed to discourage unsafe practices, and encourage safer practices among this population.

Access to resources for substance users in Harlem, New York City: service provider and client perspectives

The Urban Research Center (URC) in Harlem, New York City, is a collaboration of community members, service providers, and academics. A Community Advisory Board (CAB) meets regularly to formulate priorities for action and to direct research. A conceptual model of social determinants of health relevant to the Harlem community was developed. Early meetings of the CAB identified substance use as a health concern in the Harlem community. Access to social services was identified as a key social determinant that should guide research and intervention efforts of the URC. Surveys of service providers and of substance users were carried out to quantify availability of information and barriers to access. This article discusses the CAB process that led to the model of social determinants, development of surveys, and interpretation of results. The authors also discuss survey results and how the URC will use these results to develop interventions.

Measures to reduce HIV infection have not been successful to reduce the prevalence of HCV in intravenous drug users

The objective of the study was to determine whether measures taken to prevent human immunodeficiency virus (HIV) infection also lead to a reduction in the prevalence of hepatitis C virus (HCV) infection among intravenous drug users (IDU). Antibodies to HCV, HIV and hepatitis B virus (HBV) were determined in IDU who voluntarily attended AIDS prevention and information centres for the first time between 1990 and 1996. Of the 5473 IDU studied, determination of HCV was done in 3238 cases. The prevalence of antibodies to HCV was 85%. During the first period studied (1990-1992), the prevalence of antibodies to HCV was 84.5%, during the second (1993-1994) 84.1% and during the third (1995-1996) 87%; in the case of HBV the prevalence during the three periods was 74.5, 67.6 and 66.8% respectively, and for HIV it was 41.9, 38.8 and 36.6% respectively (RR: 0.72; 95% confidence interval (CI): 0.65-0.81). Among drug users addicted for less than 2 years, the trend of the prevalence of antibodies to HCV and HBV remained constant, while the prevalence of HIV infection decreased (RR: 0.61; 95% CI: 0.42-0.89). Measures to prevent transmission of HIV in drug users do not lead to a reduction in the prevalence of HCV infection. Further study is necessary to obtain a better understanding of how HCV is transmitted among drug users in order to apply measures which are effective in preventing HCV infection.

Risk factors for hepatitis C virus infection among homeless adults

OBJECTIVE

To describe the prevalence of hepatitis C virus (HCV) infection in a sample of homeless and impoverished adults and examine risk factors for HCV infection in the overall sample and as a function of injection drug use.

DESIGN

Assays were conducted on stored sera. Sociodemographic characteristics and risky sexual activity were measured by content-specific items. Substance use was measured by a structured questionnaire. HCV antibodies were tested by enzyme-linked immunosorbent assay; a confirmatory level was defined by recombinant immunoblot assay.

SETTINGS

Shelters ( N = 36) and outdoor locations in Los Angeles.

PARTICIPANTS

Eight hundred eighty-four homeless women and/or partners or friends.

RESULTS

Among this sample of 884 homeless and impoverished adults, 22% were found to be HCV infected. Lifetime injection drug users (IDUs) (cocaine, crack, and methamphetamine) and recent daily users of crack were more likely than nonusers or less-frequent users of these drugs to be HCV-infected. Similar results were found for those who had been hospitalized for a mental health problem. Among non-injection drug users and persons in the total sample, those who reported lifetime alcohol abuse were more likely than those who did not to be HCV infected. Controlling for sociodemographic characteristics, multiple logistic regression analyses revealed IDUs have over 25 times greater odds of having HCV infection than non-IDUs. HCV infection was also predicted by older age, having started living on one's own before the age of 18, and recent chronic alcohol use. Males and recent crack users had about one and a half times greater odds of HCV infection when compared to females and non-chronic crack users.

CONCLUSIONS

Targeted outreach for homeless women and their partners, including HCV testing coupled with referrals to HCV and substance abuse treatments, may be helpful.