Audio-computer interviewing to measure risk behaviour for HIV among injecting drug users: a quasi-randomised trial

Circumstances of first crystal methamphetamine use and initiation of injection drug use among high-risk youth

BACKGROUND

Despite the widely noted increase in crystal methamphetamine (CM) use, there are few studies on circumstances of first CM use or correlates of use among high-risk populations (e.g. street-involved youth).

METHODS

Street-involved youth in Vancouver, Canada, were enrolled in the At-Risk Youth Study (ARYS) prospective cohort. Extensive outreach produced a representative sample of Vancouver street youth who use illicit drugs. We examined circumstances of first CM use and factors associated with CM use among the cohort.

RESULTS

Among 478 participants, 339 (70.9%) had used CM previously. Despite intensive covariate adjustment, a history of CM use was associated independently with having initiated injection drug use [OR = 3.15 (95% CI: 1.89-5.2); p < 0.001]. Among those who had used CM, route of first administration included: 11 (3.2%) oral ingestion; 25 (7.4%) injected; 105 (31.0%) snorted; 231 (68.1%) smoked. The proportion of respondents reporting current CM injection was significantly greater than the proportion reporting injection as the route for first CM use (18.3% vs. 7.4%; McNemar's test p < 0.001). Ability to obtain CM the first time was reported as 'very easy' or 'easy' by 93.5% and 5.3% of participants, respectively.

CONCLUSIONS

Crystal methamphetamine use was independently associated with injection drug use, and significant increases in injecting as the primary mode of administration were observed when patterns of use were considered longitudinally. The easy accessibility of CM and its common use during transition into injection drug use demonstrate the need for innovative drug policy to address this growing concern.

A randomized intervention trial to reduce the lending of used injection equipment among injection drug users infected with hepatitis C

OBJECTIVES

We evaluated the efficacy of a peer-mentoring behavioral intervention designed to reduce risky distributive injection practices (e.g., syringe lending, unsafe drug preparation) among injection drug users with hepatitis C virus (HCV) infection.

METHODS

A randomized trial with a time-equivalent attention-control group was conducted among 418 HCV-positive injection drug users aged 18 to 35 years in 3 US cities. Participants reported their injection-related behaviors at baseline and at 3- and 6-month follow-ups.

RESULTS

Compared with the control group, intervention-group participants were less likely to report distributive risk behaviors at 3 months (odds ratio [OR]=0.46; 95% confidence interval [CI]=0.27, 0.79) and 6 months (OR=0.51; 95% CI=0.31, 0.83), a 26% relative risk reduction, but were no more likely to cite their HCV-positive status as a reason for refraining from syringe lending. Effects were strongest among intervention-group participants who had known their HCV-positive status for at least 6 months. Peer mentoring and self-efficacy were significantly increased among intervention-group participants, and intervention effects were mediated through improved self-efficacy.

CONCLUSIONS

This behavioral intervention reduced unsafe injection practices that may propagate HCV among injection drug users.

Psychosocial and behavioral correlates of depressed mood among female methamphetamine users

Female methamphetamine (meth) users report more depressive symptoms than do males. This study examined psychosocial and behavioral correlates of depressed mood in 146 heterosexual, meth-using women in San Diego, CA. Sixty percent met Beck Depression Inventory (BDI) criteria for moderate to severe depressive symptoms (i.e., higher levels of depressive symptoms); 40% had minimal to mild depressive symptoms (i.e., lower levels of depressive symptoms). The two groups were compared on background characteristics, reasons for meth use, patterns of meth use, psychosocial factors, social and sexual consequences of meth use, and sexual risk behavior. Women with higher levels of depressive symptoms were less likely to be employed, were more likely to use meth to cope with mood, used more grams of meth in a 30-day period, used meth more times per day on a greater number of consecutive days, and were more likely to be binge users of meth. They also scored lower on a measure of self-esteem and higher on measures of impulsivity, social stigma, and social network members' use of meth. In multivariate analyses, lower self-esteem and higher ratings of social network members' use of meth were significant predictors of higher levels of depressive symptoms. Psychosocial and behavioral factors are discussed in terms of treatment protocols for mood regulation and meth abatement in the target population.

Dermatologic Manifestations of Underlying Infectious Disease among Illicit Injection-Drug Users

Background:

Drug use patterns and serious bloodborne infections commonly have dermatologic manifestations among illicit injection-drug users (IDUs).

Objective:

To assess how self-reported skin conditions of IDUs may correlate with underlying infectious diseases after adjustment for drug use patterns.

Methods:

Prospective analysis of factors associated with self-reports of skin rashes, cellulitis, oral lesions, and lymphadenopathy obtained from 1,065 IDUs enrolled in a large cohort study. Variables potentially associated with each outcome were evaluated using multivariate generalized estimating equations.

Results:

In multivariate analyses, drug use patterns were associated with cellulitis, whereas human immunodeficiency virus (HIV) infection and hepatitis C (HCV) were not. HCV infection was independently associated with skin rashes (odds ratio [OR] 1.85; 95% Cl 1.17–2.94). HIV infection was independently associated with lymphadenopathy (OR 2.00; 95% CI 1.52–2.63), skin rash (OR 2.12; 95% CI 1.57–2.86), and oral lesions (OR 14.95; 95% CI 9.41–23.76).

Conclusions:

Self-reports of IDUs, which could easily be obtained as part of a functional inquiry in a clinical setting, correlate with specific drug use patterns and underlying bloodborne infections.

Computer-assisted self-interviews: a cost effectiveness analysis

Computer-assisted self-interview (CASI) questionnaires are being used with increased frequency to deliver surveys that previously were administered via self-administeredpaper-and-pencil questionnaires (SAQs). Although CASI may offer a number of advantages, an important consideration for researchers is the assessment modality's immediate and long-term costs. To facilitate researchers' choice between CASI and SAQ, this article provides theoretical cost models with specific parameters for comparing the costs for each assessment type. Utilizing these cost models, this study compared the cost effectiveness in a health behavior study in which both CASI (n = 100) and SAQ (n = 100) questionnaires were administered. Given the high initial costs, CASI was found to be less cost effective than SAQ for a single study. However, for studies with large sample sizes or when CASI software is to be used for multiple studies, CASI would be more cost effective and should be the assessment mode of choice.

Sexually active HIV-positive patients frequently report never using condoms in audio computer-assisted self-interviews conducted at routine clinical visits

HIV prevention has become a new priority for HIV clinicians, as their patients live longer and more sexually active lives. Prevention interventions can be effective in clinical settings, but first patients must be screened and inconsistent condom use must be disclosed. Audio computer-assisted self-interviews (ACASI) are an effective way to elicit this sensitive information. We assessed condom use by ACASI among 198 English- or Spanish-speaking HIV patients at 2 community hospital-based HIV clinics in Queens and the Bronx, New York. Among 120 patients reporting sex with a regular partner in the past 4 weeks, 41 (34%) reported not using a condom every time and 22 (18%) reported never using a condom. Among 81 reporting sex with a casual partner in the past 4 weeks, 21 (26%) reported not using a condom every time and 12 (15%) reported never using a condom. Overall, 24 of 129 sexually active patients (19%) reported never using a condom. In a multivariable model controlling for age, race/ethnicity, gender, and HIV exposure category, depression symptoms (Center for Epidemiological Studies Depression Scale [CES-D] score >/= 16; p = 0.03) and self-reported antiretroviral medication non-adherence (</=95% doses in past 3 days; p = 0.03) were significantly associated with never using a condom with a regular or casual partner. ACASI interviews may be an effective way of identifying patients in clinical settings who require prevention counseling as well as other psychosocial services.

Burden of HIV infection among aboriginal injection drug users in Vancouver, British Columbia

OBJECTIVES

We sought to examine whether there were differential rates of HIV incidence among Aboriginal and non-Aboriginal injection drug users in a Canadian setting.

METHODS

Data were derived from 2 prospective cohort studies of injection drug users in Vancouver, British Columbia. Using the Kaplan-Meier method and Cox proportional hazards regression, we compared HIV incidence among Aboriginal and non-Aboriginal participants.

RESULTS

Overall, 2496 individuals were recruited between May 1996 and December 2005. Compared with that of non-Aboriginal persons, the baseline HIV prevalence was higher among Aboriginal persons (16.0% vs 25.1%; P<.001). Among participants who were HIV negative at baseline, the cumulative HIV incidence at 48 months was higher among Aboriginal persons (18.5% vs 9.5%; P<.001). In multivariate analyses, Aboriginal ethnicity was independently associated with elevated HIV incidence (relative hazard=1.59; 95% confidence interval=1.12, 2.26; P=.009).

CONCLUSIONS

Aboriginal persons in Vancouver had a significantly elevated burden of HIV infection, which calls for a culturally sensitive and evidence-based response. Policymakers in other settings with at-risk Aboriginal populations should seek to avert similar public health emergencies by being proactive with evidence-based HIV-prevention programs.

Results from a randomized controlled trial of a peer-mentoring intervention to reduce HIV transmission and increase access to care and adherence to HIV medications among HIV-seropositive injection drug users

BACKGROUND

There is a lack of effective behavioral interventions for HIV-positive injection drug users (IDUs). We sought to evaluate the efficacy of an intervention to reduce sexual and injection transmission risk behaviors and to increase utilization of medical care and adherence to HIV medications among this population.

METHODS

HIV-positive IDUs (n=966) recruited in 4 US cities were randomly assigned to a 10-session peer mentoring intervention or to an 8-session video discussion intervention (control condition). Participants completed audio computer-assisted self-interviews and had their blood drawn to measure CD4 cell count and viral load at baseline and at 3-month (no blood), 6-month, and 12-month follow-ups.

RESULTS

Overall retention rates for randomized participants were 87%, 83%, and 85% at 3, 6, and 12 months, respectively. Participants in both conditions reported significant reductions from baseline in injection and sexual transmission risk behaviors, but there were no significant differences between conditions. Participants in both conditions reported no change in medical care and adherence, and there were no significant differences between conditions.

CONCLUSIONS

Both interventions led to decreases in risk behaviors but no changes in medical outcomes. The characteristics of the trial that may have contributed to these results are examined, and directions for future research are identified.

Substance use and sexual behavior during incarceration among 18- to 29-year old men: prevalence and correlates

An A-CASI survey of 197 men with a history of incarceration, ages 18-29, revealed that 50% and 17% of participants, respectively, had used substances or had sex while confined. Univariate regression analyses indicated that these two behaviors were correlated and both were associated with being older, having spent more years incarcerated, being sexual abused, and being involved with gangs and violence during incarceration. Multiple regression analyses showed that the likelihood of any substance use during incarceration was higher for men who were affiliated with a gang. Men were more likely to have had sex during incarceration if they reported having had a male sex partner in the community. The prevalence of sexual behavior also differed across sites. Findings document the occurrence of substance use and sexual behavior among incarcerated men, and highlight the need for continued research into the context of these behaviors.

Prevalence of nocturia in a Korean population aged 40 to 89 years

AIMS

The purpose of this study was to evaluate the prevalence of nocturia in Korea, to examine the relationship between nocturia and demographic variables, and to determine the impact of nocturia on daily living.

METHODS

A national telephone survey using quota sampling methods was conducted in Korea. The clinically validated computer-assisted telephone interview approach was used for the survey.

RESULTS

Of 2005 subjects (1,005 women and 1,000 men) interviewed, 33.5% reported voiding once per night and 48.2% twice or more per night. Nocturia increased with age among both genders and was more common among young women than young men. In all subjects, multivariate analysis indicated that female gender, older age and an overweight condition were independent risk factors. Body mass index was associated with an increased likelihood of nocturia in male but not in female subjects. In female subjects, the likelihood of at least one night-time void was related to delivery number (odds ratio 1.17, 95% confidence interval 1.04-1.32). An impact of nocturia on daily life was reported by 14.6% of subjects and only 3.8% (4.0% of men and 3.7% of women) sought medical care. Commonly reported reasons for not seeking medical care were the belief that nocturia is a normal consequence of aging or is not a disease (92.8% of subjects reporting an impact of nocturia on daily life).

CONCLUSIONS

Although nocturia is highly prevalent in the Korean population, it has only a minor impact on daily living, and few individuals seek medical care. Our study provides a valuable insight into the need for tailored nocturia education addressed to the population who view the condition as trivial.

Safer choices 2: rationale, design issues, and baseline results in evaluating school-based health promotion for alternative school students

BACKGROUND

Students attending 'alternative' high schools form relatively small, highly mobile high-risk populations, presenting challenges for the design and implementation of HIV-, other STI-, and pregnancy-prevention interventions. This paper describes the rationale, study design, and baseline results for the Safer Choices 2 program.

STUDY DESIGN

Modified group-randomized intervention trial with cross-over of schools but not of students. The study cohort was defined a priori as those who completed the baseline measures and were still enrolled at the time of first follow-up. DESIGN RESULTS: Of 940 students initially enrolled in the study, 711 (76%) formed the study cohort. There were significant demographic differences between those included and those excluded from the study cohort in sex, age, sexual experience, experience with pregnancy, drug use, and some psychosocial measures. There were no significant differences between the intervention and control groups within the study cohort. The only significant difference between those students excluded from the intervention group and those excluded from the control group was reported age at first intercourse. BASELINE DATA RESULTS: Students (n=940) enrolled were predominately African-American (29.7%) and Hispanic (61.3%); 57.3% were female; 66% had ever had sex; and reported drug use in the previous 30 days ran from 4.3% (cocaine) to 26.9% (marijuana). Of the 627 sexually experienced, 41.8% reported their age at first intercourse as 13 years or younger; 28.5% reported ever being or having gotten someone pregnant; 74% reported sex in the past 3 months. Of the 464 sexually active in the last 3 months, 55.4% reported unprotected intercourse and 31.3% reported using drugs beforehand.

CONCLUSION

The cross-over design will provide a rigorous test of the intervention; however, loss to follow-up of this population can result in some selection bias. Students attending dropout prevention and recovery schools are at high risk for HIV, STIs, and pregnancy, and are in need of interventions.

Elevated syringe borrowing among men who have sex with men: a prospective study

OBJECTIVE

Despite efforts to scale up HIV prevention services for drug users, high rates of HIV risk behavior persist among some subpopulations. Given that few prospective studies have considered the relationship between sexual activity and syringe sharing, we sought to evaluate syringe sharing among male injection drug users (IDUs) who have sex with men (MSM) in Vancouver.

METHODS

We performed a longitudinal analysis of factors associated with syringe borrowing among male participants enrolled in the Vancouver Injection Drug Users Study during the years 1996 to 2005 using generalized estimating equations (GEE).

RESULTS

Among the 1019 male participants included in this analysis, 553 (54.3%) reported borrowing syringes during the study period. In multivariate GEE analysis, MSM were at an elevated risk for syringe borrowing (adjusted odds ratio [AOR] = 1.50, 95% confidence interval [CI]: 1.10 to 2.04) after extensive adjustment for other known risk factors.

CONCLUSIONS

Among male participants, having sex with men was found to be strongly and independently associated with syringe borrowing. Our findings may aid policy makers in their efforts to identify IDUs who should be targeted with education and prevention efforts, and indicate the need for ongoing development of prevention interventions that address sexual orientation.

Frequent Douching and Clinical Outcomes Among HIV-Infected Women

OBJECTIVE

To determine the prevalence of douching among a cohort of HIV-infected women and to examine clinical outcomes associated with frequent douching-namely bacterial vaginosis, presence of a sexually-transmitted infections, and genital tract HIV-1 RNA shedding.

STUDY DESIGN

Participants included a concurrent cohort of 187 women attending an HIV outpatient clinic in New Orleans, LA. Subjects underwent clinical examinations and answered questions in a computer-assisted survey at each visit.

RESULTS

At baseline, 1-, and 3-month follow-ups, 64.2%, 56.5%, and 54.7% of women, respectively, indicated that they douched. In multivariable analyses, douching >1 time a month was independently associated with the outcomes of bacterial vaginosis and presence of a selected sexually transmitted infection (Trichomonas vaginalis, Neisseria gonorrhea, or Chlamydia trachomatis). Although not significant, women who douched >1 time a month were also twice as likely to have genital tract HIV-1 RNA shedding as nondouchers.

CONCLUSIONS

This is the first study performed in women infected with HIV to link a significant dose-response relationship between douching and the clinical outcomes of bacterial vaginosis and presence of a sexually transmitted infection, and to examine the association between douching and genital tract HIV-1 RNA shedding.

Differences in young people's reports of sexual behaviors according to interview methodology: a randomized trial in India

OBJECTIVES

We compared reports of sexual behaviors given in standard face-to-face interviews with reports given in audio computer-assisted self-interviews (ACASIs) and culturally specific interactive interviews among adolescents in India. We sought to determine which of the interview methods leads to higher reporting of sexual behaviors among economically disadvantaged 15-19-year-olds in urban India.

METHODS

We conducted a randomized trial in which each participant (583 boys and 475 girls) was assigned to 2 interview methods: face-to-face interview and ACASI or interactive interview. We used matched case-control analyses to assess differences in the individual's reporting on the 2 methods.

RESULTS

Female participants consistently reported fewer sexual behaviors in ACASIs than in face-to-face interviews, whereas male participants' reports differed according to type of sexual behavior and interview mode. Both male and female participants reported more sexual behaviors during interactive interviews than during face-to-face interviews. Twenty-eight percent of male participants reported having engaged in heterosexual intercourse in interactive interviews, as compared with 20% in face-to-face interviews (P< .01); the corresponding percentages for female participants were 7% and 2% (P<.01).

CONCLUSIONS

Our results showed that young people were more likely to report sexual behaviors in culturally specific interactive interviews than in face-to-face interviews. By contrast, ACASIs did not uniformly lead to higher reporting levels than did face-to-face interviews.

Methods to recruit and retain a cohort of young-adult injection drug users for the Third Collaborative Injection Drug Users Study/Drug Users Intervention Trial (CIDUS III/DUIT)

BACKGROUND

New injection drug users (IDUs) are at high risk for blood-borne viral infections. Given U.S. policy to only fund proven-effective HIV prevention interventions, insights into conducting intervention trials among young IDUs are provided here by describing methods and participants' characteristics in the CIDUS III/DUIT study.

METHODS

In 2002-2004, 15-30-year-old IDUs in Baltimore, Chicago, Los Angeles, New York, and Seattle were recruited through community outreach, advertising and coupon-based participant referrals. Baseline interviews assessed sociodemographics, injection, and sexual behaviors. Antibody tests for HIV and hepatitis A, B, and C viruses (HAV, HBV, and HCV) were conducted. IDUs who were HIV and HCV antibody negative at baseline were eligible to participate in a randomized controlled HIV/HCV prevention trial. Follow-up assessments were conducted 3 and 6 months post-intervention. Data were analyzed to identify participant differences at baseline by city, trial enrollment, and trial retention.

RESULTS

Baseline assessments were completed by 3285 IDUs. Participants were mean age 23.8 years, 69% male, 64% White, 17% Hispanic, and 8% Black. Seroprevalence of HIV, HCV, HBV, and HAV antibodies were 2.9, 34.4, 22.4, and 19.3%, respectively. Of the 2062 (62.7%) baseline participants who were HIV and HCV antibody negative, 859 (41.7%) were randomized. At least one follow-up assessment was completed by 712 (83%) randomized participants. Contextual factors, primarily homelessness, were associated with lower enrollment and retention.

CONCLUSIONS

Recruitment and retention of young-adult IDUs for complex intervention trials is complicated, yet feasible. Risk behaviors among participants enrolling in and completing the trial reflected those eligible to enroll.

Prevalence and correlates of indirect sharing practices among young adult injection drug users in five U.S. cities

BACKGROUND

Sharing of drug paraphernalia to prepare, measure and divide drugs for injection remains an important residual risk factor for hepatitis C and other blood-borne infections among injection drug users (IDUs) especially as sharing of syringes for injection decreases.

METHODS

We analyzed data from five U.S. cities to determine the prevalence and independent correlates of non-syringe paraphernalia-sharing (NSPS) and syringe-mediated drug-splitting (SMDS) among 15-30-year-old IDUs who reported not injecting with others' used syringes (receptive syringe-sharing, RSS).

RESULTS

NSPS was reported by 54% of IDUs who did not practice RSS and was independently associated (p<0.05) with having > or =5 injection partners, injecting with sex partners or regular injection partners, injecting in shooting galleries, peers' sharing behaviors, lower self-efficacy for avoiding NSPS, and less knowledge of HIV and HCV transmission. SMDS was reported by 26% of IDUs who did not practice RSS, and was independently associated with having > or =5 injection partners, injecting in shooting galleries, and inversely associated with unknown HIV status.

CONCLUSIONS

NSPS and SMDS were common among young adult IDUs. Increased efforts to prevent these risky practices should address social and environmental contexts of injection and incorporate knowledge and skills building, self-efficacy, and peer norms.

Unstable housing as a factor for increased injection risk behavior at US syringe exchange programs

OBJECTIVE

To assess variation in injection risk behavior among unstably housed/homeless injecting drug users (IDUs) across programs in a national sample of US syringe exchange programs.

METHODS

About 23 syringe exchange programs were selected through stratified random sampling of moderate to very large US syringe exchange programs operating in 2001-2005. Subjects at each program were randomly sampled. Risk behavior interviews were collected using audio-computer assisted self-interviewing (A-CASI). "Unstable housing/homelessness" was operationally defined as having lived "on the street or in a shanty" or "living in a shelter or single room occupancy hotel (SRO)" at any time in the 6 months prior to the interview. "Receptive sharing" was operationally defined as having injected with a needle or syringe that "had been used by someone else" in the 30 days prior to the interview. Six very large and nine moderate-to-large programs had at least 50 subjects who reported unstable housing, and these 15 programs were used in the analyses.

RESULTS

There was considerable variation among the 15 programs in the percentages of unstably housed participants (range from 35 to 74%, P < 0.0001), and in the percentages of unstably housed participants who reported receptive sharing (range from 8 to 52%, P < 0.0001). At each of the 15 programs, unstably housed exchange participants were approximately twice as likely to report receptive sharing than were stably housed participants. The weighted mean odds ratio was 2.02, 95% confidence interval, 1.68-2.41 (random effects model) and there was no statistically significant variation in these odds ratios. Across the 15 programs, receptive sharing among unstably housed participants was highly correlated with receptive sharing among stably housed participants (r = 0.95, P < 0.001, 90% of variance among unstably housed "explained" by variance among stably housed).

CONCLUSIONS

The programs clearly differ in the extent to which they are attracting unstably housed IDUs as participants. The consistency of more frequent injection risk behavior among unstably housed exchange participants and the lack of significant variation in the odds ratios for increased injection risk suggests that none of the programs were "better" or "worse" at reducing injection risk behavior among unstably housed participants. Reduction in injecting risk behavior among syringe exchange participants may require greater efforts to provide stable housing or the development of dramatically new interventions to reduce injecting risk behavior among IDUs with persistent unstable housing.

Rates of sexual victimization in prison for inmates with and without mental disorders

OBJECTIVE

This study estimated the rates of sexual victimization among prison inmates with and without a mental disorder.

METHODS

The study sampled inmates aged 18 or older in 13 prisons within a single mid-Atlantic state prison system (12 facilities for men and one for women). A total of 7,528 inmates completed the survey instrument, which was administered by audio-computer-assisted technology. Of the 6,964 male respondents, 58.5% were African American, 16.2% were non-Hispanic white, 19.8% were Hispanic, and 5.5% were of another race or ethnicity. Of the 564 female respondents, 48.4% were African American, 30.9% were non-Hispanic white, 14.4% were Hispanic, and 7.3% were of another race or ethnicity. Mental disorder was based on self-reported previous mental health treatment for particular mental disorders. Sexual victimization was measured by using questions adapted from the National Violence Against Women and Men surveys.

RESULTS

Approximately one in 12 male inmates with a mental disorder reported at least one incident of sexual victimization by another inmate over a six-month period, compared with one in 33 male inmates without a mental disorder. Among those with a mental disorder, sexual victimization was three times as high among female inmates (23.4%) as among male inmates (8.3%). African-American and Hispanic inmates with a mental disorder, independent of gender, reported higher rates of sexual victimization than their non-Hispanic white counterparts.

CONCLUSIONS

Prisons are hazardous places. Steps must be taken to protect inmates from predators inside prison, to screen them for posttraumatic stress disorder, to provide trauma-related treatment, and to keep them safe.

Condom use and vaginal Y-chromosome detection: the specificity of a potential biomarker

OBJECTIVE

Detection of vaginal Y-chromosome sequences (YCS) may be a useful biomarker to validate sexual behavior reporting in women. We describe the effects of condom use on the detection of vaginal YCS.

METHODS

Fifty-six women were asked to abstain from sexual intercourse for 14 days. On day 15, participants were asked to engage in sexual intercourse with their male partners using condoms. Self-collected vaginal swabs were obtained on days 14, 16, and 17. YCS were detected using the Roche LightCycler with the use of positive controls.

RESULTS

Fourty-four of 56 women completed the study. Five women (11.4%) had detectable YCS. The overall specificity of the YCS assay with condom use was 92% (95% CI: 80%-98%). Although women who reported receptive oral sex and digital penetration within 48 hours of swab collection had a higher detection rate of YCS [RR 2.3 (95% CI: 1.1-4.6) and 3.6 (95%CI: 1.6-8.5), respectively], the mean concentration of YCS was much less than that associated with unprotected vaginal intercourse (P <0.001)

CONCLUSIONS

Condom use during intercourse appears to prevent vaginal YCS detection; this may be a useful biomarker to validate self-reported condom use.

A peer-education intervention to reduce injection risk behaviors for HIV and hepatitis C virus infection in young injection drug users

OBJECTIVES

To evaluate whether a behavioral intervention, which taught peer education skills, could reduce injection and sexual risk behaviors associated with primary HIV and hepatitis C virus infection (HCV) among young injection drug users (IDU).

DESIGN

We conducted a randomized controlled trial involving HIV and HCV antibody-negative IDU, aged 15-30 years, recruited in five United States cities. A six-session, small-group, cognitive behavioral, skills-building intervention in which participants were taught peer education skills (n = 431) was compared with a time-equivalent attention control (n = 423). Baseline visits included interviews for sociodemographic, psychosocial, and behavioral factors during the previous 3 months; HIV and HCV antibody testing; and pre/posttest counselling. Procedures were repeated 3 and 6 months postintervention.

RESULTS

The intervention produced a 29% greater decline in overall injection risk 6 months postintervention relative to the control [proportional odds ratio 0.71; 95% confidence limit (CL) 0.52, 0.97], and a 76% decrease compared with baseline. Decreases were also observed for sexual risk behaviors, but they did not differ by trial arm. Overall HCV infection incidence (18.4/100 person-years) did not differ significantly across trial arms (relative risk 1.15; 95% CL 0.72, 1.82). No HIV seroconversions were observed.

CONCLUSION

Interventions providing information, enhancing risk-reduction skills, and motivating behavior change through peer education training can reduce injection risk behaviors, although risk elimination might be necessary to prevent HCV transmission.

Associations between childhood maltreatment and sex work in a cohort of drug-using youth

Although research has examined the impacts of childhood maltreatment among various marginalized populations, few studies have explored the relationship between child abuse and subsequent involvement in sex work among drug-using street-involved youth. In the present study, the relationships between the level of childhood maltreatment and involvement in sex work were examined using the Childhood Trauma Questionnaire (CTQ) as part of an extensive interview protocol in an ongoing prospective cohort study of street-involved youth in Vancouver, Canada. Between September 2005 and June 2006, 361 youth were recruited using extensive outreach methods and snowball sampling. The prevalence rates for abuse in the sample were 73% for physical abuse; 32.4% for sexual abuse; 86.8% for emotional abuse; 84.5% for physical neglect; and 93% for emotional neglect. Univariate and logistic regression analyses demonstrated that not only was sexual abuse independently associated with sex work, but emotional abuse was as well. These findings have implications for early intervention efforts aimed at vulnerable, high-risk youth populations as well as intervention strategies for active sex trade workers.

Rates of sexual victimization in prison for inmates with and without mental disorders

OBJECTIVE

This study estimated the rates of sexual victimization among prison inmates with and without a mental disorder.

METHODS

The study sampled inmates aged 18 or older in 13 prisons within a single mid-Atlantic state prison system (12 facilities for men and one for women). A total of 7,528 inmates completed the survey instrument, which was administered by audio-computer-assisted technology. Of the 6,964 male respondents, 58.5% were African American, 16.2% were non-Hispanic white, 19.8% were Hispanic, and 5.5% were of another race or ethnicity. Of the 564 female respondents, 48.4% were African American, 30.9% were non-Hispanic white, 14.4% were Hispanic, and 7.3% were of another race or ethnicity. Mental disorder was based on self-reported previous mental health treatment for particular mental disorders. Sexual victimization was measured by using questions adapted from the National Violence Against Women and Men surveys.

RESULTS

Approximately one in 12 male inmates with a mental disorder reported at least one incident of sexual victimization by another inmate over a six-month period, compared with one in 33 male inmates without a mental disorder. Among those with a mental disorder, sexual victimization was three times as high among female inmates (23.4%) as among male inmates (8.3%). African-American and Hispanic inmates with a mental disorder, independent of gender, reported higher rates of sexual victimization than their non-Hispanic white counterparts.

CONCLUSIONS

Prisons are hazardous places. Steps must be taken to protect inmates from predators inside prison, to screen them for posttraumatic stress disorder, to provide trauma-related treatment, and to keep them safe.

Risky behavior regarding drug use and HIV infection: an Internet questionnaire coupled with short education texts for Portuguese speakers

Surveys of risky behavior relating to HIV/AIDS are generally made for groups at risk of infection, for which HIV/AIDS prevalence is usually expected to be higher than in the general population. Therefore, an educational homepage in Portuguese was created on the Internet to inform/ask internauts regarding knowledge and behavior. The internauts were classified as adolescents (13 to 25 years) and adults (>25 years). The number of STDs was reported as 1. 8 ± 2. 6 infections (range: 1 to 20 infections); 43% used condoms during sexual intercourse. Alcohol consumption was reported by 63% and illicit drug use by 32% (marijuana 24% and inhalants 15%). Among the adolescents, 31% did not classified alcohol as a drug. The adults more frequently reported homosexuality, anal intercourse and STDs, although the adolescents also presented high rates of risky behavior. These results show the need to reach out to internauts through better control strategies. Different types of strategies must be encouraged, in order to reach people that use this means of communication and entertainment.

Rate of methadone use among Aboriginal opioid injection drug users

BACKGROUND

Previous studies have shown elevated rates of health-related harms among Aboriginal people who use injection drugs such as heroin. Methadone maintenance therapy is one of the most effective interventions to address the harms of heroin injection. We assessed the rate of methadone use in a cohort of opioid injection drug users in Vancouver and investigated whether methadone use was associated with Aboriginal ethnic background.

METHODS

Using data collected as part of the Vancouver Injection Drug Users Study (May 1996-November 2005), we evaluated whether Aboriginal ethnic background was associated with methadone use using generalized estimating equations and Cox regression analysis. We compared methadone use among Aboriginal and non-Aboriginal injection drug users at the time of enrollment and during the follow-up period, and we evaluated the time to first methadone use among people not using methadone at enrollment.

RESULTS

During the study period, 1603 injection drug users (435 Aboriginal, 1168 non-Aboriginal) were recruited. At enrollment, 54 (12.4%) Aboriginal participants used methadone compared with 247 (21.2%) non-Aboriginal participants (odds ratio [OR] 0.53, 95% confidence interval [CI] 0.38-0.73, p < 0.001). Among the 1351 (84.3%) participants who used heroin, Aboriginal people were less likely to use methadone throughout the follow-up period (adjusted OR 0.60, 95% CI 0.45-0.81, p < 0.001). Among people using heroin but who were not taking methadone at enrollment, Aboriginal ethnic background was associated with increased time to first methadone use (adjusted relative hazard 0.60, 95% CI 0.49-0.74, p < 0.001).

INTERPRETATION

Methadone use was lower among Aboriginal than among non-Aboriginal injection drug users. Culturally appropriate interventions with full participation of the affected community are required to address this disparity.

Association between condom use at sexual debut and subsequent sexual trajectories: a longitudinal study using biomarkers

OBJECTIVES

We compared subsequent sexual behaviors and risk of sexually transmitted infections among adolescents who did and did not use a condom at their sexual debut.

METHODS

We derived data from the National Longitudinal Study of Adolescent Health, which followed a sample of 4018 sexually active adolescents between 1994 and 2002. During waves I, II, and III of the study, data on sexual behavior were gathered, and at wave III urine specimens were collected to test for sexually transmitted infections.

RESULTS

Among interviewed adolescents, those who reported condom use at their debut were more likely than those who did not use condoms at their debut to report condom use at their most recent intercourse (on average 6.8 years after sexual debut), and they were only half as likely to test positive for chlamydia or gonorrhea (adjusted odds ratio=0.50; 95% confidence interval=0.26, 0.95). Reported lifetime numbers of sexual partners did not differ between the 2 groups.

CONCLUSIONS

Adolescents who use condoms at their sexual debut do not report more sexual partners, are more likely to engage in subsequent protective behaviors, and experience fewer sexually transmitted infections than do adolescents who do not use condoms at their sexual debut.

The relationship between lifetime abuse and suicidal ideation in a sample of injection drug users

This study examined the relationship between lifetime abuse and suicidal ideation in a sample of 245 injection drug users (IDUs) who attended the Baltimore Needle Exchange Program and received a referral for opiate agonist therapy. Data were obtained from baseline interviews and HIV antibody tests. The sample mean age was 42.2 (SD = 8.1 ); 77% were African American; 69% were male. Overall, 27% reported thoughts of suicide in the last six months, and lifetime emotional, physical and sexual abuse was reported by 17%, 12% and 10%, respectively. In bivariate analyses, recent suicidal ideation was associated with emotional (odds ratio [OR] = 3.2; p = 0.001), physical (OR = 2.5; p = 0.026), and sexual abuse (OR = 5.0; p < 0.001). In multiple logistic regression models controlling for HIV status and Center for Epidemiological Studies Depression (CES-D) score, individuals who experienced emotional abuse were more than twice as likely to report recent suicidal ideation (adjusted odds ratio [AOR] = 2.6; p = 0.011); those who experienced sexual abuse were four times more likely to report suicidal ideation (AOR = 4.0; p = 0.004). These findings suggest that emotional and sexual abuse might be risk factors for suicidality among IDUs and also might suggest that suicide prevention should be an integral part of drug treatment for treatment-seeking IDUs.

Development and use of touch-screen audio computer-assisted self-interviewing in a study of American Indians

This article describes the development and usability of an audio computer-assisted self-interviewing (ACASI) questionnaire created to collect dietary, physical activity, medical history, and other lifestyle data in a population of American Indians. Study participants were part of a cohort of American Indians living in the southwestern United States. Data were collected between March 2004 and July 2005. Information for evaluating questionnaire usability and acceptability was collected from three different sources: baseline study data, auxiliary background data, and a short questionnaire administered to a subset of study participants. For the subset of participants, 39.6% reported not having used a computer in the past year. The ACASI questionnaires were well accepted: 96.0% of the subset of participants reported finding them enjoyable to use, 97.2% reported that they were easy to use, and 82.6% preferred them for future questionnaires. A lower educational level and infrequent computer use in the past year were predictors of having usability trouble. These results indicate that the ACASI questionnaire is both an acceptable and a preferable mode of data collection in this population.

Increasing use and associated harms of crystal methamphetamine injection in a Canadian setting

BACKGROUND

There is a growing concern surrounding crystal methamphetamine use in Canada despite surprisingly little empirical data to support such claims. We evaluated the trends in crystal methamphetamine injection and factors associated with injection of the drug among a cohort of injection drug users (IDU) in Vancouver.

METHODS

We conducted a prospective analysis of factors associated with crystal methamphetamine injection among participants enrolled in the Vancouver Injection Drug Users Study (VIDUS). Since serial measures for each individual were available, variables potentially associated with crystal methamphetamine injection were evaluated using generalized estimating equations (GEE) with logit link for binary outcomes.

RESULTS

Overall, 1587 IDU were enrolled into the VIDUS cohort between May 1996 and December 2004. The proportion of IDU who reported injecting crystal methamphetamine during the last 6 months increased during the study period (Cochran-Armitage trend test, p<0.001). In multivariate GEE analyses, crystal methamphetamine injection was independently associated with younger age (adjusted odds ratio [AOR]: 4.77, 95% confidence interval [CI]=3.40-6.70), Caucasian ethnicity (AOR=2.21, 95% CI=1.57-3.12), syringe borrowing (AOR=1.62, 95% CI=1.22-2.13), and syringe lending (AOR=1.40, 95% CI=1.02-1.86).

INTERPRETATION

There was a significant trend towards increasing crystal methamphetamine injection in this setting and elevated HIV risk behavior and younger age were independently associated with crystal methamphetamine injection. Given that banning precursor chemicals has had a limited effect on reducing methamphetamine supply in other jurisdictions, pragmatic and effective interventions are needed to address the growing use of this drug.

Trends in hepatitis B virus, hepatitis C virus, and human immunodeficiency virus prevalence, risk behaviors, and preventive measures among Seattle injection drug users aged 18-30 years, 1994-2004

Injection drug users (IDUs) are at risk for infection with hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Information on time trends in prevalence of these viruses among IDUs and in behaviors influencing their transmission can help define the status of these epidemics and of public health efforts to control them. We conducted a secondary data analysis combining cross-sectional data from IDUs aged 18-30 years enrolled in four Seattle-area studies from 1994 to 2004. Participants in all four studies were tested for antibody to HIV (anti-HIV), hepatitis B core antigen (anti-HBc), and HCV (anti-HCV), and completed behavioral risk assessments. Logistic regression was used to investigate trends in prevalence over time after controlling for sociodemographic, drug use, and sexual behavior variables. Between 1994 and 2004, anti-HBc prevalence declined from 43 to 15% (p < 0.001), anti-HCV prevalence fell from 68 to 32% (p < 0.001) and anti-HIV prevalence remained constant at 2-3%. Declines in anti-HBc and anti-HCV prevalence were observed within the individual studies, although not all these declines were statistically significant. The declines in anti-HBc and anti-HCV prevalence remained significant after control for confounding. Although we did not observe coincident declines in injection equipment sharing practices, there were increases in self-reported needle-exchange use, condom use, and hepatitis B vaccination. We conclude that there has been a substantial and sustained reduction in prevalence rates for HBV and HCV infection among young Seattle IDUs, while HIV rates have remained low and stable.

Prevalence and psychosocial factors associated with being bothered by nonavailability of sexual partners among Hong Kong Chinese: a population-based study

This study investigated the prevalence of being bothered by sexual-partner non availability (SPNA), associated risk factors, and associations with mental health and sexual satisfaction using a computer-assisted telephone survey. A random sample of 3257 and 1568 Chinese male and female respondents (aged 18-59) were interviewed. Sexual partner non-availability was highest in the male nonmarried/noncohabitating group, (18.6%) and the prevalence ranged from 1.4% to 7.9% for other age-sex subgroups. Younger age and male gender were associated with SPNA. Being bothered by SPNA was significantly associated with mental health and vitality quality of life, general life satisfaction, and sexual satisfaction (OR = 1.41 to 5.21).

The Feasibility of Computerized Patient Self-assessment at Mental Health Clinics

OBJECTIVES

Improving the quality of care for severe mental illness (SMI) has been difficult because patients' clinical information is not readily available. Audio computer-assisted self-interviewing (ACASI) supports data collection by asking patients waiting for appointments clinical questions visually and aurally. It has improved outcomes for many disorders. While reliable and accurate for SMI in research settings, this study assesses questions about ACASI's feasibility in usual care.

DESIGN

Patient and provider surveys and provider focus groups after 12 months of ACASI implementation.

SETTING

Two outpatient mental health clinics in Los Angeles, one run by the Department of Veterans Affairs and the other by Los Angeles County Department of Mental Health.

PARTICIPANTS

266 patients with SMI and 14 psychiatrists.

INTERVENTION

Patients completed an ACASI survey on symptoms, drug use, medication adherence and side-effects by internet using a touch-screen monitor. A 1-page report summarizing each patient's results was printed and given to providers by patients during appointments.

MAIN OUTCOME MEASURE

Feedback surveys (patients and psychiatrists) and focus groups and interviews (psychiatrists) assessed usability, usefulness, effects on treatment, and barriers to sustaining ACASI.

RESULTS

Patients believed the PAS was enjoyable, easy to learn and use, and that it improved communication with their psychiatrists. Providers believed the PAS was easy to use, had a small impact on care, could be improved by being more detailed and comprehensive, and requires outside support to continue its use.

CONCLUSIONS

ACASI was easy to use and enhanced communication. Systems like this can be a valuable part of quality improvement projects.

Self reported risk behaviour among injecting drug users: Self versus assisted questionnaire completion

The current study aimed to compare self-reported injecting and sexual risk behaviour among Needle and Syringe Program (NSP) attendees who self-completed a questionnaire to that of those who received assistance in completing the questionnaire. Information on demographic, injecting and sexual risk behaviour was collected via a self-completed questionnaire for an annual cross-sectional survey of injecting drug users (IDUs) recruited from sentinel NSPs around Australia. Assistance was provided when necessary and recorded. Of 2,035 participants, 1,452 (71%) reported completing the questionnaire without assistance. Being male and nominating a language other than English spoken at home was independently associated with receiving assistance with questionnaire completion. Participants who reported heroin as the drug last injected were also more likely to receive assistance. Multivariate analyses revealed those who received assistance with questionnaire completion were less likely to report re-using a syringe after someone else and less likely to report sex work in the past month. The current findings suggest self-completion of risk behaviour questionnaires should be considered as an alternative to interviewer administered questionnaires to maximise accuracy of self-reports.

The feasibility of audio computer-assisted self-interviewing in international settings

OBJECTIVE

To determine the feasibility of using audio computer-assisted self-interviewing (ACASI) for data collection in developing countries, and to compare responses to questions eliciting sensitive information about sexual behavior using ACASI versus computer-assisted personal interviewing (CAPI) in five developing countries.

DESIGN

A feasibility study determined whether ACASI could be used in populations in developing countries. A follow-up, randomized crossover study compared responses to questions eliciting sensitive information about sexual behavior using ACASI versus CAPI.

METHODS

The NIMH Collaborative HIV/STD Prevention Trial conducted a feasibility study of ACASI in convenience samples in China, India, Peru, and Russia, then a randomized crossover ACASI versus CAPI study among volunteers in these countries plus Zimbabwe.

RESULTS

Approximately equal numbers of men and women completed the feasibility study; the results suggested a high comfort level among participants. Married respondents in China and India appeared to give unreliable responses on sexual activity. In the crossover study, the pattern of responses to sensitive questions showed few differences. In China, higher rates of sexual risk were reported on CAPI. In Peru and Russia, differences by mode were found in the number of partners in the past year.

CONCLUSION

Despite variable computer experience and literacy, feasibility study participants reported ease in completing ACASI, and preferred a computer to an interviewer for answering sensitive questions, or had no preference. In the crossover study, most participants gave similar responses on both modes of survey administration. ACASI appears to be feasible in these settings, although low literacy may pose problems if participants cannot clarify questions.

Alcohol consumption, ART usage and high-risk sex among women infected with HIV

We examine the role of alcohol consumption on sexual risk behavior among a cohort of 187 sexually active HIV-infected women (aged 18-61) in care at an urban ambulatory clinic in New Orleans, Louisiana, U.S. Sexual risk behavior among women on and off antiretroviral therapy (ART) and the relationship between alcohol use, ART, and behavior was also explored. One-fourth of respondents were classified as binge drinkers and the average number of drinking occasions per week ranged from none to 10-12. Approximately 60% were prescribed ART and self-reported adherence was 90%. One-third of the women reported no condom use at last vaginal sex, 62% reported inconsistent condom use for vaginal sex, and 7% had multiple male sex partners in the last month. Binge alcohol users and women on ART were significantly more likely to participate in each sexual risk outcome examined. Partner refusal of condom use was also significantly associated with binge drinking patterns. Results lend strength to the equivocal literature on the relationship between both alcohol and prescription of ART and sexual behavior. Enhanced detection of alcohol abuse, coupled with risk reduction counseling especially among women prescribed ART are important clinical practices in treating women with HIV.

Changes in injecting practices associated with the use of a medically supervised safer injection facility

Injection drug users (IDUs) are vulnerable to serious health complications resulting from unsafe injection practices. We examined whether the use of a supervised safer injection facility (SIF) promoted change in injecting practices among a representative sample of 760 IDUs who use a SIF in Vancouver, Canada. Consistent SIF use was compared with inconsistent use on a number of self-reported changes in injecting practice variables. More consistent SIF use is associated with positive changes in injecting practices, including less reuse of syringes, use of sterile water, swabbing injection sites, cooking/filtering drugs, less rushed injections, safe syringe disposal and less public injecting.

Audio computer-assisted self-interviewing in reproductive health research: reliability assessment among women in Harare, Zimbabwe

PURPOSE

Research on the measurement of HIV risk demonstrates that interview mode can affect reporting; however, few studies have applied these findings to assessments of hormonal contraceptive use. This paper examines how audio computer-assisted self-interviewing (ACASI) influenced reports of hormonal contraceptive use and pregnancy among Zimbabwean women.

METHODS

Using a prospective, randomized, cross-over design, we compared self-reports obtained with ACASI and face-to-face (FTF) interview among 655 women enrolled in a prospective study on hormonal contraceptive use and HIV acquisition. In addition, self-report data were compared to those collected during clinical exams.

RESULTS

Compared to FTF interviews, reports of hormonal contraceptive use were lower in ACASI [odds ratio (OR)=0.6; 95% confidence interval (95% CI)=0.5-0.6], and reports of pregnancy were higher (OR=1.5; 95% CI=1.1-1.9). Both modes of self-report differed from records on contraceptive method disbursement.

CONCLUSION

Although ACASI yielded higher reports of several reproductive health behaviors, discrepancies between self-reports and clinical data on method disbursement highlight persistent measurement challenges.

Design and feasibility of a randomized behavioral intervention to reduce distributive injection risk and improve health-care access among hepatitis C virus positive injection drug users: the Study to Reduce Intravenous Exposures (STRIVE)

Hepatitis C virus (HCV) is hyperendemic among injection drug users (IDUs). However, few scientifically proven interventions to prevent secondary transmission of HCV from infected IDUs to others exist. This report describes the design, feasibility, and baseline characteristics of participants enrolled in the Study to Reduce Intravenous Exposure (STRIVE). STRIVE was a multisite, randomized-control trial to test a behavioral intervention developed to reduce distribution of used injection equipment (needles, cookers, cottons, and rinse water) and increase health-care utilization among antibody HCV (anti-HCV) positive IDUs. STRIVE enrolled anti-HCV positive IDU in Baltimore, New York City, and Seattle; participants completed behavioral assessments and venipuncture for HIV, HCV-RNA, and liver function tests (LFTs) and were randomized to attend either a six-session, small-group, peer-mentoring intervention workshop or a time-matched, attention-control condition. Follow-up visits were conducted at 3 and 6 months. At baseline, of the 630 HCV-positive IDUs enrolled (mean age of 26 years, 60% white, 76% male), 55% reported distributive needle sharing, whereas 74, 69, and 69% reported sharing cookers, cottons, and rinse water, respectively. Health-care access was low, with 41% reporting an emergency room as their main source of medical care. Among those enrolled, 66% (418/630) were randomized: 53% (222/418) and 47% (196/418) to the intervention and control conditions, respectively. Follow-up rates were 70 and 73% for the 3- and 6-month visits, respectively. As distributive sharing of used injection equipment was common while reports of receiving HCV care were low, these findings indicate an urgent need for HCV-related interventions with IDUs and demonstrate the acceptability and feasibility to do so.

A large specific deterrent effect of arrest for patronizing a prostitute

Background

Prior research suggests that arrest, compared with no police detection, of some types of offenders does not decrease the chances they will reoffend.

Methodology/Principal Findings

We assessed the specific deterrent effect of arrest for patronizing a street prostitute in Colorado Springs by comparing the incidence of arrest for clients of prostitutes first detected through public health surveillance with the incidence of rearrest for clients first detected by police arrest. Although these sets of clients were demographically and behaviorally similar, arrest reduced the likelihood of a subsequent arrest by approximately 70%. In other areas of the United States, arrest did not appear to displace a client's patronizing.

Conclusions/Significance

Our results suggest that apprehending clients decreases their patronizing behavior substantially.

HAART adherence strategies for methadone clients who are HIV-positive: a treatment manual for implementing contingency management and medication coaching

Research demonstrates that injection drug users with HIV and/or AIDS have difficulty adhering to complex regimens of HIV medications. Because of the risk of increased viral resistance associated with irregular medication adherence, there is considerable clinical need to assist clients who abuse substances in taking their antiretroviral medications on time and as directed. This article outlines intervention strategies to improve medication adherence among clients who are in methadone maintenance. In this treatment manual, the authors delineate contingency management procedures, including voucher incentives and a fishbowl lottery prize system. They also describe intervention elements and adherence tools for medication coaching. The purpose of this manual is to describe the intervention procedures for clinicians and to serve as a resource for drug abuse treatment programs that serve clients who are HIV-positive.

Prevalence and correlates of cervical cancer screening among injection drug users

OBJECTIVE

Access to cervical cancer screening may be lower among lower income and socially disadvantaged populations. However, few studies have specifically examined factors associated with cervical cancer screening among socially marginalized populations, especially in settings with free health care systems.

METHODS

The present study was conducted to examine the prevalence and correlates of cervical cancer screening among injection drug users. We examined rates of Papanicolaou (Pap) smear testing among female participants in the Vancouver Injection Drug Users Study (VIDUS). Univariate and logistic regression analyses were used to evaluate factors associated with cervical cancer screening.

RESULTS

During the period from December 2004 to May 2005, 297 female injection drug users were seen. In logistic regression analyses, age (adjusted odds ratio [AOR]=0.70; 95% confidence intervals [CI] 0.53, 0.92, P=0.010), HIV infection (AOR=2.46; 95% CI 1.41,4.26, P=0.001), hepatitis C infection (AOR=0.25; 95% CI 0.09,0.71, P=0.010), and having visited a family physician in the prior six months (OR=3.10; 95% CI 1.58, 6.07, P=0.001) were independently associated with recent cervical cancer screening.

CONCLUSIONS

After adjustment for regular physician visits, HIV infection was associated with elevated rates of cervical screening. This is reassuring, given the elevated risk of cervical cancer among this population. Interventions may be required to improve uptake of screening among older injection drug users and drug users infected with hepatitis C.

Multiperson Use of Syringes Among Injection Drug Users in a Needle Exchange Program

Syringe-sharing behaviors among injection drug users (IDUs) are typically based on self-reports and subject to socially desirable responding. We used 3 short tandem repeat (STR) genetic biomarkers to detect sharing in 2,512 syringes exchanged by 315 IDUs in the Baltimore needle exchange program (NEP; 738 person-visits). Demographic characteristics as well as direct and indirect needle-sharing behaviors corresponding to the closest AIDS Link to Intravenous Experience (ALIVE) study visits were examined for association with multiperson use (MPU) of syringes. Overall, 56% of the syringes exchanged at the Baltimore NEP had evidence of MPU. Less MPU of syringes (48% vs. 71%; P < 0.0001) was seen with more rapid syringe turnaround (<3 days). IDUs always exchanging their own syringes ("primary" syringes) were less likely to return syringes with evidence of MPU (52%) than those who exchanged syringes for others ("secondary" syringes; 64%; P = 0.0001) and those exchanging primary and secondary syringes (58%; P = 0.004). In a multivariate analysis restricted to primary exchangers, MPU of syringes was associated with sharing cotton (adjusted odds ratio [AOR] = 2.06, 95% confidence interval [CI]: 1.30 to 3.28), lending syringes (AOR = 1.70, 95% CI: 1.24 to 2.34), and injecting less than daily (AOR = 0.64, 95% CI: 0.43 to 0.95). These findings support additional public health interventions such as expanded syringe access to prevent HIV and other blood-borne infections. Testing of STRs represents a promising approach to examining and accessing complex behavioral data, including syringe sharing.

Sexual violence inside prisons: rates of victimization

People in prison are exposed to and experience sexual violence inside prisons, further exposing them to communicable diseases and trauma. The consequences of sexual violence follow the individual into the community upon release. This paper estimates the prevalence of sexual victimization within a state prison system. A total of 6,964 men and 564 women participated in a survey administered using audio-CASI. Weighted estimates of prevalence were constructed by gender and facility size. Rates of sexual victimization varied significantly by gender, age, perpetrator, question wording, and facility. Rates of inmate-on-inmate sexual victimization in the previous 6 months were highest for female inmates (212 per 1,000), more than four times higher than male rates (43 per 1,000). Abusive sexual conduct was more likely between inmates and between staff and inmates than nonconsensual sexual acts. Sexual violence inside prison is an urgent public health issue needing targeted interventions to prevent and ameliorate its health and social consequences, which spatially concentrate in poor inner-city areas where these individuals ultimately return.

Accuracy of audio computer-assisted self-interviewing (ACASI) and self-administered questionnaires for the assessment of sexual behavior

This study examined the accuracy of two retrospective methods and assessment intervals for recall of sexual behavior and assessed predictors of recall accuracy. Using a 2 [mode: audio-computer assisted self-interview (ACASI) vs. self-administered questionnaire (SAQ)] by 2 (frequency: monthly vs. quarterly) design, young women (N =102) were randomly assigned to one of four conditions. Participants completed baseline measures, monitored their behavior with a daily diary, and returned monthly (or quarterly) for assessments. A mixed pattern of accuracy between the four assessment methods was identified. Monthly assessments yielded more accurate recall for protected and unprotected vaginal sex but quarterly assessments yielded more accurate recall for unprotected oral sex. Mode differences were not strong, and hypothesized predictors of accuracy tended not to be associated with recall accuracy. Choice of assessment mode and frequency should be based upon the research question(s), population, resources, and context in which data collection will occur.

High HCV seroprevalence and HIV drug use risk behaviors among injection drug users in Pakistan

Introduction

HIV and HCV risk behaviors among injection drug users (IDUs) in two urban areas in Pakistan were identified.

Methods

From May to June 2003, 351 IDUs recruited in harm-reduction drop-in centers operated by a national non-governmental organization in Lahore (Punjab province) and Quetta (Balochistan province) completed an interviewer-administered survey and were tested for HIV and HCV. Multivariable logistic regression identified correlates of seropositivity, stratifying by site. All study participants provided written, informed consent.

Results

All but two were male; median age was 35 and <50% had any formal education. None were HIV-positive; HCV seroprevalence was 88%. HIV awareness was relatively high, but HCV awareness was low (19%). Injection behaviors and percutaneous exposures such as drawing blood into a syringe while injecting ('jerking'), longer duration of injection, and receiving a street barber shave were significantly associated with HCV seropositivity.

Discussion

Despite no HIV cases, overall HCV prevalence was very high, signaling the potential for a future HIV epidemic among IDUs across Pakistan. Programs to increase needle exchange, drug treatment and HIV and HCV awareness should be implemented immediately.

Stage of change behavioral assessment tool fails to predict the prevalence of chlamydia in an urban adolescent health clinic

STUDY OBJECTIVE

Strategies to reduce STI among adolescents and young adults have failed to consistently demonstrate effectiveness. A universal approach may not be appropriate because individuals are at different stages with respect to self-management behaviors. Thus, the Stage of Change Transtheoretical Model has been advocated. This study was conducted to determine whether staging could be accomplished in an urban adolescent clinic and whether it provides a tool to predict STI risk.

DESIGN

Participants were interviewed and staged according to a standardized instrument with respect to sexual risk behaviors and contraceptive use.

SETTING

Urban adolescent health clinic.

PARTICIPANTS

103 females (ages 18-24).

INTERVENTIONS

A physical examination and diagnostic tests for syphilis, HSV, HCV, chlamydia, gonorrhea and HPV were performed.

MAIN OUTCOME MEASURES

Stages for behaviors to reduce STI risk and to utilize contraception and STI prevalence.

RESULTS

78% of the participants were in the three earliest stages of behavior (precontemplative, contemplative, and ready for action) with respect to condom use for STI prevention; conversely only 47% were in early stages with respect to birth control practices. Of the participants tested, 12/81 (15%) had chlamydial infection detected by molecular techniques, whereas no participants had gonorrhoeae. Among the subset tested for HPV DNA, 18/45 (40%) were positive. The diagnostic behavior stage for STI prevention did not correlate with the presence of chlamydia.

CONCLUSIONS

A staging instrument can be implemented into adolescent health clinic practice, but cannot be used as a risk assessment tool for the presence of chlamydia. Additionally females are more likely to protect themselves against pregnancy than against an STI.

Childhood sexual abuse and sexual risk behavior among men and women attending a sexually transmitted disease clinic

Childhood sexual abuse (CSA) is associated with a wide range of negative outcomes. The authors investigated the relation between CSA and sexual risk behavior in 827 patients recruited from a sexually transmitted disease (STD) clinic. Overall, CSA was reported by 53% of women and 49% of men and was associated with greater sexual risk behavior, including more sexual partners, unprotected sex, and sex trading. Alcohol use for men and drug use for women mediated the relation between CSA and the number of sexual partners in the past 3 months; intimate partner violence mediated the relation between CSA and the number of episodes of unprotected sex in the past 3 months for women. These results document the prevalence of CSA among patients seeking care for an STD and can be used to tailor sexual risk reduction programs for individuals who were sexually abused.