Trends of HIV risk behaviors in a cohort of injecting drug users and their sex partners in Miami, Florida, 1988-1998

Health outcomes associated with crack-cocaine use: Systematic review and meta-analyses

BACKGROUND

Crack-cocaine use is prevalent largely in socio-economically marginalized populations in the Americas. Its use has been associated with diverse health outcomes, yet no recent or systematic reviews of these exist.

METHODS

A systematic review of health outcomes associated with crack-cocaine use was performed, using MEDLINE, Scopus, Web of Science, CINAHL, PsycINFO, and LILACS up to October 2016. Search terms included crack-cocaine and health outcome-related keywords, targeting peer-reviewed studies on quantified health outcomes associated with crack-cocaine use. Random effects meta-analyses produced pooled odds ratios. Levels of evidence for major results were assessed using the GRADE approach. A review protocol was registered with PROSPERO (CRD42016035486).

RESULTS

Of 4700 articles returned, 302 met eligibility criteria, reporting on health outcomes for 14 of 22 ICD-10 chapters. Conclusive evidence and meta-analyses showed positive associations between crack-cocaine use and blood/sexually transmitted diseases (HIV and hepatitis C virus, others); moderate evidence and meta-analyses supported associations with neonatal health, and violence. There were mixed associations for mental and other health outcomes, yet insufficient evidence to perform meta-analyses for many categories (e.g., mortality). Most underlying research was of limited or poor quality, with crack-cocaine commonly assessed as a secondary covariate.

CONCLUSIONS

Crack-cocaine use was associated with a range of health outcomes, although it was unclear if there was direct causal impact, interactions between risk factors, or external drivers of both crack-cocaine use and outcomes. Rigorous epidemiological studies are needed to systematically assess health outcomes of crack-cocaine use and underlying pathways, also to inform evidence-based interventions.

Sexual HIV/HSV-2 risk among drug users in New York City: an HIV testing and counseling intervention

Undiagnosed and untreated sexually transmitted infections are highly prevalent among users of heroin, crack, cocaine, and amphetamines. Between 2008 and 2009, 58 heroin, cocaine, and crack users in New York City who reported unprotected vaginal and anal sex with more than one partner in the past 30 days were enrolled in an HIV testing and counseling intervention. Four weeks post intervention, increases were found for condom use and STI knowledge. Reductions were noted for safe-sex risk fatigue, number of same-and opposite-sex partners, and days when drugs were injected. Brief but intense counseling interventions can reduce HIV risk among high-risk populations.

Change in HIV-HCV risk-taking behavior and seroprevalence among opiate users seeking treatment over an 11-year period and harm reduction policy

Our purpose was to assess change in HIV and HCV prevalence and risk-taking behaviors among IDUs over a period of time that included changes in French Public Health policy. Risk behavior and biological testing for serostatus were collected from cross-sectional samples of yearly new requests for opiate dependence treatment in Aquitaine, France between 1994 and 2004 (n = 648). Coincident declines in injection equipment sharing and HIV prevalence among injectors were observed, while sexual behavior remained stable. There was a decline in HCV prevalence that was not significant among injectors. After controlling for potential confounding variables, participants enrolled after 1995 were less likely to share injection material and those enrolled after 1999 were less likely to share spoons. Our findings give evidence for behavioral and seroprevalence changes among IDUs over a period of time that included changes in needle access policy.

Sexual risk behavior and sex under the influence: an event analysis of men in substance abuse treatment who have sex with women

The objective of this study was to determine if there is evidence for a causative link between sex under the influence of drugs or alcohol and risky sex for men in substance abuse treatment. Men in treatment participating in a multisite HIV prevention protocol who reported on baseline, 3, or 6 months computerized assessments the details of their most recent sexual events, and who reported having sexual events under the influence and not under the influence, and who reported most recent events that did and did not include condom use served as participants (n = 37). Safe sex was not significantly more likely to happen when participants were under the influence of drugs or alcohol during their most recent sexual event (48.3%) than when they were not under the influence (49%, p = .82). In this high-risk in treatment sample, a causative link between sex under the influence of drugs or alcohol and sexual risk behavior was not supported. 

The relative risk of HIV among IDUs not in treatment in Malaysia

Despite the growing HIV threat among injecting drug users (IDUs) in Malaysia, there is a dearth of information on their HIV risk behaviour. This study focused on identifying specific risk behaviours that distinguished HIV positive IDUs from those who were not. For the first time, data on IDUs not in treatment were obtained through a cross-sectional survey of 526 subjects recruited from five selected cities across peninsular Malaysia. A structured questionnaire and face-to-face interviews were utilised to collect detailed information on their drug use practices and sexual behaviours. On-site serological testing determined their HIV and hepatitis C status. The findings indicated that ethnic Malays, who are also Muslims, form the majority of IDUs not in treatment. Bivariate analysis identified six risk factors associated with HIV seropositivity: being 44 years or younger; not holding a regular job; initiating drug use at age 23 or younger; being a morphine user; sharing injecting equipment and having multiple-sex partners. However, only the last two remained significant in multivariate analysis. That sharing contaminated injecting equipment is a significant risk factor strongly justifies the widening of the pilot needle and syringe exchange programme initiated hesitantly in late 2005 as a reaction to the worsening HIV/AIDS situation. Condom use, though not independently significant, remains important because consistent and wider use could neutralise the second risk factor--having multiple-sex partners. The finding that injecting drug use is increasingly occurring in groups underscores the need for outreach programmes that emphasise safe injecting practices in group settings. In addition, counsellors should endeavour to convince drug users to enter treatment since being in treatment appears to reduce risk behaviours. Finally, conservative Muslim unease about harm reduction must be assuaged quickly since Malay Muslims form the majority of IDUs not in treatment.

Effects of drug use on sexual risk behavior: results of an HIV outreach and education program

We evaluated the effects on drug use and sexual risk of an HIV intervention for out-of-treatment drug users, and assessed the effect of drug use on unprotected sex with main and non-main partners. The intervention significantly reduced unprotected sex with a main partner, but did not affect drug use or unprotected sex with non-main partners. Participants who stopped using drugs by follow-up were less likely to have unprotected sex with both main and other partners.

Changes in transmission risk behaviors across stages of HIV disease among people living with HIV

Advances in treatments for HIV infection and related opportunistic illnesses have significantly extended the life expectancy of people living with HIV. A review of the literature on HIV transmission risks among HIV-infected individuals shows patterns of risk behavior that vary according to HIV disease stage. Studies confirm that the period immediately preceding HIV infection is characterized by high rates of risk behaviors, indicating the potential for rapid spread of HIV during acute infection. Reductions in risk behavior are often seen immediately following an HIV diagnosis. However, these behavioral changes are not universal, and an individual's state of health is an important factor relating to transmission risks. Chronic periods of asymptomatic HIV infection are generally associated with some degree of reverting to risky behaviors. CD4 cell counts below 200 cells/mm(3), resulting in a formal diagnosis of AIDS, are associated with decreased sexual and drug-related risk behaviors. HIV risk reduction interventions for HIV-infected persons, therefore, require tailoring to address the health and psychological challenges individuals face as they progress through stages of HIV disease. Additional research on both risk behaviors of long-term HIV-infected persons and longitudinal data on risk behaviors is needed.

Needle exchange and sexual risk behaviors among a cohort of injection drug users in Chicago, Illinois

OBJECTIVE

To examine the impact of a needle exchange program (NEP) on sexual risk behaviors of injecting drug users (IDUs).

METHODS

: Between 1997 and 2000, 889 IDUs in Chicago were recruited from NEPs and an area with no NEP into a cohort study. They were interviewed and tested for HIV at baseline and 3 annual follow-up visits. Random-effect logistic models were used to compare NEP users and nonusers regarding the number of sex partners, number of unprotected sex acts, and frequency of condom use.

RESULTS

Compared to NEP nonusers, NEP users had a similar number of sex partners over time, but had 49% higher odds of using condoms with their main partners (P = 0.047). At baseline, there was no difference between NEP users and nonusers in episodes of vaginal intercourse, but over time the odds of having a higher number of unprotected instances of vaginal intercourse were reduced by 26% per year for NEP users but only 10% per year for nonusers (P = 0.02).

CONCLUSION

This study suggests that NEP participation may help reduce the absolute risk of HIV sexual transmission.

Quality of life, symptomatology and healthcare utilization in HIV/HCV co-infected drug users in Miami

HIV/HCV co-infection is becoming one of the main causes of death in HIV+ persons. We determined quality of life, clinical symptoms and health care utilization in HIV mono-infected and HIV/HCV co-infected chronic drug users. After consenting 218 HIV+ drug users, a physical examination and questionnaires on demographics, quality of life, drugs of abuse, and healthcare utilization were completed. Blood was drawn for HCV status, CD4 cell count, HIV viral load, CBC and chemistry. HIV/HCV co-infected participants had significantly higher risk of having poorer perceived outlook and health, presented significantly more frequent depression and physical symptoms, and used significantly more healthcare services than those infected with HIV only, after adjusting for age, gender, ethnicity, CD4 cell count, and viral load. Diminished quality of life in the HIV/HCV co-infected group was explained by increased frequency of depression, physical symptoms, healthcare utilization, and poor access to HCV treatment in this population.

Poverty, unstable housing, and HIV infection among women living in the United States

Women who are HIV positive incur a higher risk of mortality than men who are HIV positive, a difference which is primarily based in the social context of poverty. Economic crises that lead to homelessness, unmet subsistence needs, and sex exchange often reorder priorities among women with HIV infection, de-emphasizing consistent medical care or the use of antiretroviral therapy. High rates of mental illness, drug use, and victimization further increase health and safety risks. HIV prevention messages highlighting education and behavior change insufficiently address the predicament of indigent women where constrained survival choices in the context of poverty may take precedence over safe behaviors. In this article, we highlight the risks of poor and unstably housed women to clarify the context in which risks occur. Suggestions for service provision are offered with the understanding that providers may have limited time and expertise to meet the entire array of needs for impoverished women.

HIV risk reduction in a nurse case-managed TB and HIV intervention among homeless adults

This study evaluated a six-month nurse case-managed intervention against a standard care control program among 295 sheltered homeless adults from Los Angeles, USA. The primary aim of the intervention was encouraging latent tuberculosis infection treatment completion. The secondary aim was reducing HIV risk, the focus of this report. A longitudinal path model revealed that the intervention impacted cognitive factors of AIDS Knowledge, Perceived AIDS Risk and Self-efficacy for Condom Use, but did not impact substance use and risky sexual behaviors. The dual intervention program for HIV and TB provided promising synergistic effects by targeting risk factors common to both infections.

The HIV transmission gradient: relationship patterns of protection

We describe a gradient of potential HIV transmission from HIV-infected persons to their partners and thence to uninfected populations. The effect of this newly discovered transmission gradient is to limit the spread of HIV. We roughly estimate a 2% long-term transmission probability for sex and 14% for drug injection for two-step transmission. Then we test theories to account for this pattern on a network sample of 267 inner city drug users and nonusers. Although HIV positive persons engaged in a high level of risk with one another, they engaged in less risk with HIV negative partners, and these partners engaged in even lower levels of risk with other HIV negative persons. Analyses suggest that the primary motivation for sexual risk reduction is partner protection, while emotional closeness is the major barrier. Hypotheses accounting for risk in terms of self protection, social norms, gender power, and drug use were weakly supported or unsupported.

Perceived risk, peer influences, and injection partner type predict receptive syringe sharing among young adult injection drug users in five U.S. cities

OBJECTIVES

This study examined risk factors for receptive syringe sharing (RSS) during illicit drug injection by persons 15-30 years old in five U.S. cities.

METHODS

Participants were recruited through street outreach and respondent-driven referrals in Baltimore, Chicago, Los Angeles, New York, and Seattle between May 2002 and January 2004. Surveys of drug use, sexual behaviors, and correlates were administered through audio computer-assisted self-interviews at baseline and, for the subset of participants who enrolled in an HIV/HCV prevention intervention trial, at 3-months and 6-months post-baseline. The proportions of injections involving RSS at baseline and at follow-up were used as outcomes in multivariate models that adjusted for intervention effects.

RESULTS

At baseline, 54% of 3128 participants reported RSS in the past 3 months. RSS decreased to 21% at 6-months post-baseline for the combined trial arms. Participants were more likely to report RSS if they perceived that their peers were not against RSS and if they injected with sex partners. Lower levels of perceived risk of infection with HIV (baseline, p<.001) or HCV (follow-up, p<.001) through RSS were also significant predictors of greater RSS.

CONCLUSIONS

Perceived risks, peer influences, and type of injection partner were robust predictors of RSS. Perceived risks and peer influences are particularly amenable to intervention efforts that may prevent RSS in this age group.

Behavioral surveillance among people at risk for HIV infection in the U.S.: the National HIV Behavioral Surveillance System

The Centers for Disease Control and Prevention, in collaboration with 25 state and local health departments, began the National HIV Behavioral Surveillance System (NHBS) in 2003. The system focuses on people at risk for HIV infection and surveys the three populations at highest risk for HIV in the United States: men who have sex with men, injecting drug users, and high-risk heterosexuals. The project collects information from these three populations during rotating 12-month cycles. Methods for recruiting participants vary for each at-risk population, but NHBS uses a standardized protocol and core questionnaire for each cycle. Participating health departments tailor their questionnaire to collect information about specific prevention programs offered in their geographic area and to address local data needs. Data collected from NHBS will be used to describe trends in key behavioral risk indicators and evaluate current HIV prevention programs. This information in turn can be used to identify gaps in prevention services and target new prevention activities with the goal of reducing new HIV infections in the United States.

Correlates of condom use and reasons for condom non-use among drug users

Two hundred and seventy-seven drug using adults were interviewed regarding details of their most recent sexual encounter. Demographic, attitudinal, and context variables were associated with condom use and non-use. Greater perceived risk of STDs/HIV and positive attitudes toward condoms' effect on sexual pleasure were associated with greater likelihood of reporting condom use. Common reasons for not using condoms included lower perceived risk of contracting HIV/STDs, negative attitudes toward condoms' effect on pleasure, and lack of condom availability. Tailoring messages to modifiable perceptions of risk and condom attitudes may be useful in reducing sexual risk among drug-using individuals.

Crack users, sexual behavior and risk of HIV infection

OBJECTIVE: To compare a sample of injecting cocaine users and crack users, assessing sexual behavior, risk for infection by HIV and its seroprevalence. METHOD: 109 injecting cocaine users and 132 crack users were assessed, using the World Health Organization questionnaire from the expanded "Cross-Site Study of Behaviors and HIV Seroprevalence among Injecting Drug Users" and HIV serology. Data were assessed by Multiple Correspondences Analysis. RESULTS: Crack users showed less time of drug consumption when compared to the injecting cocaine users. Despite this fact, they had higher rates of risky sexual activity, differences in poli-consumption of drugs, and higher rates of involvement in illegal issues. HIV seroprevalence among crack users, although lower than for injecting cocaine users (7% vs. 33%) is high when compared to the general population at the same age. CONCLUSIONS: Sexual behavior of crack users in the studied sample may be considered a risk factor for HIV infection. Crack users have access to information on HIV/ AIDS, but do not make use of it to change risk behaviors that may expose them to HIV infection and dissemination. HIV seroprevalence among crack users (7%) is concerning, which makes it necessary to create preventive strategies for HIV infection and dissemination that are specifically directed toward this population.

Profile of male Brazilian injecting drug users who have sex with men

This study aims to characterize the profile of male injecting drug users who have sex with other men (MSM IDUs) recruited through a cross-sectional multi-city survey (AjUDE-Brasil II Project) in six Brazilian cities, in 2000-2001. MSM IDUs were compared to other male IDUs using bivariate and multivariate procedures (logistic regression and answer tree analysis with the CHAID algorithm). Among the 709 male IDUs, 187 (26.4%) reported ever having had sex with other men, while only 37 reported sex with other men in the previous six months. MSM IDUs were more likely to be unemployed (OR = 2.3), to have injected tranquilizers (OR = 3.6), and to be HIV-seropositive (OR = 2.1), compared to other male IDUs. Male same-sex relations in this subgroup appear to be associated with strategies to finance drug consuming habits, including sex for drugs with occasional female partners or obtaining injection paraphernalia from occasional sex partners. Further studies should focus on this especially vulnerable subgroup of IDUs, due to the bidirectional and complex interrelationships between their drug injecting habits and sexual risk behaviors.