Intersecting epidemics--crack cocaine use and HIV infection among inner-city young adults. Multicenter Crack Cocaine and HIV Infection Study Team

Identifying early intervention opportunities for illicit stimulant use: A cross-sectional study of factors associated with illicit stimulant use among young people accessing integrated youth services in British Columbia, Canada

INTRODUCTION

Illicit stimulant (cocaine and/or amphetamine) use among young people aged 12-24 is a public health priority given that substance use initiation tends to peak in this developmental period and significant associated immediate and long-term harms are associated with its use. Young people using stimulants must be engaged in services as early as possible to reduce these harms. To inform early intervention opportunities, this study aimed to identify the risk/protective factors associated with illicit stimulant use among young people.

METHODS

We conducted a cross-sectional study on routinely collected self-reported data among young people accessing integrated youth services in British Columbia (Canada) between April 2018 and January 2022. Data were collected on young peoples' socio-demographic characteristics, and social, behavioral, and health profiles. Variable selection was guided by established risk/protective factors for substance use among young people. The study used multivariable logistic regression to identify risk/protective factors that were independently associated with past 30-day illicit stimulant use.

RESULTS

The analytic sample included n = 5620 young people aged 12-24 and a total of 163 (2.9 %) reported past 30-day illicit cocaine and/or amphetamine use. Demographic characteristics that were independently associated with illicit stimulant use included older age (aOR = 1.27, 95 % CI = 1.17-1.38) and gender identity as man vs woman (aOR = 1.71, 95 % CI = 1.10-2.70). Social and environmental risk factors included recently witnessing or experiencing violence (aOR = 2.32, 95 % CI = 1.47-3.68) and higher past-year crime/violent behaviors score (aOR = 1.39, 95 % CI = 1.13-1.69). Finally, regular alcohol (aOR = 6.90, 95 % CI = 2.36-25.42), regular (aOR = 3.74, 95 % CI = 1.95-7.54) or social (aOR = 3.06, 95 % CI = 1.44-6.60) tobacco use, and lifetime hallucinogen (aOR = 3.24, 95 % CI = 1.8-5.91) and ecstasy/MDMA (aOR = 2.53, 95 % CI = 1.48-4.39) use were also statistically significant risk factors.

CONCLUSIONS

These risk/protective factors support identification of young people who may benefit from further screening, assessment, and treatment for illicit stimulant use. This study also underscores the need to expand early intervention and harm reduction programs that can comprehensively respond to young peoples' stimulant use, health, and social needs.

Methamphetamine administration dose effects on sexual desire, sexual decision making, and delay discounting

Correlational evidence has linked methamphetamine use and HIV sexual risk behavior, but the direct effects of methamphetamine on sexual desire and sexual decision making in humans have not been tested. This study was designed to test the effect of methamphetamine administration on sexual desire and hypothetical condom-use decisions as measured by the Sexual Delay Discounting Task. Recreational stimulant users (n = 19) participated in this within-subject, placebo-controlled study comparing the effects of 0 mg, 20 mg, and 40 mg of oral methamphetamine. Compared to placebo, methamphetamine caused dose-related and time-related increases in a single-item sexual desire rating and some standard stimulant abuse liability ratings, as well as dose-related increases in the Sexual Arousal and Desire Inventory (SADI; a multidimensional scale capturing positive and negative aspects of desire/arousal). However, methamphetamine caused no significant mean differences in likelihood of condom use within the Sexual Delay Discounting Task or the Monetary Discounting Task. SADI scores were negatively correlated with change from placebo in condom use likelihood in the Sexual Delay Discounting Task for some partner conditions (i.e., decreased reported likelihood of condom use in participants who experienced increased desire/arousal and vice versa). These mixed results may be consistent with methamphetamine's role as both a treatment for attention-deficit/hyperactivity disorder and as a drug of abuse associated with increased delay discounting, and they suggest that methamphetamine's effects on discounting may be modulated by the reinforcing properties of what is being discounted. Delay discounting may be an understudied element of risky sexual decision making, particularly among individuals who use methamphetamine. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Daily and near-daily cannabis use is associated with HIV viral load suppression in people living with HIV who use cocaine

Disparities remain in HIV viral load (VL) suppression between people living with HIV (PLWH) who use cocaine and those who do not. It is not known how cannabis use affects VL suppression in PLWH who use cocaine. We evaluated the relationship between cannabis use and VL suppression among PLWH who use cocaine. We conducted a secondary data analysis of 119 baseline interviews from a randomized controlled trial in the Bronx, NY (6/2012 to 1/2017). Participants were adult PLWH prescribed antiretrovirals for ≥16 weeks, who endorsed imperfect antiretroviral adherence and used cocaine in the past 30-days. In bivariate and multivariable regression analyses, we examined how cannabis use, is associated with VL suppression among PLWH who use cocaine. Participants were a mean age of 50 years; most were male (64%) and non-Hispanic black (55%). Participants with VL suppression used cocaine less frequently than those with no VL suppression (p < 0.01); cannabis use was not significantly different. In regression analysis, compared with no use, daily/near-daily cannabis use was associated with VL suppression (aOR = 4.2, 95% CI: 1.1-16.6, p < 0.05). Less-frequent cannabis use was not associated with VL suppression. Further investigation is needed to understand how cannabis use impacts HIV outcomes among PLWH who use cocaine.

Combining respondent-driven sampling with a community-based participatory action study of people who smoke drugs in two cities in British Columbia, Canada

Background

The smoking of illicit drugs presents a serious social and economic burden in Canada. People who smoke drugs (PWSD) are at increased risk of contracting multiple infections through risky drug practices. Peer-led harm reduction activities, and the resulting social networks that form around them, can potentially minimize the dangers associated with the smoking illicit drugs.

Goal

The goals of this study were to pilot test the combined approaches of respondent driven sampling with community based participatory action research in these settings and compare the attributes and social networks of PWSD in two British Columbia cities with different harm reduction programs.

Methods

Using community-based participatory action research (CBPAR) and respondent-driven sampling (RDS), individuals with lived drug experiences were employed from communities in Abbotsford and Vancouver as peer researchers to interview ten contacts from their social networks. Contacts completed a questionnaire about their harm reduction behaviours and interactions.

Results

We found that PWSD residing in Abbotsford were more likely to report engaging in harm-promoting behaviours, such as sharing, reusing, or borrowing crack pipes. However, PWSD in the Downtown East side Community of Vancouver were more likely to report engaging in harm-reducing activities, such as being trained in naloxone use and CPR. We found no differences in network sizes between the two communities, despite the population differences and harm reduction programs

Conclusion

The high participation rates and interactions between researchers, and peer researchers enriched the study implementation and successfully informed our results. The fact that there were no differences in network size suggests that people have similar support in Vancouver as in Abbotsford, and that drug use practices differ mainly due to availability of harm reduction programming and resources.

The Urgent Need to Respond to HIV- and HCV-Related Risk Practices among Youth in Ottawa Who Smoke Crack

A community-based research project, Project Rock sought to provide evidence to respond to the community-identified need to more fully understand the parameters of the social and risk profiles of youth in Ottawa who smoked crack. Objectives: In this article we examine engagement in HIV and HCV risk-related smoking practices, and experiences accessing safer inhalation supplies with the objective of identifying potential intervention points and associated harm reduction interventions to initiate and support safer inhalation practices. Methods: The study comprised four sequential components - formation and facilitation of a Youth Project team, qualitative interviews, and member checking workshops - each component building on the preceding and all contributing to the final and fourth component of the interviewer-administered quantitative survey from which data for this article are drawn. Eligibility criteria: capable of informed consent; aged between 16 and 25 years; had ever injected drugs or had ever tried crack or had used two or more hard drugs in the three months preceding their interview. Recruitment cards distributed by community agencies, honoraria and debriefing offered. Separate consent obtained for collection of finger prick blood samples for HIV and HCV laboratory testing. Results: 125 young people completed personal interviews in November 2013. This article is restricted to those 97 participants who had smoked crack. High rates of engagement in documented HIV- and HCV-related crack smoking practices were reported including nonuse of mouthpieces, use of non-recommended smoking devices and frequent engagement in equipment sharing; engagement compounded by the heightened confirmed prevalence of HCV. Conclusion: The youth in our study explained the utility of crack in their lives. Given the mental health drivers of engagement, ease of accessibility and availability, engagement in smoking crack is clearly likely to continue, firmly indicating the urgent necessity to ensure its safer use through gender neutral, youth-specific enhanced programming and resource distribution.

Survival Sex Trading in Los Angeles County, California, USA

Most studies on survival sex, defined as sex trading for money, drugs, or other needs, have limited their focus to adolescents. The current study reports about the relationships between survival sex trading (SST) and high-risk behaviors in a sample of adults. Bivariate analysis shows that HIV-positive status, use of cocaine, ketamine, methamphetamine, heroin, having received drug treatment, and having received medical services are associated with SST. SST are more likely to not use condoms with partners other than their main partner, to have partners who inject drugs and are more likely to use drugs with sex. A logistic regression model included unwanted sexual touching, partner abuse, identifying as bisexual, African American, higher age, gender (women more likely), homelessness, a higher number of sexual partners, having anal sex, injection drug use, HIV seropositivity, crack use, and the likelihood of injecting drugs. The model was retested on independently collected Risk Behavior Assessment (RBA) data and showed significant relationships between survival sex and crack use, gender (women more likely), HIV positivity, identifying as bisexual, having anal sex, African American, and a higher number of sex partners. These findings make it imperative to integrate victimization counseling and HIV education into substance abuse treatment programs.

Discrimination and sexual risk among Caribbean Latinx young adults

Objectives: Discrimination, such as being treated unfairly due to race, contributes to stress. Individuals may cope with this by engaging in risky behaviors. Consistent with this premise, prior studies found that discrimination is associated with substance use. Research has also shown that sex while 'high' on alcohol and drugs is associated with increased risk for HIV and other STIs. The present study examines the relationship between discrimination and sexual risk. We investigate whether discrimination is associated with sex while high on alcohol and drugs. Design: Analyses focus on a sample of 356 Caribbean Diasporic young adults, primarily Caribbean Latinx, aged 18 to 25 who participated in the Drug Use and HIV Risk among Youth Survey carried out from 1997 to 2000 in Brooklyn, New York. Logistic regression examined the association between self-reported discrimination and sex while high. Results: More than half (52.3%) of respondents reported moderate discrimination. Sex while high was also reported: 35.7% for alcohol, 43.3% for marijuana, and 32.6% for heroin/cocaine. Discrimination was associated with increased risk of sex while high on (1) marijuana and (2) heroin/cocaine, but was not with alcohol. Conclusions: Discrimination may be a risk factor for engaging in sex while high on drugs, which may put individuals at risk for HIV as well as other STIs. Future research should explore relationships between discrimination and sex while high on alcohol and drugs among various racial/ethnic groups and Diasporas, while also assessing how this relationship may contribute to HIV incidence.

Baseline prevalence and correlates of HIV and HCV infection among people who inject drugs accessing a syringe services program; Miami, FL

Background

Blood-borne viral infections, such as HIV and hepatitis C (HCV), are common infections among people who inject drugs (PWID). This study aims to determine the prevalence of HIV and HCV infection among PWID accessing the first legal syringe services program (SSP) in the state of Florida, along with examining baseline correlates of HIV and HCV infection.

Methods

Baseline behavioral enrollment assessments of 837 participants accessing an SSP for the first time were analyzed. Patients self-reporting or testing HIV or HCV positive at the enrollment visit were included. Socio-demographic, drug use, and injection-related risk behaviors in the last 30 days were compared across groups defined by all combinations of HIV and HCV serostatus.

Bivariate and multivariable logistic regression models were used to assess correlates of baseline HCV and HIV infection independently.

Results

Overall prevalence for HCV and HIV infection were 44.4% and 10.2%, respectively. After adjusting for confounders, the most significant correlates of baseline HCV infection were age (aOR = 1.01), lower education level (aOR = 1.13), currently homeless (aOR = 1.16), injecting more than seven times a day (aOR = 1.14), reusing syringes (aOR = 1.18), and sharing injection equipment (aOR = 1.13). The most significant predictors of baseline HIV infection were age (aOR = 1.01), non-Hispanic Black race (aOR = 1.28), Hispanic ethnicity (aOR = 1.12), gay or bisexual orientation (aOR = 1.22), and methamphetamine injection (aOR = 1.22). In addition, heroin injection (aOR = 0.92) was significantly associated with a lower odds of HIV infection.

Discussion/conclusion

Baseline behavioral predictors differed between HIV infection and HCV infection among participants accessing syringe services. Understanding the risk factors associated with each infection should be considered when developing additional harm reduction interventions tailored for diverse PWID populations served at SSPs.

Clinic-Based Delivery of the Young Men's Health Project (YMHP) Targeting HIV Risk Reduction and Substance Use Among Young Men Who Have Sex with Men: Protocol for a Type 2, Hybrid Implementation-Effectiveness Trial

BACKGROUND

Young men who have sex with men (YMSM) are disproportionately at risk for HIV and sexually transmitted infections. Adapting and testing the effectiveness of the Young Men's Health Project (YMHP), an efficacious intervention designed to reduce substance use and condomless anal sex (CAS) among YMSM, at clinics in Miami, Detroit, and Philadelphia has the potential to reduce HIV and STI disparities among urban YMSM.

OBJECTIVE

This study (Adolescent Medicine Trials Network for HIV/AIDS Interventions [ATN] 145 YMHP) aims to adapt YMHP for clinic and remote delivery by existing clinic staff and compare their effectiveness in real-world adolescent HIV clinics. This protocol is part of the ATN Scale It Up program described in a recently published article by Naar et al.

METHODS

This is a comparative effectiveness hybrid type-2 trial of the YMHP intervention with 2 delivery formats-clinic-based versus remote delivery-offered following HIV counseling and testing. Phase 1 includes conducting focus groups with youth to obtain implementation feedback about the delivery of the YMHP intervention and intervention components to ensure culturally competent, feasible, and scalable implementation. Phase 2 includes recruitment and enrollment of 270 YMSM, aged 15 to 24 years, 90 at each of the 3 sites. Enrollment will be limited to HIV-negative YMSM who report recent substance use and either CAS or a positive STI test result. Participants will be randomized to receive the YMHP intervention either in person or by remote delivery. Both conditions involve completion of the 4 YMHP sessions and the delivery of pre-exposure prophylaxis information and navigation services. A minimum of 2 community health workers (CHWs) will be trained to deliver the intervention sessions at each site. Sessions will be audio-recorded for Motivational Interviewing Treatment Integrity (MITI) fidelity coding, and CHWs and supervisors will be given implementation support throughout the study period.

RESULTS

Phase 1 focus groups were completed in July 2017 (n=25). Feedback from these focus groups at the 3 sites informed adaptations to the YMHP intervention manual, implementation of the intervention, and recruitment plans for phase 2. Baseline enrollment for phase 2 began in November 2018, and assessments will be at immediate posttest (IP)-, 3-, 6-, 9-, and 12-months after the intervention. Upon collection of both baseline and follow-up data, we will compare the effectiveness and cost-effectiveness of clinic-based versus remote delivery of YMHP in the context of health care access.

CONCLUSIONS

We are conducting YMHP in 3 cities with high rates of YMSM at risk for HIV and STIs. When adapted for real-world clinics, this study will help substance-using YMSM at risk for HIV and STIs and allow us to examine differences in effectiveness and cost by the method of delivery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03488914; https://clinicaltrials.gov/ct2/show/NCT03488914 (Archived by WebCite at http://www.webcitation.org/770WaWWfi).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/11184.

The prevalence and patterns of substance use by birth cohort among HIV-positive adults in Florida

OBJECTIVES

Antiretroviral therapy is affording longer lifespans for people living with HIV (PLWH), yet factors such as substance use play an increasing role in morbidity and mortality in this population. Though previous studies have examined substance use differences between age cohorts of PLWH, no study has examined the influence of birth cohort on current substance use patterns. Thus, this study investigated the prevalence of past 12-month self-reported substance use between four birth cohorts, <1970 (M age = 54.1), 1970s (M age = 41.5), 1980s (M age = 31.3 years old), and 1990s (M age = 23.2 years old) of PLWH in Florida.

METHODS

PLWH (N = 934) recruited from community health clinics in Florida completed a questionnaire assessing sociodemographics, health status, and substance use. Multivariate logistic regressions utilizing the <1970 cohort as the referent group examined the relationship between birth cohort and substance use.

RESULTS

The 1980s cohort had significantly greater odds of marijuana use compared to the oldest cohort (<1970s), while the three younger cohorts (1970s, 1980s, and 1990s) evidenced a significantly greater odds of ecstasy use compared to the oldest group. Contrastingly, the three younger birth cohorts reported significantly less crack use than the oldest cohort, while the youngest group (1990s) also demonstrated an 80% reduction in injection drug use compared to the oldest group.

CONCLUSION

The older cohort evidenced significantly greater crack and injection drug use, while the younger cohorts evidenced greater marijuana and ecstasy use. Therefore, it is important to develop age-specific substance use interventions among PLWH.

America's Declining Well-Being, Health, and Life Expectancy: Not Just a White Problem

Although recent declines in life expectancy among non-Hispanic Whites, coined "deaths of despair," grabbed the headlines of most major media outlets, this is neither a recent problem nor is it confined to Whites. The decline in America's health has been described in the public health literature for decades and has long been hypothesized to be attributable to an array of worsening psychosocial problems that are not specific to Whites. To test some of the dominant hypotheses, we show how various measures of despair have been increasing in the United States since 1980 and how these trends relate to changes in health and longevity. We show that mortality increases among Whites caused by the opioid epidemic come on the heels of the crack and HIV syndemic among Blacks. Both occurred on top of already higher mortality rates among all Americans relative to people in other nations, and both occurred among declines in measures of well-being. We believe that the attention given to Whites is distracting researchers and policymakers from much more serious, longer-term structural problems that affect all Americans.

Exchange Sex Among Persons Who Inject Drugs in the New York Metropolitan Area: The Importance of Local Context, Gender and Sexual Identity

Exchanging sex for money or drugs is known to increase risk for HIV among persons who inject drugs (PWID). To better understand determinants of exchange sex among PWID we examined factors associated with exchange sex in the New York metropolitan area-defined as New York City (NYC), NY; Newark, NJ; and Long Island, NY-using data from the 2012 National HIV Behavioral Surveillance system cycle on injection drug use. Of the 1160 PWID in this analysis, 24% reported exchange sex, with differences in gender and sexual identity by location. In multivariable analysis gay/bisexual men, heterosexual women, and lesbian, gay, or bisexual (LGB) women were more likely to exchange sex compared to heterosexual men. Exchange sex was also associated with race/ethnicity, homelessness, incarceration, location, and non-injection crack and cocaine use. We find that heterosexual women and LGB women who injected drugs residing in Newark were more likely to report exchange sex compared to NYC. This study highlights how local conditions impact exchange sex.

HIV-1 infection among crack cocaine users in a region far from the epicenter of the HIV epidemic in Brazil: Prevalence and molecular characteristics

Brazil has the largest cocaine market in South America, and crack cocaine use is closely associated with HIV-1 infection. This study investigated the prevalence, risk factors, and HIV-1 subtypes, including recombinant forms and mutations associated with drug resistance, among crack cocaine users in Central-West Brazil. We recruited 600 crack cocaine users admitted to a referral hospital in Goiânia for psychiatric disorders. The participants were interviewed; blood samples were collected for anti-HIV-1/2 serological screening. HIV-1 pol gene sequences (entire protease [PR] and partial reverse transcriptase [RT]) were obtained from plasma RNA. HIV-1 subtypes, recombinant viruses, transmitted drug resistance (TDR), and secondary drug resistance mutations were investigated. The median participant age was 30 years (range, 18-68 years); most were male, single, unemployed, and of mixed races. Among them, 2.8% (17/600) were HIV-1 positive: 2.2% of men (11/507) and 6.5% of women (6/93). The main predictors of HIV-1 seropositivity were a sexual partner with HIV infection, irregular condom use, and previous homelessness. HIV-1 pol sequences (12/17) indicated the predominance of subtype B (n = 7), followed by recombinant forms FPR/BRT (n = 1) and BPR/FRT (n = 2) and subtypes F1 (n = 1) and C (n = 1). TDR prevalence was 58.3% (7/12). Isolates from two participants showed mutations associated with resistance to nucleoside reverse transcriptase inhibitors (NRTI) only (M41L, T125C, T125F, M184V), while an isolate from one patient who had received antiretroviral therapy (ART) since 2008 had a mutation associated with resistance to non-NRTI (G190S). Five isolates had secondary mutations to protease inhibitors (K20M, L10V, L33I, A71T, A71V). In conclusion, the findings of HIV-1 circulation, TDR to NRTI, and secondary mutations to protease inhibitors in ART-naïve crack cocaine users support the importance of monitoring this population in regions far from the epicenter of the HIV epidemic.

Getting to Zero: We Can't Do It Without Addressing Substance Use

HIV elimination by 2030 cannot occur without attention to substance use. It cuts across risk groups and affects sexual risk behavior, treatment adherence, and systemic processes such as immunity and inflammation. There continues to be often limited attention to non-injection drug use and the syndemic character of HIV and substance use. There is a need for a more comprehensive approach that addresses the multiple influences of substance use on HIV prevention and care, integrating this into evidence-based services and building on the successes of comprehensive Seek, Test, Treat, and Retain approaches to substantially reducing new HIV cases among drug users.

History of Sex Exchange in Women with a History of Incarceration

Sex exchange among incarcerated women is not well-described in the literature. Sex exchange can lead to numerous adverse health outcomes, especially when combined with individual factors (e.g., depression and homelessness) and larger systemic inequalities. The purpose of this study was to explore factors associated with having a history of sex exchange among a sample of incarcerated women. Of 257 women surveyed in this study, 68 women (26.5%) reported a history of sex exchange. In multivariate logistic regression analysis, physical abuse history (p=.05, OR 2.20), history of two or more sexually transmitted infections (p=.01, OR 2.90), injection drug use (p=.04, OR 2.46) and crack-cocaine use (p&lt;.01, OR 3.42) were associated with prior sex exchange. This is one of only two studies to examine factors associated with prior sex exchange among incarcerated women. Our study has important implications for corrections providers to provide more comprehensive care, directly addressing the unique needs of this population.

Correlates of exchange sex among a population-based sample of low-income women who have heterosexual sex in Baltimore

Sex exchange is associated with HIV and other morbidities yet has received little research, surveillance, and programmatic attention in the U.S. This study identified correlates of exchange sex and among low-income women in Baltimore, Maryland. Participants were recruited into the National HIV Behavioral Surveillance (NHBS) system in 2013 using respondent driven sampling (RDS) and completed a survey and HIV testing. The analytic sample (n = 253) consisted of women aged ≥18 years who had recent (past year) heterosexual sex. Multivariable logistic regression identified correlates of recent exchange sex. Independently associated with recent exchange sex were history of injection drug use (adjusted odds ratio (AOR) = 3.4, 95% CI: 1.1-10.3), recent prescription painkiller use (AOR = 3.7, 95% CI: 1.4-9.9), recent crack/cocaine use (AOR = 6.6, 95% CI: 2.1-20.9), recent arrest (AOR = 4.1, 95% CI: 1.2-14.8), and recent consistent condom use (AOR 1.1; 95% CI: 1.0-1.3). Women who exchanged sex exhibited heightened social and structural vulnerability and substance use. These data demonstrate the need for further research examining the context of exchange sex among low-income women and synergies between substance use and HIV risk.

Substance Abuse and HIV/AIDS in the Caribbean

The Caribbean and Central America represent a formidable challenge for researchers and policy makers in the HIV field, due to their pronounced heterogeneity in terms of social, economic, and cultural contexts and the different courses the HIV epidemic has followed in the region. Such contrasting contexts and epidemics can be exemplified by 2 countries that share the island of Hispaniola, the French Creole-speaking Haiti, and the Spanish-speaking Dominican Republic. Haiti has experienced the worst epidemics outside of sub-Saharan Africa. Following a protracted economic and social crisis, recently aggravated by a devastating earthquake, the local HIV epidemic could experience resurgence. The region, strategically located on the way between coca-producing countries and the profitable North American markets, has been a transshipment area for years. Notwithstanding, the impact of such routes on local drug scenes has been very heterogeneous and dynamic, depending on a combination of local mores, drug enforcement activities, and the broad social and political context. Injecting drug use remains rare in the region, but local drug scenes are dynamic under the influence of increasing mobility of people and goods to and from North and South America, growing tourism and commerce, and prostitution. The multiple impacts of the recent economic and social crisis, as well as the influence of drug-trafficking routes across the Caribbean and other Latin American countries require a sustained effort to track changes in the HIV risk environment to inform sound drug policies and initiatives to minimize drug-related harms in the region.

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.

Reductions in HIV Diagnoses Among African American Women: A Search for Explanations

BACKGROUND

African American women experienced a 46% reduction in the rate of HIV diagnoses from 56.0 in 2008, to 30.0 in 2014 (per 100,000). The reasons for this decrease are unknown; however, we hypothesize that improvements in socioeconomic status, health care access, and risk behaviors may have contributed to this reduction.

METHODS

We analyzed data from 2006, 2010, and 2013 of the National HIV Behavioral Surveillance system. African American women living at or below poverty were surveyed from 19 United States cities using respondent-driven and venue-based sampling, and tested for HIV infection. We used generalized estimating equations to determine differences for selected outcomes regarding health care and risk behaviors over time.

RESULTS

Among 11,065 women, we found increases in the percentage of women who reported having a recent HIV test (P value = 0.0002); having health insurance (P < 0.0001); and recently visiting a health care provider (P < 0.0001). Being unemployed declined significantly (P = 0.0057), as did reporting recent injection drug use (P < 0.0001). Crack use declined among women aged 25-44 years (P < 0.0001). However, reporting condomless vaginal sex at last sex (P = 0.0268), condomless anal sex at last sex (P = 0.6462), or 3 or more sex partners in the past 12 months (P = 0.5449) remained stable.

DISCUSSION

Enhanced health care access and socioeconomic status and reductions in drug use may have contributed to the declines in HIV diagnoses among African American women in the United States.

"I love having benzos after my coke shot": The use of psychotropic medication among cocaine users in downtown Montreal

BACKGROUND

Cocaine abuse is a major public health issue due to its role in the HIV and hepatitis C virus (HCV) epidemics in North America. A significant area of concern among people who use cocaine (PWUC), injected or smoked, is their frequent misuse of prescription drugs, particularly psychotropic medication (PM), such as tranquilizers, sedatives, stimulants, and antipsychotics. This paper aims to describe and understand practices of PM use among PWUC in downtown Montreal.

METHOD

Ethnographic methods including participant observation and semi-structured interviews were used in an iterative manner.

RESULTS

Two thirds of the 50 participants were male. They ranged in age from 20 to 60 and most were homeless. A significant proportion of them reported polydrug use patterns that included frequent concomitant opioid use (heroin and/or prescription opioids (PO)). Benzodiazepine-based tranquilizers and the atypical antipsychotic quetiapine were the most frequently used PM. Routes of PM administration were oral, nasal and, to a lesser degree, intravenous. Five main PM use practices were identified: 1) "downers" from cocaine high (benzodiazepines and quetiapine); 2) enhancers of heroin/PO effects (benzodiazepines); 3) reducers or suppressors of heroin/PO withdrawal symptoms (benzodiazepines); 4) enablers of a different type of "trip" (benzodiazepines); and 5) treatment for mental and physical problems (benzodiazepines and quetiapine).

CONCLUSION

PM use practices showed several complementary functions that PM fulfill in a context of polydrug use. The soothing and stimulating effects of PM reinforce the patterns of drug use among participants, posing various risks including overdose, HIV/HCV transmission, PM dependence and accidents. The results highlight the need for clinicians to assess clients' substance use patterns when prescribing PM and to question PWUC about PM use. The findings also underline certain unmet service needs in relation to overdose, HIV/HCV and mental health prevention/treatment among cocaine users.

Primary Care Issues in Inner-City America and Internationally

Inner-city patient populations are high-risk for poor outcomes, including increased risk of mortality. Barriers to delivering high-quality primary care to inner-city patients include lack of access, poor distribution of primary care providers (PCPs), competing demands, and financial restraints. Health care issues prevalent in this population include obesity, diabetes, cancer screening, asthma, infectious diseases, and obstetric and prenatal care. Population health management and quality improvement (QI) activities must target disparities in care. Partnering with patients and focusing on social determinants of health andmedical care are key areas inwhich to focus toimprove overall healthoutcomes inthispopulation.

Continuing Links Between Substance Use and HIV Highlight the Importance of Nursing Roles

Links between HIV and substance use were identified early in the U.S. HIV epidemic. People who use drugs are at risk of HIV infection through shared injection equipment and risky sexual behaviors. In addition, substance use has negative health consequences for people living with HIV. The prescription opioid misuse epidemic, linked to injection drug use, hepatitis C infection, and HIV, poses a new threat to declining HIV rates. We reviewed evidence-based interventions that decrease HIV risk in people who use drugs (needle/syringe programs, medication-assisted treatment, engagement in HIV care, and preexposure prophylaxis/postexposure prophylaxis). The critical roles of nurses in HIV prevention/care for this population are described, including applying the principles of harm reduction, screening for substance use, and undertaking implementation and research efforts. As the nation's largest health care profession, nurses are positioned to contribute to the quality of HIV-related prevention/care for people who use drugs and to lead practice initiatives.

Sociodemographic and Substance Use Disorder Determinants of HIV Sexual Risk Behavior in Men and Women in Outpatient Drug Treatment in the NIDA National Drug Abuse Treatment Clinical Trials Network

BACKGROUND

Sexual risk behavior is now the primary vector of HIV transmission among substance users in the United States with gender as a crucial moderator of risk behavior.

OBJECTIVES

The purpose of this study was to examine gender differences in factors (age, race/ethnicity, education) that predict main-partner unprotected sexual occasions (USO) using the unique platform of two parallel NIDA National Drug Abuse Treatment Clinical Trials Network gender-specific safer sex intervention trials.

METHODS

Baseline assessments of male (N = 430) and female (N = 377) participants included demographic characteristics; past 3-month sexual activity; and a diagnostic assessment for alcohol, cocaine/stimulant, and opioid use disorders. Using mixed effects generalized linear modeling of the main outcome USO, two-way interactions of gender with age, race/ethnicity, and education were evaluated and adjusted by alcohol, cocaine/stimulant, or opioid use disorder.

RESULTS

When adjusted for alcohol use disorder, the interaction of education and gender was significant. For men, a high school or greater education was significantly associated with more USO compared to men with less than high school. For women, greater than high school education was significantly associated with less USO compared to women with a high school education. None of the other interactions were significant when adjusted for cocaine/stimulant or opioid use disorder. Conclusions/Importance: This study demonstrates gender differences in the relationship of education, alcohol use disorder, and main-partner USO in individuals in substance abuse treatment. This underscores the importance of considering demographic and substance use factors in HIV sexual risk behavior and in crafting prevention messages for this population.

Effect of Continuing Care for Cocaine Dependence on HIV Sex-Risk Behaviors

Evaluate the effect of continuing care interventions for cocaine use with HIV risk-reduction components on HIV sex-risk. Explore whether cocaine use at treatment initiation interacts with the type of continuing care intervention to affect HIV sex-risk. Cocaine dependent participants (N = 321) were randomized to: (1) Treatment as usual (TAU): intensive outpatient treatment, (2) TAU and telephone monitoring and counseling (TMC), and (3) TAU and TMC plus incentives for participation in telephone contacts (TMC+). Participants in TMC and TMC+ received a brief HIV intervention, with booster sessions as needed. Generalized estimating equations analysis compared TAU, TMC and TMC+ at 6, 12, 18, 24 months post-baseline on the following outcomes: overall HIV sex-risk, number of sexual partners, condom usage, exchange of drugs for sex, exchange of sex for drugs, exchange of money for sex, exchange of sex for money, and crack house visits. Overall sex-risk decreased for all treatment conditions at follow-up, with no treatment main effects. For people with no cocaine use at baseline, TAU experienced greater sex-risk reductions than TMC (p < .01) and TMC+ (p < .001). The three treatment conditions are effective in reducing HIV sex-risk. TMC with HIV risk-reduction components is unnecessary for cocaine-dependent clients who stop using cocaine early in treatment.

Multiplex Relationships and HIV: Implications for Network-Based Interventions

The number of network members and the roles they play can influence risk behaviors and consequently intervention strategies to reduce HIV transmission. We recruited 652 people who use drugs (PWUD) from socially disadvantaged neighborhoods in New York City (07/2006-06/2009). Interviewer-administered surveys ascertained demographic, behavioral, and network data. We used logistic regression, stratified by exchange sex, to assess the relationship between HIV status and the number of network members with different roles, treated as independent and multiplex (i.e., drug + sex). Those with more multiplex risk ties were significantly more likely to be HIV positive, but only among those not reporting exchange sex (AOR = 3.2). Among those reporting exchange sex, men reporting recent male sex partners were more likely to report HIV positive status (AOR = 12.6). These data suggest that sex and drug relationships among PWUD are interrelated. Interventions that target multiplex rather than single-role relationships may be more effective in influencing behavior change.

Sexual risk behaviors and predictors of inconsistent condom use among crack cocaine users in the French overseas territories in the Americas

The French overseas territories in the Americas are the French territories most affected by HIV. Crack cocaine users are particularly impacted. The objective of this study was to describe sexual risk behaviors and inconsistent condom use among crack cocaine users. A total of 640 crack cocaine users were interviewed. The sampling method was non-probabilistic. An anonymous standardized questionnaire of 110 questions was used. Over a third of persons did not use condoms systematically with casual sex partners (36.2%) or commercial sex partners (32.3%), and 64% did not use condoms systematically with regular sex partners. In a context of multiple sexual partnerships, frequent forced sex, and insufficient HIV testing, the lack of systematic condom use may favor the spread of HIV. Different predictive factors of inconsistent condom use were identified, depending on the type of partner, with a log binomial regression. However, among the predictor variables identified, two predictive factors frequently occur among the different type of sex partners: high perceived risk of HIV and self-perceived capacity to persuade a sex partner to use condom. These results pointed towards interventions improving access to rights and raising perceived self-efficacy.

Cocaine administration dose-dependently increases sexual desire and decreases condom use likelihood: The role of delay and probability discounting in connecting cocaine with HIV

OBJECTIVES

Although cocaine use has been linked to sexual HIV risk behavior for decades, the direct effects of cocaine on sexual desire and sexual decision-making are unexamined. Research suggests delay discounting (devaluation of future outcomes) and probability discounting (devaluation of uncertain outcomes) play roles in condom use decisions. This study examined the effect of cocaine administration on sexual desire, hypothetical condom use, and discounting tasks.

METHODS

This double-blind, within-subjects study compared the effects of 0, 125, and 250 mg/70 kg oral cocaine HCl in 12 cocaine users. Measures included sexual desire and other subjective ratings, the Sexual Delay Discounting Task, the Sexual Probability Discounting Task, and monetary delay and probability discounting tasks.

RESULTS

Cocaine caused dose-related increases in sexual desire and prototypical stimulant abuse-liability ratings. Relative to placebo, cocaine did not significantly alter condom use likelihood when condoms were immediately available or when sex was associated with 100% certainty of sexually transmitted infection (STI). In contrast, cocaine dose-dependently strengthened the effect of delay (sexual delay discounting) and STI uncertainty (sexual probability discounting) in decreasing condom use likelihood. Cocaine caused no significant change in monetary delay and probability discounting.

CONCLUSION

This is the first study showing that cocaine administration increases sexual desire. Detrimental effects of cocaine on sexual risk were only observed when safer sex required delay, or STI risk was uncertain (representative of many real-world scenarios), suggesting a critical role of discounting processes. Lack of monetary effects highlights the importance of studying clinically relevant outcomes when examining drug effects on behavioral processes.

What happened to the HIV epidemic among non-injecting drug users in New York City?

BACKGROUND AND AIMS

HIV has reached high prevalence in many non-injecting drug user (NIDU) populations. The aims of this study were to (1) examine the trend in HIV prevalence among non-injecting cocaine and heroin NIDUs in New York City, (2) identify factors potentially associated with the trend and (3) estimate HIV incidence among NIDUs.

DESIGN

Serial-cross sectional surveys of people entering drug treatment programs. People were permitted to participate only once per year, but could participate in multiple years.

SETTING

Mount Sinai Beth Israel drug treatment programs in New York City, USA.

PARTICIPANTS

We recruited 3298 non-injecting cocaine and heroin users from 2005 to 2014. Participants were 78.7% male, 6.1% white, 25.7% Hispanic and 65.8% African American. Smoking crack cocaine was the most common non-injecting drug practice.

MEASURES

Trend tests were used to examine HIV prevalence, demographics, drug use, sexual behavior and use of antiretroviral treatment (ART) by calendar year; χ² and multivariable logistic regression were used to compare 2005-10 versus 2011-14.

FINDINGS

HIV prevalence declined approximately 1% per year (P < 0.001), with a decline from 16% in 2005-10 to 8% in 2011-14 (P < 0.001). The percentages of participants smoking crack and having multiple sexual partners declined and the percentage of HIV-positive people on ART increased. HIV incidence among repeat participants was 1.2 per 1000 person-years (95% confidence interval = 0.03/1000-7/1000).

CONCLUSIONS

HIV prevalence has declined and a high percentage of HIV-positive non-injecting drug users (NIDUs) are receiving antiretroviral treatment, suggesting an end to the HIV epidemic among NIDUs in New York City. These results can be considered a proof of concept that it is possible to control non-injecting drug use related sexual transmission HIV epidemics.

Correlates of sex trading among male non-injecting drug users in Myanmar: a cross-sectional study

BACKGROUND

Sex trading is a recognized risk factor for human immune deficiency virus infection and other sexually transmitted infections among non-injecting drug users (NIDUs). However, very little research has addressed the factors associated with sex trading among male NIDUs in Myanmar.

METHODS

A cross-sectional study was conducted from January to February 2010 using the respondent-driven sampling method. In total, 210 NIDUs aged between 18 and 49 years, with no history of injecting drug use, and who used non-injected illicit drugs in the last 6 months were recruited. Face-to-face interviews were conducted using a structured questionnaire to collect information on participants' sexual and drug use behaviors. Binary and multivariate logistic regressions were applied to analyze the resulting data.

RESULTS

Of 210 NIDUs, 84 (40%) reported involvement in the sex trade during the last 3 months. In the adjusted model, factors associated with sex trade involvement included homosexual preference (adjusted odds ratio [AOR] 4.90; 95% confidence interval [CI] 1.61-14.95), having more than two partners (AOR = 3.88; 95% CI 1.55-9.72), had a regular job (AOR = 5.10; 95% CI 1.65-15.72), use of stimulant drugs rather than opiate (AOR = 2.38; 95% CI 1.10-5.15), and who used drugs more than twice per day.

CONCLUSIONS

More than one third of NIDUs were involved in sex trading. This study suggested that further comprehensive intervention programs that aim to reduce risk factors of trading sex among NIDUs may consider including NIDUs who used stimulant drugs, had regular/full-time jobs, used drugs more than twice per day, and had homosexual preferences.

Substance Use and Adherence Among People Living with HIV/AIDS Receiving cART in Latin America

This cross-sectional study describes substance use prevalence and its association with combination antiretroviral therapy (cART) adherence among 3343 individuals receiving care at HIV clinics in Argentina, Brazil, Chile, Honduras, Mexico, and Peru. A rapid screening tool evaluated self-reported 7-day recall of alcohol, marijuana, cocaine, heroin, and methamphetamine use, and missed cART doses. Overall, 29.3 % individuals reported having ≥1 alcoholic drinks, 5.0 % reported any illicit drug use and 17.0 % reported missed cART doses. In the logistic regression model, compared to no substance use, alcohol use [adjusted odds ratio (AOR) = 2.46, 95 % confidence interval (CI): 1.99-3.05], illicit drug use (AOR = 3.57, 95 % CI: 2.02-6.30), and using both alcohol and illicit drugs (AOR = 4.98, 95 % CI: 3.19-7.79) were associated with missed cART doses. The associations between substance use and likelihood of missing cART doses point to the need of targeting alcohol and illicit drug use to improve adherence among people living with HIV in Latin America.

Intersecting motivations for leaving abusive relationships, substance abuse, and transactional sex among HIV high-risk women

BACKGROUND

Women bear a significant burden of the HIV epidemic in the United States. Women classified as 'HIV high-risk' often bring co-existing histories of intimate partner violence (IPV), drug use, and transactional sex. To help inform future comprehensive HIV prevention strategies, we aimed to explore common motivating reasons and barriers to leaving and/or terminating engagement in each of these risk-promoting situations.

METHODS

Between August and November 2014, in-depth interviews were conducted with 14 HIV high-risk women in Atlanta, Georgia who had experienced IPV in the previous 12 months, and used drugs and/or engaged in transactional sex in the previous five years. Participants were asked about histories of IPV, drug use, and/or engagement in transactional sex, and the motivating reasons and barriers to terminating each.

RESULTS

Women reported a range of motivating reasons for leaving IPV, drug use, and transactional sex. Overlapping themes included impact on children, personal physical health/safety, and life dissatisfaction. Financial need was identified as a common barrier to leaving.

CONCLUSIONS

Future HIV prevention research should further explore the perceived impact of IPV, drug use, and transactional sex on physical health/safety, life dissatisfaction, one's children, and financial need as motivators and barriers to reducing upstream HIV risk.

Role of Autophagy in HIV Pathogenesis and Drug Abuse

Autophagy is a highly regulated process in which excessive cytoplasmic materials are captured and degraded during deprivation conditions. The unique nature of autophagy that clears invasive microorganisms has made it an important cellular defense mechanism in a variety of clinical situations. In recent years, it has become increasingly clear that autophagy is extensively involved in the pathology of HIV-1. To ensure survival of the virus, HIV-1 viral proteins modulate and utilize the autophagy pathway so that biosynthesis of the virus is maximized. At the same time, the abuse of illicit drugs such as methamphetamine, cocaine, morphine, and alcohol is thought to be a significant risk factor for the acquirement and progression of HIV-1. During drug-induced toxicity, autophagic activity has been proved to be altered in various cell types. Here, we review the current literature on the interaction between autophagy, HIV-1, and drug abuse and discuss the complex role of autophagy during HIV-1 pathogenesis in co-exposure to illicit drugs.

Abriendo Puertas: Feasibility and Effectiveness a Multi-Level Intervention to Improve HIV Outcomes Among Female Sex Workers Living with HIV in the Dominican Republic

Female sex workers (FSW) are disproportionately affected by HIV. Yet, few interventions address the needs of FSW living with HIV. We developed a multi-level intervention, Abriendo Puertas (Opening Doors), and assessed its feasibility and effectiveness among a cohort of 250 FSW living with HIV in the Dominican Republic. We conducted socio-behavioral surveys and sexually transmitted infection and viral load testing at baseline and 10-month follow-up. We assessed changes in protected sex and adherence to antiretroviral therapy (ART) with logistic regression using generalized estimating equations. Significant pre-post intervention changes were documented for adherence (72-89 %; p < 0.001) and protected sex (71-81 %; p < 0.002). Higher intervention exposure was significantly associated with changes in adherence (AOR 2.42; 95 % CI 1.23-4.51) and protected sex (AOR 1.76; 95 % CI 1.09-2.84). Illicit drug use was negatively associated with both ART adherence and protected sex. Abriendo Puertas is feasible and effective in improving behavioral HIV outcomes in FSW living with HIV.

Initiation of drug dealing among a prospective cohort of street-involved youth

BACKGROUND

Street-involved youth who use drugs may have limited income-generation options and are known to commonly become immersed in illicit drug markets to generate funds. However, little attention has been given to factors that may drive drug dealing initiation among this vulnerable population.

OBJECTIVES

This longitudinal study examines drug dealing initiation among street-involved youth.

METHODS

Data were derived from the At-Risk Youth Study from September 2005 to November 2014; a prospective cohort of 194 street-involved youth who use drugs aged 14-26, in Vancouver, Canada. Extended Cox model was used to identify factors independently associated with time to first drug dealing.

RESULTS

Among street-involved youth who had never dealt drugs at baseline, 56 (29%) individuals initiated drug dealing during the study period for an incidence density of 13.0 per 100 person-years (95% confidence interval [CI]: 9.9-17.2). In multivariable Cox regression analysis, male gender (adjusted hazard ratio [AHR] = 1.90, 95% CI: 1.06-3.42), homelessness (AHR = 1.88, 95% CI: 1.05-3.35), crystal methamphetamine use (AHR = 2.48, 95% CI: 1.47-4.20), and crack cocaine use (AHR = 2.35, 95% CI: 1.38-4.00) were positively and independently associated with initiating drug dealing.

CONCLUSION

Homelessness and stimulant drug use were key risk factors for drug dealing initiation among street-involved youth. Findings indicate that evidence-based and innovative interventions, including youth-centric supportive housing, low threshold employment programs, and stimulant addiction treatment should be implemented and evaluated as strategies to help prevent this vulnerable population from engaging in risky illegal income generation practices.

Factors associated with optimal pharmacy refill adherence for antiretroviral medications and plasma HIV RNA non-detectability among HIV-positive crack cocaine users: a prospective cohort study

Background

Crack cocaine use is known to contribute to poor adherence to antiretroviral medications; however, little is known about facilitators of or barriers to effective HIV treatment use among HIV-infected crack cocaine users. We sought to identify correlates of optimal pharmacy refill adherence for antiretroviral medications and plasma HIV RNA viral load (pVL) suppression among this population.

Methods

Data from a prospective cohort of HIV-positive people who use illicit drugs in Vancouver, Canada, were linked to comprehensive HIV clinical monitoring and pharmacy dispensation records. We used multivariable generalized linear mixed-effects modelling to longitudinally identify factors associated with ≥95 % adherence to pharmacy refills for antiretroviral medications and pVL <50 copies/mL among crack cocaine users exposed to highly-active antiretroviral therapy (HAART).

Results

Among 438 HAART-exposed crack cocaine users between 2005 and 2013, 240 (54.8 %) had ≥95 % pharmacy refill adherence in the previous 6 months at baseline. In multivariable analyses, homelessness (adjusted odds ratio [AOR]: 0.58), ≥daily crack cocaine smoking (AOR: 0.64), and ≥ daily heroin use (AOR: 0.43) were independently associated with optimal pharmacy refill adherence (all p < 0.05). The results for pVL non-detectability were consistent with those of medication adherence, except that longer history of HAART (AOR: 1.06), receiving a single tablet-per-day regimen (AOR: 3.02) and participation in opioid substitution therapies was independently associated with pVL non-detectability (AOR: 1.55) (all p < 0.05).

Conclusions

Homelessness, and daily crack cocaine and/or heroin use were independently and negatively associated with optimal HAART-related outcomes. With the exception of opioid substitution therapies, no addiction treatment modalities assessed appeared to facilitate medication adherence or viral suppression. Evidence-based treatment options for crack cocaine use that also confer benefits to HAART need to be developed.

Male Condom Use by Type of Relationship following an HIV Intervention among Women Who Use Illegal Drugs

Predictors of increased male condom use are investigated following a recent, gender-specific HIV intervention among African-American women. Data were analyzed from 138 women (aged 18 to 59), recruited from inner-city Atlanta (Georgia, U.S.) neighborhoods. Predictors of condom use with steady and casual paying partners were examined separately. Increased condom use with steady partners was associated with drug-using status, intervention assignment, sexual relationship characteristics, age at first condom use, and HIV testing history. Condom use with casual paying partners was associated with having sex while high and the frequency of crack cocaine use. Personalized norms regarding condom use were not salient factors in predicting increased rates of condom use with either partner type. Findings indicate the continued need to consider sex in the context of drug use, and reveal the importance of measuring such influences and all antecedents of condom use separately for steady versus casual sexual relationships.

Cocaine-dependent adults and recreational cocaine users are more likely than controls to choose immediate unsafe sex over delayed safer sex

Cocaine users have a higher incidence of risky sexual behavior and HIV infection than nonusers. Our aim was to measure whether safer sex discount rates-a measure of the likelihood of having immediate unprotected sex versus waiting to have safer sex-differed between controls and cocaine users of varying severity. Of the 162 individuals included in the primary data analyses, 69 met the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) criteria for cocaine dependence, 29 were recreational cocaine users who did not meet the dependence criteria, and 64 were controls. Participants completed the Sexual Discounting Task, which measures a person's likelihood of using a condom when one is immediately available and how that likelihood decreases as a function of delay to condom availability with regard to 4 images chosen by the participants of hypothetical sexual partners differing in perceived desirability and likelihood of having a sexually transmitted infection. When a condom was immediately available, the stated likelihood of condom use sometimes differed between cocaine users and controls, which depended on the image condition. Even after controlling for rates of condom use when one is immediately available, the cocaine-dependent and recreational users groups were more sensitive to delay to condom availability than controls. Safer sex discount rates were also related to intelligence scores. The Sexual Discounting Task identifies delay as a key variable that impacts the likelihood of using a condom among these groups and suggests that HIV prevention efforts may be differentially effective based on an individual's safer sex discount rate. (PsycINFO Database Record

Women's Sexual Health: The Need for Feminist Analyses in Public Health in the Decade of Behavior

Women's sexual health is directly affected by women's low status in society. This low status, and subsequent lack of sexual autonomy not only increases risk for sexual health problems, it also decreases ability to obtain treatment and support when a sexual health concern arises. This has clearly been demonstrated in the HIV epidemic within the U.S. Earlier in the epidemic, women were simply ignored by public health research and practice. Once they could no longer be ignored, they were blamed and viewed as vectors. Current seroprevalence rates among men reveal that women are not significant vectors. In contrast, rates among women indicate that infection from men is the primary mechanism by which women are contracting HIV, and male-controlled sexual decision-making, male partner violence against women, and histories of sexual assault all contribute to increased HIV risk for women. Once infected, women are not given the support and resources they need as mothers and caretakers of HIV-positive partners and/or children. These findings are especially true for marginalized women such as women of color, poor women, women addicted to alcohol or drugs, and women who exchange sex for drugs or money. Findings from this review demonstrate the need for feminist approaches in understanding and addressing this issue in the Decade of Behavior. Such approaches must include an understanding of the needs of diverse women. An empowerment approach is needed to better contend with the sexual health needs of women; this must include the goal of ensuring women's control of their own bodies.

Risky and rushed public crack cocaine smoking: the potential for supervised inhalation facilities

BACKGROUND

Despite the multitude of public health and community harms associated with crack cocaine use, little is known about factors associated with smoking crack in public and related risks such as rushed public crack smoking.

METHODS

Data were derived from two prospective cohort studies of people who use illicit drugs in Vancouver, Canada between 2010 and 2014. Multivariable generalized estimating equations were used to identify the prevalence and correlates of public crack smoking and rushed public crack smoking.

RESULTS

In total, 1085 participants who had smoked crack in the prior six months were eligible for the analysis, of which 379 (34.9 %) reported always or usually smoking crack in public in the previous six months at some point during the study period. Factors positively and independently associated with public crack smoking included public injection drug use (adjusted odds ratio [AOR]: 5.42, 95 % confidence interval [CI]: 3.76-7.82), homelessness (AOR: 3.48, 95 % CI: 2.77-4.36), at least daily crack use (AOR: 2.69, 95 % CI: 2.19-3.31), crack pipe sharing (AOR: 1.98, 95 % CI: 1.60-2.46), drug dealing (AOR: 1.59, 95 % CI: 1.30-1.94), recent incarceration (AOR: 1.47, 95 % CI: 1.09-1.98), noticing police presence when buying or using drugs (AOR: 1.30, 95 % CI: 1.06-1.60), and younger age (AOR: 1.03, 95 % CI: 1.01-1.04). Rushed public crack smoking, which was reported by 216 (28.8 %) of 751 participants who had smoked crack in public at least once during the study period, was positively and independently associated with homelessness (AOR: 2.61, 95 % CI: 1.96-3.49), at least daily crack use (AOR: 1.48, 95 % CI: 1.11-1.98), crack pipe sharing (AOR: 1.44, 95 % CI: 1.10-1.89), drug dealing (AOR: 1.39, 95 % CI: 1.04-1.86), and younger age (AOR: 1.02, 95 % CI: 1.01-1.04).

CONCLUSIONS

A high prevalence of public crack smoking and rushed public crack smoking was observed in this setting. These findings point to the need for implementing and evaluating evidence-based public health interventions, such as supervised inhalation facilities, to reduce the risks and harms associated with smoking crack in public.

Correlates of Mandrax use and condom beliefs in preventing sexually transmitted infections among a cohort of South African prison inmates

BACKGROUND

This study was designed to identify the extent to which self-reported Mandrax use impacts condom-use beliefs amongst South African prison inmates.

METHODS

Participants were inmates from four prisons in the provinces of KwaZulu-Natal and Mpumalanga. In total, 357 inmates participated in the parent study of which 121 are included in this analysis based on their self-reported use of Mandrax. The questionnaire was developed in English, translated into Zulu, and back translated into English. Age significantly predicted the use of Mandrax: younger prison inmates reported higher use. Linear regression analysis was conducted to determine whether the use of Mandrax was associated with length of incarceration and other demographic variables, as well as participants' self-reported condom use beliefs behavior.

RESULTS

Regression results indicated that two factors operationalizing condom-use beliefs were impacted by Mandrax use: 1) it is important to use condoms every time you have sex (p<0.01); 2) condoms work well to prevent the spread of HIV (p<0.02). Both factors were also inversely related to Mandrax use.

CONCLUSION

STI prevention programs among prison inmates that seek to promote safer sex behaviors among men must address attitudes to condom use, specifically consistent and correct use of latex condoms and reducing substance misuse.

Maids, Migrants and Occupational Health in the London Sex Industry

It has been argued that norms of occupational health have weakened with diversification in the sex industry. We explore this issue in walk-in flats in London, focusing on relationships between managers (maids) and sex workers. Today, most maids are local and most sex workers are 'migrants'. We collected data on 117 maids and sex workers, and carried out intensive fieldwork with seven maids and 17 sex workers. Managers take prime responsibility for educating and inducting new workers. Authoritarian management has been considered bad for health both in these walk-in flats and in the '100 per cent condom use programme' criticized by sex workers' projects. Yet, we found that maids acted as friends and managers, which helped settle new sex workers. Over time, however, migrants were more affected by issues of isolation and exploitation than local workers. Alternative models of health promotion such as peer education must be seen in a wider legal context where the lack of rights makes it difficult to appeal against exploitation, or to become mobile.

The Relationship Between Non-Medical Use of Prescription Opioids and Sex Work Among Adults in Residential Substance Use Treatment

High rates of substance use (e.g., alcohol, cocaine, heroin) have been documented among individuals who engage in sex work (SW), and adults seeking substance use disorder (SUD) treatment frequently report prior engagement in SW. Non-medical use of prescription opioids (NMUPO) has increased over the last decade, but little is known about the relationship between NMUPO with sex exchange. The purpose of this study was to describe the prevalence of recent SW among patients at a large residential SUD treatment center and examine the association between NMUPO and SW. Approximately 14% of 588 adults reported involvement in SW in the month prior to treatment. NMUPO was more common among those with a history of SW (95% of sex workers vs. 74% of non-sex-workers), and this association remained statistically significant after controlling for demographic factors, other substance use and psychiatric symptom severity (odds ratio=3.38). SW is relatively common among patients in residential SUD treatment, and is associated with greater psychiatric severity and more extensive substance use, including alarming rates of NMUPO. Addiction treatment for individuals involved in SW may benefit from the addition of content related to NMUPO.

Post-traumatic Stress Disorder Symptoms and Mental Health over Time among Low-Income Women at Increased Risk of HIV in the U.S

Women living in poverty suffer more post-traumatic stress disorder (PTSD) symptoms than do members of the general population; however we know little about factors associated with changes in their PTSD symptoms over time. Using data from HPTN 064, a cohort of women from low-income, high-HIV-prevalence communities across six eastern states (n=1,860), we assessed the prevalence of and changes in PTSD symptoms over 12 months and the effect of potential predictors on symptom acquisition and remission (via the Primary Care-PTSD symptoms scale). Forty-three percent screened positive for PTSD symptoms. Those reporting food insecurity, ongoing abuse, depressive symptoms, or binge drinking were more likely to acquire PTSD symptoms. Those with ongoing abuse or depressive symptoms were less likely to experience PTSD symptom remission. Findings suggest a need to integrate programs to reduce abuse, depression, and economic hardship with those that address sexual health risks among women living in low-income, high-HIV-prevalence neighborhoods.

Substance Use, Depression and Sociodemographic Determinants of HIV Sexual Risk Behavior in Outpatient Substance Abuse Treatment Patients

OBJECTIVES

The NIDA Clinical Trials Network trial of rapid HIV testing/counseling in 1281 patients was a unique opportunity to examine relationships among substance use, depressive symptoms, and sex risk behavior.

METHODS

Past 6-month substance use; substance use severity (Drug Abuse Screening Test - 10); depressive symptoms (Quick Inventory of Depressive Symptomatology); and three types of sex risk behavior (unprotected sex occasions [USOs] with primary partners; USOs with nonprimary partners; and USOs while high/drunk) were assessed. Zero-inflated negative binomial analyses provided: probability and rate of sex risk behavior (in risk behavior subsample).

RESULTS

Levels of sexual risk behavior were high, while variable across the three types of sex risk behaviors. Among the patients, 50.4% had engaged in USOs with primary partners, 42% in sex while drunk or high, and 23.8% in USOs with nonprimary partners. Similar factors were significantly associated with all three types of sex risk behaviors. For all types, problem drinking, cocaine use, and substance use severity had an exacerbating effect. Older age was associated with lower risk behavior; other relationship categories (eg, married, separated/divorced, cohabitating) were associated with greater risk behavior than was single status. Depressive symptoms were associated with decreased likelihood of USOs with a primary partner.

CONCLUSIONS

Sexual risk behavior is common among individuals in outpatient substance abuse treatment. Results highlight problem drinking (eg, up to three-fold) and cocaine (eg, up to twice) in increasing sex risk behavior. They demonstrate the utility of distinguishing between partner types and presence/absence of alcohol/drugs during sex. Findings argue for the need to integrate sex risk reduction into drug treatment.

"We need somewhere to smoke crack": An ethnographic study of an unsanctioned safer smoking room in Vancouver, Canada

INTRODUCTION

Many cities around the globe have experienced substantial increases in crack cocaine use. Public health programmes have begun to address crack smoking, primarily through the distribution of safer crack use equipment, but their impacts have been limited. More comprehensive safer environmental interventions, specifically safer smoking rooms (SSR), have been implemented only in select European cities. However, none have been subjected to rigorous evaluation. This ethnographic study was undertaken at an 'unsanctioned' SSR operated by a drug user-led organization in Vancouver, Canada, to explore how this intervention shaped crack smoking practices, public crack smoking, and related harms.

METHODS

Ethnographic fieldwork was undertaken at this SSR from September to December 2011, and included approximately 50 hours of ethnographic observation and 23 in-depth interviews with people who smoke crack. Data were analyzed by drawing on the 'Risk Environment' framework and concepts of 'symbolic', 'everyday', and 'structural' violence.

FINDINGS

Our findings illustrate how a high demand for SSRs was driven by the need to minimize exposure to policing (structural violence), drug scene violence (everyday violence), and stigma (symbolic violence) that characterized unregulated drug use settings (e.g., public spaces). Although resource scarcity and social norms operating within the local drug scene (e.g., gendered power relations) perpetuated crack pipe-sharing within unregulated drug use settings, the SSR fostered harm reduction practices by reshaping the social-structural context of crack smoking and reduced the potential for health harms.

CONCLUSION

Given the significant potential of SSRs in reducing health and social harms, there is an urgent need to scale up these interventions. Integrating SSRs into public health systems, and supplementing these interventions with health and social supports, has potential to improve the health and safety of crack-smoking populations.

Effectiveness of secondary prevention and treatment interventions for crack-cocaine abuse: a comprehensive narrative overview of English-language studies

There are an estimated several million crack-cocaine users globally; use is highest in the Americas. Most crack users are socio-economically marginalized (e.g., homeless), and feature elevated risks for morbidity (e.g., blood-borne viruses), mortality and crime/violence involvement, resulting in extensive burdens. No comprehensive reviews of evidence-based prevention and/or treatment interventions specifically for crack use exist. We conducted a comprehensive narrative overview of English-language studies on the efficacy of secondary prevention and treatment interventions for crack (cocaine) abuse/dependence. Literature searches (1990-2014) using pertinent keywords were conducted in main scientific databases. Titles/abstracts were reviewed for relevance, and full studies were included in the review if involving a primary prevention/treatment intervention study comprising a substantive crack user sample. Intervention outcomes considered included drug use, health risks/status (e.g., HIV or sexual risks) and select social outcome indicators. Targeted (e.g., behavioral/community-based) prevention measures show mixed and short-term effects on crack use/HIV risk outcomes. Material (e.g., safer crack use kit distribution) interventions also document modest efficacy in risk reduction; empirical assessments of environmental (e.g., drug consumption facilities) for crack smokers are not available. Diverse psycho-social treatment (including contingency management) interventions for crack abuse/dependence show some positive but also limited/short-term efficacy, yet likely constitute best currently available treatment options. Ancillary treatments show little effects but are understudied. Despite ample studies, pharmaco-therapeutic/immunotherapy treatment agents have not produced convincing evidence; select agents may hold potential combined with personalized approaches and/or psycho-social strategies. No comprehensively effective 'gold-standard' prevention/treatment interventions for crack abuse exist; concerted research towards improved interventions is urgently needed.

Gender and social rejection as risk factors for engaging in risky sexual behavior among crack/cocaine users

Crack/cocaine and engagement in risky sexual behavior represent important contributors to the escalation of the HIV infection among women. Several lines of research have emphasized the role of social factors in women's vulnerability for such practices and stressed the importance of understanding such factors to better inform prevention efforts and improve their effectiveness and efficiency. However, few studies have attempted to pinpoint specific social/contextual factors particularly relevant to high-risk populations such as female crack/cocaine users. Extensive previous research has related the experience of social rejection to a variety of negative outcomes including, but not limited to, various forms of psychopathology, self-defeating, and self-harm behavior. Motivated by this research, the current study explored the role of laboratory-induced social rejection in moderating the relationship between gender and risky sexual behavior among a sample of crack/cocaine users (n = 211) at high risk for HIV. The results showed that among women, but not among men, experiencing social rejection was significantly associated with a greater number of sexual partners. Further, experiencing social rejection was not related to the frequency of condom use. Implications for future research, prevention, and treatment are discussed.

PrEP in substance abuse treatment: a qualitative study of treatment provider perspectives

OBJECTIVES

To examine substance abuse treatment providers' views on engaging clients in Pre-exposure Prophylaxis (PrEP) care and research trials.

METHODS

Thirty-six medical and counseling service providers in six New York City outpatient substance abuse treatment programs participated in semi-structured qualitative interviews. Thematic content analysis was conducted by three coders, independently.

RESULTS

Providers' perspectives toward PrEP were characterized by six salient themes: 1) Limited PrEP awareness. 2) Ambivalence about PrEP; 3) Perception of multiple challenges to delivery; 4) Uncertainty about clients' ability to be adherent to medication; 5) Concerns about medication safety/side effects; and 6) Perception of multiple barriers to conducting clinical trials.

CONCLUSIONS

Despite anticipated challenges, providers supported the introduction of PrEP in outpatient substance abuse treatment. Comprehensive training for providers is needed and should include PrEP eligibility criteria, strategies to support adherence and medication monitoring guidelines. Linkages between substance abuse treatment and primary care and/or enhancement of capacity within clinics to offer PrEP may help facilitate PrEP delivery. When conducting research in outpatient clinics, it is particularly important to protect client confidentiality.