Behavior change and health-related interventions for heterosexual risk reduction among drug users

Drug Injection-Related and Sexual Behavior Changes in Drug Injecting Networks after the Transmission Reduction Intervention Project (TRIP): A Social Network-Based Study in Athens, Greece

The Transmission Reduction Intervention Project (TRIP) was a network-based, enhanced contact tracing approach, targeting recently HIV-infected people who inject drugs (PWID) in Athens, Greece (2013–2015). This analysis examines behavioral changes of participants in TRIP and their determinants between baseline and follow-up visits to the program. All participants of TRIP were tested for HIV and interviewed using a questionnaire with items on drug injection-related and sexual behaviors. Multivariable logistic regression models were used to examine potential relationships between participants’ behaviors and sociodemographic or other characteristics. The analysis included 292 participants. At follow-up, the percentage of participants who injected drugs decreased [92.5%, n = 270 versus 72.3%, n = 211 (p < 0.001)], and more participants adopted safer behaviors. Employment, age, and gender were significantly associated with some behavioral changes. For instance, unemployed participants were half as likely as the employed to stop drug injection [adjusted odds ratio (aOR): 0.475, 95% confidence interval (CI): 0.228, 0.988]. Increasing age was associated with lower probability of sharing syringes at follow-up (aOR: 0.936, 95%CI: 0.887, 0.988). Finally, females were less likely than males to improve their behavior related to sharing cookers, filters, or rinse water (aOR: 0.273, 95% CI: 0.100, 0.745). In conclusion, adoption of safer behaviors was observed following TRIP implementation. Future prevention programs should focus on younger PWID and especially females. Social efforts to support employment of PWID are also important.

A dyadic approach to understanding safer sex behavior in intimate heterosexual relationships

This study applied a dyadic approach to condom-use research. Partners from 124 heterosexual couples independently completed a questionnaire assessing condom-related attitudes, subjective norms, perceived behavioral control, and intentions to use condoms. Results demonstrate the superiority of a dyadic approach to understanding couples’ condom-use intentions and behavior over traditional, individual-level approaches. The addition of partner effects to the model, via the actor–partner interdependence model, resulted in an increase in the variance accounted for in condom-use intentions and this dyadic model showed better fit compared to the individual-level model. The results suggest that consideration of relationship partners plays an important role in the prediction of safer sex intentions.

Gender and race as correlates of high risk sex behaviors among injection drug users at risk for HIV enrolled in the HPTN 037 study

BACKGROUND

Sexual contact has been shown to be a major mode of HIV transmission among people who inject drugs (PWID). This study examined gender and racial differences among PWID' sexual risk behaviors from the perspective of sexual scripts.

METHODS

696 PWID enrolled from Philadelphia on HPTN 037 were classified as engaging in high-risk sex behaviors if they reported having sex in the past 30 days and condomless sex with a non-primary partner, giving/receiving sex for money, or multiple partners. A multivariable logistic regression model was used to assess associations between demographic factors and high risk sex.

RESULTS

Findings of the multivariable regression analysis demonstrated that being White (OR = 0.52, p < 0.001) and male (OR = 0.59, p = 0.002) were protective of high risk sex, while homelessness (OR = 1.7, p = 0.005), and being single (OR = 1.83, p = 0.006) were positively associated with high risk sex. African American (AA) women were 1.7 times more likely to report high-risk sex than AA men (p = 0.002), 3.28 times more likely than White men (p < 0.001), and 1.93 times more likely than White women (p < 0.001).

CONCLUSIONS

Since AA women report high-risk sex behaviors more than other demographic groups, behavioral interventions for HIV risk reduction among PWID may benefit from focusing on sex-risk reduction among AA women.

The potential for bridging: HIV status awareness and risky sexual behaviour of injection drug users who have non-injecting permanent partners in Ukraine

Objective

To quantify potential bridging of HIV transmission between the injection drug using subpopulation to the non-injection drug using population through unprotected heterosexual sex.

Design

Secondary analysis of cross-sectional data.

Methods

A sub-sample of participants who reported having a permanent partner who are not injection drug users and have not injected drugs in the past (N=1379) was selected from a survey implemented in 26 Ukrainian cities in 2011. This study evaluates the association between consistent condom use and awareness of HIV status as measured by rapid testing during the study (known/unknown HIV+, known/unknown HIV− and undetermined) among a sub-sample of male injection drug users (IDUs) who have a non-injecting permanent partner. Poisson regression, with robust variance estimates, was utilized to identify associations while adjusting for other factors.

Results

Reported consistent condom use varied between 15.5% (unknown HIV−) and 37.5% (known HIV+); average use was 19.3%. In multivariate analysis, males who were aware of their HIV+ status were more likely to report recent consistent condom use compared to those who were unaware of their HIV+ status. This association remains after adjustment for age, region, education level, years of injection, alcohol use, self-reported primary drug use and being an NGO client (prevalence ratio=1.65; 95% CI 1.03–2.64). No such association was found for those who were HIV−.

Conclusions

Our results regarding HIV-positive male IDUs reinforce previous findings that HIV testing and counselling may be an effective means of secondary prevention. Further research is needed to understand how to effectively promote safer sex behaviours for IDUs who are currently HIV−.

Public health strategies for prevention and control of HSV-2 in persons who use drugs in the United States

BACKGROUND

Herpes simplex virus type 2 (HSV-2) affects HIV acquisition, transmission, and disease progression. Effective medications for genital herpes and for HIV/AIDS exist. Parenteral transmission of HIV among persons who inject drugs is decreasing. Reducing sexual transmission of HIV and HSV-2 among persons who use drugs (PWUD; i.e., heroin, cocaine, "speedball", crack, methamphetamine through injection or non-injection) necessitates relevant services.

METHODS

We reviewed HSV-2 sero-epidemiology and HSV-2/HIV associations in U.S.-based studies with PWUD and the general literature on HSV-2 prevention and treatment published between 1995 and 2012. We used the 6-factor Kass framework to assess relevant HSV-2 public health strategies and services in terms of their goals and effectiveness; identification of, and minimization of burdens and concerns; fair implementation; and fair balancing of benefits, burdens, and concerns.

RESULTS

Eleven studies provided HSV-2 serologic test results. High HSV-2 sero-prevalence (range across studies 38-75%) and higher sero-prevalence in HIV-infected PWUD (97-100% in females; 61-74% in males) were reported. Public health strategies for HSV-2 prevention and control in PWUD can include screening or testing; knowledge of HSV-2 status and partner disclosure; education, counseling, and psychosocial risk-reduction interventions; treatment for genital herpes; and HIV antiretroviral medications for HSV-2/HIV co-infected PWUD.

CONCLUSIONS

HSV-2 sero-prevalence is high among PWUD, necessitating research on development and implementation of science-based public health interventions for HSV-2 infection and HSV-2/HIV co-infections, including research on effectiveness and cost-effectiveness of such interventions, to inform development and implementation of services for PWUD.

An international systematic review and meta-analysis of multisession psychosocial interventions compared with educational or minimal interventions on the HIV sex risk behaviors of people who use drugs

This systematic review and meta-analysis examines the effectiveness of multisession psychosocial interventions compared with educational interventions and minimal interventions in reducing sexual risk in people who use drugs (51 studies; 19,209 participants). We conducted comprehensive searches (MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and PsychINFO 1998-2012). Outcomes (unprotected sex, condom use, or a composite outcome) were extracted by two authors and synthesised using meta-analysis. Subgroup analyses and meta-regression were conducted to explore heterogeneity. Multisession psychosocial interventions had modest additional benefits compared to educational interventions (K = 46; OR 0.86; 95% CI 0.77, 0.96), and large positive effects compared to minimal interventions (K = 7; OR 0.60; 95% CI 0.46, 0.78). Comparison with previous meta-analyses suggested limited progress in recent years in developing more effective interventions. Multisession psychosocial and educational interventions provided similar modest sexual risk reduction justifying offering educational interventions in settings with limited exposure to sexual risk reduction interventions, messages, and resources.

Qualitative analysis of cocaine and heroin users' main partner sex-risk behavior: is safety in love safety in health?

Background

In 2009, 27% of the 48,100 estimated new cases of HIV were attributed to heterosexual contact with an infected or at-risk person. Sexually active adults are less likely to use condoms in relationships with main partners than with non-regular partners, despite general knowledge that condom use reduces HIV transmission.

Methods

The purpose of this secondary qualitative analysis was to explore and contextualize perceptions of main partnerships, HIV risk, and attitudes toward condom use within main partner relationships among a subsample of intervention-arm cocaine- and/or heroin-using patients enrolled in a negative trial of brief motivational intervention to reduce the incidence of sexually transmitted disease and unsafe sexual behaviors. The open-ended portion of these interview audiotapes consisted of questions about perceptions of risk and attitudes about condom use with main partners. Enrollees were aged 18-54, English or Spanish speaking, and included in this analysis only if they reported having a main partner. We identified codes and elaborated important themes through a standard inductive three step coding process, using HyperRESEARCH™ software.

Results

Among 48 interviewees, 65% were male, half were non-Hispanic white, over 60% were 20-39 years of age, 58% had intravenous drug use (IDU), and 8% were HIV-positive. Participants defined respect, support, trust, and shared child-rearing responsibility as the most valued components of main partner relationships. Condom use was viewed occasionally as a positive means of showing respect with main partners but more often as a sign of disrespect and a barrier to intimacy and affection. Enrollees appraised their partners’ HIV risk in terms of perceptions of physical health, cleanliness, and sexual and HIV testing history. They based decisions regarding condom use mainly on perceived faithfulness, length of involvement, availability of condoms, and pregnancy desirability.

Conclusions

Risk appraisal was commonly based on appearance and subjective factors, and condom use with main sexual partners was described most often as a demonstration of lack of trust and intimacy.

Trial registration

NCT01379599

Three city feasibility study of a body empowerment and HIV prevention intervention among women with drug use histories: Women FIT

BACKGROUND

New intervention models are needed for HIV prevention among drug-using women.

METHODS

The Women Fighting Infection Together (Women FIT) feasibility study enrolled 189 women in three U.S. cities (Providence, New York, Philadelphia) with drug-using histories, who also reported risky sexual behavior. Eligible women had participated previously in a yearlong study of HIV Counseling and Testing (HIV-CT) and limited case management. Two thirds of the sample were black, most were unemployed, and about two thirds reported prior or current crack use. Women were randomized into two groups. In one group, women participated in a manualized, four-session, peer-led, interactive group intervention that stressed body knowledge, woman-initiated HIV/sexually transmitted infection (HIV/STI) prevention, including a focus on women's health (reproductive health screening, sexual violence, self-breast examination, STI signs, symptoms), which aimed to increase comfort with and pride in their bodies. Control group women received HIV-CT enriched by female condom counseling. Outcomes included study retention, session attendance and ratings, changes in knowledge, and use of protection methods.

RESULTS

The study successfully retained 95% of the participants for a 2-month follow-up. Positive assessments from participants and peer leaders exceeded preset thresholds for success. Pre-post changes in body knowledge (p < 0.0001) and protection methods knowledge (p < 0.01) was greater among the intervention women than the control women.

CONCLUSIONS

The body empowerment model deserves further elaboration in interventions focusing on women at high risk of HIV/STI acquisition.

Developing effective health interventions for women who inject drugs: key areas and recommendations for program development and policy

Women who inject drugs face multiple gender-specific health risks and barriers to healthcare access. These gendered factors may contribute to elevated rates of HIV for this population. Though few countries systematically collect gender-disaggregated data related to injecting drug use, evidence indicates that there are large populations of women who inject drugs and who are in need of improved health services, including HIV prevention. Research on the effectiveness of interventions specifically tailored for women who inject drugs, along with the experience of programs working with this subpopulation, suggests that HIV risk practices need to be addressed within the larger context of women's lives. Multifaceted interventions that address relationship dynamics, housing, employment, and the needs of children may have more success in reducing risky practices than interventions that focus exclusively on injecting practices and condom use. Improved sexual and reproductive healthcare for women who use drugs is an area in need of development and should be better integrated into basic harm reduction programs.

Sexual pleasure and sexual risk among women who use methamphetamine: a mixed methods study

BACKGROUND

The intersection of drug use, sexual pleasure and sexual risk behaviour is rarely explored when it comes to poor women who use drugs. This paper explores the relationship between sexual behaviour and methamphetamine use in a community-based sample of women, exploring not only risk, but also desire, pleasure and the challenges of overcoming trauma.

METHODS

Quantitative data were collected using standard epidemiological methods (N=322) for community-based studies. In addition, using purposive sampling, qualitative data were collected among a subset of participants (n=34). Data were integrated for mixed methods analysis.

RESULTS

While many participants reported sexual risk behaviour (unprotected vaginal or anal intercourse) in the quantitative survey, sexual risk was not the central narrative pertaining to sexual behaviour and methamphetamine use in qualitative findings. Rather, desire, pleasure and disinhibition arose as central themes. Women described feelings of power and agency related to sexual behaviour while high on methamphetamine. Findings were mixed on whether methamphetamine use increased sexual risk behaviour.

CONCLUSION

The use of mixed methods afforded important insights into the sexual behaviour and priorities of methamphetamine-using women. Efforts to reduce sexual risk should recognize and valorize the positive aspects of methamphetamine use for some women, building on positive feelings of power and agency as an approach to harm minimization.

HIV/STI Risk Behavior of Drug Court Participants

Drug abusing offenders have high rates of HIV and other sexually transmitted infections (STI). To date, the HIV/STI prevention needs of offenders in drug court programs have been ignored. This multi-method study employed interviews to assess drug court professionals' perceptions of the need for an HIV risk reduction intervention to be integrated into the services provided to drug court participants. Then, surveys were completed by 235 drug court participants to assess whether their sexual risk behaviors affirmed the need for such an intervention. The survey also assessed demographic characteristics, drug use prior to program entry, HIV knowledge, and condom attitudes. The relationship between duration in the drug court program and sexual risk behavior was also examined. Implications for the development and delivery of HIV risk reduction interventions within drug court programs are discussed.

The impact of a brief motivational intervention on unprotected sex and sex while high among drug-positive emergency department patients who receive STI/HIV VC/T and drug treatment referral as standard of care

This randomized, controlled trial, conducted among out-of-treatment heroin/cocaine users at an emergency department visit, tests the impact on sexual risk of adding brief motivational intervention (B-MI) to point-of-service testing, counseling and drug treatment referral. 1,030 enrollees aged 18-54 received either voluntary counseling/testing (VC/T) with drug treatment referral, or VC/T, referral, and B-MI, delivered by an outreach worker. We measured number and proportion of non-protected sex acts (last 30 days) at 6 and 12 months (n = 802). At baseline, 70% of past-30-days sex acts were non-protected; 35% of sex acts occurred while high; 64% of sexual acts involved main, 24% casual and 12% transactional sex partners; 1.7% tested positive for an STI, and 8.8% for HIV. At six or 12 month follow-up, 20 enrollees tested positive for Chlamydia and/or Gonorrhea, and 6 enrollees HIV sero-converted. Self-reported high-risk behaviors declined in both groups with no significant between-group differences in behaviors or STI/HIV incidence.

The relative role of perceived partner risks in promoting condom use in a three-city sample of high-risk, low-income women

We examined the effect of women’s perceptions of sexual partner risks on condom use. Women from three US cities (n = 1,967) were recruited to provide data on HIV risks. In univariate models, increased odds of condom use were associated with perceiving that partners had concurrent partners and being unaware of partners': (a) HIV status, (b) bisexuality, (c) concurrency; and/or (d) injection drug use. In multivariate models, neither being unaware of the four partner risk factors nor perceiving a partner as being high risk was associated with condom use. Contextual factors associated with decreased odds of condom use were having sex with a main partner, homelessness in the past year, alcohol use during sex, and crack use in the past 30 days. Awareness of a partner’s risks may not be sufficient for increasing condom use. Contextual factors, sex with a main partner in particular, decrease condom use despite awareness of partner risk factors.

Correlates of trichomonas prevalence among street-recruited, drug-using women enrolled in a randomized trial

OBJECTIVES

Substance-using women need prevention technologies and programs to reduce risk of HIV/sexually transmitted infection (STI). We examined STI prevalence and identified risk correlates for female drug users.

METHODS

We used interviewer-administered and computer-assisted surveys, and tested specimens for four, treatable STIs (trichomonas, early syphilis, gonorrhea, chlamydia) on 198 HIV-seronegative, street-recruited, substance-using women enrolled in a randomized trial to reduce HIV/STI risk.

RESULTS

Most women were crack users (88%), reported sex exchange (80%) and were not in drug user treatment (74%). Two-thirds were African-American and nearly all were unemployed. Protection during sex was infrequent. African-American women reported fewer unprotected sex acts and fewer sexual partners, but greater crack use and more sex-for exchange, than whites or Hispanics. Trichomonas prevalence (36.9%) exceeded that for chlamydia (3.5%), syphilis (1.5%), and gonorrhea (0%). In multivariate logistic regression, having a primary and casual partner more than doubled (AOR 2.86) the risk of having trichomonas and being African-American raised the risk by more than 8 times (AOR 8.45).

CONCLUSIONS

African-American, drug-using women, and women with multiple partner types, are in urgent need of effective STI/HIV prevention interventions.

Reducing alcohol use, sex risk behaviors, and sexually transmitted infections among Filipina female bar workers: effects of an ecological intervention

This article presents the outcomes of a quasi-experimental community-based research intervention initiative targeting sexually transmitted infections (STIs) testing and condom use among Filipina female bar workers (FBWs). Established at the peer, organizational, and policy levels, bar managers and peer educators from 110 different establishments, in 4 southern Philippines regions, were trained. Only FBWs in the combination peer educator and manager training intervention condition significantly increased STI testing from baseline to follow-up. STI testing was significantly associated with higher HIV/AIDS knowledge, lower probability of contracting HIV, and increased condom use. Based on the findings, future research on the adaptability of this intervention to FBWs residing in HIV epicenters is warranted.

Prevention of HIV infection among injection drug users in resource-limited settings

Injection drug use contributes to considerable global morbidity and mortality associated with human immunodeficiency virus (HIV) infection and AIDS and other infections due to blood-borne pathogens through the direct sharing of needles, syringes, and other injection equipment. Of approximately 16 million injection drug users (IDUs) worldwide, an estimated 3 million are HIV infected. The prevalence of HIV infection among IDUs is high in many countries in Asia and eastern Europe and could exacerbate the HIV epidemic in sub-Saharan Africa. This review summarizes important components of a comprehensive program for prevention of HIV infection in IDUs, including unrestricted legal access to sterile syringes through needle exchange programs and enhanced pharmacy services, treatment for opioid dependence (ie, methadone and buprenorphine treatment), behavioral interventions, and identification and treatment of noninjection drug and alcohol use, which accounts for increased sexual transmission of HIV. Evidence supports the effectiveness of harm-reduction programs over punitive drug-control policies.

Heterosexual HIV and sexual partnerships between injection drug users and noninjection drug users

Sex partnerships with injection drug users (IDU) are an understudied network-level risk factor for heterosexual HIV infection. Heterosexuals with no history of injection were recruited from high-risk areas in New York City through respondent-driven sampling. We examined the prevalence of IDU sex partnerships among these non-IDU, the factors associated with having a past year IDU partner, and the independent association of HIV infection and IDU sex partnerships in multiple logistic regression. Of the 601 non-IDU in this analysis, 13.8% had a sex partner in the past year with a history of injection. IDU partnerships were significantly more common among women and those with higher levels of unprotected sex and drug and alcohol use. Overall, 7.0% tested positive for HIV. HIV prevalence was higher (p = 0.07) for participants with IDU partners (9.6%) compared to those with no IDU partners (4.6%). In multiple logistic regression, participants with IDU partners were over twice as likely to be HIV-infected (p = 0.08). Sex partnerships with IDU were common and may play an important role in heterosexual HIV transmission in areas with large IDU populations. Prevention interventions to encourage the disclosure of injection history and risk reduction specifically for those with IDU partners are indicated.

Meth/amphetamine use and associated HIV: Implications for global policy and public health

Amphetamine type stimulants (ATS) have become the focus of increasing attention worldwide. There are understandable concerns over potential harms including the transmission of HIV. However, there have been no previous global reviews of the extent to which these drugs are injected or levels of HIV among users. A comprehensive search of the international peer-reviewed and grey literature was undertaken. Multiple electronic databases were searched and documents and datasets were provided by UN agencies and key experts from around the world in response to requests for information on the epidemiology of use. Amphetamine or methamphetamine (meth/amphetamine, M/A) use was documented in 110 countries, and injection in 60 of those. Use may be more prevalent in East and South East Asia, North America, South Africa, New Zealand, Australia and a number of European countries. In countries where the crystalline form is available, evidence suggests users are more likely to smoke or inject the drug; in such countries, higher levels of dependence may be occurring. Equivocal evidence exists as to whether people who inject M/A are at differing risk of HIV infection than other drug injectors; few countries document HIV prevalence/incidence among M/A injectors. High risk sexual behaviour among M/A users may contribute to increased risk of HIV infection, but available evidence is not sufficient to determine if the association is causal. A range of possible responses to M/A use and harm are discussed, ranging from supply and precursor control, to demand and harm reduction. Evidence suggests that complex issues surround M/A, requiring novel and sophisticated approaches, which have not yet been met with sufficient investment of time or resources to address them. Significant levels of M/A in many countries require a response to reduce harms that in many cases remain poorly understood. More active models of engagement with M/A users and provision of services that meet their specific needs are required.

Brief counseling for reducing sexual risk and bacterial STIs among drug users--results from project RESPECT

OBJECTIVE

Project RESPECT's brief risk reduction counseling (BRRC) reduced sexual risk and bacterial STIs among at-risk heterosexuals and has been packaged for use with this population. We assessed BRRC's efficacy with RESPECT participants who used drugs and examined BRRC's applicability to present-day users of heroin, cocaine, speedball, or crack.

METHODS

We compared baseline demographic and economic variables, risk behaviors, and prevalence and correlates of bacterial STIs for ever-injectors ([EIs], N=335) and never-injectors ([NIs], N=3963). We assessed changes in risk behaviors and bacterial STIs for EIs and NIs at 12 months. We compared prevalence of HSV-2, hepatitis B core antigen virus (HBV), hepatitis C virus (HCV), and trichomonas among EIs with recently reported rates among drug users.

RESULTS

At baseline, 19% of EIs and 29% of NIs had bacterial STIs. Both groups had similar baseline STI correlates. At 12 months, 4% of EIs and 7% of NIs had bacterial STIs. Twelve-month cumulative incidence of bacterial STIs in BRRC was 21% lower among EIs and 18% lower among NIs compared to the informational condition. At 12 months, EIs reported fewer sexual risk behaviors than at baseline. Baseline positivity rates of trichomoniasis in EIs (female: 15%) and in male and female EIs of HSV-2 (39%, 68%), HBV (41%, 37%), and HCV (60%, 58%) were similar to rates in present-day drug users.

CONCLUSION

Efficacy of BRRC in reducing sexual risk and bacterial STIs in EIs, and similar profiles for EIs and present-day drug users suggest evaluating BRRC with present-day drug users.

Gender differences in high risk sexual behaviors and injection practices associated with perceived HIV risk among injection drug users

This study compared male and female injection drug users (IDUs) on perceived risk of contracting HIV and examined the associations between risk perceptions and sharing injection drugs or equipment, engaging in casual sex, and engaging in commercial sex. We used baseline data from 271 IDUs recruited between 2000 and 2005 from the Baltimore, Maryland site of the International Neurobehavioral HIV Study. We found that although there was no significant difference in levels of perceived risk between males and females, males reported significantly more casual sex, whereas females reported more commercial sex. Logistic regression analyses with the entire sample indicated that sharing of injection drugs or equipment was consistently associated with greater perceived risk. We also found a significant interaction between gender and having had casual sex, such that females who had engaged in casual sex were significantly more likely to perceive that they were at greater risk for contracting HIV. Our results suggest that male IDUs should be targeted for HIV risk-reduction programs focusing on casual and commercial sex.

Predictors of sexual risk reduction among Mexican female sex workers enrolled in a behavioral intervention study

OBJECTIVE

We recently showed efficacy of an intervention to increase condom use among female sex workers (FSWs) in Tijuana and Ciudad Juarez, situated on the Mexico-United States border. We determined whether increases in condom use were predicted by social cognitive theory and injection drug user status among women randomized to this intervention.

METHODS

Four hundred nine HIV-negative FSWs aged >or=18 years having unprotected sex with clients within the prior 2 months received a brief individual counseling session integrating motivational interviewing and principles of behavior change (ie, HIV knowledge, self-efficacy for using condoms, and outcome expectancies).

RESULTS

Increases in self-efficacy scores were associated with increases in percent condom use (P = 0.008), whereas outcome expectancies were not. Female sex workers who inject drugs (FSW-IDUs) increased condom use with clients but not to the same extent as other FSWs (P = 0.09). Change in HIV knowledge was positively associated with change in percent condom use among FSW-IDUs (P = 0.03) but not noninjection drug users.

CONCLUSIONS

Increases in self-efficacy significantly predicted increased condom use among FSWs, consistent with social cognitive theory. Increased HIV knowledge was also important among FSW-IDUs, but their changes in condom use were modest. Enhanced interventions for FSW-IDUs are needed, taking into account realities of substance use during sexual transactions that can compromise safer sex negotiation.

Recently arrested adolescents are at high risk for sexually transmitted diseases

BACKGROUND

Adolescent offenders may be at high risk for sexually transmitted diseases (STDs). With previous research and interventions focused on incarcerated adolescents, data are needed on STD prevalence and risk factors among newly arrested youth released to the community, a far larger subgroup.

METHODS

Participants were recruited from all arrested youth processed at the Hillsborough County, Florida Juvenile Assessment Center during the last half of 2006 (506 males, 442 females). Participants voluntarily providing urine samples for drug testing as part of standard protocol were also consented to having their specimens split and tested for chlamydia and gonorrhea, using an FDA-approved nucleic acid amplification test.

RESULTS

STD prevalence was similar to those previously reported among incarcerated adolescents: 11.5% tested positive for chlamydia, 4.2% for gonorrhea, and 13.2% for either or both infections. Prevalence was significantly higher among females: 19.2% of females had either or both infections compared with 10.5% of males. Prevalence was higher for 17 to 18 year olds (15.2% of males, 25.5% of females), blacks, detained youths, drug users, and those engaged in sexual risk behaviors. Previous STD testing experience was limited.

CONCLUSIONS

The study indicated that a voluntary STD screening protocol is feasible for arrested youth entering the juvenile justice system, and these offenders are at high risk for STDs. Because most arrested youths are released back to the community, routine testing and treatment of recently arrested youths, and expanded access to risk reduction and prevention programs, can yield substantial public health benefits.

Recently arrested adolescents are at high risk for sexually transmitted diseases

BACKGROUND

Adolescent offenders may be at high risk for sexually transmitted diseases (STDs). With previous research and interventions focused on incarcerated adolescents, data are needed on STD prevalence and risk factors among newly arrested youth released to the community, a far larger subgroup.

METHODS

Participants were recruited from all arrested youth processed at the Hillsborough County, Florida Juvenile Assessment Center during the last half of 2006 (506 males, 442 females). Participants voluntarily providing urine samples for drug testing as part of standard protocol were also consented to having their specimens split and tested for chlamydia and gonorrhea, using an FDA-approved nucleic acid amplification test.

RESULTS

STD prevalence was similar to those previously reported among incarcerated adolescents: 11.5% tested positive for chlamydia, 4.2% for gonorrhea, and 13.2% for either or both infections. Prevalence was significantly higher among females: 19.2% of females had either or both infections compared with 10.5% of males. Prevalence was higher for 17 to 18 year olds (15.2% of males, 25.5% of females), blacks, detained youths, drug users, and those engaged in sexual risk behaviors. Previous STD testing experience was limited.

CONCLUSIONS

The study indicated that a voluntary STD screening protocol is feasible for arrested youth entering the juvenile justice system, and these offenders are at high risk for STDs. Because most arrested youths are released back to the community, routine testing and treatment of recently arrested youths, and expanded access to risk reduction and prevention programs, can yield substantial public health benefits.

HIV prevention for injecting drug users: the first 25 years and counting

During the last three decades, both the injection of illicit psychoactive drugs and HIV infection among injecting drug users (IDUs) have spread throughout industrialized and developing countries. Extremely rapid transmission of HIV has occurred in IDU populations with incidence rates of 10 to 50/100 person-years. In sharp contrast, there are many examples of very effective HIV risk reduction for IDUs, both in preventing initial epidemics and in bringing existing epidemics under control. IDUs are capable of learning basic information about HIV/AIDS and modifying their behavior to protect both themselves and their peers. Effective HIV prevention for IDUs requires programs that treat IDUs with dignity and respect, provide accurate information and the means for behavior change-access to sterile injection equipment, condoms, and drug abuse treatment. Programs that provide these services need to be implemented on a public health scale for IDU populations at risk for HIV infection.

Attitudes toward needle-sharing and HIV transmission risk behavior among HIV+ injection drug users in clinical care

Risky behavior related to injection drug use accounts for a considerable proportion of incident HIV infection in the United States. Large numbers of injection drug users (IDUs) currently receive antiretroviral therapy in clinical settings and are accessible for risk-reduction interventions to reduce transmission of drug-resistant HIV and spread of HIV to uninfected others. The current study examined attitudes toward needle- or equipment-sharing among 123 HIV-positive IDUs in clinical care in an effort to understand the dynamics of such behavior and to create a basis for clinic-based risk-reduction interventions. Results indicate that at baseline, participants who reported extremely negative attitudes toward needle-sharing were less likely to have shared during the past month than those with less-extreme negative attitudes. Demographic, behavioral, and attitudinal variables were entered into a logistic regression model to examine needle-sharing group membership among HIV-positive IDUs. Being female and having less-extreme negative attitudes toward sharing were independent and significant correlates of sharing behavior. Interventions targeting needle-sharing attitudes deployed within the clinical care setting may be well-positioned to reduce HIV transmission among HIV-positive IDUs.

A neglected population: drug-using women and women's methods of HIV/STI prevention

Women drug users are at extremely high risk of HIV and sexually transmitted infections (STIs) from sexual transmission, but remain seriously neglected in intervention research promoting women-initiated methods of HIV/STI prevention. Sparse available data indicate a high interest and enthusiasm for women-initiated methods among these women. Moreover, drug-using women may be in a position to capitalize most on the myriad advantages of women-initiated methods and be the least hindered by their disadvantages, as compared with other populations of at-risk women. These advantages include, for example, the potential for prior placement and use of a female condom without being noticed by a drunk or "high" partner, long-term and/or clandestine use of cervical barriers, and the "contraceptive justification" to partners or clients initially unwilling to accede to use of a female barrier. Targeted, community-based outreach and educational efforts to this extremely hard-to-reach group as well as expanded public funding for women's methods are urgent priorities.

Addiction and sexually transmitted disease (STD), human immunodeficiency virus, (HIV), and acquired immune deficiency syndrome (AIDS): their mutual interactions

We explore the links between substance use, misuse, addiction, and dependency1 and sexuality, sexually transmitted diseases (STD), human immunodeficiency virus (HIV), and acquired immune deficiency syndrome (AIDS) to increase our awareness of their interdependence and to identify new ways to perceive, judge, and intervene (or not to) with associated problems. We consider the sociocultural and economic context in which these behaviors occur; the impact these behaviors have on one another; the personal opinions and attitudes; the religious, moral, or political beliefs and agendas; the physiological and fiscal constraints; and theories of rational decision-making and psychological motivation that act to increase or reduce the incidence of these behaviors and their sequellae, while hindering or facilitating prevention, harm reduction, and treatment interventions. Mechanisms of epidemic spread of STDS/HIV/AIDS are presented in the Appendix. Each of these terms are loaded "container concepts" that are culture-bound and stakeholder-driven and whose dimensions are less than consensus-based. They represent a range of meanings, uses, and misuses in an ongoing politicalized area of human and systemic functioning and adaptations.