Gender differences in risk behaviors among HIV+ persons with an IDU history. The link between partner characteristics and women's higher drug-sex risks. The Manif 2000 Study Group

Network Correlates of Using a Syringe After an Injection Partner Among Women Who Inject Drugs in Philadelphia Pennsylvania

This analysis aims to identify relationship-level correlates of receptive syringe sharing among women who inject drugs in Philadelphia. Sixty-four women who injected daily were recruited from Prevention Point Philadelphia's syringe exchange program (9/2/20 - 11/23/20). Interviewer-administered surveys collected (1) individual-level demographics and risk behaviors and (2) relationship-level information about each past-6-month injection partner and injecting practices between the two. We built two separate log-binomial regression models which accounted for clustering of network members within participants to identify relationship-level correlates of using a syringe after a partner. Women reported injecting with a syringe previously used by 21.14% of partners. Women were more likely to use a syringe after sex partners (Adjusted Prevalence Ratio [APR]model_1=2.77) and those who provided injection assistance (APRmodel_1=1.92) or emotional support (APRmodel_2=6.19). Future harm reduction efforts could train women to negotiate safer injection practices with sex partners and those who provide injection assistance and/or emotional support.

Age of Initiation and Patterns of Use among People Who Inject Drugs Welcomed in Harm Reduction Facilities in France from 2006 to 2015

This exploratory analysis of time-series cross-sectional data provides insights on trends in age at first injection among people who inject drugs in France, and on associations with recent risky injecting behaviors. Data were collected from a national survey conducted in harm reduction facilities in five phases between 2006 and 2015. Standardized questionnaires collected information on demographics, substance use, and route of administration, as well as lifetime and past-month injection. Descriptive and multilevel models were applied to account for the hierarchical structure of the data. Prevalence of lifetime and past-month injection remained stable over time, while the prevalence of daily injection increased significantly. Mean age at first injection only appeared to increase for data collected after 2010. Gender differences in mean age at first injection decreased over time, suggesting the development of converging patterns of initiation independent of sex. After controlling for covariates, early initiation of injection was unrelated to daily injection or material sharing, and associated with the number of recently injected substances. Early initiation is likely a predictor of injected polysubstance use. Findings are relevant to the planning, implementation, and evaluation of prevention programs.

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<.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.

The Effect of Female Sex on Hepatitis C Incidence Among People Who Inject Drugs: Results From the International Multicohort InC3 Collaborative

Background

The objective of this study was to assess differences in hepatitis C virus (HCV) incidence by sex in people who inject drugs (PWID), using a large international multicohort set of pooled biological and behavioral data from prospective observational studies of incident human immunodeficiency virus (HIV) and HCV infections in high-risk cohorts (the InC3 Collaborative).

Methods

HCV infection date was estimated based on a hierarchy of successive serological (anti-HCV), virological (HCV RNA), and clinical (symptoms and/or liver function tests) data. We used a Cox proportional hazards model to calculate the crude and adjusted female to male (F:M) hazard ratio (HR) for HCV incidence using biological sex as the main exposure.

Results

A total of 1868 PWID were observed over 3994 person-years of observation (PYO). Unadjusted F:M HR was 1.38 (95% confidence interval [CI], 1.15-1.65) and remained significant after adjusting for behavioral and demographic risk factors (1.39 [95% CI, 1.12-1.72]). Although syringe and equipment sharing were associated with the highest HCV incidence rate in women (41.62 and 36.83 PYO, respectively), we found no sex differences attributed to these risk factors.

Conclusions

Our findings indicate that women who inject drugs may be at greater risk of HCV acquisition than men, independent of demographic characteristics and risk behaviors. Multiple factors, including biological (hormonal), social network, and differential access to prevention services, may contribute to increased HCV susceptibility in women who inject drugs.

Gender Differences in HIV Sexual Risk Behaviors Among Clients of Substance Use Disorder Treatment Programs in the U.S

This study examined differences in sexual risk behaviors by gender and over time among 1281 patients (777 males and 504 females) from 12 community-based substance use disorder treatment programs throughout the United States participating in CTN-0032, a randomized control trial conducted within the National Drug Abuse Treatment Clinical Trials Network. Zero-inflated negative binomial and negative binomial models were used in the statistical analysis. Results indicated significant reductions in most types of sexual risk behaviors among substance users regardless of the intervention arms. There were also significant gender differences in sexual risk behaviors. Men (compared with women) reported more condomless sex acts with their non-primary partners (IRR = 1.80, 95 % CI 1.21-2.69) and condomless anal sex acts (IRR = 1.74, 95 % CI 1.11-2.72), but fewer condomless sex partners (IRR = 0.87, 95 % CI 0.77-0.99), condomless vaginal sex acts (IRR = 0.83, 95 % CI 0.69-1.00), and condomless sex acts within 2 h of using drugs or alcohol (IRR = 0.70, 95 % CI 0.53-0.90). Gender-specific intervention approaches are called for in substance use disorder treatment.

Innovative community-based educational face-to-face intervention to reduce HIV, hepatitis C virus and other blood-borne infectious risks in difficult-to-reach people who inject drugs: results from the ANRS-AERLI intervention study

AIMS

To study the effectiveness of an educational intervention on risks associated with drug injection, comparing primary [unsafe HIV-hepatitis C virus (HCV) practices] and secondary (local complications at injecting site) end-points in harm reduction (HR) programmes offering this intervention versus HR programmes not offering it.

DESIGN

This non-random clustered intervention study was conducted in nine intervention groups (programmes offering the intervention) and eight control groups (programmes not offering it). Each participant was followed-up through a telephone interview at enrolment and at 6 and 12 months.

SETTING

The study took place in 17 cities throughout France.

PARTICIPANTS

Of the 271 participants, 144 were enrolled into the intervention group and 127 in the control group. Of the latter, 113 received at least one educational session.

INTERVENTION

A series of participant-centred face-to-face educational sessions. Each session included direct observation by trained non-governmental organization (NGO) staff or volunteers of participants' self-injecting the psychoactive product they used habitually; analysis by the trained NGO staff or volunteers of the participant's injecting practices, identification of injection-related risks and explanation of safer injecting practices; and an educational exchange on the individual participant's injection practices and the questions he or she asked.

MEASUREMENTS

Primary and secondary outcomes were 'at least one unsafe HIV-HCV practice' and at least one injection-related complication (derived from a checklist).

FINDINGS

The proportion of participants with at least one unsafe HIV-HCV practice in the intervention group decreased significantly, from 44% at M0 to 25% at M6, as well as complications at the injection site (from 66 to 39% at M12), while in the control group it remained mainly stable. Multivariate probit analyses showed that the intervention group experienced a significant reduction in unsafe HIV-HCV practices at M6 [coefficient, 95% confidence interval (CI) = -0.73 (-1.47 to 0.01)] and in injection-related complications at M12 [coefficient, 95% CI = -1.01 (-1.77 to -0.24)], compared with the control group.

CONCLUSIONS

An inexpensive and easily implemented educational intervention on risks associated with drug injection reduces significantly unsafe HIV-HCV transmission practices and injection-related complications.

The role of social networks and geography on risky injection behaviors of young persons who inject drugs

BACKGROUND

Little is known about young persons who inject drugs (PWID), who are increasingly from suburban communities and predominantly non-Hispanic white.

METHODS

We conducted a cross-sectional personal network (egocentric) and geographic study of young PWID and their drug-using, sexual, and support network members in 2012-13 in metropolitan Chicago, Illinois, U.S.

RESULTS

We enrolled 164 young (median age=26), mostly male (65%), non-Hispanic white PWID (71%), with a self-reported HCV prevalence of 13%. Many (59%) reported multiple residences (i.e., were transient) in the past year, 45% of whom reported living in both urban and suburban places (i.e., were cross-over transients). In multivariable analyses that adjusted for participant and network member characteristics, (1) large injection networks were more common among homeless participants; and (2) syringe sharing was (a) highest among cross-over transients compared to suburban (OR=4.19 95% CI 1.69-10.35) and urban only residents (OR=2.91 95% CI 1.06-8.03), (b) higher among HCV-unknown compared HCV-negative participants (OR=4.62 95% CI 1.69-10.35), (c) more likely with network members who were cross-over transients compared to urban (OR=4.94, 95% CI 2.17-11.23) and (d) less likely with network members with HCV-unknown compared to HCV-negative status (OR=0.4 95% CI 0.19-0.84).

CONCLUSIONS

We identified homelessness as a significant risk factor for large networks and cross-over transience as a significant risk factor for syringe sharing. Further research is needed to understand the role of geographic factors promoting higher risk among these crossover transient PWID.

Higher risk of incident hepatitis C virus among young women who inject drugs compared with young men in association with sexual relationships: a prospective analysis from the UFO Study cohort

BACKGROUND

Female injection drug users (IDUs) may report differences in injection behaviours that put them at greater risk for hepatitis C virus (HCV). Few studies have examined these in association with HCV incidence.

METHODS

Longitudinal data from a cohort of 417 HCV-uninfected IDU aged 30 or younger were analysed. Cox proportional hazards was used to model female sex as a predictor of new HCV infection. General estimating equation (GEE) analysis was used to model female sex as a predictor of HCV-associated risk behaviour prospectively.

RESULTS

Women were significantly more likely than men to become infected with HCV during study follow-up (HR 1.4, p<0.05), and were also more likely than men to report high-risk injecting behaviours, especially in the context of sexual and injecting relationships. Sex differences in injecting behaviours appeared to explain the relationship between sex and HCV infection.

CONCLUSIONS

Young women's riskier injection practices lead to their higher rates of HCV infection. Further study on the impact of intimate partnership on women's risk behaviour is warranted.

Having Multiple Sexual Partners among Iranian Intra-Venous Drug Users

BACKGROUND

Transmission of HIV from intra-venous drug users (IDUs) to the community occurs predominantly through high-risk sexual behaviors. Limited information exists regarding the high-risk sexual behaviors of IDUs in Iran.

AIM

The aim of this study was to determine the prevalence and factors associated with having multiple sexual partners among Iranian IDUs.

METHODS

This is a national survey on drug-dependent adults. Participants were sampled from medical centers, prisons, and streets of capitals of 29 provinces in Iran between May 2007 and February 2008. We analyzed data of 1416 current IDUs. Socio-demographics and drug use characteristics were entered into a binary logistic regression model to determine predictors of having multiple sexual partners.

RESULTS

Having multiple sexual partners in the past or at the time of survey was reported by 56.4% of Iranian IDUs. Multivariate analysis showed that the likelihood of having multiple sexual partners in IDUs decreased by being married [odds ratio (OR), 0.38; P < 0.001] and increased by female gender (OR, 13.44; P = 0.02), having illegal income (OR, 1.72; P = 0.003), higher monthly family income (OR, 1.01; P = 0.003), pleasure, curiosity, and recreation as cause of first drug use (OR, 1.37; P = 0.04), ruins as usual place for injection (OR, 1.89; P = 0.001) and history of syringe sharing (OR, 1.50; P = 0.02).

CONCLUSION

Having multiple sexual partners was reported by majority of Iranian IDUs, and this was linked to socio-demographics, initiation data, and other risk behaviors. This information should be considered in prevention efforts to reduce sexual transmission of HIV infection in Iran.

Refining HIV risk: the modifying effects of youth, gender and education among people who inject drugs in Poland

OBJECTIVE

The goal of this study was to examine specific factors placing young (aged <30) women who inject drugs at higher risk for HIV, and to establish the need for targeted interventions within this population.

METHODS

A national cross-sectional sero-survey was conducted in 2004-2005 in six regions in Poland. A snowball sample of ever-injectors was recruited from drug treatment facilities and the surrounding community. Log-binomial regression was used to estimate adjusted prevalence ratios (PRs).

RESULTS

A total of 491 injection drug users younger than 30 were recruited, of whom 159 were women and 332 were men. The prevalence of HIV was 16.4% and 9.6% among women and men, respectively. In multivariate analysis, young female injectors whose education terminated at the primary level were more likely to be HIV-positive compared to males with a similar level of education (PR = 3.34, 95% CI = 1.86-6.00) and more highly educated women (PR = 4.16, 95% CI = 2.21-7.82).

CONCLUSIONS

This study confirms an elevated risk of HIV among under-educated young women. Suggestions for specific interventions to reduce HIV transmission are presented. Additional research is needed to quantify the differential distribution of risk behaviors which amplify their likelihood of transmission.

Control over drug acquisition, preparation and injection: Implications for HIV and HCV risk among young female injection drug users

Young female injection drug users (IDUs) are at risk for HIV/HCV, and initiating the use of a new drug may confer additional and unexpected risks. While gender differences in the social context of injection drug use have been identified, it is unknown whether those differences persist during the initiation of a new drug. This mixed-methods study examined the accounts of 30 young female IDUs in Los Angeles, CA, USA from 2004 to 2006, who described the social context of initiating injection drug use and initiating ketamine injection. The analysis aimed to understand how the social context of young women's injection events contributes to HIV/HCV risk. Women's initiation into ketamine injection occurred approximately 2 years after their first injection of any drug. Over that time, women experienced changes in some aspects of the social context of drug injection, including the size and composition of the using group. A significant proportion of women described injection events characterized by a lack of control over the acquisition, preparation, and injection of drugs, as well as reliance on friends and sexual partners. Findings suggest that lack of control over drug acquisition, preparation, and injection may elevate women's risk; these phenomena should be considered as a behavioral risk factor when designing interventions.

Peters C. Gender disparities in HIV risk behavior and access to health care in St. Petersburg, Russia

Over 40,000 HIV-infected individuals live in St Petersburg, Russia. Population characteristics and barriers to care are largely undefined. 152 consecutive patients receiving HIV care at two sites completed a questionnaire in Spring 2011. Rates of chronic hepatitis C virus (HCV) and hepatitis B virus (HBV) infection, alcohol use, and rates of antiretroviral uptake were similar by gender. Males reported a higher history of injection drug use (80.3% vs. 48.7%; p<0.01) and tuberculosis infection (18.8% vs. 1.6%; p<0.01). Females were more likely to have had a child (63.3% vs. 31.5%; p<0.01) and be currently raising that child within their residence (49.3% vs. 15.3%; p<0.01). Unprotected sex (60.5% vs. 17.8%; p<0.01) and a history of sexually transmitted infection (37.7% vs. 20.3%; p=0.03) were more common in females. Females utilized social services more frequently (34.2% vs. 11.9%; p<0.01). There is a heavy burden of concurrent infectious disease, substance use and abuse, mental health illness, and need for social service support in this population. Important differences exist between genders in service uptake and utilization. Further evaluation of these differences may help inform the allocation of limited resources in this high HIV prevalence region of Russia.

Gender differences in HIV risk behaviours among intravenous drug users in Catalonia, Spain

OBJECTIVE

To describe gender differences in injection and sexual risks behaviours, and human immunodeficiency virus (HIV) and hepatitis C (HCV) prevalence among injecting drug users (IDU) in Catalonia, Spain.

METHODS

Cross-sectional studies in 2008-2009 (n=748) and 2010-2011 (n=597) in the network of harm reduction centres. Face to face interviews were conducted and oral fluid samples were collected to estimate HIV/HCV prevalence.

RESULTS

Female were more likely than male IDU to have had a steady sexual partner (68.2% versus 44.9%), to have had an IDU steady sexual partner (46.6% versus 15.1%) and to have exchanged sex for money or drugs in the last 6 months (25.5% versus 2.3%). There were no gender differences in injecting risk behaviours. HIV prevalence was 38.7% (91/235) in women and 31.5% (347/1103) in men (p=0.031). HIV prevalence among female IDU who reported having exchange sex for money or drugs was 53.3% (32/60). The prevalence of HCV was 67.4% (159/236) and 73.6% (810/1101) in female and male IDU, respectively (p=0.053). After adjustment by immigrant status, age and years of injection, differences among HIV/HCV prevalence by gender were not significant.

CONCLUSIONS

This study demonstrated differences in sexual risk behaviours between male and female IDU, but failed to find gender differences in injecting risk behaviours. Apart from that, the higher prevalence of HIV among women than among men, together with a lower prevalence of HCV, provides evidence that sexual transmission of HIV is important among female IDU. Additional studies are needed to analyze in-depth these specific risk factors for women in order to develop appropriate prevention and health education programs.

Differing HIV risks and prevention needs among men and women injection drug users (IDU) in the District of Columbia

Washington, DC has among the highest HIV/AIDS rates in the US. Gender differences among injection drug users (IDUs) may be associated with adoption of prevention opportunities including needle exchange programs, HIV testing, psychosocial support, and prevention programming. National HIV Behavioral Surveillance data on current IDUs aged ≥18 were collected from 8/09 to 11/09 via respondent-driven sampling in Washington, DC. HIV status was assessed using oral OraQuick with Western Blot confirmation. Weighted estimates were derived using RDSAT. Stata was used to characterize the sample and differences between male and female IDU, using uni-, bi-, and multivariable methods. Factors associated with HIV risk differed between men and women. Men were more likely than women to have had a history of incarceration (86.6 % vs. 66.8 %, p < 0.01). Women were more likely than men to have depressive symptoms (73.9 % vs. 47.4 %, p < 0.01), to have been physically or emotionally abused (66.1 % vs. 16.1 %, p < 0.0001), to report childhood sexual abuse (42.7 % vs. 4.7 %, p < 0.0001), and pressured or forced to have sex (62.8 % vs. 4.0 %, p < 0.0001); each of these differences was significant in the multivariable analysis. Despite a decreasing HIV/AIDS epidemic among IDU, there remain significant gender differences with women experiencing multiple threats to psychosocial health, which may in turn affect HIV testing, access, care, and drug use. Diverging needs by gender are critical to consider when implementing HIV prevention strategies.

Are females who inject drugs at higher risk for HIV infection than males who inject drugs: an international systematic review of high seroprevalence areas

OBJECTIVE

There are multiple reasons why females who inject drugs may be more likely to become infected with HIV than males who inject drugs. Where this is the case, special HIV prevention programs for females would be needed.

DESIGN

International systematic review and meta-analysis of studies across 14 countries.

METHODS

Countries with high seroprevalence (>20%) HIV epidemics among persons who inject drugs (PWID) were identified from the Reference Group to the UN on HIV and Injecting Drug Use. Systematic literature reviews collected data on HIV prevalence by gender for these countries. Non-parametric and parametric tests along with meta-analytic techniques examined heterogeneity and differences in odds ratios (OR) across studies.

RESULTS

Data were abstracted from 117 studies in 14 countries; total sample size N = 128,745. The mean weighted OR for HIV prevalence among females to males was 1.18 [95% CI 1.10-1.26], with high heterogeneity among studies (I(2)= 70.7%). There was a Gaussian distribution of the log ORs across studies in the sample.

CONCLUSION

There was a significantly higher HIV prevalence among females compared to males who inject drugs in high seroprevalence settings, but the effect size is extremely modest. The high level of heterogeneity and the Gaussian distribution suggest multiple causes of differences in HIV prevalence between females and males, with a specific difference determined by local factors. Greater understanding of factors that may protect females from HIV infection may provide insights into more effective HIV prevention for both females and males who inject drugs.

Transitions from injection-drug-use-concentrated to self-sustaining heterosexual HIV epidemics: patterns in the international data

BACKGROUND

Injecting drug use continues to be a primary driver of HIV epidemics in many parts of the world. Many people who inject drugs (PWID) are sexually active, so it is possible that high-seroprevalence HIV epidemics among PWID may initiate self-sustaining heterosexual transmission epidemics.

METHODS

Fourteen countries that had experienced high seroprevalence (<20%) HIV epidemics among PWID and had reliable data for injection drug use (IDU) and heterosexual cases of HIV or AIDS were identified. Graphs of newly reported HIV or AIDS cases among PWID and heterosexuals were constructed to identify temporal relationships between the two types of epidemics. The year in which newly reported cases among heterosexuals surpassed newly reported cases among PWID, aspects of the epidemic curves, and epidemic case histories were analyzed to assess whether it was "plausible" or "highly unlikely" that the HIV epidemic among PWID might have initiated the heterosexual epidemic in each country.

RESULTS

Transitions have occurred in 11 of the 14 countries. Two types of temporal relationships between IDU and heterosexual HIV epidemics were identified, rapid high incidence transitions vs. delayed, low incidence transitions. In six countries it appears "plausible" that the IDU epidemic initiated a heterosexual epidemic, and in five countries it appears "highly unlikely" that the IDU epidemic initiated a heterosexual epidemic. A rapid decline in incidence among PWID after the peak year of new cases and national income were the best predictors of the "highly unlikely" initiation of a heterosexual epidemic.

DISCUSSION

Transitions from IDU concentrated epidemics to heterosexual epidemics are common in countries with high seroprevalence among PWID though there are distinct types of transitions. Interventions to immediately reduce HIV incidence among PWID may reduce the likelihood that an IDU epidemic may initiate a heterosexual epidemic.

Trajectories of injection drug use over 20 years (1988-2008) in Baltimore, Maryland

The objective of this study was to identify longitudinal patterns of injection drug use over 20 years in the AIDS Linked to the Intravenous Experience (ALIVE) Study, a community-based cohort of injection drug users (IDUs) in Baltimore, Maryland, with a focus on injection cessation. Starting in 1988, persons over 18 years of age with a history of injection drug use were recruited into the study. Participants provided information on their injection drug use semiannually through 2008. The analysis was restricted to 1,716 IDUs with at least 8 study visits. Finite mixture models were used to identify trajectories and predictors of injection patterns over time. The mean age of participants was 35 years; 75% were male, and 95% were African-American. Five distinct patterns were identified: 2 usage patterns (32% engaged in persistent injection and 16% had frequent relapse) and 3 cessation patterns (early cessation (19%), delayed cessation (16%), and late cessation (18%)). A history of drug treatment, no recent use of multiple substances, and less frequent injection distinguished the early cessation group from the other groups. This study demonstrated multiple trajectories of drug injection behaviors, with a substantial proportion of IDUs stopping injection over extended time frames. For maximum effectiveness, public health programs for IDUs should be long-term, comprehensive, and targeted toward individual patterns of use.

Tillotson C, Choi D, Robinson J, Calsyn DA, Mandler RN, Jenkins LM, Thompson LL, Dempsey CL, Liepman MR, McCarty D. Reducing HIV-related risk behaviors among injection drug users in residential detoxification

This study of 632 drug injectors enrolled in eight residential detoxification centers within the National Drug Abuse Treatment Clinical Trials Network tested three interventions to reduce drug and sex risk behaviors. Participants were randomized to: (a) a two-session, HIV/HCV counseling and education (C&E) model added to treatment as usual (TAU), (b) a one-session, therapeutic alliance (TA) intervention conducted by outpatient counselors to facilitate treatment entry plus TAU, or (c) TAU. Significant reductions in drug and sex risk behaviors occurred for all three conditions over a 6-month follow-up period. C&E participants reported significantly greater rates of attending an HIV testing appointment, but this was not associated with better risk reduction outcomes. Reporting treatment participation within 2 months after detoxification and self-efficacy to practice safer injection behavior predicted reductions in injection risk behaviors. Findings indicate that participation in detoxification was followed by significant decreases in drug injection and risk behaviors for up to 6-months; interventions added to standard treatment offered no improvement in risk behavior outcomes.

Preventing relapse in incarcerated drug users in Yunnan Province, China

INTRODUCTION AND AIMS

The mainstay of drug control in China is compulsory incarceration and detoxification, but relapse rates following release are very high. The aim of the study was to explore factors which would help prevent relapse in injecting drug users following release from detoxification centres.

DESIGN AND METHODS

Semi-structured interviews were carried out at three compulsory detoxification centres in Derhong prefecture, Yunnan Province, which has the highest proportion of injecting drug users in China.

RESULTS

Interviews were completed with 235 men and 125 women aged between 15 and 64 years. They had been injecting heroine for between 3 months and 25 years; the median number of times of previous compulsory detoxification was four, with 11% having undergone this more than 10 times. All but six wanted to quit permanently, but almost all acknowledged that relapse on release was almost inevitable. The month immediately following release was identified as most vulnerable time for relapse. Respondents identified three measures which would help decrease the rate of relapse. First, the environment of the detoxification centres should emphasise support and counselling rather than punishment. Second, families should be provided with support to help the user immediately after release. Third, arrangements could be made to help those individuals who request relocation, to find work elsewhere away from accustomed drug-using social networks.

DISCUSSION AND CONCLUSIONS

While a combination of these measures could help in some way to reduce rates of relapse following detention, given the failure of the detoxification/detention regimes to reduce drug use, consideration must be given to other approaches.

Gender, personal networks, and drug use among rural African Americans

One of the main unifying concepts of research examining gender variations in drug use behavior is the social network. Yet, research specifically focusing on how the social networks of these groups differ by gender is limited. Few studies have investigated the social networks of rural African Americans who use drugs. In this study, we compared the personal networks of 20 rural African-American men and women addicted to cocaine using social network analysis (SNA) methods. The data do not support strong assertions about gender differences in the personal networks of the study sample. However, the results of the study suggest that men tend to have more drug users in their networks than women, as well as less structurally cohesive networks. Women tend to include more men in their personal networks than men included women. Implications of the research results for network-based drug prevention intervention as well as the value of SNA methods for drug use research are discussed.

Increasing proportion of AIDS diagnoses among older adults in Italy

We evaluated the impact of AIDS among older persons in Italy and compared these cases with cases among younger persons. The data source was Italy's National AIDS Registry. We considered adults diagnosed with AIDS between 1982 and 2005. Older adults were defined as those aged 50 years or older at diagnosis. Of the total adult cases, 8.8% were among older adults. This proportion increased over time, from 4.9% in 1982-1990 to 15.9% in 2000-2005. Among older adults, the most represented exposure category (80.8%) was sexual intercourse (heterosexual and homosexual). At AIDS diagnosis, older adults, compared to younger adults, had a higher risk of developing AIDS dementia complex or wasting syndrome, and of presenting multiple AIDS-defining illnesses. A significantly lower proportion of older adults were undergoing antiretroviral therapy, compared to younger adults. Among older adults, 67.2% were late testers, compared to 32.8% of younger adults. Most of the older adults acquired the infection through sexual contact; approximately two thirds of them were diagnosed late (i.e., first HIV-positive test 6 months or less before AIDS diagnosis); and only one fourth were undergoing antiretroviral therapy at diagnosis. These observations stress the need to more seriously consider the possibility of HIV infection among older individuals and to collect more detailed information on their sexual behavior.

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.

Gender differences in sex risk behaviors among Ukraine injection drug users

OBJECTIVE

To assess gender differences in drug and sex risk behaviors and evaluate predictors of HIV-related sex risk behaviors among heterosexual injection drug users (IDUs) in Ukraine.

DESIGN

Street-recruited IDUs from Kiev, Odessa, and Makeevka/Donesk, Ukraine.

METHODS

From June 2004 through November 2006, outreach workers recruited 1557 IDUs, including 526 from Kiev, 494 from Odessa, and 537 from Makeevka/Donesk. Participants were administered a standardized computer-assisted interview assessing HIV-related drug and sex risk behaviors, self-efficacy for practicing safe sex, and HIV knowledge.

RESULTS

Overall, 80% of the participants were sexually active in the 30-day period before their interview. They also engaged in high-risk sex behaviors during this brief 30-day window: 53% reported anal or vaginal sex without a condom, 27% had sex with more than 1 partner, 41% had an IDU sex partner, and 37% had an HIV-positive sex partner or a partner whose HIV status they did not know. Overall, women were at higher risk than men and were more likely to have been told they were HIV-positive.

CONCLUSION

The extremely high HIV prevalence rate in Ukraine and in this cohort, combined with their recent high-risk sex behaviors, forecasts not only a continuance of the epidemic in the region but an escalation.

HIV risk behaviors among female IDUs in developing and transitional countries

BACKGROUND

A number of studies suggest females may be more likely to engage in injection and sex risk behavior than males. Most data on gender differences come from industrialized countries, so data are needed in developing countries to determine how well gender differences generalize to these understudied regions.

METHODS

Between 1999 and 2003, 2512 male and 672 female current injection drug users (IDUs) were surveyed in ten sites in developing countries around the world (Nairobi, Beijing, Hanoi, Kharkiv, Minsk, St. Petersburg, Bogotá, Gran Rosario, Rio, and Santos). The survey included a variety of questions about demographics, injecting practices and sexual behavior.

RESULTS

Females were more likely to engage in risk behaviors in the context of a sexual relationship with a primary partner while males were more likely to engage in risk behaviors in the context of close friendships and casual sexual relationships. After controlling for injection frequency, and years injecting, these gender differences were fairly consistent across sites.

CONCLUSION

Gender differences in risk depend on the relational contexts in which risk behaviors occur. The fact that female and male risk behavior often occurs in different relational contexts suggests that different kinds of prevention interventions which are sensitive to these contexts may be necessary.

Prevalence and correlates of risky sexual behaviors among injection drug users in Tashkent, Uzbekistan

The objective of this paper is to describe prevalence and correlates of sexual risk behaviors among injection drug users (IDUs) in Tashkent, Uzbekistan. Participants in this cross-sectional study completed a questionnaire detailing sociodemographic, medical and drug and sexual risk behaviors and HIV antibody testing. Of 701 IDUs surveyed, only 20.5% reported consistent condom use, which was more likely for women. Prior sexually-transmitted infection (STI) diagnosis was reported by 36.2% of participants and was associated with early (</=18 years) drug initiation, group drug use, being older, higher educational level, marriage, needle sharing, multiple sex partners in the preceding month and daily injection use. Having multiple partners in the preceding month was common (29.71%) and related to employment, consistent condom use with regular partners and STI self-treatment in multivariate logistic regression. Participants with a history of sharing needles were less likely to have had multiple partners in the previous month. Risky sexual behaviors are common and interrelated with risky injection habits among IDUs in Tashkent, Uzbekistan, representing a continued threat of infection with HIV and other blood-borne agents.

A qualitative exploration of gender in the context of injection drug use in two US-Mexico border cities

Injection drug use is of increasing concern along the U.S.-Mexico border where Tijuana and Ciudad (Cd.) Juarez are located. We conducted a qualitative study to explore the context of drug use, with a focus on gender differences. In-depth interviews were conducted with 10 male and 10 female injection drug users (IDUs) in Tijuana and 15 male and 8 female IDUs in Cd. Juarez. Topics included types of drugs used, injection settings, access to sterile needles and environmental influences. Interviews were taped, transcribed and translated. Content analysis was conducted to identify themes. Several themes emerged with respect to gender: (a) how drugs were obtained; (b) where drugs were used; (c) relationship dynamics surrounding drug use; and (d) sex in exchange for money or drugs. Men reported buying and injecting in shooting galleries and other locations, whereas women tended to buy and inject drugs with people they knew and trusted. All men reported having shared syringes in shooting galleries, often with strangers. In these two cities, venue-based interventions may be more appropriate for male IDUs, whereas personal network interventions may be more appropriate among female IDUs.

Unsafe sex in regular partnerships among heterosexual persons living with HIV: evidence from a large representative sample of individuals attending outpatients services in France (ANRS-EN12-VESPA Study)

OBJECTIVE

Risky sexual behaviour remains frequent among people living with HIV. We analysed factors associated with unsafe sex within serodiscordant couples among heterosexual individuals living with HIV in France.

METHODS

In 2003, a face-to-face survey was conducted among individuals selected in a random stratified sample of 102 French hospital departments delivering HIV care. This analysis included adults heterosexual participants in a regular partnership for at least 12 months with a seronegative/unknown serostatus partner, HIV-diagnosed for at least 12 months. Unsafe sex was defined as reporting inconsistent condom use in the prior 12 months. Among men and women, participants who reported unsafe sex were compared with those who did not.

RESULTS

663 heterosexual adults reported being in a serodiscordant regular partnership. Women accounted for 41% of participants and 26% of the sample were immigrants. Unsafe sex with the steady partner was reported by 26% of men and 34% of women (p=0.024). For men, factors independently associated with unsafe sex were being in a relationship for more than 10 years, being in a difficult financial situation and reporting regular consumption of alcohol to excess. Among women, having a history of drug use, not being aware of partner's serostatus, and reporting a difficult financial situation were independently associated with unsafe sex. In addition, immigrant women were associated with safer sex.

CONCLUSIONS

A high number of serodiscordant couples continue to report risky sexual behaviour, and related factors are gender-specific. Couple-level interventions are essential in order to prevent HIV-transmission and to encourage negotiation within couples.

Profiles of risk: a qualitative study of injecting drug users in Tehran, Iran

Background

In Iran, there are an estimated 200,000 injecting drug users (IDUs). Injecting drug use is a relatively new phenomenon for this country, where opium smoking was the predominant form of drug use for hundreds of years. As in many countries experiencing a rise in injecting drug use, HIV/AIDS in Iran is associated with the injection of drugs, accounting for transmission of more than two-thirds of HIV infections. This study aimed to: describe the range of characteristics of IDUs in Tehran, Iran's capital city; 2) examine the injecting-related HIV risk behaviors of IDUs, and 3) suggest necessary interventions to prevent HIV transmission among IDUs and their families and sex partners.

Methods

Using rapid assessment and response methods with a qualitative focus, six districts of Tehran were selected for study. A total of 81 key informants from different sectors and 154 IDUs were selected by purposeful, opportunistic and snowball sampling, then interviewed. Ethnographic observations were done for mapping and studying injecting-related HIV risk settings and behaviors. Modified content analysis methods were used to analyze the data and extract typologies of injecting drug users in Tehran.

Results

Evidence of injecting drug use and drug-related harm was found in 5 of 6 study districts. Several profiles of IDUs were identified: depending on their socioeconomic status and degree of stability, IDUs employed different injecting behaviors and syringe hygiene practices. The prevalence of sharing injection instruments ranged from 30–100%. Varied magnitudes of risk were evident among the identified IDU typologies in terms of syringe disinfection methods, level of HIV awareness, and personal hygiene exhibited. At the time of research, there were no active HIV prevention programs in existence in Tehran.

Conclusion

The recent rise of heroin injection in Iran is strongly associated with HIV risk. Sharing injection instruments is a common and complex behavior among Iranian IDUs. For each profile of IDU we identified, diverse and targeted interventions for decreasing sharing behavior and/or its harms are suggested. Some notable efforts to reduce the harm of injecting drug use in Iran have recently been accomplished, but further policies and action-oriented research for identification of effective preventive interventions are urgently needed.

Gender and HIV risk behavior among intravenous drug users in Sichuan Province, China

Using data from a community-based study of injection drug users (IDUs) in Sichuan Province in China, this study compared the level of HIV risk behavior (needle sharing and unsafe sex) amongst female and male IDUs, and examined the risk factors separately for these two groups. Five risk factors were examined in the analysis, including a lack of family support, having an IDU primary sex partner, economic pressure, lack of access to a methadone program, and younger age. Regression results showed that male and female IDUs had different risk factors. For male IDUs, younger age and a lack of family support increased their level of HIV risk behavior. For female IDUs, having an IDU primary sex partner and economic pressure were predictive of their HIV risk behavior. Sex differences in risk factors are explained with respect to gender norms surrounding HIV risk behavior in the context of social relations. Female IDUs who were sex workers suffered additional HIV risk due to their powerlessness in negotiating safe sex with male customers. Practical implications of the findings for HIV/AIDS prevention and intervention work in China are discussed.

Access and utilization of HIV treatment and services among women sex workers in Vancouver's Downtown Eastside

Many HIV-infected women are not realizing the benefits of highly active antiretroviral therapy (HAART) despite significant advancements in treatment. Women in Vancouver's Downtown Eastside (DTES) are highly marginalized and struggle with multiple morbidities, unstable housing, addiction, survival sex, and elevated risk of sexual and drug-related harms, including HIV infection. Although recent studies have identified the heightened risk of HIV infection among women engaged in sex work and injection drug use, the uptake of HIV care among this population has received little attention. The objectives of this study are to evaluate the needs of women engaged in survival sex work and to assess utilization and acceptance of HAART. During November 2003, a baseline needs assessment was conducted among 159 women through a low-threshold drop-in centre servicing street-level sex workers in Vancouver. Cross-sectional data were used to describe the sociodemographic characteristics, drug use patterns, HIV/hepatitis C virus (HCV) testing and status, and attitudes towards HAART. High rates of cocaine injection, heroin injection, and smokeable crack cocaine use reflect the vulnerable and chaotic nature of this population. Although preliminary findings suggest an overall high uptake of health and social services, there was limited attention to HIV care with only 9% of the women on HAART. Self-reported barriers to accessing treatment were largely attributed to misinformation and misconceptions about treatment. Given the acceptability of accessing HAART through community interventions and women specific services, this study highlights the potential to reach this highly marginalized group and provides valuable baseline information on a population that has remained largely outside consistent HIV care.

Injection risk behavior among women syringe exchangers in San Francisco

Women who inject drugs in cities where syringe exchange programs (SEPs) are well established may have different risks for HIV infection. In 1997, we interviewed 149 female syringe exchangers in San Francisco, CA, a city with high rates of injection drug use that is home to one of the largest and oldest SEPs in the United States. In this report, we describe their sociodemographics, health, and risk behavior, and we examine factors associated with recent syringe sharing. Fifty percent of respondents were women of color and the median age was 38 years. Most (86%) injected heroin and nearly half were currently homeless or had recently been incarcerated. One-third of all women reported needle sharing in the prior month. This was higher than the rate of needle sharing reported by a mixed gender sample of San Francisco exchangers in 1993, although it resembled the rate reported by a mixed gender sample in 1992. In a multivariate analysis, syringe sharing was associated with age, housing status, and sexual partnerships. Syringe sharers were more likely to be young, homeless, or have a sexual partner who was also an injection drug user. While wide access to sterile syringes is an important strategy to reduce HIV transmission among injection drug users (IDU), syringe exchange alone cannot eradicate risky injection by female IDU. Additional efforts to reduce risky injection practices should focus on younger and homeless female IDU, as well as address selective risk taking between sexual partners.

Knowledge of HIV Postexposure Prophylaxis in a Population of HIV-Positive Outpatients: Results of a French National Survey

Since 1998, French HIV guidelines have recommended use of HIV prophylaxis after unprotected sex (postexposure prophylaxis, or PEP) with an HIV-positive partner. To characterize factors associated with lack of PEP knowledge in an HIV-positive population, a cross-sectional survey was conducted of 737 French HIV-positive outpatients followed in AIDS care units of 2 regions accounting for 60% of French AIDS cases. Information was collected through face-to-face interviews. The sample was weighted to improve national validity. Median age was 41 years, 73.2% of patients were male, and 8.5% reported HIV-related risk behaviors. Those who knew about PEP and those who did not were compared with chi2 tests and logistic regression. One third of the sample had never heard of PEP. In multivariate analysis, lack of PEP knowledge was associated with older age, low educational level, unstable housing, unawareness of current HIV laboratory data, and lack of ability to confide in nurse and to seek out information from various sources. The increased number of people living with HIV infection as a chronic disease raises new challenges for its secondary prevention. Preventive programs aimed at HIV-positive individuals and their sexual partners are strongly needed.

Evaluation of buprenorphine maintenance treatment in a French cohort of HIV-infected injecting drug users

BACKGROUND

Buprenorphine was approved in France for treating opiate dependence in July 1995 and can be prescribed by general practitioners (GPs). Most studies assessing buprenorphine maintenance treatment (BMT) outcomes have taken place in GP settings. An evaluation of BMT outcomes in patients already followed for their HIV-infection could supply additional information about the changes in addictive practices in a non-GP setting.

METHODS

We assessed BMT discontinuations and the course of self-reported addictive behaviours and characteristics associated with buprenorphine-injection misuse in 114 HIV-infected patients on BMT who were followed in a hospital-based outpatient department.

RESULTS

The continuous series of follow-up visits at which these 114 patients reported regular buprenorphine prescriptions accounted for 237.5 person-years of observation, i.e. 475 follow-up visits. Of the 114 patients on BMT, 43% continued BMT throughout the follow-up, 40% stopped it, and results for 17% were not available either because they did not answer the self-administered questionnaire (5%) or because they were lost to follow-up (12%). Addictive behaviours declined but buprenorphine injection misuse remained stable. Depression measured by the CESD score (RR=1.04 95%CI [1.01-1.06]), cocaine use (RR=2.48 95%CI [1.31-4.68]) and alcohol consumption exceeding 4 alcohol units (AU) per day (RR=2.29, 95%CI [1.17-4.46]) were independently associated with buprenorphine injection misuse among stabilised BMT patients.

CONCLUSIONS

Despite the reduction in drug injection after starting BMT, buprenorphine injection misuse mainly involves patients with characteristics of severe addiction. Better monitoring of the illicit drug use patterns of patients on BMT may suggest new medical strategies for GPs to improve BMT outcomes.

Hospitalization for depressive syndrome in a cohort of HIV-infected patients contaminated through injecting drug use: MANIF 2000 cohort, France, 1995-1999

The objective of this study was to estimate the relative impact of hospitalization for depressive syndrome (DS) on all causes of hospitalization and characterize individuals more likely to experience hospitalization for DS in the French cohort study, Manif 2000, of patients HIV infected through injection drug use. We selected all patients followed-up to the 24-month visit (C24) who missed no more than one visit. Using medical records, dates and causes of hospitalizations, were collected retrospectively. A Poisson regression model based on generalized estimating equations was used to identify factors associated with hospitalization for DS. During the study period, 223 hospitalizations were recorded for 120 of the 335 selected patients. DS was the second reason for hospitalization after infections, accounting for 14.3% of the total number of hospitalizations. DS was reported in 32 hospitalizations and involved 24 patients, five of them being hospitalized more than once for the same cause. Factors independently associated with hospitalization for DS were history of multiple incarceration (RR = 2.1, 95% CI: 1.0-4.7), polydrug use (RR = 2.6, 95% CI: 1.1 -5.9) and lack of stable relationship (RR = 4.2, 95% CI: 1.6- 11. 1). In the HAART era, DS represents an important cause of hospitalization of HIV-infected injecting drug users, mainly concerning patients presenting no stable relationship and signs of social instability. Scheduled psychiatric consultations for these patients would permit us to identify those for whom major depression might lead to hospitalization and provide them with timely and appropriate care.

Taking action in communities: women living with HIV/AIDS lead the way

For the past 5 years, a successful collaboration of a medical center, a community-based HIV/AIDS service organization, a university school of nursing, and women living with HIV/AIDS in an inner city community resulted in a series of educational programs1 for women living with HIV/AIDS, their family, friends and caregivers. These programs were intended to provide inner-city women who were living with HIV/AIDS with knowledge and new insights from the voices of their peers. Topics focused on their self-care and empowerment so that they could take control of their wellness and their health care while remaining in their community. The efforts made in launching the collaborative educational series created trusting relationships between academic, clinical, and community service agencies, professional caregivers, and the recipients of their care. The most significant contribution belonged to the women living with HIV/AIDS themselves: After the programming they turned their health and life experiences into "action" by planning a research project that will test the efficacy of an intergenerational HIV prevention program for adolescent women of color in their community in the future.

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

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

Highly active antiretroviral treatment does not increase sexual risk behaviour among French HIV infected injecting drug users

STUDY OBJECTIVE

This study examined the impact of highly active antiretroviral therapies (HAART) on sexual risk behaviours of HIV infected injecting drug users (IDUs) included in the French MANIF 2000 cohort study.

DESIGN

Longitudinal analysis including baseline and last follow up characteristics using generalised estimating equations (GEE).

SETTING

Hospital departments for specialist AIDS care in south eastern France and inner suburbs of Paris.

PATIENTS

All patients antiretrovial treatment naive, who reported being sexually active at enrollment, and who had at least one follow up visit in the cohort between October 1996 and May 1998 (n=188).

MAIN RESULTS

Of the 188 HIV infected IDUs who were antiretroviral treatment naive at enrollment, 34 were prescribed HAART during follow up. Proportion of patients who reported at least one episode of unprotected sexual intercourse in the previous six months only significantly decreased in the HAART treated group (from 47.1% to 23.5%, p=0.008, compared with 43.5% to 35.7% in the rest of the sample, p=0.10). GEE multivariate model confirmed that prescription of HAART was associated with reduced sexual risk.

CONCLUSIONS

The concern that HAART might result in clinical improvement leading to resumption of high risk activities that could inadvertently result in HIV transmission was not supported by these data. Reasons for further reductions in HIV risk with taking HAART remain to be clarified.

HIV-positive notification and behavior changes in Montreal injection drug users

This study examined the effect of an HIV-positive notification on the sexual and injection behaviors, living conditions, and medical demands of injection drug users (IDUs) in Montreal. The behavior changes of 73 IDUs who received an HIV-positive test result, and 219 IDUs who tested negative were compared, and the net difference (ND) in the proportion of IDUs adopting the particular change was determined. No significant changes were found in drug use or needle sharing practices. A higher proportion of IDUs who received an HIV-positive notification acquired unstable living conditions, ND = 20.7% (95% CI = 3.3, 38.1), began medical follow up, ND = 34.4% (95% CI = 20.8, 48.7), and increased needle exchange program (NEP) utilization, ND = 20.5% (95% CI = 8.3, 32.8). Compared with HIV-negative males, more HIV-positive male IDUs stopped sexual relations, ND = 24.6% (95% CI = 0.4, 48.9), and sex work, ND = 31.8% (95% CI = 12.4, 51.3), and fewer began new relations, ND = -38.2% (95% CI = -52.6, -23.9). The medical community and NEPs have an important role in providing support for newly diagnosed IDUs.

Social factors related to syringe sharing among injecting partners: a focus on gender

The study of social networks has become an increasingly utilized method of examining the relationship between injection drug users' social environment and risk of HIV. This study examined relational aspects of two injection drug users (IDUs) within a single social network as they relate to sharing syringes. Data presented in this study were derived from baseline interviews of 508 IDUs from Baltimore, MD. Analyses were performed separately for male and female participants in an effort to understand gender differences in social aspects of syringe sharing. Among this sample, women shared syringes with a significantly higher percentage of injecting partners compared to men. In separate multilevel logistic regression models, significant variables associated with males' and females' syringe sharing were: sharing drugs daily with female injecting partners, injecting partners' provision of drugs when indexes' were withdrawing, being sexual partners, and injecting partners' injecting speedballs. Factors associated with male injecting dyads sharing of syringes were: being kin, injecting partners' injection of heroin and daily drug use, and drinking alcohol together. Results from this study demonstrate the usefulness of examining relationship characteristics of injecting dyads related to syringe sharing as they differ between men and women.

Conducting meta-analyses of HIV prevention literatures from a theory-testing perspective

Using illustrations from HIV prevention research, the current article advocates approaching meta-analysis as a theory-testing scientific method rather than as merely a set of rules for quantitative analysis. Like other scientific methods, meta-analysis has central concerns with internal, external, and construct validity. The focus of a meta-analysis should only rarely be merely describing the effects of health promotion, but rather should be on understanding and explaining phenomena and the processes underlying them. The methodological decisions meta-analysts make in conducting reviews should be guided by a consideration of the underlying goals of the review (e.g., simply effect size estimation or, preferably theory testing). From the advocated perspective that a health behavior meta-analyst should test theory, the authors present a number of issues to be considered during the conduct of meta-analyses.

Sexual behaviour of heterosexual individuals with HIV infection naive for antiretroviral therapy in Italy

BACKGROUND

Specific information about determinants of sexual behaviour of HIV infected heterosexuals, like injecting drug use (IDU), are essential to design interventions aimed at promoting safer sex practices.

METHODS

We analysed data on sexual behaviour collected, between March 1997 and March 1999, through a self administered questionnaire among 1050 IDUs and 642 non-IDU heterosexuals enrolled in a prospective multicentre cohort study on the natural history of HIV infection.

RESULTS

Among non-IDU heterosexuals, more women (48.5%) than men (25.1%) (p<0.001) reported that they were infected by HIV positive regular partners whose HIV status they were not aware of. Among the 1119 heterosexual males, one fifth reported having had more than 25 sexual partners during their lifetime. Condom use in the last sexual intercourse was more common among heterosexual IDUs (64.9%) than among non-IDU heterosexual males (58.3%) (p=0.05). Heterosexual IDU males were more likely (66.7%) than non-IDU heterosexuals (50.6%) to have an HIV negative partner (p<0.001). Of the 573 heterosexual females studied, 10.2% reported having had more than 25 lifetime sex partners. This proportion was higher among heterosexual IDUs (18.8%) than among non-IDU heterosexuals (4.3%) (p<0.001). Nearly 50% of the women in both groups reported having used a condom in the last intercourse. Almost 57% of heterosexual IDUs had a current HIV negative partner, compared with 34.9% non-IDU heterosexuals (p<0.001). In both sexes, the findings from univariate analysis were confirmed by multiple logistic regression analysis.

CONCLUSIONS

This study identified some important differences, in both males and females, in sexual lifestyles according to injecting drug use (for example, in terms of HIV negative partners). This observation indicates the need to tailor HIV prevention messages according to history of injecting drug use.

Networks, resources and risk among women who use drugs

The public health tradition of intervening at the environmental level has not been fully exploited in terms of HIV prevention efforts among drug users. Women who use drugs are at particularly high risk of acquiring HIV and other blood borne and sexually transmitted infections, such as hepatitis B (HBV) and hepatitis C (HCV), and could potentially benefit from environmental level interventions. In a review of the existing literature, we examine the extent to which the linkages among multiple causal levels may contribute to the disease transmission risk experienced by women who use drugs. The multiple causal levels of risk potentially involved in the transmission dynamics of infectious pathogens include biological, behavioral, dyadic relationship, network, and structural levels. Biological and behavioral risk factors have already been examined in depth; yet, little empirical research currently exists for other causal levels. Increasingly, investigators suggest that the character and dynamics of relationships with sex partners may be an important determinant of risk, both for engaging in risk behaviors and for doing so with high-risk partners. The influence of higher-order causal level factors, specifically network and structural factors, are the least well documented, but are posited to be a principal underlying cause of the current differential HIV incidence rates between men and women who use drugs. Future research should focus on these higher-order causal levels, in order to better understand disease transmission dynamics; to better evaluate the limitations, as well as the opportunities, of current intervention efforts; to develop interventions that improve and supplement current HIV prevention efforts among women who use drugs; and to inform public policy debate.

Physician recognition of active drug use in HIV-infected patients is lower than validity of patient's self-reported drug use

A French survey of 325 HIV-infected subjects with a history of injecting drugs allowed us to study the recognition of patients' injection drug use (IDU) by physicians providing HIV-infection care, and to analyze the correlation between patient demographics and incorrect IDU identification. Kappa for concordance of physician's reports of their patient's IDU with patient's declaration was 0.37; concordance was lower among socially vulnerable patients. This contrasted with a nested study of validity of patient's self-report of opioid use: Kappa for patient's declaration of opioid use within the past two days against a biological assay was 0.61, and concordance was higher among socially vulnerable patients. Concordance of physicians' ratings and patients' reports of IDU was not more than fair, even though physicians were knowledgeable about their patient's IDU history. This concordance varied with social status in a way that did not correspond with variations in self-reported opioid use validity, suggesting that identification of active IDU might be partly based on incorrect interpretation of subjective cues.

Sex, drugs, and HIV: does methadone maintenance reduce drug use and risky sexual behavior?

This study examined differences in drug use, sexual behavior, attitudes, and perceptions of vulnerability for AIDS between injection drug users who received methadone treatment in the previous 6 months and those who did not. Of the 123 participants assessed, 62 (50%) received methadone treatment. Methadone patients reported fewer sexual partners and greater use of condoms compared to nonmethadone patients. Methadone patients also reported fewer high-risk sexual partners than those not in treatment. Women reported more high-risk partners than men. Methadone patients reported drinking alcohol less, but smoking marijuana more than nonmethadone users. Methadone users had more positive beliefs about the efficacy of condoms for preventing AIDS and expressed less anger than nonmethadone users in situations related to condom usage. These findings have important implications for using methadone maintenance to reduce the dual risk for HIV in injection drug users.

HIV/AIDS social and behavioural research: past advances and thoughts about the future

This paper is an introduction to the various contributions in this special issue of Social Science & Medicine which are an attempt to synthesise the main debates of the 2nd European Conference on Social and Behavioural Research on AIDS held in Paris, in January 1998. The paper discusses how the recent advent of highly active antiretroviral therapies (HAART) and new trends in the epidemic (its concentration in the socially most vulnerable groups and countries) have affected the research agenda of European social and behavioural sciences (SBS) in HIV/AIDS. Questions which had already been thoroughly studied by SBS (like determinants of HIV-related risk behaviours, or impact of gender and socio-economic inequities as well as discrimination on the diffusion of HIV) will have to be "revisited" in light of these recent changes. New issues (such as risk behaviours among already infected patients. impact of therapeutic advances on psychosocial and daily life management of their disease by people living with HIV/AIDS, adherence to treatment, or "normalisation" of AIDS public policies) will have to be strongly and quickly dealt with, in order for SSB to keep the pace with the rapid evolution of the epidemic and of the societal responses to it. Finally, the paper argues that to face these challenges, new theoretical and methodological advances will have to go beyond the classical oppositions in internal debates among SSB between individualistic and holistic approaches, or between radical criticism of the existing state of the world and practical involvement in public health decision-making.