The 1993 Okey Memorial Lecture. Cross-national studies of AIDS among injecting drug users

Towards combination HIV prevention for injection drug users: addressing addictophobia, apathy and inattention

PURPOSE OF REVIEW

Recent breakthroughs in HIV-prevention science led us to evaluate the current state of combination HIV prevention for injection drug users (IDUs). We review the recent literature focusing on possible reasons why coverage of prevention interventions for HIV, hepatitis C virus (HCV) and tuberculosis among IDUs remains dismal. We make recommendations for future HIV research and policy.

RECENT FINDINGS

IDUs disproportionately under-utilize voluntary HIV counseling and testing (VCT), primary care and antiretroviral therapy (ART), especially in countries that have the largest burden of HIV among IDUs. IDUs present later in the course of HIV infection and experience greater morbidity and mortality. Why are IDUs under-represented in HIV-prevention research, access to treatment for both HIV and addiction, and access to HIV combination prevention? Possible explanations include addictophobia, apathy, and inattention, which we describe in the context of recent literature and events.

SUMMARY

This commentary discusses the current state of HIV-prevention interventions for IDUs including VCT, needle and syringe program (NSP), opioid substitution therapy (OST), ART and pre-exposure chemoprophylaxis (PrEP), and discusses ways to work towards true combination HIV prevention for IDU populations. Communities need to overcome tacit assumptions that IDUs can navigate through systems that are maintained as separate silos, and begin to take a rights-based approach to HIV prevention to ensure that IDUs have equitable access to life-saving prevention and treatments.

Injecting shared drugs: an observational study of the process of drug acquisition, preparation, and injection by Puerto Rican drug users

The practice of injecting shared drugs, in which drug users prepare, divide and inject portions of a drug solution, is a means of transmitting HIV, HCV, and other blood-borne pathogens. This study examined the process of injecting shared drugs among drug users in San Juan, Puerto Rico, through detailed observations of 25 episodes of the injection of shared drugs, and by informal interviewing of episode participants. The ways in which price and packaging of drugs, access to drug preparation materials, and social and economic relations between drug-sharing "partners" influence the process of injecting shared drugs are explored. Because differential power relations, and in turn, injection drug users' exposure to HIV and HCV, are apparent in some drug-sharing partnerships, a key objective of this study was to extend our understanding of contributions or "investments" made by different drug-sharing partners, the benefits and costs that different partners experience, and the extent to which IDUs assume different partner roles. The findings of this small, in-depth qualitative study provide insight into drug users' motivations for injecting shared drugs, and suggest reasons why certain standardized, countrywide HIV/HCV intervention efforts have not been entirely successful in preventing the devastating illnesses that disproportionately affect injection drug users.

Tendência da epidemia de AIDS em usuários de drogas injetáveis no Município de São Paulo de 1985 a 1997

OBJETIVO: Analisar a tendência da epidemia de AIDS em adultos, no período de 1985 a 1997, no Município de São Paulo, focalizando principalmente os usuários de drogas injetáveis (UDI), considerando o grande impacto da epidemia nesse grupo populacional. METODOLOGIA: A fonte dos dados foi a vigilância de AIDS do Estado de São Paulo. O método estatístico utilizado para a análise de tendência temporal dos 8.558 casos de AIDS entre UDI, e dos 16.756 entre não UDI, foi a regressão polinomial. RESULTADOS: No período de 1985 a 1992 a tendência foi de ascensão para os casos de AIDS entre UDI e não UDI a partir desse ponto e, observou-se um declínio para UDI e manutenção em platô elevado para os não UDI, em conseqüência do crescimento constante do número de casos entre as mulheres e homens heterossexuais. Os coeficientes de regressão ajustados (R²a) de todos os modelos ficaram acima de 70%, e os modelos que melhor explicaram as tendências foram os de segunda ordem (parábola), exceto para heterossexuais não UDI cuja tendência foi de aumento linear. CONCLUSÃO: No final do período considerado, os dados sugerem um declínio da epidemia em UDI, a estabilização em níveis elevados para o total de não UDI, e a manutenção da tendência de crescimento da epidemia para pessoas heterossexuais não UDI.

Between-city variation in frequency of injection among Puerto Rican injection drug users: East Harlem, New York, and Bayamon, Puerto Rico

Frequency of injection has been consistently found to be higher among Puerto Rican Injection drug users (IDUs) than among other groups of IDUs. Several explanations have been suggested, but an empirical explanation has yet to be presented. This study compares the frequency of injection of Puerto Rican IDUs in East Harlem, New York, with that of IDUs in Bayamon, Puerto Rico. Study subjects comprised 521 Puerto Rican IDUs from East Harlem and 303 IDUs from Bayamon. The mean frequency of injection among IDUs in East Harlem was 2.8, the corresponding mean in Bayamon was 5.4. Younger IDUs reported a higher number of daily injection episodes than older IDUs, and the IDU group in Bayamon was 5 years younger than the group in East Harlem. The drug use variables accounted for a greater portion of the between-city difference than the demographic and psychosocial variables. Use of noninjected drugs, as well as the use of prescribed methadone, were found to be associated with a lower number of daily injections. Conversely, injection of cocaine, injection of cocaine mixed with heroin ("speedball"), and injection of larger amounts of drug solution were found to be associated with a higher number of daily injections.

Characteristics of heroin and cocaine users unknown to treatment agencies. Results from the Swiss Hidden Population Study

The aim of this study was to compare the characteristics of heroin or cocaine users who are not in contact with drug-treatment agencies in Switzerland to the characteristics of a group who are in treatment. A sample of 917 users of heroin and/or cocaine was recruited outside treatment settings by 31 Privileged Access Interviewers. Respondents were divided into a study group of 512 heroin and/or cocaine users not following any treatment, and a control group of 238 users who were following treatment. Respondents in the no-treatment group use drugs less frequently, are less likely to inject drugs, have a more social pattern of use and more often have the impression of controlling their drug use. They have less contact with the legal system and the police, are in a better social situation and more often perceive themselves to be in good health. In both groups, respondents whose main drug of use is heroin generally have a more problematic pattern of use than those who use mainly cocaine. There are no significant differences between the two groups regarding present HIV-risk behaviour and prevention. The data show no significant association between the duration of use of heroin or cocaine and signs for problem use. These findings support the hypothesis that drug users not in treatment and drug users in treatment are two distinct populations, in terms of profile of drug use and prevalence of social or health problems that are associated to it.

Stories of AIDS outreach and case management: context and activities

Research has shown that injection drug users (IDUs) are now at greater risk for contracting HIV infection. Studies also show that seroincidence has begun to decrease among IDUs in a number of cities due to risk-reduction interventions. One important intervention is the use of indigenous outreach workers, shown to be an effective method in reducing HIV risk behavior and promoting preventive actions among IDUs in various settings. This study explores continuities and changes in the activities of outreach workers and in their changing role as case managers in the long-standing Community Outreach Intervention Project in Chicago. It examines their efforts to change risk behaviors and improve the health and living conditions of IDUs. This research is based on outreach and case-worker perspectives and related background data gathered from 10 outreach workers and the four ethnographers that supervise the project. Outreach and case workers describe the diverse populations and contexts in which they operate and the growing complexity and depth of the issues they face, especially in working with HIV and AIDS-afflicted clients. These descriptions demonstrate the important role "indigenous" outreach and case workers play in engaging out-of-treatment IDUs, supporting meaningful changes in their lives, and responding to their particular and emerging needs.

Longitudinal changes in sexual risk behavior among HIV+ and HIV- male injecting drug users

Injecting drug users (IDUs) play a prominent role in the transmission of human immunodeficiency virus (HIV), particularly in urban areas such as New York City, where they comprise nearly half of all adult acquired immunodeficiency syndrome (AIDS) cases. Intervention studies have demonstrated that IDUs are responsive to safer sex messages, but sexual behavior appears to be more resistant to change than drug use behavior. This multidisciplinary study (without an intervention component) assesses changes in sexual risk behavior as a function of time, HIV status, and disease progression in a cohort of HIV+ and HIV- male IDUs (N = 144) for 4 years.

RESULTS

For HIV+ and HIV- men, there were increases in abstinence and monogamy, with decreases in the frequency of unprotected vaginal/anal sex and sexual risk index scores. With the exception of monogamy, HIV+ men reported lower levels of risk. Although there was also a decline in substance use, this accounted for only some of the decline in sexual risk behavior. Among the HIV+ men, a CD4 level below 200 was associated with more abstinence and monogamy. HIV-related medical symptoms were associated with increased abstinence, less unprotected sex, and lower sexual risk index scores. Lower neuropsychological memory test scores were associated with increased abstinence and lower sexual risk index scores. Neurological impairment and depression were not associated with sexual risk behavior.

CONCLUSION

IDU men in New York City have modified their sexual behavior toward safer practices. Lower levels of risk are found among HIV+ men, particularly those with more progressed HIV illness. Nevertheless, a substantial amount of sexual risk behavior remained in this cohort, indicating the continued need for education and intervention.

AIDS risk behavior in opioid dependent patients treated with community reinforcement approach and relationships with psychiatric disorders

This study examined the Community Reinforcement Approach's (CRA) effect on AIDS risk behaviors and the relationship between comorbid psychiatric disorders and the risk for AIDS behavior in opioid dependent patients entering methadone maintenance treatment. Additionally, we looked at AIDS risk behaviors as they related to the Addition Severity Index (ASI), Beck Depression Inventory, Symptom Checklist-90-Revised (SCL-90-R), and the Social Adjustment Scale-Self Report (SAS-SR). Subjects (N = 227) were drawn from a large clinical trial that examined the effectiveness of a Community Reinforcement Approach for treatment of opioid dependence. Both CRA and standard treatment demonstrated a significant effect on reduction of AIDS risk behaviors. There was no relationship found regarding comorbid psychiatric disorders with the risk for AIDS behavior. However, there were correlations with other psychiatric, social, and substance abuse variables. Multivariate analyses indicated that increased drug and legal ASI composite scores were the primary predictors of increased AIDS risk behavior.

Drug users' sexual relationships and the social organisation of risk: the sexual relationship as a site of risk management

Research on "risk behaviour" in the time of AIDS has emphasised how social relationships influence individuals' responses to risk. Yet the social relationship remains an under-utilised unit of analysis in risk behaviour research. Drawing on qualitative research with illicit drug users in London, this paper illustrates how drug users' sexual relationships act as key sites of risk management in individuals' drug use and everyday lifestyles. First, while recent research has almost exclusively focused on the dangers of disease transmission, our findings show that drug users perceived their sexual relationships as influencing a variety of risks associated with heroin and other opioid drugs. Here, two types of relationships--"gear" and "straight" relationships--were perceived to be particularly important. Second, while research has tended to focus on drug and health risks as an outcome of relationships, drug users' accounts emphasise that managing risks to their relationships is an important facet of everyday risk management made complicated by drug use. It is argued that risk is a product of social interactions, and that the sexual relationship is an important site of risk management in this process. Future interventions should target drug users' sexual relationships as agents of risk management and behaviour change.

Impact of HIV risk and infection and the role of prevention services

Blood-borne infection associated with injection drug use is a significant cause of morbidity and mortality. Over the last decade, HIV infection and its clinical sequelae have had a significant impact on research and interventions involving injecting drug users (IDUs) in the United States and elsewhere. Discussed are some of the major intervention options for reducing blood-borne infections in general and HIV in particular. The use of multiple interventions is considered within the community context in which both IDUs and service providers operate. Intervention options discussed include treatment for drug dependence; voluntary and confidential HIV testing and counseling; community health outreach; bleach distribution; and easy, legal access to needles and syringes through pharmacy sales and needle exchange programs. Many surveillance and evaluative studies have examined multiple intervention efforts that include all or some of these program components and suggest positive outcomes. However, these studies tend to be limited by experimental designs that restrict attribution of causal inference. Examples of such programs in the United States and abroad are examined in terms of their potential for reducing HIV risk behaviors and averting new infections. The article concludes that diversity among AIDS prevention programs, rapid deployment (at earlier stages of epidemics), and effective coordination (minimization of interagency conflicts) are important factors in successful AIDS prevention programming and attaining disease prevention objectives.