Reduced probability of HIV infection among crack cocaine--using injection drug users

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exploring the role of an unsanctioned, supervised peer driven injection facility in reducing HIV and hepatitis C infections in people that require assistance during injection

Background

Supervised consumption rooms or supervised injection facilities (SIFs) are venues that have reduced the risk of needle sharing and deaths caused by drug overdose among people who inject drugs (PWID). As a result of such a decline in the mortality rate, numerous studies have been able to illustrate its cost-effectiveness. However, studies have neglected to examine the same phenomena for unsanctioned SIFs that are run by peer drug users and provide assisted injections.

Methods

The current study will determine whether the former unsanctioned SIF, that provided assisted injection and was operated by the grass root organization called Vancouver Area Network of Drug Users (VANDU), cost less than the health care consequences of not having such a program in Vancouver, Canada. By analyzing data gathered in 2013, this paper relies on two mathematical models to estimate the number of new HIV and HCV infections prevented by the former unsanctioned facility in Vancouver’s Downtown Eastside.

Results

A conservative estimate indicates that the SIF location that provided assisted injections has a benefit-cost ratio of 33.1:1 due to its low operational cost. At the baseline sharing rate, the facility, on an average, reduced 81 HCV and 30 HIV cases among PWID each year. Such reductions in blood borne infections among PWID resulted in annual savings worth CAN$4.3 million dollars in health care expenditure. In addition to this, the current paper relies on a sensitivity analysis based on different needle sharing rate scenarios.

Conclusions

The sensitivity analysis and the baseline rates indicate that funding SIF facilities operated by peer drug users that facilitate assisted injection appear to be an efficient and effective use of financial resources in the public health domain since they lead to a significant decline in the rate of mortality within a vulnerable population.

Depression, sexually transmitted infection, and sexual risk behavior among young adults in the United States

OBJECTIVE

To measure associations among depression, sexual risk behaviors, and sexually transmitted infection (STI) among white and black youth in the United States.

DESIGN

Analysis of prospective cohort study data. Wave I of the National Longitudinal Study of Adolescent Health occurred in 1995 when participants were in grades 7 through 12. Six years later, all Wave I participants who could be located were invited to participate in Wave III and to provide a urine specimen for STI testing.

SETTING

In-home interviews in the continental United States, Alaska, and Hawaii.

PARTICIPANTS

Population-based sample. A total of 10 783 Wave I (adolescence) and Wave III (adulthood) white and black respondents with sample weight variables. Main Exposures Chronic depression (detected at Waves I and III) and recent depression (detected at Wave III only) vs no adult depression (not detected at Wave III).

OUTCOME MEASURES

Multiple sexual partners and inconsistent condom use in the past year and a current positive test result for Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis (adulthood).

RESULTS

Recent or chronic depression in adulthood was more common for blacks (women, 19.3%; men, 11.9%) than for whites (women, 13.0%; men, 8.1%). Among all groups (white men and women, and black men and women), adult depression was associated with multiple partners but not with condom use. Among black men, depression was strongly associated with STI (recent: adjusted prevalence ratio, 2.36; 95% confidence interval, 1.26-4.43; chronic: adjusted prevalence ratio, 3.05; 95% confidence interval, 1.48-6.28); having multiple partners did not mediate associations between depression and STI.

CONCLUSIONS

Integration of mental health and STI programs for youth is warranted. Further research is needed to elucidate how depression may influence the prevalence of STI among black men.

Incarceration and high-risk sex partnerships among men in the United States

Incarceration is associated with multiple and concurrent partnerships, which are determinants of sexually transmitted infections (STI), including HIV. The associations between incarceration and high-risk sex partnerships may exist, in part, because incarceration disrupts stable sex partnerships, some of which are protective against high-risk sex partnerships. When investigating STI/HIV risk among those with incarceration histories, it is important to consider the potential role of drug use as a factor contributing to sexual risk behavior. First, incarceration's influence on sexual risk taking may be further heightened by drug-related effects on sexual behavior. Second, drug users may have fewer economic and social resources to manage the disruption of incarceration than nonusers of drugs, leaving this group particularly vulnerable to the disruptive effects of incarceration on sexual risk behavior. Using the 2002 National Survey of Family Growth, we conducted multivariable analyses to estimate associations between incarceration in the past 12 months and engagement in multiple partnerships, concurrent partnerships, and unprotected sex in the past 12 months, stratified by status of illicit drug use (defined as use of cocaine, crack, or injection drugs in the past 12 months), among adult men in the US. Illicit drug users were much more likely than nonusers of illicit drugs to have had concurrent partnerships (16% and 6%), multiple partnerships (45% and 18%), and unprotected sex (32% and 19%). Analyses adjusting for age, race, educational attainment, poverty status, marital status, cohabitation status, and age at first sex indicated that incarceration was associated with concurrent partnerships among nonusers of illicit drugs (adjusted prevalence ratio (aPR) 1.55, 95% confidence interval (CI) 1.06-2.22) and illicit drug users (aPR 2.14, 95% CI 1.07-4.29). While incarceration was also associated with multiple partnerships and unprotected sex among nonusers of illicit drugs (multiple partnerships: aPR 1.66, 95% CI 1.43-1.93; unprotected sex: aPR 1.99, 95% CI 1.45-2.72), incarceration was not associated with these behaviors among illicit drug users (multiple partnerships: aPR 1.03, 95% CI 0.79-1.35; unprotected sex: aPR 0.73, 95% CI 0.41-1.31); among illicit drug users, multiple partnerships and unprotected sex were common irrespective of incarceration history. These findings support the need for correctional facility- and community-based STI/HIV prevention efforts including STI/HIV education, testing, and care for current and former prisoners with and without drug use histories. Men with both illicit drug use and incarceration histories may experience particular vulnerability to STI/HIV, as a result of having disproportionate levels of concurrent partnerships and high levels of unprotected sex. We hypothesize that incarceration works in tandem with drug use and other adverse social and economic factors to increase sexual risk behavior. To establish whether incarceration is causally associated with high-risk sex partnerships and acquisition of STI/HIV, a longitudinal study that accurately measures incarceration, STI/HIV, and illicit drug use should be conducted to disentangle the specific effects of each variable of interest on risk behavior and STI/HIV acquisition.

Incarceration and risky sexual partnerships in a southern US city

Incarceration is strongly associated with HIV infection and may contribute to viral transmission by disrupting stable partnerships and promoting high-risk partnerships. We investigated incarceration and STI/HIV-related partnerships among a community-based sample recruited for a sexual behavior interview while frequenting venues where people meet sexual partners in a North Carolina city (N = 373). Men reporting incarceration in the past 12 months were more likely than men without recent incarceration to experience multiple new sexual partnerships (unadjusted prevalence ratio [PR] 1.8, 95% confidence interval [CI]: 1.1-3.1) and transactional sex defined as trading sex for money, goods, or services (unadjusted PR: 4.0, 95% CI: 2.3-7.1) in the past 4 weeks. Likewise, women who were ever incarcerated were more likely than never-incarcerated women to experience recent multiple new partnerships (unadjusted PR: 3.1, 95% CI: 1.8-5.4) and transactional sex (unadjusted PR: 5.3, 95% CI: 2.6-10.9). Sexual partnership in the past 12 months with someone who had ever been incarcerated versus with partners with no known incarceration history was associated with recent multiple new partnerships (men: unadjusted PR 2.0, 95% CI 1.4-2.9, women: unadjusted PR 4.8, 95% CI 2.3-10.1) and transactional sex (men: unadjusted PR 3.3, 95% CI 1.7-6.6, women: unadjusted PR 6.1, 95% CI 2.4-15.4). Adjustment for demographic and socioeconomic variables had minimal effect on estimates. However, the strong overlap between incarceration, partner incarceration, and substance abuse had substantial effects in multivariable models. Correctional-facility and community-based HIV prevention, with substance abuse treatment, should reach currently and formerly incarcerated individuals and their sexual partners.

Demographic, HIV risk behavior, and health status characteristics of "crack" cocaine injectors compared to other injection drug users in three New England cities

OBJECTIVES

To compare demographic, HIV risk behaviors, and health status characteristics of injection drug users (IDUs) who have injected "crack" cocaine with IDUs who have not.

METHODS

Nine hundred and eighty-nine IDUs were recruited in New Haven, CT, Hartford, CT and Springfield, MA from January 2000 to May 2002. Participants were administered a modified version of the National Institute on Drug Abuse Risk Behavior Assessment Questionnaire.

RESULTS

Nine percent (n = 89) of participants reported "ever" injecting crack cocaine and 4.2% (n = 42) reported injecting crack in the past 30 days. Lifetime and current crack injectors did not differ significantly on any demographic characteristics. Lifetime and current crack injectors did not differ on gender, age or marital status from IDUs who have never injected crack. Significant differences were found on race, education, employment and residence, with crack injectors more likely to be white, employed, better educated and living in New Haven than IDUs who have never injected crack. After adjusting for current (past 30 day) speedball and powder cocaine injection, crack injectors reported higher rates of risky drug use behaviors and female crack injectors reported higher rates of risky sexual behaviors. Crack injectors reported higher rates of abscesses, mental illness and Hepatitis C infection, but not Hepatitis B or HIV infection.

CONCLUSIONS

The emergence of crack cocaine injection requires urgent attention, as this new drug use behavior is associated with elevated rates of high risk behaviors.

Recruiting drug-using men who have sex with men into behavioral interventions: a two-stage approach

Drug-using men who have sex with men (MSM) are at high risk of acquiring or transmitting HIV infection. Efforts to change behaviors in this population have been hampered by difficulties in recruiting drug-using MSM into behavioral interventions. This study sought to develop an effective strategy for recruiting drug-using MSM into behavioral interventions that consist of motivational interviewing alone or motivational interviewing plus contingency management. MSM were recruited through advertising and community outreach into groups to discuss party drugs, party burnout, and sexual behavior, with the intervention subsequently described and enrollment offered in the group setting. Many more eligible MSM responded to advertisements for the discussion groups than advertisements for the interventions, and 58% of those who participated in the discussion groups volunteered for counseling. Men who entered counseling reported high levels of drug use and sexual activity and were racially and ethnically diverse; only 35% were willing to accept drug treatment. Results demonstrate that a two-stage strategy in which drug-using MSM are first recruited into discussion groups before they are offered a behavioral intervention can be an effective way to induce voluntary acceptance of an intervention employing a behavioral risk-reduction approach.

Injection drug use and crack cocaine smoking: independent and dual risk behaviors for HIV infection

PURPOSE

Previous studies have examined the practices of injecting drugs or smoking crack cocaine as high-risk, but independent, factors for HIV transmission. To explore the independent and dual risks of injection practices and crack smoking, this study examined HIV seroprevalence rates among distinct drug user groups, based on patterns of daily administration.

METHODS

A sample of 3,555 drug users and neighborhood controls in urban Miami, FL and rural Belle Glade and Immokalee, FL were partitioned into four mutually-exclusive groups: 1) injection drug users (IDUs); 2) crack-cocaine smokers; 3) dual users who both smoked crack and injected drugs; and 4) non-drug-user controls.

RESULTS

HIV seroprevalence rates were 45.1% for IDUs, 30.5% for dual users, 20.1% for crack smokers and 7.3% for controls. Multivariate logistic regression analysis found that when compared with controls odds ratios for HIV seropositivity were 9.81 for IDUs, 5.27 for dual users, and 2.24 for crack smokers.

CONCLUSIONS

These findings provide evidence of: 1) behavioral and structural co-factors that influence HIV exposure patterns among drug users; and 2) the substantially higher risk of HIV infection among IDUs compared with other drug users. Intervention strategies must be tailored for the specific drug use subpopulations to optimize efficacy.

Risk correlates of prevalent HIV, hepatitis B virus, and hepatitis C virus infections among noninjecting heroin users

OBJECTIVE

To examine lifetime correlates of HIV and hepatitis B and C (HBV and HCV) infections among noninjecting heroin users (NIUs).

METHODS

Between March 1996 and March 2001, 483 eligible NIUs were tested for HIV, HBV, and HCV antibodies and administered structured interviews. Multivariate logistic regression analyses were stratified by injecting history.

RESULTS

Among never-injectors (69.8%), significant (p <.05) correlates were unprotected sex with men who have sex with men (HIV and HBV), unprotected sex with NIUs (HIV), self-reported syphilis infection (HBV), longer duration of heroin use (HBV and HCV), shorter duration of cocaine use (HIV), blood transfusion before 1986 (HIV), and having been tattooed (HCV). Among former injectors (30.2%), significant correlates were receptive syringe sharing (HIV and HBV), frequent lifetime injection (HCV), longer duration of sexual activity (HBV), and having been tattooed (HCV).

CONCLUSION

Never-injectors infected with HIV and HBV appear to have become infected mainly through sexual transmission, whereas former injectors appear to have become infected with HIV and HCV mainly though injecting risk and with HBV through both injecting and sexual risk. Interventions targeted at NIUs should prevent unsafe sex as well as the initiation or resumption of injecting. In addition, unhygienic tattooing, which may lead to HCV exposure, should be a focus of prevention efforts.

Men who have sex with men and also inject drugs-profiles of risk related to the synergy of sex and drug injection behaviors

OBJECTIVES

Men who have sex with men and also inject drugs (MSM-IDU) are among the groups at highest risk for acquiring and transmitting HIV in Colorado and the US. We conducted formative research and a survey among MSM-IDU in Denver to better understand sexual and drug HIV risk behaviors and how they interact.

METHODS

Formative data were collected with 30 persons who work, live or otherwise interact with MSM-IDU using a semi-structured interview instrument. Survey data on sexual and drug risk behaviors were collected with 100 MSM-IDU; eligible participants have had sex with men and injected drugs within the past six months.

RESULTS

Results from formative research were used to generate the survey instrument. The survey results demonstrate high-risk sexual behaviors with multiple partners of both genders; 82% of the sample had primary and non-primary male partners, 20% had non-primary female partners, and 15% exchanged money or drugs for sex. Condom use was inconsistent and infrequent for all types of sex (vaginal, anal and oral) and with all types of partners. Drug risk behaviors highlight that the injection drugs of choice for this sample (90% shoot cocaine and 59% shoot methamphetamine) stimulate sexual desire and cocaine injection increases opportunities for injection risk behavior. Forty-five percent of the sample were HIV-infected. Significant differences between HIV infected and non-infected men were not observed with regard to many sexual and drug risk behaviors.

CONCLUSIONS

These data show that MSM-IDU are engaging in multiple risk behaviors that may have a synergistic effect on HIV transmission, and that their injection drug of choice contributes to their risk. That there do not appear to be consistent differences in preventive behaviors between men with or without HIV infection suggests a greatly increased risk for HIV transmission in this group of men and their partners. Because MSM-IDU do not identify strongly with either MSM because they may not gay identify or IDU because they do not use heroin, targeted HIV prevention strategies for this group are urgently needed.

Trends in HIV seroprevalence and needle sharing among Puerto Rican drug injectors in Puerto Rico and New York: 1992-1999

This study assessed trends in HIV seroprevalence and needle-sharing behaviors among Puerto Rican injection drug users (IDUs) in Puerto Rico and New York. Data from two studies of IDUs conducted from 1992 through 1995 and 1998 through 1999 in Bayamón, Puerto Rico, and East Harlem, New York, were examined to assess trends over this period. Separate analyses were conducted for IDUs who were current crack smokers. Significant decreasing trends in seroprevalence were found among IDUs in the New York and Puerto Rico samples (p <.001). Significant decreasing trends in receptive and distributive needle sharing were found in the New York sample, and a significant decline in receptive sharing was found in the Puerto Rico sample. Overall, higher levels of needle-sharing behaviors were reported in Puerto Rico compared with New York. Decreasing trends in needle sharing and seroprevalence in both communities are an encouraging finding. Ongoing epidemiologic studies to monitor the epidemic and continued prevention efforts to help maintain or further these declines are needed, particularly to address the higher rates of needle sharing in Puerto Rico.

Violence and HIV Risk Behavior among Male and Female Crack Users

Crack users are a critical group on which to focus, given their potential for both violence and HIV risk behavior. However, little is known about specific interpersonal acts of violence perpetrated by male and female crack users or the association of HIV risk behavior with interpersonal violence among male and female crack users. The purpose of this paper is to examine drug use and HIV risk behavior among three groups of crack users (those reporting no violence, those reporting a moderate rate of interpersonal violence, and those reporting a high rate of interpersonal violence) and to examine gender differences among crack users who are and are not involved in violence. Results indicate that violence is associated with higher HIV risk behavior and that there were no gender by violence group differences.

Sexual and drug use behaviors among female crack users: a multi-site sample

The purpose of this paper was to compare female crack users who report exchanging sex for drugs and/or money with female crack users who did not report exchanging sex for drugs and/or money. A multi-site sample of (n = 4667) female crack users who participated in the National Institute of Drug Abuse (NIDA) AIDS Cooperative Agreement Project from 20 sites were interviewed. Statistical analysis compared two groups on selected variables of interest: women crack users who reported exchanging sex for drugs and/or money (n = 2658) and women crack users who did not report exchanging sex (n = 2009). Results indicated that both groups of women had frequent unprotected sex. However, women who exchanged sex had more sexual partners, had sex more often, used drugs before and during sex more often, and had a higher rate of STDs than women who did not exchange sex. In addition, African-American women, homeless women, and women who reported past substance abuse treatment were about twice as likely to exchange sex. Regional differences were also examined.

HIV needle risk behaviors and drug use: a comparison of crack-smoking and nonsmoking injection drug users in Ohio

This study compares the drug use and needle risk behaviors among 733 crack-smoking injection drug users (IDUs) and 518 nonsmoking IDUs. Participants were recruited in Dayton and Columbus, Ohio, for the Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research Program from 1992 to 1996. Crack-smoking IDUs were more likely to be male, African-American, and 30 to 40 years of age, but less likely to be married or living with a sex partner compared to nonsmokers. Daily crack users were less likely to be daily injectors but more likely to use alcohol daily when compared to non-crack users and less-than-daily crack smokers. IDUs who smoked crack less than daily were more likely to have injected with needles and syringes used by others. There is an urgent need for additional research on the relationship between drug injection and crack smoking as well as improved HIV risk-reduction interventions that include drug abuse treatment components focusing on issues surrounding crack-cocaine addiction.

Behavioral factors affecting HIV prevention for adolescent and young adult IDUs

Epidemiological and sociobehavioral data regarding HIV-related risk and injection drug use among adolescents and young adults are examined to provide insight and assistance to nurses delivering preventive intervention and community and clinical care. The increase in HIV/AIDS cases among injection drug users (IDUs), adolescents, and African Americans strongly suggests that clinical care providers acquire a better understanding of the sociocultural and behavioral context within which health care is provided. Transition into injection drug use, high-risk injecting and sexual behaviors, sociodemographic differences, and the importance of social networks are discussed. Nurses are encouraged to provide health promotion, disease prevention messages, and health care to IDUs in small nontraditional clinical settings and to seek out the assistance of the IDUs' social network to increase adherence and compliance to complex prevention and therapeutic efforts.