Hepatitis C among noninjecting drug users: a report

OBJECTIVES

This report documents the prevalence of hepatitis C virus (HCV) infection among self-reported noninjecting drug users recruited from two New York City neighborhoods.

METHODS

Participants were recruited in separate studies from East Harlem and the Lower East Side of Manhattan and were administered structured questionnaires and tested for HCV.

RESULTS

HCV prevalence rates among those reporting no history of injecting drugs ranged from 5% to 29%, according to age, gender, and study location.

CONCLUSIONS

Our results suggest that more research is needed to elucidate potential noninjecting routes of HCV transmission among drug users. Moreover, policies that rely predominantly on injector status as the only drug-related risk factor for HCV screening need to be reassessed in light of these findings.

Cessation of drug use: impact of time in treatment

Many studies have found that the longer a drug user remains in treatment, the more positive the outcome. The majority of studies on the effects of time in treatment have followed subjects from the time they enter treatment. The subjects of the present study are injection drug users and crack users who were out of treatment at the time of their recruitment to the study. Between the initial and six-month follow-up interviews, some chose to enroll in drug treatment. The more time a subject spent in treatment during the follow-up period, the more likely it was that s/he was not using heroin or cocaine at follow-up (OR=.51; 95% C.I., .39-.67; p<.001). Unlike the results of some prior studies, positive effects of time in treatment were found even when time in treatment was less than 90 days. The findings of the present study strongly suggest that treatment is beneficial even for those who remain for less than 90 days. Those who provide treatment services to drug users should attempt to maintain contact with dropouts, and support their return to treatment.

HIV infection and patterns of risk among women drug injectors and crack users in low and high sero-prevalence sites

As AIDS cases among US women continue to increase, a better understanding of women's behavioural risk patterns is needed to inform intervention efforts. Data were from 2,945 women drug injectors and crack users. Statistical analyses compared sociodemographic variables, lifetime behavioural risk patterns, HIV sero-prevalence and history of sexually transmitted diseases, and determined predictors of HIV infection separately in 16 low and four high sero-prevalence sites. Based on risk patterns, four behaviourally-defined sub-groups were constructed, and rates of HIV sero-prevalence were compared. In comparisons between low and high sero-prevalence sites, there were significant differences on most variables examined, and in the relative importance of the sociodemographic characteristics and risk patterns predicting HIV. Drug injection and sex exchange were each independent, significant, behavioural predictors of infection, with no significant difference between the odds ratios attributed to each predictor. HIV sero-prevalence was significantly different among four sub-groups. Interventions must be tailored to address observed differences among women in low and high sero-prevalence sites. Injection drug use and exchanging sex each play a major role in the transmission of HIV infection to US women. Prevention efforts targeted at women should address differences in behavioural risk patterns. Aggressive and innovative interventions are needed for women who exchange sex. AIDS research must investigate how socioeconomic factors impact women's risk for HIV infection.

Agreement between urinalysis and self-reported drug use

One hundred fifty-eight drug users received an interview that included self-reported drug use. Opiate/cocaine use in the prior 48 hours was assessed by urinalysis. Fifty-five subjects received a urine test after the interview and 103 were tested before. Chi-square tests were performed to determine if agreement between self-reported drug use and urine test results was associated with timing of urine testing. The rate of agreement was 58% when the urine test was performed after the interview and 93% when performed before the interview (chi2 = 28.6, p < .001). Conducting urine tests before an interview can increase the accuracy of self-reports.

Predictors of change in frequency of crack cocaine use in a street-recruited sample

Crack cocaine users are at high risk for HIV, with higher frequency crack users engaging in higher rates of HIV-related sexual risk behaviors. This study will assess the variables impacting changes in crack use frequency. Out-of-treatment crack users were street recruited in East Harlem, NY. Subjects (n = 727) were 33% female, 91% minority, and 28% reported recent drug injecting. Baseline and 6-month follow-up interviews were administered. There was a significant reduction in crack use over time (p < .0001). Subjects were categorized according to five groups, based on their change in level of crack use between the two interviews, to predict those who stopped, maintained, or changed their level of use. Discriminant analyses identified six variables as the best predictors of the five groups, including having been in drug treatment since baseline and having been a drug injector (both related to reduced levels of crack use). The overall reduction in crack use for the sample masked the fact that important subgroups remained at high use levels or increased their use. The identification of subgroups who may be most resistant to reducing drug use can be helpful in developing more effective interventions.

Trends in injection risk behaviors in a sample of New York City injection drug users: 1992-1995

OBJECTIVES

This study assessed the relation between year of recruitment into an AIDS prevention project and likelihood of engaging (yes/no) in injection risk behaviors.

METHODS

In total, 834 injection drug users were recruited over a 44-month period (January 1992-August 1995) in New York City. Logistic regression was used to examine trends in three behaviors, across four successive annual cohorts: using needles/syringes that were previously used by another person, using injection supplies (e.g., cookers, cotton, rinse water) that had been previously used, and giving or lending of used needles/syringes to another person.

RESULTS

Significant (p < .0001) decreasing trends occurred in two behaviors: giving or lending of used needles/syringes to another person and use of injection supplies that had been used by another person. Sample characteristics were generally consistent over time and did not obviate significant injection risk trends.

CONCLUSIONS

Decreasing trends in injection risk behaviors could not be explained by changing sample characteristics. Even though some injectors report engaging in risky injection practices, the confluence of numerous AIDS prevention efforts in the 1990s has contributed to an overall reduction in the likelihood of such behaviors.

Declining seroprevalence in a very large HIV epidemic: injecting drug users in New York City, 1991 to 1996

OBJECTIVES

This study assessed recent trends in HIV seroprevalence among injecting drug users in New York City.

METHODS

We analyzed temporal trends in HIV seroprevalence from 1991 through 1996 in 5 studies of injecting drug users recruited from a detoxification program, a methadone maintenance program, research storefronts in the Lower East Side and Harlem areas, and a citywide network of sexually transmitted disease clinics. A total of 11,334 serum samples were tested.

RESULTS

From 1991 through 1996, HIV seroprevalence declined substantially among subjects in all 5 studies: from 53% to 36% in the detoxification program, from 45% to 29% in the methadone program, from 44% to 22% at the Lower East Side storefront, from 48% to 21% at the Harlem storefront, and from 30% to 21% in the sexually transmitted disease clinics (all P < .002 by chi 2 tests for trend).

CONCLUSIONS

The reductions in HIV seroprevalence seen among injecting drug users in New York City from 1991 through 1996 indicate a new phase in this large HIV epidemic. Potential explanatory factors include the loss of HIV-seropositive individuals through disability and death and lower rates of risk behavior leading to low HIV incidence.

Urban crack users: gender differences in drug use, HIV risk and health status

This study assessed gender differences in drug use, HIV risk, and health status in a sample of urban crack users. Using targeted sampling, 1434 crack users (66% male and primarily African-American and Puerto Rican), were recruited from the streets of East Harlem, New York City. A standardized, structured interview was administered, drug use was validated by urinalysis, and HIV testing was offered. Gender differences were observed on sociodemographic variables and patterns of drug use. Other than welfare, men and women cited different major sources of income. Women reported greater use of crack, and men were more likely to use injection drugs as well as crack. Data on sexual risk indicated that women had more sexual partners than men, but the percentage of unprotected vaginal sex for both men and women was greater for those who did not exchange sex for drugs and/or money. The number of persons already infected with HIV was substantial. Many reported histories of other sexually transmitted diseases which were generally higher among men. Future research should investigate the relationship between gender and other factors (e.g., ethnicity, geographic location) associated with HIV risk.

Differences in condom behaviors and beliefs among female drug users recruited from two cities

This paper examines predictors of condom cognitions and condom use for vaginal sex within women's main and paying partnerships. The sample consisted of active injection drug and crack-using women recruited from two cities with disparate HIV rates. A total of 338 drug-using women who reported vaginal sex with a main and/or paying partner in the prior 30 days were recruited for this study. Recruitment site was a significant predictor for several of the variables examined, for both main and paying partners. Ethnicity and prior HIV test result were also significant predictors, but only for main sex partners. Findings support previous research and suggest that the factors which predict condom beliefs, intention, and behaviors are different for main versus paying partners. Interventions designed to increase condom use must recognize that cognitive factors associated with condom use may vary by partner type, ethnicity, and recruitment site, particularly when important contextual variables, such as local seroprevalence, vary.

Predictors of HIV infection among women drug users in New York and Miami

In the US, the number of women diagnosed with AIDS continues to increase. In this study, women in New York City (East Harlem) and Miami, two sites with high rates of drug use and HIV infection, were first compared on sociodemographic variables and risk behaviors. Logistic regression analyses were used to identify significant, independent predictors of HIV infection in each city. In comparing women from the two cities, several differences in sociodemographic characteristics and drug use were observed. In both cities, ever exchanging sex for drugs and/or money was predictive of HIV infection; and in East Harlem only, other lifetime risk variables independently predicted HIV infection: drug injection, having a sexually transmitted disease, and not having graduated from high school. Results suggest that intervention efforts with women who exchange sex should be intensified in both cities. Also, further comparisons of women drug users in AIDS epicenter cities are necessary to provide information on similarities and differences in sociodemographic characteristics and individual risk behaviors. More research attention should be focused on examining the social context of HIV risk in order to develop innovative intervention strategies which focus on the link between contextual factors and HIV infection.

Crack users in east Harlem, New York and Philadelphia, Pennsylvania: HIV-related risk behaviors and predictors of serostatus

Crack use has been associated with increased risk for HIV seropositivity. This study was undertaken to examine HIV-related risk behaviors among crack users in East Harlem, New York and Philadelphia, Pennsylvania, two northeastern communities which have reported extensive crack use. Crack users recruited in East Harlem (n = 1434) and Philadelphia (n = 694) were compared on demographics, drug and sex-related risk behaviors, health-related behaviors, and HIV serostatus. Many significant differences were found, and seropositivity was higher in the New York sample (25% vs. 11%, chi 2 = 36.28, p < .001). Being a recent drug injector was a significant predictors of seropositivity in both communities, and differences between communities were found in additional predictors of serostatus. Results suggest that tailored HIV interventions may be needed for different communities. In addition, aggregate data across communities, even those that may be in geographical proximity, may obfuscate differences important to incorporate in developing prevention/intervention efforts.

Gender differences and other factors associated with HIV testing in a national sample of active drug injectors

Gender, health, HIV risk, and demographic factors were examined with chi-square and logistic regression analyses to assess which of these factors are most predictive of active injection drug users' (IDUs') getting tested for HIV. Analyses were based on 36,898 IDUs recruited to participate in a nationwide multisite HIV prevention project. Women IDUs were recently tested (prior 6 months) more than men IDUs. Health factors, particularly for women IDUs, predicted who got tested for HIV more than risk or demographic factors. HIV testing usually occurred when disease symptomatology developed, after a long period of being capable of transmitting HIV to others, and when the benefits of AZT and other interventions may be reduced. Preventive interventions with IDUs are needed that emphasize the possible benefits of HIV testing and that encourage testing before symptoms develop.

Outcomes of a risk-reduction intervention with high-risk populations: the Harlem AIDS project

Many studies of interventions with high-risk populations have reported reductions in risk behaviors. To assess effectiveness of interventions, data are also needed on the characteristics of subjects lost to follow-up, and on follow-up risk behaviors for subjects who were not participants in the intervention. This paper reports on a study conducted in Harlem, New York, recruiting 1,770 injection drug users (IDUs) and sex partners of IDUs, randomly assigned to two interventions. Repeated-measures analyses for the two intervention groups and those who participated in no intervention indicated that all groups reported significant reductions in risk behaviors, with no group effect. Comparisons of those followed-up and not followed-up indicate that those followed-up were less likely to: be homeless, be Latinos, and to use "shooting galleries." The discussion focuses on the need to assess outcomes for all types of participants, and to distinguish the impact of interventions from other explanations for behavior changes.

The risk of HIV infection in a national sample of women with injection drug-using partners

OBJECTIVES

This study reports on a large, national cohort of women with injection drug-using sex partners. Information is provided on demographic characteristics; human immunodeficiency virus (HIV) risk factors, including unprotected sex and incidence of sexually transmitted diseases; use of noninjected drugs; HIV serostatus; and other selected health variables.

METHODS

A sample of 5162 heterosexual women was recruited for a national acquired immunodeficiency syndrome (AIDS) research and demonstration project. A structured interview was administered, and the women had the option of undergoing HIV testing. Statistical analyses compared three groups on variables of interest: women with single sex partners, women with multiple partners, and women with multiple partners who exchanged sex for drugs and/or money.

RESULTS

These groups differed significantly on virtually all of the demographic and risk variables examined. Women with multiple partners who exchanged sex for drugs and/or money were at higher risk for HIV than women in the other groups, even when selected demographic variables were controlled.

CONCLUSIONS

Research is needed on the efficacy of prevention efforts involving these diverse groups of women at risk for AIDS.

The impact of providing incentives for attendance at AIDS prevention sessions

The research literature on AIDS prevention efforts contains many reports on the impact of intervention sessions. Little information is available, however, on the success of various strategies to recruit clients to attend these sessions. An assessment of the comparative impact of money and other types of incentives on group attendance in two AIDS risk reduction projects, in the Harlem area of New York City and in Cleveland, OH, was undertaken. In both projects, injecting drug users and the sex partners of injecting drug users were recruited to participate in group sessions that focused on the reduction of AIDS risk behaviors. Data on group attendance were analyzed for 838 people in the New York project and 1,168 in the Ohio project. After the projects were underway, attendance incentives at both were changed from money to food coupons or gift certificates. Results indicated that a nonmonetary incentive was associated with a significant decline in group attendance. Concerns regarding paying monetary incentives to injecting drug users are discussed.

HIV risk factors among pregnant and non-pregnant high-risk women in New York City

A comparison of high-risk pregnant (n = 55) and non-pregnant (n = 598) women from Harlem, New York City on HIV-related drug and sexual risk behaviors was undertaken to identify appropriate prevention and intervention policy recommendations. Clients were recruited for an AIDS risk reduction research demonstration project and were either intravenous drug users (IVDUs) or sexual partners of IVDUs. There was a higher percentage of IVDUs among the non-pregnant women, and no significant differences were found between pregnant and non-pregnant IVDUs in terms of needle risk behaviors. The two groups were also similar in non-injected drug use behaviors. Pregnant women were significantly less likely to use condoms. Recommendations focused on the need for increased HIV risk reduction among high-risk women in general, and increased education efforts among pregnant high-risk women regarding condom use as protection from HIV and the potential consequences of maternal substance use for their children.

Preventing adolescent drug abuse through a multimodal cognitive-behavioral approach: results of a 3-year study

Students (N = 4,466) attending 56 schools in New York State were involved in a 3-year study testing the effectiveness of a cognitive-behavioral approach to substance abuse prevention. In a randomized block design, schools were assigned to receive (a) the prevention program with formal provider training and implementation feedback, (b) the prevention program with videotaped provider training and no feedback, or (c) no treatment. After pretest equivalence and comparability of conditions with respect to attrition were established, students who received at least 60% of the prevention program (N = 3,684) were included in analyses of program effectiveness. Significant prevention effects were found for cigarette smoking, marijuana use, and immoderate alcohol use. Prevention effects were also found for normative expectations and knowledge concerning substance use, interpersonal skills, and communication skills.

Preventing adolescent drug abuse through a multimodal cognitive-behavioral approach: Results of a 3-year study

Students (N = 4,466) attending 56 schools in New York State were involved in a 3-year study testing the effectiveness of a cognitive-behavioral approach to substance abuse prevention. In a randomized block design, schools were assigned to receive (a) the prevention program with formal provider training and implementation feedback, (b) the prevention program with videotaped provider training and no feedback, or (c) no treatment. After pretest equivalence and comparability of conditions with respect to attrition were established, students who received at least 60% of the prevention program (N = 3,684) were included in analyses of program effectiveness. Significant prevention effects were found for cigarette smoking, marijuana use, and immoderate alcohol use. Prevention effects were also found for normative expectations and knowledge concerning substance use, interpersonal skills, and communication skills.

Smokeless tobacco use among adolescents: correlates and concurrent predictors

Seventh grade students (N = 1539) from three regions of New York State were surveyed to determine the prevalence of smokeless tobacco use and its relationship to seven background variables, 13 substance use variables, and 19 psychosocial variables. Significant correlations with smokeless tobacco use were found within each of these variable domains. Concurrent predictors for each domain were determined using logistic regression analysis. The resulting three models were combined in a stepwise fashion in an effort to determine the most complete prediction model. The final model indicated that individuals at the highest risk for using smokeless tobacco were rural males who had smoked more than four cigarettes in their lifetime, were more heavily involved with alcohol, had a lower degree of assertiveness and social anxiety, and had reported eating as a coping response. Implications for prevention are discussed.

School-based smoking prevention: the teacher training process

Effective in-service teacher training must be regarded as a critical aspect of the implementation of any innovative school-based smoking prevention curriculum. Inadequate training or lack of training often leads to implementation failure, which, in turn, may be interpreted as program failure. To be effective, teacher training must include a presentation of the theory underlying the program, a demonstration of the skills to be learned, an opportunity to practice the new skills being taught, feedback, and coaching for application. Training activities must include a training workshop and ongoing consultation during the teacher's first experience with classroom implementation. Adequate preparation before the beginning of training will help to ensure that the necessary components are combined in a meaningful training sequence.