HIV Risk Behaviors Among Homeless Injection Drug Users of Different Ethnicities

The objectives of this study were to assess the prevalence of HIV risk behaviors among homeless injection drug users (IDUs) and to determine whether these risk behaviors vary by ethnicity. A face-to-face interview was administered to 769 homeless IDUs in Portland, Oregon, from 1993 to 1996. Homeless IDUs had a high prevalence of needle sharing and sexual intercourse with casual partners, and a low prevalence of condom use. African Americans had the lowest rate of needle sharing, and Hispanics the highest. Compared to Whites, African Americans and Hispanics were both more likely to have had sex with casual partners in the last 30 days. African Americans were most likely to have used a condom with casual partners. Results indicate the need for more effective and culturally tailored interventions. Special efforts are needed to reduce needle sharing and increase condom use among Hispanic homeless IDUs, who exhibited the highest rates of risk behaviors.Correspondence should be directed to Jin T. Song, Oregon Health, Division, 800 NE Oregon St., Suite 550, Portland, Oregon 97232     

The Association of Human Immunodeficiency Virus Infection with Spontaneously Resolved Hepatitis C Virus Infection and Level of Viremia Among Injection Drug Users

This study aimed to investigate whether HIV and HIV-related factors are associated with spontaneously resolved hepatitis C virus (HCV) infection and levels of hepatitis C viremia. Among 351 anti-HCV(+) injection drug users, with and without HIV infection, multivariate methods were used to evaluate whether HIV status and HIV viral load, CD4 T-cell count, and concurrent HIV antiretroviral therapy were associated with (1) spontaneously resolved HCV infection and (2) HCV RNA levels. In 186 HIV patients, decreased HCV resolution was independently associated with Black race and modestly associated with CD4 T-cell count <200 cells/ml. Among 310 patients with persistent HCV infection, higher HCV RNA levels were independently associated with HIV status but not with other HIV-related factors. HIV may be associated with persistent HCV infection in patients with low CD4 T-cell counts. Moreover, HIV is associated with increased HCV viral load, which may attenuate response to HCV antiviral treatment in coinfected patients.     

Chapter 9: Alcohol Use Among Adult Puerto Rican Injection Drug Users

SUMMARY

This study explores the association between race/ethnicity and alcohol use for a population of 27,117 Massachusetts injection drug users. This population had all entered the Massachusetts drug treatment system between 1996-2002. Through logistic regression methods, controlling for age, gender, education, employment and homelessness, the study identified that Puerto Rican IDUs were close to 40% less likely to have ever used alcohol compared to their African American counterparts and 60% less likely to have ever used alcohol compared to their White counterparts. To further verify this finding, a sensitivity analysis was conducted for a subsample (n = 469) of IDUs who were not in treatment and who were interviewed by trained interviewers rather than by administrative intake workers. This sensitivity analysis confirmed the relationship between race/ethnicity and alcohol use for IDUs. This finding suggests that drug treatment for Puerto Rican IDUs should focus on their opiate addiction rather than on poly-drug use.     

Predictors of Injection Drug Use Cessation Among Puerto Rican Drug Injectors in New York and Puerto Rico

More than half of all AIDS cases among Puerto Ricans have been attributed to injection drug use. Predictors of injection drug use cessation were examined among Puerto Rican injection drug users (IDUs) in New York and Puerto Rico. Analysis of baseline and 6-month follow-up data from 670 IDUs in NY and 316 in PR showed that 47% NY and 20% in PR reported cessation of injection at follow-up (p < .001). In multivariate analyses, having been in drug treatment since baseline was the only significant predictor of cessation for both sites (NY: AOR = 1.80; PR: AOR = 3.10). Increasing availability of methadone maintenance treatment, especially in PR, was indicated.     

Social Support Among HIV Positive Injection Drug Users: Implications to Integrated Intervention for HIV Positives

The study compared social support networks of HIV seropositive versus seronegative injection drug users (IDUs). Participants were 635 low income African Americans; 47% were HIV seropositive (of whom 17% had AIDS), 45% female, and 45% current drug users. A social network methodology elicited structural, functional, and relational network components. After controlling for confounders, HIV seropositive compared with HIV seronegative IDUs had larger support networks, including more females, kin and sources of instrumental assistance, and marginally more sources of emotional support, though they were less likely to have a sex partner. There was no difference between HIV status and number of active drug users in support networks. Results suggest that HIV seropositive IDUs had mobilized a range of network support but that they also relied on drug using social influences. Findings may have implications to the development of integrated HIV prevention and care intervention that builds on HIV seropositives natural support structures.     

Alcohol Use and T-Lymphocyte Subsets among Injection Drug Users with HIV-1 Infection: A Prospective Analysis

Objectives: Alcohol use is known to alter immune function and has immunosuppressive effects that may modify T-lymphocyte subpopulations. However, there is no clear evidence regarding the relationship of alcohol use with the progression of immunodeficiency in human immunodeficiency virus-type 1 (HIV-1)-seropositive individuals, particularly injection drug users (IDUs). Methods: Using prospective data from a cohort of IDUs in a study of the natural history of HIV infection, we examined the relationship of alcohol use and changes in T-lymphocyte subsets. Among the 2921 IDUs followed semiannually in outpatient clinics, 188 were documented HIV-1 seroconverters with known time of seroconversion. At each visit, all study participants were interviewed, underwent physical examinations, and had blood drawn for laboratory studies. Alcohol use was measured by reported frequency and quantity of alcoholic beverages. Longitudinal analyses included data for up to 5 years postseroconversion. To formally test the association of alcohol use with change in levels of CD4⁺ and CD8⁺ cells subsequent to HIV seroconversion, regression models incorporating autocorrelation structure were applied. Results: Alcohol use was not appreciably related to age, gender, marital status, income, education, or the duration of intravenous drug use. CD4% decreased for all IDUs within the first 5 years after seroconversion, with no significant differences between alcohol categories. CD8% increased for all IDUs, with no significant differences by alcohol category within the first 2 years after seroconversion. However, between 2 to 5 years postseroconversion, there was a statistically significant increase among the heaviest drinkers: CD8% increased 6.9%/year [95% confidence interval (CI): 4.7, 8.0] for the IDUs who reported <21 drinks/week, 2.4%/year (95% CI: 0.8, 4.0) for IDUs who drank 21 drinks/week or less, and 0.4% (95% CI: -2.1, 2.9) for abstainers. Similar results were obtained for CD4 and CD8 absolute counts. Conclusions: In this study population of IDUs, CD8% (but not CD4%) is associated with alcohol consumption early after HIV seroconversion. This is the first prospective study to date to assess the relationship of alcohol use with HIV progression from the time of HIV seroconversion among a cohort of IDUs. If confirmed in future investigations, the findings may have significant implications for prevention and early intervention programs aimed at inhibiting disease progression among HIV-positive IDUs.     

A Qualitative Exploratory Study of Injection Drug Users' Participation in a Long-Term Epidemiological Study of HIV

An exploratory study was conducted with 15 current or former injecting drug users to gain an understanding of the motivations for and reactions to participating in ALIVE (AIDS Link to Intravenous Experiences), a longitudinal natural history study of HIV among urban drug users in Baltimore, Maryland. Semistructured qualitative interviews explored participants' perceptions of ALIVE and of its benefits and the factors that might influence accuracy of self-report. Participants described benefiting from the study in many tangible and intangible ways. ALIVE was the sole source of health care for many, as only a third of the participants had health insurance. Participants' biggest challenge in the ALIVE survey were questions related to sexuality, which were perceived as too personal or elicited shame. Results indicate the importance of qualitative research in understanding how and why people are motivated to participate in epidemiological studies and how these perceptions might relate to their responses in survey research.     

Predictors of Current Housing Status Among HIV-Seropositive Injection Drug Users (IDUs): Results from a 1-Year Study

Using longitudinal data collected from 821 HIV-seropositive injection drug users (IDUs) who participated in a multi-site behavioral intervention study, we identified predictors of current housing status at baseline and 12-month follow-up time points. The study was conducted in Baltimore, Miami, New York, and San Francisco from 2001 to 2005. Logistic regression, incorporating the general estimating equations (GEE) method was performed. Multivariate analysis found that Miami participants (OR = 0.56) were less likely to report having current housing (P < 0.05). Among the potential barriers to housing, lower income (OR = 0.68), injection cocaine/crack use (OR = 0.66) and recent incarceration (OR = 0.10) were statistically significant (P < 0.05). Among the potential facilitators of housing, case management (OR = 1.38), outpatient drug treatment attendance (OR = 1.74), and social support (OR = 1.39) were significant. The association between social support and housing was stronger among those who had been recently incarcerated. Additional research is needed to identify types of support and resources beyond what is currently provided in order to better serve housing needs of HIV-seropositive IDUs. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.     

Writing About Risk: Use of Daily Diaries in Understanding Drug-User Risk Behaviors

As part of a larger syringe access and HIV risk study, a subsample of 23 current injection drug users completed daily diaries, highlighting activities related to syringe acquisition, use, and discard. Diaries have been previously utilized in a variety of psychological, public health, and nutrition studies to assess risk as well as correlated behaviors. We piloted the diary methodology in three northeastern U.S. cities (Hartford and New Haven, CT, and Springfield, MA) to learn about correlates of HIV risk. We discovered that the method provided advantages over several other qualitative and ethnographic methods. Results indicate that daily diaries elucidated (1) patterns of injection drug use, (2) sporadic and high-risk events, (3) HIV and hepatitis risk related to the syringe life cycle, and (4) emotional correlates of drug use. Furthermore, we witnessed an unexpected intervention effect that the diary may have in the lives of drug users.     

The Relationship of Sexual Dyad and Personal Network Characteristics and Individual Attributes to Unprotected Sex Among Young Injecting Drug Users

We examine in the heterosexual partnerships (dyads) of IDUs the correlates of engaging in unprotected sex on three levels: individual attributes, social network characteristics, and dyad characteristics. Unprotected sex was significantly less likely to occur in dyads where the participant injected daily or had high safe-sex attitude scores, and in dyads where both members encouraged each other to use condoms. Unprotected sex was significantly more likely to occur in dyads that smoked crack together, shared needles with each other, and where the participant knew that the sex partner had concurrent sex partners. In the sexual dyads of IDUs there is a combined risk of unsafe injecting and unsafe sex. Both injecting and sexual risk, and their combination need to be addressed in interventions that target the sexual partnerships of IDUs. Such interventions should also aim to reduce injected and non-injected crack and other stimulant use associated with high-risk sex.     

HIV Voluntary Counseling and Testing among Injection Drug Users in South China: A Study of a Non-Government Organization Based Program

HIV voluntary counseling and testing (VCT) programs are usually delivered by government health agencies in China. This study examined the feasibility of using a Chinese non-government organization (NGO) to deliver a VCT program to injection drug users (IDUs) in a southern Chinese city. The process data indicated the program successfully recruited and served 226 male and female IDUs in 4 months. The HIV prevalence rate of the study population was 57.5% by rapid HIV testing with a secondary rapid test to confirm. Quantitative and qualitative evaluations indicated that the VCT program was implemented appropriately and participants' HIV knowledge and safe drug and sex practices were significantly improved after participation in the VCT program. This study demonstrates the feasibility of a Chinese NGO to provide VCT for IDUs and documents the processes and outcomes of the program. There remains a great need to find additional sources to provide VCT and other HIV prevention services to IDUs and other high-risk populations in China. Chinese NGOs have the potential to fill this need.     

Correlates of HIV Antibody Testing Among a Sample of Injection Drug Users: The Role of Social and Contextual Factors

As injection drug users (IDUs) continue to be infected by HIV, an important component of prevention efforts is the identification of factors that are associated with utilization of HIV testing programs. The purpose of this study was to identify correlates of HIV testing within the past 12 months among IDUs. A sample of 558 IDUs, recruited from street-based and community venues, completed a cross-sectional survey. Multivariate logistic regression indicates factors independently associated with having been tested recently, including social structural factors such as being incarcerated, having interactions with an HIV prevention outreach worker, and having used a case manager. Furthermore, main sex partner's testing status was positively associated with recent testing. Support of programs that are designed to serve hard-to-reach populations and target couples may be effective in increasing HIV testing among active IDUs.     

Needle Sharing: a Longitudinal Study of Female Injection Drug Users

The objective of this study was to examine the psychosocial risk and protective factors related to needle-sharing behavior among female intravenous drug users (IDUs) positive (N = 96) and negative (N = 128) for human immunodeficiency virus (HIV). Participants in this longitudinal study were interviewed individually at two points in time, with a 6-month interval between interviews. The interviewers used a structured questionnaire, which included psychosocial measures and questions about drug and sexual risk behaviors. Data were analyzed using Pearson correlations and hierarchical regression analyses. The findings supported a developmental model in which the psychosocial domains and HIV status predicted T1 (initial) needle-sharing behavior, which in turn was related to T2 (follow-up) needle-sharing behavior. In addition, the relationship between personality and peer risk factors and T2 needle sharing was buffered by family-related protective factors. While HIV-positive status had a direct effect on T1 needle sharing with strangers, its effect was mediated by all of the psychosocial variables in its relation to T1 needle sharing with familiar people. Comparisons of these results were made with a companion study of male IDUs. The results suggest several intervention and treatment approaches that can be implemented at different points in the developmental pathways leading to risky needle-sharing practices among female IDUs.     

The Effect of Intimate Partner Violence on Receptive Syringe Sharing Among Young Female Injection Drug Users: An Analysis of Mediation Effects

This study sought to explore the relationship between intimate partner violence (IPV) and receptive syringe sharing (RSS) among young female injection drug users (IDUs) and to examine mediating variables. Cross-sectional behavioral assessments were completed by 797 female IDUs in five U.S. cities who reported having at least one main sexual partner in the past three months. Linear regression was used to estimate direct and mediated effects. The product of coefficients method was used to statistically evaluate mediation. Respondents were predominantly white (70%) and mean age was 23 years. Sixty percent reported RSS in the past three months and 33% reported IPV in the past year. The association between IPV and RSS was independently mediated by self-esteem and depression, but not by self-efficacy for safer drug injection. Findings suggest that interventions focused on improving victimized women’s self-esteem and depression may help mitigate some of the negative health effects of IPV.     

A Follow-up Study of 300 Ex-Clients of a Drug-Free Narcotic Treatment Program in New York City

This article deals with an attempt at evaluating the success of a drug-free narcotic treatment program in New York City through a follow-up study of 300 ex-clients of the program. Two hundred ex-clients out of the 300 target population were actually interviewed. The number of months the clients had remained in the treatment program was found to be a key factor in the outcome of the program. The length of time in the program was itself highly dependent upon the client's background: the higher the pretreatment pathology the lower the chance of treatment success.     

Awareness of HCV Status and Preferences for Testing and Treatment among People with Recent Injecting Drug Use at a Peer-Led Needle and Syringe Program: The TEMPO Pilot Study

Background: New technologies and therapies allow the possibility of a single-visit test and treat model for hepatitis C virus (HCV), addressing some of the barriers to care faced by people who inject drugs. Methods: The TEMPO Pilot Study was an interventional cohort study evaluating a single-visit test and treat intervention among people with recent injecting drug use at a one peer-led needle and syringe program (NSP) in Sydney, Australia between September 2019 and February 2021. This analysis evaluated awareness of HCV status and agreement of self-report with HCV RNA test results. The analysis also assessed acceptability of: modality of result delivery, modality of blood sampling, site of treatment, and duration of treatment. Results: Among 101 participants (median age 43; 31% female), 100 had a valid HCV RNA test result and 27% (27/100) were HCV RNA detectable. Overall, 65% (65/100) were aware of their status. Among people with a positive HCV RNA result, 48% (13/27) were aware of their status. People preferred same-day HCV test results (95%, 96/101), and preferred to receive results in person (69%, 70/101). Receiving treatment at an NSP was acceptable (100%, 101/101) and 78% (79/101) were willing to discuss their health with a peer NSP worker. Conclusion: Half of people with current HCV infection were aware of their status. The high acceptability of simplified testing and treatment pathways delivered at NSPs indicates that this is an appropriate strategy to improve HCV awareness and treatment uptake in this population.