Drug use, AIDS knowledge, and HIV risk behaviors of Cuban-, Mexican-, and Puerto-Rican-born drug injectors who are recent entrants into the United States.

To date, relatively little research attention has been devoted to the HIV-risky behaviors of persons who are newly arrived in the United States and who use drugs. Data gathered from street-recruited injection drug users (IDUs) recruited in 10 United States cities who were born in Mexico, Cuba, and Puerto Rico and who are recent entrants into the United States suggest that, in comparison to US-born IDUs, Mexican-born subjects are at elevated risk for acquiring and transmitting HIV as a result of sharing needles with friends and running partners; sharing drug injection implements such as cookers, cotton, and rinse water; frequent injection in HIV-risky settings; use of unsterilized needles; and relatively frequent trading of sex for drugs or money. Puerto-Rican-born IDUs were found to inject drugs relatively frequently, and to do so relatively often in high-risk settings in which sterile injecting equipment and cleaning materials often are scarce. These data also show generally lower levels of AIDS knowledge among the in-migrant IDUs than among US-born IDUs. Respondents from each nationality group most often cited television as the source of their most useful and reliable AIDS information, but also tended to regard community outreach workers as a significant source of reliable AIDS and needle cleaning information. The high levels of involvement in HIV-risky behaviors, deficits in knowledge concerning the means of HIV transmission, and relative ease of mobility of the at-risk (for HIV) individuals examined here indicate a need for a comprehensive public health prevention initiative to limit the future spread of HIV. At a minimum, such an undertaking would do well to incorporate group-specific, culturally appropriate behavioral interventions as well as an information campaign.     

Drug use,AIDS Knowledge,and HIV Risk Behaviors of Cuban-, Mexican-, and Puerto-Rican-Born Drug Injectors who are Recent Entrants into the United States

To date, relatively little research attention has been devoted to the HIV-risky behaviors of persons who are newly arrived in the United States and who use drugs. Data gathered from street-recruited injection drug users (IDUs) recruited in 10 United States cities who were born in Mexico, Cuba, and Puerto Rico and who are recent entrants into the United States suggest that, in comparison to US-born IDUs, Mexican-born subjects are at elevated risk for acquiring and transmitting HIV as a result of sharing needles with friends and running partners; sharing drug injection implements such as cookers, cotton, and rinse water; frequent injection in HIV-risky settings; use of unsterilized needles; and relatively frequent trading of sex for drugs or money. Puerto-Rican-born IDUs were found to inject drugs relatively frequently, and to do so relatively often in high-risk settings in which sterile injecting equipment and cleaning materials often are scarce. These data also show generally lower levels of AIDS knowledge among the in-migrant IDUs than among US-born IDUs. Respondents from each nationality group most often cited television as the source of their most useful and reliable AIDS information, but also tended to regard community outreach workers as a significant source of reliable AIDS and needle cleaning information. The high levels of involvement in HIV-risky behaviors, deficits in knowledge concerning the means of HIV transmission, and relative ease of mobility of the at-risk (for HIV) individuals examined here indicate a need for a comprehensive public health prevention initiative to limit the future spread of HIV. At a minimum, such an undertaking would do well to incorporate group-specific, culturally appropriate behavioral interventions as well as an information campaign.     

African-American injection drug users: tensions and barriers in HIV/AIDS prevention.

This exploratory study utilized a focus group methodology to explore tensions and barriers in HIV/AIDS prevention among African-American injection drug users. Participants discussed HIV infection risks, national/community HIV prevention effectiveness, prevention barriers, ideas on barrier removal, and the tensions which exist between users and the larger African-American community. Recognizing the inevitability of continued drug use for many injectors, participants requested basic harm-reduction supplies including condoms, needle exchange programs, additional drug user treatment services, and the use of culturally- and gender-matched peer-led prevention and treatment outreach. Preliminary recommendations are made for consideration in HIV/AIDS prevention among African-American IDUs.     

AFRICAN-AMERICAN INJECTION DRUG USERS: TENSIONS AND BARRIERS IN HIV/AIDS PREVENTION

This exploratory study utilized a focus group methodology to explore tensions and barriers in HIV/AIDS prevention among African-American injection drug users. Participants discussed HIV infection risks, national/community HIV prevention effectiveness, prevention barriers, ideas on barrier removal, and the tensions which exist between users and the larger African-American community. Recognizing the inevitability of continued drug use for many injectors, participants requested basic harm-reduction supplies including condoms, needle exchange programs, additional drug user treatment services, and the use of culturally- and gender-matched peer-led prevention and treatment outreach. Preliminary recommendations are made for consideration in HIV/AIDS prevention among African-American IDUs. [Translations are provided in the International Abstracts Section of this issue.]     

AIDS update: prevalence, prevention, and medical management

This article summarizes the epidemiology of AIDS and human immunodeficiency virus (HIV) infection among intravenous drug abusers (IVDAs) in the United States and discusses the status of approaches to prevent HIV infection and to treat AIDS patients. Finally, the status of research of selected community-based prevention programs, such as needle-exchange programs and programs distributing bleach to IVDAs for needle and syringe cleaning, will be reviewed.     

Overview of HIV Among Injection Drug Users in New York City: Critical Next Steps to Eliminate Racial/Ethnic Disparities

At the start of the HIV epidemic, 50% of new infections were among injection drug users (IDUs) in New York City. While HIV has declined among IDUs since the mid-1990s, parenteral transmission continues to overburden Blacks/Hispanic IDUs. Individual risk behaviors do not explain the distribution of HIV/AIDS among IDUs. Social and/or structural factors are likely fueling racial disparities creating a high-risk socioenvironmental context. While increased access to structural interventions (i.e., syringe exchange and pharmacy syringe access) is needed, it may not be sufficient to eliminate HIV/AIDS disparities among IDUs. Research on incorporating structural factors into intervention strategies is needed.     

Overview of HIV among injection drug users in New York City: critical next steps to eliminate racial/ethnic disparities

At the start of the HIV epidemic, 50% of new infections were among injection drug users (IDUs) in New York City. While HIV has declined among IDUs since the mid-1990s, parenteral transmission continues to overburden Blacks/Hispanic IDUs. Individual risk behaviors do not explain the distribution of HIV/AIDS among IDUs. Social and/or structural factors are likely fueling racial disparities creating a high-risk socioenvironmental context. While increased access to structural interventions (i.e., syringe exchange and pharmacy syringe access) is needed, it may not be sufficient to eliminate HIV/AIDS disparities among IDUs. Research on incorporating structural factors into intervention strategies is needed.     

Expanding research on the role of alcohol consumption and related risks in the prevention and treatment of HIV/AIDS

This article is a review of some of the major epidemiological, behavioral, biological, and integrative prevention research issues and priorities in the area of HIV/AIDS and alcohol consumption. Drinking alcohol increases both the risk for infection with HIV and related illnesses and the morbidity and mortality of patients who progress to AIDS. New and improved measurement procedures have helped in assessment of the complex patterns of alcohol use, identification of intervening explanatory mechanisms for risk behaviors and contexts, and determination of intervention outcomes. Both the direct and indirect effects of alcohol misuse appear to be major contributors to both the risk for infection with HIV and the transmission of HIV/AIDS at the individual and population levels. There is increasing evidence that perhaps no level of alcohol consumption is "safe" for those who are HIV infected and receiving antiretroviral treatment. Interdisciplinary basic behavioral and biomedical research is needed to develop comprehensive culturally appropriate strategies for programs that can be effectively delivered in community contexts in the United States and abroad and that focus on the integration of our understanding of individual behaviors, high-risk group membership, biological mechanisms, and the social and physical environments that place individuals at risk for HIV infection. High-priority topics include improving adherence to antiretroviral medications, prevention of infection in young minority women in the United States, and treatment of HIV+ pregnant women who are alcohol abusers to prevent adverse fetal outcomes, which is an international focus in under-resourced settings in Africa.     

Effectiveness of community-based outreach in preventing HIV/AIDS among injecting drug users

This paper focuses on the evidence for the effectiveness of community-based outreach intervention as one component of a comprehensive HIV prevention model for preventing HIV infection in injecting drug user (IDU) populations. Three empirical questions guided the review of the evidence. This article includes primarily published literature on community-based outreach derived mostly from developing countries but also unpublished literature. Wherever possible, evidence from multi-country, multi-site studies or meta-analytical studies is included. More than 40 published studies reveal that injecting drug users (IDUs), who are reached by community-based outreach and provided with access to risk reduction services, report reducing HIV risk behaviours. The strength of the evidence was assessed using Hill's criteria, which permit a review of multiple studies with different designs. Using the criteria, it is possible to infer causation about the evidence of effectiveness of the intervention. The evidence for the effectiveness of a community-based outreach strategy is strong. Despite evidence from 20 years of evaluation studies of the effectiveness of community-based outreach, a huge gap exists in most countries between the number of IDUs who want or could benefit from outreach services and the number of IDUs who actually receive them. Findings from evaluation studies on the effectiveness of community-based outreach must be made accessible, disseminated globally and provided to policy- and decision-makers to persuade them to take action and implement scaled-up prevention programmes. This requires ongoing advocacy and constant strengthening of the evidence base. Plans are needed to link evidence-based findings with technical assistance as well as training to enhance the capacity of regions and countries to introduce, scale up and sustain HIV prevention outreach to IDUs as part of a comprehensive HIV prevention strategy.     

Preventing HIV Transmission in Drug Treatment Programs:

The AIDS epidemic has dramatically affected drug treatment programs, creating both an epidemiological crisis and a psychological one. A paramount question for treatment program staff is how to prevent patients from acquiring or spreading HIV. The health belief model has been useful in generating prevention approaches, including programs that raise the threat of infection, provide alternative behaviors, and build social support. Some of these programs have been effective in changing attitudes and reducing the behaviors that put drug users at risks for acquiring or transmitting HIV. Future research will develop collaborative studies, disseminate techniques to drug treatment programs, and develop more powerful interventions for patients who continue with risky behviors.     

Preventing HIV transmission in drug treatment programs: what works?

The AIDS epidemic has dramatically affected drug treatment programs, creating both an epidemiological crisis and a psychological one. A paramount question for treatment program staff is how to prevent patients from acquiring or spreading HIV. The health belief model has been useful in generating prevention approaches, including programs that raise the threat of infection, provide alternative behaviors, and build social support. Some of these programs have been effective in changing attitudes and reducing the behaviors that put drug users at risk for acquiring or transmitting HIV. Future research will develop collaborative studies, disseminate techniques to drug treatment programs, and develop more powerful interventions for patients who continue with risky behaviors.     

Expanding Research on the Role of Alcohol Consumption and Related Risks in the Prevention and Treatment of HIV_AIDS

This article is a review of some of the major epidemiological, behavioral, biological, and integrative prevention research issues and priorities in the area of HIV_AIDS and alcohol consumption. Drinking alcohol increases both the risk for infection with HIV and related illnesses and the morbidity and mortality of patients who progress to AIDS. New and improved measurement procedures have helped in assessment of the complex patterns of alcohol use, identification of intervening explanatory mechanisms for risk behaviors and contexts, and determination of intervention outcomes. Both the direct and indirect effects of alcohol misuse appear to be major contributors to both the risk for infection with HIV and the transmission of HIV_AIDS at the individual and population levels. There is increasing evidence that perhaps no level of alcohol consumption is “safe” for those who are HIV infected and receiving antiretroviral treatment. Interdisciplinary basic behavioral and biomedical research is needed to develop comprehensive culturally appropriate strategies for programs that can be effectively delivered in community contexts in the United States and abroad and that focus on the integration of our understanding of individual behaviors, high-risk group membership, biological mechanisms, and the social and physical environments that place individuals at risk for HIV infection. High-priority topics include improving adherence to antiretroviral medications, prevention of infection in young minority women in the United States, and treatment of HIV+ pregnant women who are alcohol abusers to prevent adverse fetal outcomes, which is an international focus in under-resourced settings in Africa.     

HIV risk reduction and service delivery strategies in criminal justice settings

Because of the HIV risk behaviors of substance abusers, particularly injection drug users and those who exchange sex for drugs, and the large numbers who are already infected with HIV or showing symptoms of AIDS, significant service delivery issues are associated with their criminal justice processing. Many strategies have been implemented in correctional settings in an effort to prevent and control the transmission of HIV. A number of these are for the purpose of lowering transmission risk in institutions, whereas others have been structured for the sake of offering prevention/intervention to inmates before they return to the free community. As such, prisons and jails represent opportune settings for HIV prevention and education. The most common HIV control/prevention/education strategies include mandatory testing of inmates for HIV, segregating infected inmates from the general prison population, establishing special health care units for HIV positive and AIDS symptomatic inmates, offering HIV prevention and risk reduction programs, and granting medical parole for the terminally ill. Because drug abuse treatment results in substantial declines in the use of heroin, cocaine, and other drugs, treatment per se can play a significant role in reducing the spread of HIV and AIDS among those coming to the attention of the criminal justice system. Most promising are continuous and integrated treatment services that are tied to the stages of correctional supervision: primary treatment while incarcerated; secondary treatment while on work release, halfway house or community supervision; and, tertiary treatment in ongoing aftercare.     

Doing the possible: harm reduction, injecting drug use and blood borne viral infections in Australia

Most surveys show that, other than among men who inject drugs and have a history of homosexual contact, the prevalence of HIV infection among injecting drug users (IDUs) in Australia is about 2%. Rates of needle sharing have also declined greatly in the last decade, although the high prevalence and incidence of hepatitis C infection suggest that existing strategies have not yet brought this epidemic under control. Harm reduction has been the major Australian approach to the reduction of blood borne viral infections (BBVIs) in IDUs. Harm reduction strategies include needle distribution schemes, drug substitution therapies and education about safe administration practices. Importantly, with IDUs as with gay men, the infected and affected communities have been brought into partnership with health educators, researchers and policy makers. This paper will review Australia's approach to the prevention of BBVI in IDUs and the effectiveness of current strategies. I will argue that while HIV/AIDS among heterosexual IDUs appears to have been successfully prevented, international experiences of rapidly emerging epidemics demonstrate there is little room for complacency. Moreover, reducing the incidence of hepatitis C and hepatitis B among IDUs remains a major challenge.     

中缅边境社区静脉注射吸毒人员高危注射行为对比分析

目的 分析中缅边境社区静脉注射吸毒人员（IDUs）高危注射行为情况,为下一步加强边境地区跨境吸毒人员综合干预提供有利依据.方法 2009年在云南2个边境县,采用滚雪球方法选取社区内跨境缅甸籍和中国籍IDUs,知情同意后,采用自行设计并经预测试的双语问卷进行调查并进行血清学检测.调查内容包括基本情况、艾滋病知识、人类免疫缺陷病毒（HIV）相关高危行为等.数据采用Excel2003建库录入,SPSS16.0 软件进行统计分析.结果 两地共调查249例吸毒人员,其中中国籍100例,缅甸籍149例.20.0%中国籍及10.1%缅籍IDUs上月注射时有共针现象,中缅IDUs的HIV感染率分别为32.0%、19.5%.两地吸毒人员上月注射时是否共用针具、或共用过毒品稀释溶液或容器及上次注射使用新针具体情况比较,差异有统计学意义（P＜0.05）.结论 为控制边境吸毒人员HIV感染传播,加强跨边境吸毒人员的综合干预,特别是边境中国吸毒人员的综合干预十分重要.     

Reaching and enrolling drug users for HIV prevention: a multi-site analysis

Since 1994, several sites have participated in a NIDA Cooperative Agreement for AIDS Community-based Outreach/Intervention Research Program to examine rates of HIV risk behaviors and evaluate HIV risk reduction interventions among out-of-treatment drug injection and crack cocaine and heroin smokers. We studied the process and outcome of community outreach for recruitment of drug users in AIDS research and education projects in three metropolitan areas: St. Louis, MO; San Antonio, TX, and Durham and Wake Counties, NC. There were two primary areas of focus: (1) the level of accuracy among community health outreach workers (CHOWs) in identifying potentially eligible persons for HIV prevention, and (2) overall effectiveness in recruiting and enrolling persons in formal assessment and intervention studies. We found cross-site and within-site differences in levels of accuracy and in recruitment and enrollment yields. Drug users who had never been in treatment and drug users who had never been tested for HIV infection were underrepresented at all sites. We discuss the factors which may have contributed to cross-site and within-site differences. The findings suggest a need for continued study, refinement, and evaluation of community outreach strategies in order to enroll a broad spectrum of vulnerable groups in HIV prevention activities.     

Practice Guidelines

State agencies have been profoundly impacted by the AIDS epidemic. In the absence of a vaccine that would prevent AIDS or of medacines that would cure it, the primary strategies of such agencies have focused on reducing the spread of AIDS by promoting cessation of high risk behaviors and thus preventing or slowing its transmission. Recent research indicates that the primary route of AIDS transmission into the general heterosexual population is by intravenous (IV) drug abusers, who directly account for about 17% of AIDS cases nationwide. Reducing the spread of AIDS within this group would not only reduce the overall toll of the disease but should limit its spread to the population at large. Infection by the human immunodeficiency virus (HIV) can be minimized by reducing or eliminating certain high-risk activities. In the IV drug using community, the primary intervention strategies include: educating IV drug users about the hazards of AIDS and sharing of needles; enrolling them in treatment programs to reduce drug use; promoting the use of new or sterilized syringes and needles among those who will not abstain from drug use; and discouraging high-risk sexual activity among thsoe who are already infected by HIV. The State of California has already increased the number of treatment slots for IV drug users and, through the Department of Alcohol and Drug Programs, is scaling up its educational, prevention, and intervention activities, particularly those related to safe sex, promoting the cessation of IV drug use, and improving equipment hygience by those who continue use.     

Needle syringe acquisition and HIV prevention among injecting drug users: a treatise on the "good" and "not so good" public health practices in South Asia

This article describes the prevalence of HIV/AIDS and other bloodborne infections is well established among injection drug user (IDU) populations in South Asia (SA). IDU populations in SA are diverse and display different demographic and socioeconomic profiles. The current provision of sterile injecting equipment as part of public health initiatives is suboptimal. Although some needle and syringe exchange programs (NSEPs) operate in the region, pharmacies and "friends" continue to be a major source of syringe acquisition. It is suggested that the cost of syringes in the region is significantly higher in real terms than in several other countries and negatively impacts on the ability of IDUs to acquire needles and syringes. In addition, existing NSEPs offer poor coverage both at the population and individual level. Their effective functioning is hampered by resource constraints, ambivalent policy positions, little attention to quality, and environmental factors. Secondary syringe exchange is a nascent phenomenon in SA that needs to be adequately documented and evaluated. Urgent attention needs to be given to developing alternative models of needle syringe delivery to scale-up HIV prevention interventions for IDUs. This study was conducted in the first quarter of 2004 and updated in 2006. We used key informants, previously unpublished and published data from research studies, and interventions programs, service statistics, and primary data to inform this study.     

Opioids and HIV/HCV Infection

Since human immunodeficiency virus (HIV) and hepatitis C virus (HCV) share the same modes of transmission and common risk factors for infection, co-infections with HIV and HCV are frequently found in injection drug users (IDUs). IDUs represent one of the largest reservoirs of HIV as well as HCV in the United States. These two pathogens are also likely to be responsible for the highest infectious disease morbidity and mortality rates among IDUs. IDUs frequently involve the abuse of heroin, the most common abused opiate. Opiates have been suggested to have a cofactor role in the immunopathogenesis of HIV disease, as they have the potential to compromise host immune responses and enhances microbial infections. Although in vitro studies have yielded relatively agreeable data that morphine, the active metabolite of heroin, exacerbate HIV infection/replication, epidemiologic studies as well as in vivo non-human primate investigations on the impact of opiate abuse on HIV disease progression have yielded the conflicting data. Given immunomodulation and immunocompromising effect as well as demonstrated impact to enhance HIV replication in vitro, it is reasonable to believe that opiate abuse is a facilitator in HIV and/or HCV disease progression. However, much remain to be learned about the mechanisms of opiate-mediated broad influence on host immunity and viral expression. Thus, more extensive studies are needed in order to determine the effects of different conditions of opiate abuse and to define the understanding of the role of opiate in modulating HIV and/or HCV disease progression.     

Integrating multiple programme and policy approaches to hepatitis C prevention and care for injection drug users: a comprehensive approach

BackgroundNew York State is home to an estimated 230,000 individuals chronically infected with hepatitis C virus (HCV) and roughly 171,500 active injection drug users (IDUs). HCV/HIV co-infection is common and models of service delivery that effectively meet IDUs’ needs are required. A HCV strategic plan has stressed integration.MethodsHCV prevention and care are integrated within health and human service settings, including HIV/AIDS organisations and drug treatment programmes. Other measures that support comprehensive HCV services for IDUs include reimbursement, clinical guidelines, training and HCV prevention education. Community and provider collaborations inform programme and policy development.ResultsIDUs access 5 million syringes annually through harm reduction/syringe exchange programmes (SEPs) and a statewide syringe access programme. Declines in HCV prevalence amongst IDUs in New York City coincided with improved syringe availability. New models of care successfully link IDUs at SEPs and in drug treatment to health care. Over 7000 Medicaid recipients with HCV/HIV co-infection had health care encounters related to their HCV in a 12-month period and 10,547 claims for HCV-related medications were paid. The success rate of transitional case management referrals to drug treatment is over 90%. Training and clinical guidelines promote provider knowledge about HCV and contribute to quality HCV care for IDUs. Chart reviews of 2570 patients with HIV in 2004 documented HCV status 97.4% of the time, overall, in various settings. New HCV surveillance systems are operational. Despite this progress, significant challenges remain.DiscussionA comprehensive, public health approach, using multiple strategies across systems and mobilizing multiple sectors, can enhance IDUs access to HCV prevention and care. A holisitic approach with integrated services, including for HCV–HIV co-infected IDUs is needed. Leadership, collaboration and resources are essential.