HIV among drug users at Beth Israel Medical Center, New York City, the first 25 years

New York City experienced the first and largest HIV epidemic among injecting drug users (IDUs). Using data collected from IDUs entering the Beth Israel drug detoxification program, we trace the history of this epidemic from the mid-1970s through the early 2000s. The epidemic can best be described in terms of successive stages: (1) introduction and rapid transmission of HIV in the IDU population; (2) stabilization of HIV prevalence at a high level (over 50%); (3) a decline in incidence and prevalence, following large-scale implementation of syringe exchange programs; and (4) a sexual transmission phase, in which HIV prevalence is approximately equal among injecting and noninjecting heroin and cocaine users, and sexual transmission is more important than injecting-related transmission among IDUs. Given the current spread of HIV among IDUs in many places in the world, New York City provides a very strong example for implementation of large-scale comprehensive syringe exchange programs as early as possible in HIV epidemics among IDUs.     

Sociodemographic Disparities in Access to Addiction Treatment Among a Cohort of Vancouver Injection Drug Users

Vancouver's explosive HIV epidemic among injection drug users (IDUs) has received international attention due to the presence of a large needle exchange program. The role of addiction treatment has not been evaluated in this setting. We evaluated factors associated with use of addiction treatment among a prospective cohort of Vancouver IDUs. Addiction treatment was negatively associated with Aboriginal ethnicity and unstable housing, both of which have been associated with HIV infection in previous studies. These findings demonstrate low levels of addiction treatment among Vancouver IDUs and suggest that programs may need to be targeted towards specific populations with poor access.     

Cultural Factors Influencing HIV Risk Behavior Among Dominicans in New York City

Abstract

Hispanics in the United States have disproportionately high rates of HIV. The existence of ethnically and culturally diverse Hispanic communities indicate that qualitative research on HIV-related attitudes and behaviors within subgroups is needed to develop successful interventions. Findings from interviews with 20 Dominicans involved with drug-related or sex work-related activities in New York City are presented in terms of predominant cultural influences and specific issues regarding sex work, drug use, and HIV/AIDS. Several directions for interventions in the Dominican community are indicated, e.g., outreach efforts sensitive to the stigmatization of behaviors such as needle use and homosexuality, and the encouragement of sex workers to use condoms with their partners as well as clients. Additional information regarding such areas as contraception, family planning, and drug treatment services is needed within this community. A knowledge of cultural norms can serve as a foundation for these intervention and education efforts.     

Predictors of Sharing Drugs Among Injection Drug Users in the South Bronx: Implications for HIV Transmission

Abstract

HIV may be transmitted in the process of sharing injected drugs, even if all participants have their own syringes. In an effort to gain understanding of the extent and predictors of drug sharing, data were obtained via personal interviews with 1,024 injection drug users from four neighborhoods in the South Bronx. The relationship between drug-sharing and demographic, sexual, and drug-related variables was first examined in a bivariate analysis, and then via multiple logistic regression. Individuals who split drugs were more likely to be female, have had sex with a casual partner, exchanged sex for drugs or other needs, recently smoked crack cocaine, and shared needles. They were less likely to live or inject at their own home or have used a new needle the last time they injected. In a final logistic model, correlates of drug sharing included trading sex, injecting outside one's home, and using borrowed, rented or shared needles. Despite the lack of significance for gender in the final logistic model, females were at high risk of drug sharing because they constituted the great majority of those who exchanged sex. Continuing research is needed to understand how drug-sharing contributes to the spread of HIV and other infections, as are studies of approaches to reducing drug sharing. Prevention strategists and outreach organizations should be aware of the HIV risks inherent in the widespread practice of drug sharing.     

HIV Risk Behaviors Among Young Drug Using Women Who Have Sex With Women (WSWs) in New York City

Previous research has suggested that multiple stressors may work in tandem to affect the health of women who have sex with women (WSWs). WSWs have been a part of the HIV epidemic in New York City since the beginning, making it an ideal setting to further explore these women's risk. Among a sample of 375 heroin, crack and/or cocaine using women recruited from economically disadvantaged communities in New York City, we examined HIV seroprevalence and risk behaviors among WSWs as compared to women who have sex with men only (WSMOs). We also explore differences between WSWs and WSMOs with respect to potential stressors (i.e., decreased access to resources and health care utilization and violence victimization) that might contribute overall HIV risk. The study's limitations are noted.     

Continuing HIV Risk in New York City Injection Drug Users: The Association of Syringe Source and Syringe Sharing

Sterile syringe access is an important means to reduce HIV risk, but many injection drug users (IDU) who obtain syringes from sterile sources continue to share syringes. We examined the factors associated with continuing syringe sharing in New York City. We recruited 500 active IDU in 2005 through respondent-driven sampling. In multiple logistic regression, not obtaining all syringes in the past year exclusively from sterile sources was associated with increased syringe sharing. Ensuring adequate syringe availability as well as engaging and retaining nonusers and inconsistent users in sterile syringe services may increase sterile syringe access and decrease syringe sharing.     

Sexual Risk and HIV Infection Among Drug Users in New York City: A Pilot Study

Measures of sexual health were assessed during 2008–2009 in a New York City sample of 102 injection and noninjection users of heroin, cocaine, or crack. There was considerable overlap and transitioning between crack smoking and injecting. Crack users were also significantly more likely to be gay, lesbian, or bisexual than other drug users. In multivariate analysis, HIV infection was independently associated with crack use and with being gay or bisexual. In New York City, HIV prevention for drug users has focused on syringe access, safe injection, and drug user treatment, but further progress in HIV control will require strategies to address sexual health among people who use drugs. The study's limitations are noted.     

A Perfect Storm: Crack Cocaine,HSV-2, and HIV Among Non-Injecting Drug Users in New York City

Prevalence of human immunodeficiency virus (HIV) infection has reached 16% among non-injecting drug users (NIDU) in New York City, an unusually high prevalence for a predominantly heterosexual population that does not inject drugs. Using a long-term study (1983–2011, >7,000 subjects) among persons entering the Beth Israel drug-treatment programs in New York City, we identified factors that contributed to this high prevalence: a preexisting HIV epidemic among injectors, a crack cocaine epidemic, mixing between injectors and crack users, policy responses not centered on public health, and herpes-simplex virus 2 facilitating HIV transmission. Implications for avoiding high prevalence among NIDU in other areas are discussed.     

Binge Drug Use Independently Predicts HIV Seroconversion Among Injection Drug Users: Implications for Public Health Strategies

Several studies have highlighted risk factors that cause HIV vulnerability among injection drug users (IDUs); these studies in turn have prompted public health officials to take action to minimize these risks. We sought to evaluate the potential association between binge drug use and HIV seroconversion and, subsequently, risk factors associated with binge drug use among a cohort of IDUs. To do this, we performed analyses of (1) associations with HIV seroconversion and (2) associations with binge drug use among participants enrolled in the Vancouver Injection Drug Users Study (VIDUS), a prospective cohort of IDU. Because serial measures for each individual were available, we undertook a time-updated Cox regression analysis to detect associations with HIV incidence and variables potentially associated with binge drug use were evaluated by using generalized estimating equations (GEE). Overall, 1548 IDU were enrolled into the VIDUS cohort between May 1996 and May 2003. There were 1013 individuals who were HIV seronegative at enrollment and had at least one follow-up visit; 125 (12%) became HIV positive during the study period for a cumulative incidence rate of 14% at 64 months after enrollment. In the final multivariate model, binge drug use [Adjusted Hazards Ratio: 1.61 (CI: 1.12, 2.31)] was independently associated with HIV seroconversion. In subanalyses, when we evaluated associations with binge drug use in GEE analyses, borrowing [Odds Ratio (OR): 153 (CI: 1.33–1.76)] and lending [OR: 1.73 (CI: 1.50–1.98)] syringes, sex trade work [OR: 1.14 (CI: 1.01–1.29)], frequent cocaine [OR: 2.34 (CI: 2.11–2.60)] and heroin [OR: 1.29 (CI: 1.17–1.43)] injection were independently associated with binge drug use and methadone [OR: 0.80 (CI: 0.71–0.89)] was protective against binge drug use. Our study identified an independent association between binge drug use and HIV incidence and demonstrated several high-risk drug practices associated with bingeing. Given the unaddressed public health risks associated with bingeing, a public health response protocol must be developed to minimize the personal and public health risks associated with the binge use of drugs.     

Sexual HIV/HSV-2 Risk Among Drug Users in New York City: An HIV Testing and Counseling Intervention

Undiagnosed and untreated sexually transmitted infections are highly prevalent among users of heroin, crack, cocaine, and amphetamines. Between 2008 and 2009, 58 heroin, cocaine, and crack users in New York City who reported unprotected vaginal and anal sex with more than one partner in the past 30 days were enrolled in an HIV testing and counseling intervention. Four weeks post intervention, increases were found for condom use and STI knowledge. Reductions were noted for safe-sex risk fatigue, number of same-and opposite-sex partners, and days when drugs were injected. Brief but intense counseling interventions can reduce HIV risk among high-risk populations.     

The Relationship Between Housing Status and HIV Risk Among Active Drug Users: A Qualitative Analysis

This paper examines the relationship between housing status and HIV risk using longitudinal, qualitative data collected in 2004–2005, from a purposeful sample of 65 active drug users in a variety of housed and homeless situations in Hartford, Connecticut. These data were supplemented with observations and in-depth interviews regarding drug use behavior collected in 2001–2005 to evaluate a peer-led HIV prevention intervention. Data reveal differences in social context within and among different housing statuses that affect HIV risk or protective behaviors including the ability to carry drug paraphernalia and HIV prevention materials, the amount of drugs in the immediate environment, access to subsidized and supportive housing, and relationships with those with whom drug users live. Policy implications of the findings, limitations to the data, and future research are discussed.     

Physicians' Assessment of Drug Use and Other HIV Risk Behavior: Reports by Female Drug Users

SUMMARY

With epidemiological trends indicating that Acquired Immune Deficiency Syndrome (AIDS) is the third leading cause of death among women ages 25 to 44 in the United States, it is becoming increasingly important to deal with the issue of Human Immunodeficiency Virus (HIV) prevention for women. Recommendations for primary and secondary prevention strategies tailored to the needs of women have been formulated. Such calls have included the recommendation that prevention efforts be intensified in medical settings regularly frequented by women. One setting identified is that of gynecological and obstetric services where HIV risk assessment, testing, and counseling would be an excellent means of reaching a maximum number of women of child-bearing age. Despite calls by the American College of Obstetricians and Gynecologists for OB/ GYN service providers to engage in HIV prevention, research has shown that physicians remain reluctant to address the issue with patients. This study explored the likelihood of physicians and other health service providers to engage in HIV prevention through risk behavior assessment, HIV testing, and HIV counseling by requesting information from female drug abusers not currently in substance abuse treatment. Sixty percent of the drug abusing women in this study did not receive HIV information from their health care provider, 70% did not receive HIV counseling, 68% were not offered HIV testing, and 66% were not asked to provide a drug history. Of those participants who had not been asked to provide a drug history, almost half indicated that they would have been willing to provide truthful answers had they been asked. These findings indicate that a prime opportunity for HIV prevention is being missed by women's health care providers. Neglecting to ask female patients about their drug use history and to explore their risk for HIV infection can have dire consequences for these women. Early intervention is less likely if the topic is not broached by service providers, increasing the likelihood of infection and the spread of the disease.     

Club Drug Use Among Minority Substance Users in New York City

Abstract

Surveillance data suggests that club drug use (Ecstasy, GHB, ketamine, LSD, methamphetamine, PCP and flunitrazepam) has been a predominantly White adolescent and young adult phenomenon in the United States. The authors investigated the use of club drugs among 323 streetrecruited minority substance users in northern New York City (66.3% were Hispanic, 23.8% were Black, and 9.9% were White/other race; median age = 32 years old). While Whites were more likely than others to have used club drugs, club drug use among Hispanics and Blacks was not uncommon; 45.3% Hispanics and 56.4% of Blacks reported a lifetime history of club drug use. PCP was the most commonly reported club drug used among all racial/ethnic groups. Further investigation of club drug use in minority populations is warranted.     

HIV-Risk Behavior Among Injecting or Non-Injecting Drug Users in Cape Town,Pretoria, and Durban,South Africa

The rapid assessment aimed to describe drug use and sexual practices that place injection and noninjection drug users (IDUs/NIDUs) at risk for HIV in South Africa. The sample comprised 85 key-informant (KI) and focus-group (FG) interviewees in or serving locations with high levels of drug use in Cape Town, Durban, and Pretoria. HIV testing of drug-using KIs was conducted using the SmartCheck Rapid HIV-1 Antibody Test. The findings indicated that commonly used drugs had differing effects on sexual and drug-use practices. Risky injecting behaviors among IDUs were common, and most interviewees engaged in sex when on drugs, some without condoms. These behaviors were also influenced by trust in intimate relationships. Injection drug users seemed more knowledgeable about HIV transmission than NIDUs, and 20% of IDUs who agreed to HIV screening tested positive. Views about drug- and HIV-intervention services, accessibility, and their efficacy were mixed. The findings suggest greater synergy is needed between drug- and HIV-intervention sectors and that consideration should be given to making various risk-reduction strategies more accessible. The study's limitations have been noted.     

Perceptions of Risk in Research Participation Among Underserved Minority Drug Users

Research with underserved minority drug users is essential to quality health care and prevention. Understanding how participants perceive risk in research is necessary to inform research regulators so that research protections are neither lax, exposing participants to harm, nor overly stringent, thereby denying access to beneficial research. Data from 37 semistructured interviews of underserved, African-American crack cocaine users, collected from February to May 2006 in a large, urban setting, were analyzed using content analysis. In three hypothetical studies, participants recognized risks as relative and articulated and evaluated specific risks. Research regulators may enhance the accuracy of risk assessment in research by incorporating the views of participants. Study implications and limitations are noted. Future research on risk perception in research participation is suggested.     

Age Shift in Patterns of Injection Drug Use Among the HIV_AIDS Population in Miami-Dade County,Florida

Analysis of HIV exposure category for 20,034 persons in three age groups (13–29, 30–49, 50 and over) who were alive through 2003 and had been reported to the Florida Department of Health with HIV or AIDS in Miami-Dade County, Florida, found that having a history of injection drug use increases with increasing age (p <. 001). Consideration of age-specific HIV risk profiles has implications for primary and secondary HIV prevention interventions, planning, and policy.     

Behavior Change and Health-Related Interventions for Heterosexual Risk Reduction Among Drug Users

Prevention of heterosexual transmission of HIV between and from drug users is important for controlling the local and global HIV heterosexual epidemic. Sex risk reduction interventions and health-related interventions are important for reducing the sex risk behaviors of drug users. Sex risk reduction interventions address individual-level, peer-level, and structural-level determinants of risk reduction. Health-related interventions include HIV counseling and testing, prevention and treatment of sexually transmitted diseases, and delivery of highly active antiretroviral therapy. It is important to adapt effective interventions implemented in resource-rich countries to the realities of the resource-constrained settings and to address relevant contextual factors.     

Active and Former Injection Drug Users Report of HIV Risk Behaviors During Periods of Incarceration

American prisons have increasing numbers of inmates incarcerated for drug offenses. This population is at high risk for HIV-infection and may continue HIV transmission risk behaviors while incarcerated. We find that 31% of injection drug users with a history of imprisonment had used illicit drugs in prison, and nearly half of these persons had injected drugs while incarcerated. Male gender and number of times incarcerated were associated with drug use in prison. Interventions for drug-using prisoners that are advocated in some European prisons, such as needle exchange programs and methadone maintenance, need attention in the United States.     

Needle Sharing Among Puerto Rican Injection Drug Users in Puerto Rico and Massachusetts: Place of Birth and Residence Matter

This study explored whether place of birth and residence was associated with needle sharing for Puerto Rican injection drug users (IDUs) (N = 348). In-person interviews were conducted in Puerto Rico and Massachusetts during 2005–2007. Multivariate regression analyses revealed IDUs born and living in Puerto Rico were four times more likely to have shared needles compared to those residing in Massachusetts. Respondents residing in Massachusetts were 76% less likely to have ever shared needles with an HIV-positive individual, controlling for covariates. Findings highlight the increased HIV-risk of Puerto Rican IDUs born and residing in Puerto Rico. Prevention and treatment needs are discussed.