Monetary versus nonmonetary incentives for TB skin test reading among drug users

BACKGROUND: In a prior study, we reported that monetary incentives were effective in increasing return for tuberculosis (TB) skin test reading. The purpose of this study was to compare the effects of monetary versus nonmonetary incentives and a theory-based educational intervention on return for TB skin test reading in a sample of newly recruited active injection and crack cocaine users, and to determine the prevalence of TB infection in this sample. METHODS: Active injection drug and/or crack cocaine users (n = 1,078), recruited using street outreach techniques, were skin tested for TB. They were randomly assigned to 1 of 5 experimental treatment conditions: $10 cash, grocery store coupons, bus tokens/fast-food coupons, motivational education, or usual encouragement to return. Nonmonetary incentives had a $10 value, and all incentives were provided at return for skin test reading. RESULTS: Ninety-five percent of those who received $10 returned for skin test reading compared to 86% of those who received grocery store coupons and 83% of those who received either bus tokens or fast-food coupons. In contrast, only 47% of those who received the educational session and only 49% of those who received usual encouragement returned for skin test reading. The prevalence of a positive tuberculin test was 21%, and was similar for crack cocaine and injection drug users. CONCLUSIONS: Nonmonetary and monetary incentives dramatically increased the return rate for TB skin test reading among drug users who are at high risk of TB infection. Nonmonetary incentives were somewhat less effective than monetary incentives.     

Tuberculosis knowledge among New York City injection drug users.

Structured interviews measuring tuberculosis knowledge were administered to 494 New York City injection drug users, 31% of whom reported a history of having a reactive tuberculin skin test. Medical records review of a subsample confirmed the validity of self-reported data. Most respondents understood the mechanisms of tuberculosis transmission. Three fourths of the subjects did not fully understand the distinction between a reactive skin test and active tuberculosis, but those who reported a history of skin test reactivity were twice as likely to understand this distinction. Forty percent of subjects did not understand the importance of medication adherence. Misunderstandings, based on a recent lack of tuberculosis education, may contribute to the fear and confusion that interfere with efforts to control tuberculosis.     

Bacterial infections and skin cleaning prior to injection among intravenous drug users.

In a survey of 1,057 active intravenous drug users in Baltimore, MD, who were recruited through extensive community outreach, 12 reported endocarditis and 113 reported subcutaneous abscesses in the 6 months before being interviewed. Of all the persons surveyed, 556 reported cleaning their skin prior to injection at any time and 173 reported cleaning their skin all the time in the 6 months before the interview. The frequency of subcutaneous abscesses was lower among those who reported skin cleaning all the time; a similar trend was noted for frequency of endocarditis. The relatively simple procedure of encouraging intravenous drug users to clean their skin prior to injection will not eliminate but might reduce the frequency of these serious and expensive infectious complications of intravenous drug use.     

Met and unmet need for dental services among active drug users in Miami,Florida

This study considers both met and unmet need for dental services among chronic drug users in Miami, Florida, and compares them with non-drug users recruited from the same neighborhoods (N=1,479). Three primary findings emerged: (1) dental problems are among the most frequently reported health problems, (2) drug use is independently associated with need for dental services, and (3) injection drug use is independently associated with increased odds of unmet need for dental services. These findings suggest that policies that increase access to dental services for drug users and other disadvantaged groups are needed. These services could be integrated into existing behavioral health programs already targeting active drug users.     

Follow-up for medical care among drug users with hepatitis C

Prevalence of hepatitis C (HCV) in injection drug users (IDUs) is high and once HCV has been detected, follow-up medical care is essential. Six hundred and one current and former IDUs who tested positive for HCV antibodies received referrals for medical care. Twenty-four percent (147) of participants returned to be interviewed regarding their medical follow-ups. Of these, only 42% (61) had sought additional medical care in the form of further liver or blood tests or liver ultrasound. Four variables predicted seeking medical care: (a) ever being in residential drug treatment, (b) ever trading sex for money, (c) self-reported homelessness, and (d) living in one's own apartment or house. Having income from a job was inversely associated with seeking medical care. Knowledge of HCV infection alone does not mean that IDUs will seek medical care. Additional education concerning medical care and treatment options are needed to address IDU needs.     

Patterns of drug use and associated harms among rural injecting drug users: comparisons with metropolitan injecting drug users

OBJECTIVE: Given the harms associated with injecting drug use to both individuals and community and the paucity of such data from rural areas, the study aimed to compare: patterns of drug use, harms, and service access and utilisation among rural and metropolitan injecting drug users (IDU). DESIGN: Cross-sectional survey, using interviewer-administered structured questionnaire. PARTICIPANTS: One hundred and sixty-four rural and 96 metropolitan IDU from seven different New South Wales Area Health Services, recruited through needle and syringe programs (NSPs), snowballing techniques and advertisement. RESULTS: Age, gender, education and employment were similar for rural and metropolitan participants. Both samples reported use of a range of drugs, but rural participants were less likely than metropolitan participants to report daily heroin use (2% vs 10%), but more likely to report having injected morphine (50% vs 21%) in the last six months. Similar proportions reported using a needle/syringe after another person. Rural participants were less likely to report use of NSPs (36% vs 80%) and reported a number of barriers to NSP access and also to drug treatment services. Rural participants reported a significantly longer period of time between blood-borne virus testing. CONCLUSION: Samples of rural IDU are similar to metropolitan, although report some differences in patterns of drug use. Service provision, including access to new injecting equipment, blood-borne virus testing and drug treatment was found to cause considerable problems for rural IDU. These issues warrant further consideration.     

Effectiveness of highly active antiretroviral therapy among injection drug users with late-stage human immunodeficiency virus infection

Highly active antiretroviral therapy (HAART) has been shown to be effective in different populations, but data among injection drug users are limited. Human immunodeficiency virus-infected injection drug users recruited into the Acquired Immunodeficiency Syndrome Link to Intravenous Experiences (ALIVE) Study as early as 1988 were tested semiannually to identify their first CD4-positive T-lymphocyte cell count below 200/microl; they were followed for mortality through 2002. Visits were categorized into the pre-HAART (before mid-1996) and the HAART eras and further categorized by HAART use. Survival analysis with staggered entry was used to evaluate the effect of HAART on acquired immunodeficiency syndrome-related mortality, adjusting for other medications and demographic, clinical, and behavioral factors. Among 665 participants, 258 died during 2,402 person-years of follow-up. Compared with survival in the pre-HAART era, survival in the HAART era was shown by multivariate analysis to be improved for both those who did and did not receive HAART (relative hazards = 0.06 and 0.33, respectively; p < 0.001). Inferences were unchanged after restricting analyses to data starting with 1993 and considerations of lead-time bias and human immunodeficiency viral load. The annual CD4-positive T-lymphocyte cell decline was less in untreated HAART-era participants than in pre-HAART-era participants (-10/microl vs. -37/microl, respectively), suggesting that changing indications for treatment may have contributed to improved survival and that analyses restricted to the HAART era probably underestimate HAART effectiveness.     

Satisfaction with access to health care among injection drug users,other drug users,and nonusers

This article examines the satisfaction of users of cocaine and/or opiates and non-drug users with access to the health care system. Data were obtained from a sample of 1,477 injection drug users, non-injection drug users, and non-drug users recruited from neighborhoods with high drug use. Multiple regression examined the relationship between satisfaction with access to health care and demographic, health status and health care utilization, ability to pay, and alcohol and drug use variables. Age, ethnicity, health status, having received health care in the last 12 months, not having received health care when needed, having received preventive health care, health insurance, and drug use were independently associated with satisfaction. Injection drug users and non-injection drug users were less satisfied with access to health care. The article discusses strategies to improve health care delivery to drug users.     

Variables influencing condom use among intravenous drug users.

Correlates of condom use were identified using cross-sectional data from a convenience sample of 211 sexually active intravenous drug users enrolled in methadone maintenance in New York City. Sixty-eight percent did not use condoms at all in the previous month and only 11 percent used condoms every time. Nineteen percent were planning on conception, only 20 percent of whom had been tested for human immunodeficiency virus (HIV) antibody (all seronegative). Multiple logistic regression analysis indicated that condom use was independently associated with greater personal acceptance of condoms, greater partner receptivity to sexual protection, and recent entry to methadone treatment.     

Correlates of needle sharing among injection drug users.

OBJECTIVES. The sharing of contaminated injection equipment is the primary mode of human immunodeficiency virus (HIV) transmission for injection drug users. This study examined demographic factors, life events, and drug use practices that are potential risk factors for sharing injection equipment. METHODS. Between February 1988 and March 1989, 2921 active injection drug users were interviewed and questioned about their backgrounds, life-styles, and patterns of injection drug use. RESULTS. Of 2524 participants who reported injecting drugs within the 6 months prior to study enrollment, 70.4% reported recent needle sharing. A multivariate analysis found needle sharing to be more frequent among those with a history of arrest and lower socioeconomic status, even after accounting for other demographic and drug use variables. In addition, recent needle sharing was higher in male homosexual or bisexual men than in their heterosexual counterparts. CONCLUSIONS. These data suggest that injection drug users have an economic motive to share needles and that the availability of free and legal needles may reduce levels of needle sharing.     

Determinants of needle sharing among intravenous drug users.

Data from 110 IV-drug abusing persons in methadone maintenance were analyzed to determine the correlates of needle sharing. Sharing was directly related to peer group behavior, attitudes conducive to sharing, economic motivation to share, not owning injection equipment, and fatalism about developing AIDS. Sharers were aware of their AIDS risk. Indicated measures to reduce needle sharing would be positive peer support groups to help resist pressures to share, legal and free access to fresh injection equipment, education on the utility of risk reduction, and increased treatment options for IV cocaine users.     

Risk factors for shooting gallery use and cessation among intravenous drug users.

BACKGROUND. Shooting galleries, locations where intravenous drug users (IVDUs) can rent or borrow needles and syringes, are a high-risk environment for HIV-1 transmission. This study investigates risk factors for lifetime attendance at shooting galleries and differentiates characteristics of those who continue to frequent shooting galleries and those who have stopped. METHODS. We interviewed 2615 active IVDUs in Baltimore in 1988 and 1989 and determined patterns of IV drug use, sociodemographics, and HIV-1 serostatus as related to persistence vs cessation of shooting gallery use. RESULTS. Over half (52%) of active IVDUs reported ever using a shooting gallery, with 33% reporting use within the prior 3 months. In multivariate analysis, lifetime shooting gallery use was associated with male gender, homosexuality/bisexuality, low socioeconomic status, Black race, and heavier drug involvement. Persistent shooting gallery users were more frequently male, homosexual/bisexual, homeless, less educated, and started IV drug use more recently compared with those who ceased going to shooting galleries. CONCLUSIONS. Shooting gallery attendance may be pragmatic from a sociological and economic perspective, but it carries with it a heightened risk of acquiring HIV-1 infection.     

Relationships and diseases among drug users and nonusers

Human immunodeficiency virus (HIV) and syphilis are relationship-based diseases that are typically transmitted by the cooperative activities (sex or drug injection) of two persons. A sample of 215 drug users and 52 sociodemographically matched nonusers was collected to examine the behaviors and relationships related to HIV and syphilis transmission. Results showed that, although drug users had more risk opportunities (more sex partners and, of course, more injection partners) than nonusers, actual sex risk behaviors (never using condoms) did not differ appreciably among drug users and nonusers or with opposite-sex partners and same-sex partners. The similarity of sexual risk was supported by the similar levels of syphilis between drug users and nonusers. The unique risk to drug users was drug injection, although drug users were found to engage in fewer risky injection behaviors (sharing of drug injection equipment) than the risky sexual behaviors in which all participants engaged. Although drug users interacted as frequently with partners as nonusers, nonuser relationships were longer lasting and emotionally closer.     

Abnormal chest x-rays in intravenous drug users: implications for tuberculosis screening programs.

OBJECTIVES. The purpose of the study was to (1) determine the prevalence of significant abnormalities in routine chest x-rays used to screen for pulmonary tuberculosis in intravenous drug users and (2) evaluate the ability of the purified protein derivative skin test to identify persons with such abnormalities. METHODS. We conducted a cross-sectional screening study on 1314 persons admitted to an opiate detoxification unit in an urban jail. Purified protein derivative tuberculin reactivity and the prevalence of abnormalities consistent with tuberculosis on screening chest x-rays were evaluated. The chest x-ray was obtained independent of the skin test. RESULTS. The chest x-rays of 73 of the inmates (5.6%) showed abnormalities consistent with tuberculosis. Tuberculin skin testing missed 17 of 26 chest x-rays (65%) with significant infiltrates. CONCLUSIONS. Purified protein derivative screening is insensitive to chest x-ray abnormalities that require additional diagnostic evaluation for tuberculosis. Routine chest studies should be performed on all intravenous drug users admitted to congregate housing settings.     

Mortality among injecting drug users: a critical reappraisal.

STUDY OBJECTIVE--The aim was to quantify all cause mortality among injecting drug users. DESIGN--This was a retrospective analysis of 1989 data on injecting drug users and mortality obtained from three independent agencies: the Procurator Fiscal's Office, the General Register Office, and the Scottish HIV-test register. SETTING--Greater Glasgow, Scotland. SUBJECTS--Drug injectors, estimated population 9424. MAIN RESULTS--81 names were found using the three sources to identify deaths. After removing duplicates, 51 deaths were found. This represented a mortality rate of 0.54% in the estimated population. Among female injectors the mortality rate was 0.85%, significantly higher than the rate of 0.42% among male injectors (95% CI for the true difference in mortality rates between female and male injectors was 0.31%-0.55%). Over 90% of deaths were attributed to overdose or suicide. Although AIDS caused only one death, 19% of cases (5/27) whose HIV antibody status could be ascertained were positive. The mortality rate among HIV positive injectors (3.8%) was significantly higher than among HIV negative injectors (0.49%). CONCLUSIONS--Comprehensive coverage using three data sources revealed a far greater annual number of all cause deaths among injectors than would have been expected from previous research. The observed mortality rate was lower than in previous studies where the denominators used to calculate rates had an element of underenumeration. For the foreseeable future it is unlikely that AIDS will have much impact on mortality among injectors in Glasgow, because of the low prevalence of HIV infection among injectors in the city, and because HIV positive injectors are dying for reasons other than AIDS; rather, overdose and suicide will continue to be the main causes of death.     

Contact-tracing among injection drug users in a rural area.

An epidemic of hepatitis B occurring in 1988 and 1989 in Cape Breton brought to light the existence of a group of "buddies" who engaged in injection drug use. Interviewing was conducted by Public Health in 82% of the 186 IDU contacts named. In comparison with published reports of contact-tracing efforts for viral hepatitis among IDUs, the Cape Breton experience seems successful. This article describes the approach used by Public Health. Aspects of the management of the epidemic and the interview technique which may have contributed to the comparative success of contact-tracing include collaboration with family physicians and laboratories; collaboration among public health investigators; and a nonjudgemental interview technique with 6 "golden rules".     

The hepatitis C virus epidemic among injecting drug users.

Given the economic and health costs of hepatitis C virus (HCV) infection, and the ongoing transmission within the injecting drug user (IDU) population, there is a need for improved understanding of HCV epidemiology within this risk group. We employed a recently developed method based on phylogenetic analysis to infer HCV epidemic history and to provide the first estimates of the rate of spread of subtypes 1a and 3a circulating within injecting drug user populations. The data indicates that HCV subtype 1a entered the IDU population on at least three separate occasions. Both subtypes demonstrate exponential population growth during the 20th century, with a doubling time of 7-8 years. The results provide a baseline for prediction of the future course of the HCV epidemic, and its likely response to transmission control policies.