Alcohol and HIV sexual risk behaviors among injection drug users

We analyzed data from 6341 injection drug users (IDUs) entering detoxification or methadone maintenance treatment in New York City between 1990 and 2004 to test the hypothesis that alcohol use and intoxication is associated with increased HIV sexual risk behaviors. Two types of associations were assessed: (1) a global association (i.e., the relationship between HIV sexual risk behaviors during the 6 months prior to the interview and at-risk drinking in that period, defined as more than 14 drinks per week for males or 7 drinks per week for females), and (2) an event-specific association (i.e., the relationship between HIV sexual risk behaviors during the most recent sex episode and alcohol intoxication during that episode). Sexual risk behaviors included multiple sex partners and engaging in unprotected sex. After adjusting for the effects of other variables, at-risk-drinkers were more likely to report multiple sex partners and engaging in unprotected sex with casual sex partners (both global associations). IDUs who reported both they and their casual partners were intoxicated during the most recent sex episode were more likely to engage in unprotected sex (an event-specific association). We also observed two significant interactions. Among IDUs who did not inject cocaine, moderate-drinkers were more likely to report multiple partners. Among self-reported HIV seropositive IDUs, when both primary partners were intoxicated during the most recent sex episode they were more likely to engage in unprotected sex. These observations indicate both global and event-specific associations of alcohol and HIV sexual-risk behaviors.     

四川省凉山地区静脉吸毒人群药物滥用及其行为特征调查

目的:了解四川省凉山地区静脉吸毒人群药物滥用及行为特征情况,为采取有针对性的戒毒干预措施预防艾滋病病毒的传播提供数据.方法:以社区为基础招募了379名静脉吸毒人员,调查其人口学特征,艾滋病病毒感染情况,药物滥用的种类、吸毒方式和频率,口吸和静脉吸毒时间,共用注射器具情况等.结果:静脉吸毒人群艾滋病病毒感染率为11.3%(43/379).379名被调查者全部为海洛因滥用者,其中247人(65.2%)单独使用过海洛因,297人(78.4%)混合注射过海洛因与安定,滥用过的其他药物有安定(8.2%)和鸦片(1.3%).300人(79.2%)每天静脉注射吸毒一次及以上;曾经共用注射器具静脉吸毒的为247人(65.2%),87人(35.2%)首次静脉注射吸毒即与他人共用注射器具;初次口吸吸毒和静脉注射吸毒的平均年龄分别为22.37岁和25.35岁,口吸吸毒和静脉注射吸毒的平均时间分别为6.41年和3.42年.结论:加强青少年、吸毒人员关于毒品危害和拒绝毒品的健康教育活动,以及开展美沙酮或丁丙诺啡口服治疗海洛因依赖者,降低静脉注射吸毒行为,控制艾滋病病毒的传播.     

Longitudinal predictors of injection cessation and subsequent relapse among a cohort of injection drug users in Baltimore, MD, 1988-2000

OBJECTIVE: To determine predictors of injection drug use cessation and subsequent relapse among a cohort of injection drug users (IDUs). METHODS: IDUs in Baltimore, MD were recruited through community outreach in 1988-1989. Among IDUs with at least three follow-up visits, parametric survival models for time to injection cessation (>or=6 months) and subsequent relapse were constructed. RESULTS: Of 1327 IDUs, 94.8% were African American, 77.2% were male, median age was 34 years, and 37.7% were HIV-infected. Among 936 (70.5%) subjects who ceased injection, median time from baseline to cessation was 4.0 years. Three-quarters subsequently resumed injection drug use, among whom median time to relapse was 1.0 year. Factors independently associated with a shorter time to cessation were: age <30 years, stable housing, HIV seropositivity, methadone maintenance treatment, detoxification, abstinence from cigarettes and alcohol, injecting less than daily, not injecting heroin and cocaine together, and not having an IDU sex partner. Factors independently associated with shorter time to injection relapse were male gender, homelessness, HIV seropositivity, use of alcohol, cigarettes, non-injection cocaine, sexual abstinence and having a longer time to the first cessation. CONCLUSIONS: This study provides strong support for targeting cessation efforts among young IDUs and severely dependent, unstably housed, and HIV-infected individuals.     

Methadone Maintenance Therapy Outcomes in Iran

Introduction: Because of the increasing number of injecting drug users (IDUs) in Iran and the risk of the spread of HIV infection, harm reduction programs have been considered for conventional law enforcement measures. The aim of this study was to evaluate the efficacy of methadone maintenance therapy (MMT) in IDUs and the associated health and social outcomes. Material and Methods: This case–control study was conducted at the Persepolis Harm Reduction Center in Tehran during the year 2006. Data were gathered from two groups of randomly chosen patients. The first group consisted of 75 IDU patients who had undergone at least 6 months of methadone treatment (the MMT group), and second group consisted of 75 newly admitted clients (the control group). Participants were assessed on their dangerous injection and sexual behaviors, social well-being, and patterns of drug use. The results were compared between the two groups. Results: The mean age of participants in the two groups was almost the same (34.28 years in the control group and 35.68 years in the MMT group, p >.05). Prevalence of drug injection in the MMT group was less than that in the control group (16% vs. 100%). There was also a dramatic difference in needle and syringe sharing (40% in the control group vs. 4% in the MMT group) but not in crimes and arrests (p = .4). Those in the MMT group had a better relationship with their families, partners, coworkers, and neighbors compared with controls. There was no considerable difference in dangerous sexual behaviors between the two groups. Conclusions: Given the large number of HIV-positive cases among IDUs and considering that injection drug use is the main spreading factor for HIV, MMT would play a major role in controlling the HIV epidemic through reduction of heroin injection and the risk behaviors related to it. High inflation rate, lack of interorganization coordination, budget limitation, and no follow-up were the most important limitations of this study.     

Ethnic differences in HIV risk behaviors among methadone-maintained women receiving contingency management for cocaine use disorders

OBJECTIVE: To identify ethnic differences in HIV risk behaviors among cocaine using women receiving methadone maintenance for opioid dependence, and to evaluate the efficacy of contingency management (CM) for cocaine use disorders in reducing HIV risk behaviors. METHODS: African American (N=47), Hispanic (N=47), and White women (N=29) were randomized to standard methadone treatment or standard methadone treatment plus a CM intervention. They completed the HIV Risk Behavior Scale (HRBS) indicating frequency of drug use and sexual behaviors across the lifetime, in the month before baseline, and in the 3 months following clinical trial participation. Ethnic group differences and the effect of CM on change in HIV risk behaviors between baseline and follow-up were evaluated. RESULTS: White women reported significantly higher lifetime rates of risky drug use and sexual behaviors on the HRBS than African American women; neither group differed significantly from Hispanic women. No ethnic group differences in HIV risk behaviors were identified in the month prior to baseline. At follow-up, African American women reported fewer high-risk drug use behaviors than White or Hispanic women, and Hispanic women reported more high-risk sexual behaviors than White or African American women. CM was associated with reduction in high-risk drug use behaviors regardless of ethnicity, but did not affect high-risk sexual behaviors. CONCLUSIONS: White women receiving methadone maintenance engage in more lifetime HIV risk behaviors than African American women. CM for cocaine use reduces risky drug use behaviors, but certain ethnic groups may benefit from additional targeted HIV prevention efforts.     

Relationship Between Menopause Symptoms and HIV Risk Among Midlife Women in Methadone Treatment: A Pilot Study

This pilot study explores somatic, psychological, and urogenital menopause symptoms associated with HIV drug and sexual risk among midlife women with substance abuse histories in methadone maintenance treatment. The Menopause Rating Scale (MRS) assessed menopause symptoms and severity. The Risk Behavior Assessment assessed demographic characteristics, drug, and sexual risk behaviors. Menopause symptom associations of HIV drug and sexual risk findings indicated that high school graduates and women not having sex with a regular partner scored significantly higher on the MRS somatic symptom subscale. HIV negative women had higher total MRS scores compared with HIV positive women. Forty-six percent of the sample was sexually active with almost half engaged in unprotected sex. Significant associations with sexual risk were high MRS somatic subscale scores with inconsistent condom use for vaginal sex, HIV negative with inconsistent protected vaginal sex, heroin use with having sex while high with HIV negative status. Preliminary data provide a basis for further exploration and designing intervention approaches to reduce HIV risk and further transmission among midlife women in methadone treatment.     

Anticholinergic Delirium: Etiology,Presentation, Diagnosis and Management

Abstract

The propensity to engage in risk behaviors confers an elevated risk of HIV and other infectious disease transmission in opioid-dependent populations. Although drug abuse treatment may decrease drug-related risk behaviors such as needle-sharing, additional intervention may be needed to reduce HIV risk behavior. In this investigation, we assessed sexual HIV risk behaviors in opioid-dependent patients who were engaging in regular drug use despite ongoing counseling and methadone maintenance therapy. Potential risk and protective factors for engaging in sexual HIV risk behavior were examined. Taking into account demographic, psychiatric, substance use, and psychological variables, the only significant predictor of risk behavior was age. Specifically, younger patients were more likely to engage in sexual HIV risk behavior. The implications of these results for reducing sexual HIV risk behavior and for HIV prevention in methadone-maintained, treatment-refractory opioid-dependent patients are discussed.     

Methadone maintenance and other factors associated with intraindividual temporal trends in injection-drug use

The objective of this study was to determine what sociodemographic, lifestyle, or drug-related characteristics predict temporal changes in self-reported drug injection frequencies among HIV-seronegative injection-drug users (IDUs) who were being given HIV testing and risk reduction counseling. The 277 subjects were given 4–11 quarterly interviews including a detailed history of drug use and other HIV risk factors, HIV risk reduction counseling, and venipuncture for HIV antibody testing. A regression slope of change over time in drug injection frequency was calculated for each subject, and categories were created of decreasing temporal slope, increasing slope, relapse (decrease initially, then increase), or no substantial change. Only 44% of subjects decreased their drug injection frequencies despite repetitive HIV testing and counseling. In multivariate logistic analyses, decreasing temporal trends were associated with consistent enrollment in methadone maintenance (p < .1), whereas increasing trends conversely were associated with inconsistent enrollment (p < .01) and also with an absence of crack use (p < .01). Relapses were significantly associated with needle sharing with multiple partners and a low frequency of smoking. The data suggest that methadone maintenance facilitates a positive response to HIV risk reduction counseling. However, the fact that only a minority of subjects displayed a decreasing temporal trend in drug injection frequencies emphasizes the need for improved therapeutic and counseling techniques.     

Change in Drug-Using Networks of Injecting Drug Users during Methadone Treatment: A Pilot Study Using Snowball Recruitment and Intensive Interviews

This pilot study used snowball recruitment methods and intensive interviews to assess personal drug-using networks and HIV risk behavior of injection drug users (IDUs). Index subjects were 22 methadone maintenance patients reporting current drug injection who were interviewed about personal drug-using networks both current and prior to treatment entry. The index subjects were then asked to recruit other network members to the study. Ninety-seven network members were identified and 40 interviewed, including 18 not in treatment. Index IDUs reported fewer co-IDUs for the treatment period than the pre-treatment period, suggesting a reduction in risk of exposure to HIV. The combination of snowball recruitment and intensive interview procedures constitutes a useful method for studying IDU networks.     

Methadone maintenance treatment reduces heroin injection in New South Wales prisons

The purpose of this study was to examine whether methadone maintenance treatment reduces injecting risk behaviour (and therefore transmission of blood-borne viral infections) among prisoners in New South Wales (NSW), using comparison of retrospective reports of drug use in prisons for people who received standard drug treatment, time-limited methadone treatment and methadone maintenance treatment. The setting for the study was the NSW prison system. One hundred and eighty-five injecting drug users who had been recently released from NSW prisons were recruited in 1993. Self-reported drug use and injecting risk behaviour were compared in inmates who received standard drug treatment (counselling), time-limited methadone treatment and methadone maintenance treatment. HIV status was determined by serology. Intervention comprised high and low dose methadone treatment and counselling. The groups were similar in terms of most basic demographic characteristics but subjects who had been maintained on methadone reported a significantly lower prevalence of heroin injection, syringe sharing and scored lower on an HIV Risk-taking Behavioural Scale than subjects who received standard drug treatment and time-limited methadone treatment. This study suggests that methadone treatment is associated with reduced injecting risk behaviour in prison with adequate (greater than 60 mg) dose and duration in treatment. These treatment conditions are known to increase effectiveness in community-based methadone programmes. Prospective studies are required to evaluate the effectiveness of methadone programmes in the prevention of HIV and other blood-borne viral infections among IDU prisoners.     

Linkage with methadone treatment upon release from incarceration: a promising opportunity

Injection drug users (IDUs) are at increased risk for HIV, viral hepatitis, and tuberculosis, and making up more than a quarter of the incarcerated population in the United States. Methadone maintenance treatment of opiate addiction is highly effective at reducing drug use, drug-related criminal activity, and risk of HIV transmission. Recently released inmates are at particularly high risk for overdose and disease transmission. Linkage to methadone treatment immediately upon release from incarceration is a promising opportunity to combat disease transmission, facilitate reentry into the community, and reduce recidivism.     

Racial and ethnic differences in drug treatment entry of injection drug users in Massachusetts.

This article examines patterns of drug treatment entry among 28,000 adult injection drug users (IDUs), with special attention to racial and ethnic differences. The data analyzed originates from a statewide drug-treatment database covering four years. Through the use of logistic regression analysis, the study identified significant population differences between those who used detoxification only, those who used residential treatment and those who used methadone maintenance. Latino IDUs were approximately a third less likely than Caucasian IDUs to enter residential treatment and African American IDUs were half as likely as Caucasian IDUs to enter methadone maintenance treatment. This article discusses specific programmatic and research implications including the need to determine whether differential entry rates are due to access, client awareness, cultural, referral or other factors.     

Effectiveness of drug dependence treatment in HIV prevention

This review considers the effectiveness of drug dependence treatment in preventing HIV transmission among injecting drug users (IDUs). Substitution programmes using agonist pharmacotherapy (e.g. methadone and buprenorphine maintenance treatment) are available only for drug users who are primarily opioid dependent. There are over half a million people in receipt of methadone maintenance treatment (MMT) and it is estimated that this number will double in the coming decade. There is evidence that MMT is associated with a significant decrease in injecting drug use and sharing of injecting equipment. Data on sex-related risk behaviour change are limited, but suggest that MMT is associated with a lower incidence of multiple sex partners or exchanges of sex for drugs or money, but no change, or only small decreases, in unprotected sex. Studies of seroconversion, which is the toughest and most robust standard for assessing the role of MMT in HIV prevention, suggest that the reductions in risk behaviours do translate into actual reductions in cases of HIV infection. While the data on HIV risk behaviour are limited, there is strong evidence that substitution treatment with either methadone or buprenorphine suppresses illicit opioid use. There is also evidence that substitution treatment for HIV-positive IDUs is associated with better compliance with anti-retroviral treatment and improved health outcomes. The only antagonist being used for opioid dependence relapse prevention treatment is naltrexone. There is currently insufficient evidence to draw firm conclusions as to its effectiveness. Behavioural interventions add to the effectiveness of substitution treatment, while the effectiveness of different types of psychological therapy alone has been found to be variable. There have been few comparative studies of abstinence-based treatment, however, available evidence indicates good outcomes for those who remain in treatment for three months or more. All countries with a population of IDUs should aim to develop a comprehensive range of treatments, including substitution treatment, as a critical component of HIV prevention.     

Parental Status of Women Injection Drug Users and Entry to Methadone Maintenance

This article examines patterns of methadone maintenance treatment entry among 9018 adult women injection drug users (IDUs), with special attention to parental-status differences. The data originate from a statewide drug-treatment database covering all women IDUs who entered drug treatment in the State of Massachusetts over a four-year period. Through the use of logistic regression analysis, the study found that among these women IDUs, those who resided with their children were significantly more likely to enter methadone maintenance than women who were mothers but did not reside with their children. Mothers residing with their children were 73% more likely to enter methadone maintenance than mothers who do not reside with their children. The authors discuss specific programmatic and policy implications including the need to determine whether methadone maintenance should be promoted as an alternative drug treatment option in order to preserve family unification or promote family reunification.     

Maintenance of HIV risk reduction among injection opioid users: a 12 month posttreatment follow-up

Study objectives were to examine HIV risk behaviors 12 months following methadone maintenance (MM) treatment termination, and to assess the effects of treatment tenure, cocaine use, and gender on posttreatment HIV risk. Injection and sex risk behaviors were measured at treatment entry and 12 months after leaving treatment among 435 injection opioid users. Multi-way contingency tables for treatment tenure and HIV risk at treatment intake and at 12 month follow-up were analyzed using the GSK weighted least-squares estimation procedure. The effects of treatment tenure, gender, and cocaine use on risk behavior at follow-up, while controlling for intake risk and background variables were tested using a series of multiple logistic regression analyses. Results showed that injection and sex risk behaviors were significantly lower at 12 month follow-up than at treatment entry. Additionally, increased tenure was related to risk reductions, while cocaine use was related to increased risk-taking. Gender was generally unrelated to risk changes. These findings support broader use of MM in helping reduce HIV risks among injection drug users and highlight the need to explore ways to encourage treatment compliance in order to reduce risky practices.     

Parental status of women injection drug users and entry to methadone maintenance

This article examines patterns of methadone maintenance treatment entry among 9018 adult women injection drug users (IDUs), with special attention to parental-status differences. The data originate from a statewide drug-treatment database covering all women IDUs who entered drug treatment in the State of Massachusetts over a four-year period. Through the use of logistic regression analysis, the study found that among these women IDUs, those who resided with their children were significantly more likely to enter methadone maintenance than women who were mothers but did not reside with their children. Mothers residing with their children were 73% more likely to enter methadone maintenance than mothers who do not reside with their children. The authors discuss specific programmatic and policy implications including the need to determine whether methadone maintenance should be promoted as an alternative drug treatment option in order to preserve family unification or promote family reunification.     

Alcohol and HIV risk taking among intravenous drug users

PURPOSE: To determine if drug risk days are also alcohol use days for active injection drug users (IDUs). METHODS: Cross-sectional interview of 187 AUDIT-positive (> or = 8) active IDUs recruited between 2/98 and 10/99 from a needle exchange program (NEP) in Providence, RI. A drug risk day is defined as "using needles, cotton, or cookers after someone else had used it," measured using a 30-day Timeline Follow-Back procedure. RESULTS: The sample was 64% male, 87% white, with 85% meeting DSM-IV criteria for alcohol abuse/dependence. Of the total days analyzed (n = 5610), 25% were drug risk days; on 40% of these days, drinking also occurred. Using a generalized estimating equation (GEE) model to cluster by subject, alcohol use was associated with drug risk days (OR 1.53; 95% CI 1.2-1.9; P < .001), controlling for gender, age, race, cocaine use, number of daily injections, methadone treatment, and partner drug use. CONCLUSIONS: Using a data analytic strategy that allows examination of self-reports of behaviors on a day-to-day basis, we found that alcohol use is associated with drug risk taking behavior among IDUs. Whether alcohol use precedes or is subsequent to risky HIV behaviors remains to be determined.     

广西河池市美沙酮门诊海洛因依赖人群HIV、HCV、TB、梅毒感染情况调查

目的獉獉:了解河池市美沙酮门诊海洛因依赖人群的特征,HIV、HCV、TB和梅毒感染情况及其危险因素。方法獉獉:对参加美沙酮维持治疗的388名海洛因依赖者进行治疗前的问卷调查,HIV、HCV、TB、梅毒血清学检测及胸部X线摄片检查。结果獉獉:87.11%的海洛因依赖者采用静脉注射方式吸毒,46.15%的静脉吸毒者共用注射器。HIV抗体阳性率7.99%(31/388),其中静脉注射吸毒HIV抗体阳性率8.88%(30/338)。HCV抗体阳性率72.16%(280/388),其中静脉注射吸毒HCV抗体阳性率74.85%(253/338)。TB抗体阳性率0.26%(1/388),梅毒抗体阳性率13.66%(53/388)。结论獉獉:河池市美沙酮门诊海洛因依赖人群,尤其是静脉吸毒者中HCV和梅毒感染较高。在海洛因依赖人群中推广针具交换、安全套免费发放和相关知识的健康教育、行为干预尤为重要。     

Differences Found Between Women Injectors In and Out of Treatment: Implications for Interventions

SUMMARY

Women substance abusers, particularly those who are injecting drug users, are at high risk for HIV infection. It has been demonstrated that injecting drug users found out of drug treatment settings show different patterns of drug use and HIV risk than those who enter treatment. Previous studies, however, have not indicated the extent to which women injectors in and out of treatment exhibit these same differences. This study examines data from two studies sponsored by the National Institute on Drug Abuse to determine similarities and differences between women encountered by outreach efforts in four cities and those entering methadone treatment programs in the same cities.

The results indicate significant differences in race, drugs used (both injecting and non-injecting), injecting risk behavior, and treatment history. However, the two groups of women shared similar histories of first injecting use and sexual risk. Women who entered methadone treatment reported higher frequencies of injecting drug use and HIV risk behaviors, both direct (sharing needles) and indirect (sharing cookers, cotton, and water); yet they were also more likely to clean needles and to use new needles than the women encountered through outreach. The outreach women were more likely to be African American, to inject less than daily, and to use alcohol, crack, and non-injecting cocaine daily.

The results suggest that women injectors entering treatment and those encountered in outreach are very different in their injecting intensity and HIV risk behaviors. However, both groups are still at risk for HIV infection, particularly as a result of multiple sexual partners and little reported condom use. The need to identify the risk, reinforce risk reduction maintenance, and further develop HIV prevention strategies that successfully address both the needs of these women and the differences that exist between them will be essential to stopping the spread of HIV.     

Antiretroviral adherence and HIV treatment outcomes among HIV/HCV co-infected injection drug users: the role of methadone maintenance therapy

OBJECTIVE: We examined the association of methadone maintenance therapy (MMT) with highly active antiretroviral therapy (HAART) adherence and HIV treatment outcomes among a cohort of HIV/HCV co-infected injection drug users (IDUs). METHODS: We obtained demographic, drug use, and addiction care history from the Vancouver Injection Drug User Study (VIDUS), which is an open cohort study of IDUs. The questionnaires were longitudinally linked to the British Columbia HIV/AIDS Drug Treatment Program to obtain HAART adherence and HIV treatment outcome data. There were 278 VIDUS participants who accessed HAART from August 1, 1996 to November 24, 2003. We constructed longitudinal logistic models using generalized estimating equations to examine the independent associations between methadone maintenance therapy and the following outcomes: HAART adherence; plasma HIV-1 RNA suppression; and CD4 cell rise of 100cells/mm(3). RESULTS: Among participants who reported at least weekly heroin use, MMT was independently associated with lower odds of subsequent weekly heroin use during the follow-up period (adjusted odds ratio; 95% confidence interval [AOR; 95% CI]: 0.24; 0.14-0.40). We also found that MMT was positively associated with adherence (AOR 1.52; 95% CI 1.16-2.00), HIV-1 RNA suppression (AOR 1.34; 95% CI 1.00-1.79), and CD4 cell count rise (AOR 1.58; 95% CI 1.26-1.99). CONCLUSIONS: Among HIV/HCV co-infected IDUs on HAART, enrollment in MMT was associated with reduced heroin use, and improved adherence, HIV-1 RNA suppression and CD4 cell count response. Integrating opiate addiction care and HIV care may provide improved health outcomes for this vulnerable population and should be further explored.