The impact of training on consumer participation in the delivery of health services.

A retrospective evaluation of training provided to six hospital consumer advisory groups is described. The training program was designed to provide information and decision-making skills to consumers of services and community representatives serving on voluntary hospital advisory boards. The evaluation, initiated after the end of the training program, demonstrates different effects of training depending on the stage of development of the consumer board. All but one of the six boards studied showed positive changes in the number and type of activities following training.     

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.     

"The rock always comes first": drug users' accounts about using formal health care

Illicit drug use remains a significant public health threat. The issues surrounding drug use are recognized by public health professionals as important for several reasons. The incidence and prevalence of drug use persists in spite of the extensive societal, interpersonal, and individual consequences. In addition, the chronic health issues and health care costs associated with drug use continue to spiral. A wide variety of quantitative studies have examined the extent of health care problems, access, cost, and health care satisfaction among illicit drug users. While these studies offer important information through survey formats, fewer studies focus on subjective constructions of health care management from the users' perspective. This article examines the elements of the decision-making process involved in accessing formal health care among chronic and injecting street drug users. Twenty-eight in-depth interviews provide the data for this analysis, which is part of a large quantitative study of 1,479 injecting and chronic drug users and nondrug users in Miami, Florida. By exploring the elements of health care access through the eyes of the drug users, researchers and treatment professionals may gain insights into new ways to improve health care access for this at-risk population.     

Injection drug use and crack cocaine smoking: independent and dual risk behaviors for HIV infection

PURPOSE: Previous studies have examined the practices of injecting drugs or smoking crack cocaine as high-risk, but independent, factors for HIV transmission. To explore the independent and dual risks of injection practices and crack smoking, this study examined HIV seroprevalence rates among distinct drug user groups, based on patterns of daily administration. METHODS: A sample of 3,555 drug users and neighborhood controls in urban Miami, FL and rural Belle Glade and Immokalee, FL were partitioned into four mutually-exclusive groups: 1) injection drug users (IDUs); 2) crack-cocaine smokers; 3) dual users who both smoked crack and injected drugs; and 4) non-drug-user controls. RESULTS: HIV seroprevalence rates were 45.1% for IDUs, 30.5% for dual users, 20.1% for crack smokers and 7.3% for controls. Multivariate logistic regression analysis found that when compared with controls odds ratios for HIV seropositivity were 9.81 for IDUs, 5.27 for dual users, and 2.24 for crack smokers. CONCLUSIONS: These findings provide evidence of: 1) behavioral and structural co-factors that influence HIV exposure patterns among drug users; and 2) the substantially higher risk of HIV infection among IDUs compared with other drug users. Intervention strategies must be tailored for the specific drug use subpopulations to optimize efficacy.     

An HIV prevalence-based model for estimating urban risk populations of injection drug users and men who have sex with men

Issues of cost and complexity have limited the study of the population sizes of men who have sex with men (MSM) and injection drug users (IDUs), two groups at clearly increased risk for human immunodeficiency virus (HIV) and other acute and chronic diseases. We developed a prototypical, easily applied estimation model for these populations and applied it to Miami, Florida. This model combined HIV prevalence estimates, HIV seroprevalence rates, and census data to make plausible estimates of the number and proportion of MSM and IDUs under a number of assumptions. Sensitivity analyses were conducted to test the robustness of the model. The model suggests that approximately 9.5% (plausible range 7.7%–11.3%) of Miami males aged 18 years or older are MSM (point estimate, N=76,500), and 1.4% (plausible range 0.9%–1.9%) of the total population aged 18 years or older are IDUs (point estimate, N=23,700). Males may be about 2.5 times more likely than females to be IDUs. The estimates were reasonably robust to biases. The model was used to develop MSM and IDU population estimates in selected urban areas across Florida and should be replicable in other medium-to-large urban areas. Such estimates could be useful for behavioral surveillance and resource allocation, including enhanced targeting of community-based interventions for primary and secondary HIV prevention. Dr. Friedman is with National Development Research Institutes, Inc. Dr. Gates is with the Urban Institute.     

Alternative Strategies for Sexual Risk Reduction Used by Active Drug Users

Recent studies continue to document lack of consistent condom use by active drug users. However, personal HIV risk reduction strategies other than, or in addition to, condom use may be practiced. In this study, data from qualitative interviews with 92 active users of crack and injection drugs illustrate risk reduction strategies employed either instead of or in addition to condom usage. Findings are based on narrative accounts of methods used to reduce personal risk of contracting HIV during sexual acts. Precoital alternative strategies focused on partner selection techniques based on the belief that safe partners can be selected. Coital strategies included the selection of specific sex acts that were presumed to be safe or safer than others or cleanliness rituals or both. Postcoital strategies included techniques such as washing sex organs with bleach or lemon juice. Implications of these findings for intervention and prevention efforts are discussed.     

Acceptability of A-CASI by HIV-positive IDUs in a multisite, randomized, controlled trial of behavioral intervention (INSPIRE)

Audio computer-assisted self-interviewing (A-CASI) is now widely used to gather information from many types of research participants, including injection drug users (IDUs). The purpose of this study was to describe how HIV-positive IDUs participating in an intervention trial viewed A-CASI and to identify the characteristics of participants who held unfavorable attitudes toward A-CASI. Using a sample of participants who completed 12-month assessments (n=821), we found that most (>80%) of the sample held favorable or neutral attitudes toward A-CASI. Approximately 18% said that they would prefer an interview with a person to a computer, 12% said that they did not understand the questions they heard on the computer, and 14% said that the computer made it hard to be open and honest about risk behavior. Multivariate analyses found that participants who were more socially marginalized (with unstable housing and lower sense of empowerment) and had greater physical limitations and lower CD4 cell counts were consistently more likely to report various negative A-CASI attitudes; however, some outcome-specific findings were also noted. Our research supports the feasibility and general acceptability of A-CASI with HIV-positive IDUs, and it suggests further research exploring the associations between A-CASI attitudes and characteristics of disadvantaged populations.