Research Findings - Research on AIDS and Other Medical Consequences of Drug Abuse - AIDS Research
Drug Use Patterns and STIs among Young Adults in a High-Risk Neighborhood of NYC
Researchers sought to examine whether and how drug users, particularly IDUs and crack smokers, may be a core group for some sexually transmitted infections (STIs). They conducted a cross-sectional survey on drug use and assays for HIV, hepatitis B and C, syphilis, gonorrhea, and other sexually transmitted infections among 363 young (18-24) adults in an impoverished New York City minority neighborhood with major drug markets. They found that hepatitis C and HIV were concentrated among IDUs and that herpes, syphilis, and hepatitis B increased among women in relation to "hardest drug ever used." These findings suggest that using harder drugs (defined in increasing order of hardness as no drug use, marijuana use, non-injected heroin or cocaine use, crack smoking and injection drug use) is associated with some but not all of these STIs. The findings underscore the importance of targeted HIV prevention efforts to reduce unsafe sex and drug use among high-risk youth. Friedman, S.R., Flom, P.L., Kottiri, B.J., Zenilman, J., Curtis, R., Neaigus, A., Sandoval, M., Quinn, T. and Des Jarlais, D. Drug Use Patterns and Infection with Sexually Transmissible Agents Among Young Adults in a High-Risk Neighborhood in New York City. Addiction, 98, pp. 159-169, 2003.
HIV Risk Behaviors in African American Drug Injector Networks
Researchers examined the mechanism by which "partnership-level" variables (the mix of characteristics of individuals who inject drugs together) affect the incidence of HIV risk behaviors, including receptive syringe sharing, and facilitate or impede the spread of HIV. They analyzed data on injection partnerships (pairs of individuals who inject together) using a network sample of 401 African American IDUs in Washington, DC. Drug injectors tended to select injection partners of the same gender and similar age, but risk behaviors were most common in partnerships between individuals who were dissimilar in gender and age. Partners who had a sexual relationship, injected drugs frequently together, smoked crack cocaine regularly, injected speedball regularly, and/or had close social ties were more likely to engage in risky injection practices than otherwise similar partners. These factors accounted for the association between the gender-age mix of the partnership and injection risk behavior. These findings show that, among African American IDUs in Washington, DC, partnership-level variables have a critical role in the transmission of HIV. Johnson, R.A., Gerstein, D.R., Pach, A., Cerbone, F., and Brown, J. HIV Risk Behaviors in African-American Drug Injector Networks: Implications of Injection-Partner Mixing and Partnership Characteristics. Addiction, 97, pp. 1011-1024, 2003.
Depression and HIV Risk Behavior Among Seattle-Area IDUs and Young MSM
Psychological depression has been identified as a condition that may influence HIV risk behavior among IDUs and men who have sex with men (MSM). Researchers analyzed data from the Center for Epidemiological Studies Depression Scale (CES-D) for two Seattle studies involving 1,228 IDUs and 429 MSM. They found that 47% of IDUs had CES-D scores > 23, and that a high score was significantly associated with injection with a syringe used by another IDU (adj OR=1.4) but not other injection risk behavior. Among MSM, CES-D scores > 16 were related to reporting 3 or more sex partners in the last 6 months but not to other sexual risk behavior. These findings indicate that psychological depression may influence certain HIV risk behavior in young MSM and IDUs, and that interventions addressing depression should be considered for these populations. Perdue, T., Hagan, H., Thiede, H., and Valleroy L. Depression and HIV Risk Behavior Among Seattle-Area IDUs and Men Who Have Sex with Men. AIDS Educ & Prev, 15(1), pp. 81-92, 2003.
Effectiveness of an HIV Intervention Among African American Women Who Use Crack
Researchers evaluated the effectiveness of an HIV intervention for African American women who use crack cocaine. Two hundred sixty-five women (aged 18-59 years) were randomly assigned to one of two enhanced intervention conditions or to the NIDA standard condition. A substantial proportion of women reported no past 30-day crack use at 6-month follow-up (100%-61%, p<.001). Significant decreases in the frequency of crack use; the number of paying partners, the number of times unsafe sex occurred with a paying partner; and sexual risks, such as trading sex for drugs, were reported over time. Significant increases in male condom use with sex partners were also observed, as well as decreases in casual partners' refusal of condoms. These findings suggest that combined components of the culturally appropriate, gender-tailored HIV intervention are likely to be most effective in enhancing preventive behavior among similar high risk populations. Sterk, C., Theall, K., and Elifson, K. Effectiveness of a Risk Reduction Intervention Among African American Women Who Use Crack Cocaine. AIDS and Behavior, 15(1), pp. 15-32, 2003.
HIV Risk Reduction Among African American Women Who Inject Drugs
Researchers evaluated a community-based HIV intervention for African American women who are active IDUs. Seventy-one women (aged 20-54 years) were randomly assigned to one of two enhanced gender- and culturally-specific intervention conditions or to the NIDA standard condition. Substantial decreases (p<.001) were found in the frequency of drug use and the frequency of drug injection as well as in the sharing of injection works or water and the number of injections. Trading sex for drugs or money, having sex while high, and other sexual risk behaviors were also reduced significantly. Women in both enhanced intervention conditions were more likely to reduce their drug-using and sexual risk behaviors than were women in the standard condition. Results indicate the value of including additional components in interventions designed to reduce the risk of infection with HIV among women who inject drugs. Sterk, C., Theall, K., Elifson, K., and Kidder, D. HIV Risk Reduction Among African American Women Who Inject Drugs: A Randomized Controlled Trial. AIDS and Behavior, 7(1), pp. 73-86, 2003.
Feasibility of Referring Drug Users from a Needle Exchange Program (NEP) to an Addiction Treatment Program
This study evaluated program entry, retention, and early treatment response of NEP attendees referred to a drug treatment program using LAAM. Of 163 referrals, 114 (70%) entered the program, and 84% were retained for at least 90 days. Comparing baseline and follow-up visits after 1 month, there were significant reductions in the Addiction Severity Index subscale scores for drug and alcohol use and legal situation. A 31% and 22% reduction in heroin-and cocaine-positive urine tests, respectively, was observed (p<.001). Although LAAM is no longer considered a first line treatment for heroin addiction, these results demonstrate the feasibility of utilizing long-acting agonist therapies such as LAAM to treat opioid dependence among NEP attendees. Kuo, I., Brady, J., Butler, C., Schwartz, R., Brooner, R., Vlahov, D., and Strathdee, S. Feasibility of Referring Drug Users from a NEP into an Addiction Treatment Program: Experience with a Mobile Treatment Van and LAAM Maintenance. J Subst Abuse Treat, 24, pp. 67-74, 2003.
Readiness for Cessation of Drug Use Among Recent Needle Exchange Program (NEP) Attenders vs Nonattenders
It has been shown that NEPs represent a bridge to drug abuse treatment, but that many NEP attenders have more severe drug problems and may be less ready to reduce their drug use than other drug users. In this study, researchers investigated the relationship between NEP attendance and readiness for cessation of drug use in a community-based sample of IDUs that have participated in semiannual interviews and HIV testing since 1988-1989. A total of 288 IDUs completed a questionnaire on readiness for cessation of drug use, which was assessed with a validated scale of problem drug use and intention to quit, based on the "stages of change" model. Thirty percent of respondents attended the NEP in the past month. Stage of change in readiness for cessation of drug use did not differ between NEP attenders and nonattenders. Similar proportions of persons recently attending and not attending the NEP were classified as ready to stop drug use (about 30%). In multivariate analysis, readiness for cessation of drug use was associated with speedball injection and previous enrollment in drug treatment but not with NEP attendance. NEP attenders, although exhibiting characteristics consistent with more severe drug dependence, were as motivated for cessation of drug use as were nonattenders. These findings suggest that formal collaboration between NEPs and drug treatment programs could increase the proportion of IDUs in treatment. Henerdson, L., Vlahov, D., Celentano, D., and Strathdee, S. Readiness for Cessation of Drug Use Among Recent Attenders and Nonattenders of a Needle Exchange Program. J Acquir Immune Defic Syndr, 32(2), pp. 229-237, 2003.
HIV Knowledge and Risk Behaviors Among Pakistani and Afghani Drug Users in Quetta
Researchers studied HIV knowledge and risk behaviors among Pakistani and Afghani drug users between July 2001 and November 2001. Of 959 drug users, all were male and the majority used heroin. Most were Pakistani (84.8%), 14.9% were Afghani, and 0.3% were Iranian. Relative to Pakistani drug users, a higher proportion of Afghanis reported no formal education, homelessness, and unemployment (p<.001). Afghanis were significantly more likely to have used an opiate as their first illicit drug, to have ever injected, to report needle sharing, or to report a drug user in their family. None of the sexually active Afghanis had ever used a condom compared with 5.0% of the Pakistanis. Only 4.3% of Afghans had ever heard of HIV/AIDS compared with 18.3% of Pakistanis (p<.001). Extremely low levels of HIV/AIDS awareness and high HIV risk behaviors were evident among drug users in Quetta, among whom Afghanis were especially vulnerable. Interventions to prevent transition to injection, drug treatment, and needle exchange are urgently required to prevent blood-borne infections. Zafar, T., Brahmbhatt, H., Imam, G., Hassan, S., and Strathdee, S. HIV Knowledge and Risk Behaviors Among Pakistani and Afghani Drug Users in Quetta, Pakistan. J Acquir Immune Defic Syndr, 32, pp. 394-398, 2003.
Norms, Social Networks, and HIV Risks Among Urban Disadvantaged Drug Users
This study sought to examine the relationship between condom use, norms, and social network characteristics among a sample of economically impoverished individuals at risk for acquiring and transmitting HIV. Participants were 1051 individuals from a drug using community in the USA. Eighty percent were current drug users; 17% were HIV seropositive. Reported condom use was strongly associated with peer norms about condom use (friends talking about condoms, encouraging condom use, and using condoms). Women were less likely than men to report that their friends used condoms. Injection drug use was negatively associated with peer norms about condom use, while church attendance and network characteristics were positively associated with condom-promoting norms. Network research and methodologies are useful for identifying specific ties that promote condom use norms in a population. The findings of the study have implications for norm change interventions among disadvantaged communities at high risk for HIV/AIDS. Latkin, C., Forman, V., Knowlton, A., and Sherman, S. Norms, Social Networks, and HIV-Related Risk Behaviors Among Urban Disadvantaged Drug Users. Social Science and Medicine, 56, pp. 465-476, 2003.
Psychological Distress and Progression to AIDS in a Cohort of IDUs
Researchers investigated whether psychological distress was independently associated with more rapid progression to AIDS among HIV-infected IDUs. They followed a cohort of IDUs in Baltimore from 1988 to 1999, of which a total of 451 IDUs met the eligibility criteria of being HIV+ but AIDS-free at baseline. Of the 451 participants, 76.3% were male and 95.8% were African American; the median age at enrollment was 34 years. The cumulative incidence of AIDS within 2 years of baseline was 7.1%. In multiple regression analysis, distress was associated with more rapid time to AIDS. The strongest association was observed among IDUs with the lowest CD4 counts (<200 x 106 /L). Psychological distress was independently associated with shorter time to AIDS among HIV-infected IDUs, especially among those with the lowest CD4 cell counts, but was not predictive of mortality in this cohort. Further study of the effects of psychological distress on AIDS progression within this population is warranted. Golub, E., Astemborski, J., Hoover, D., Anthony, J., Vlahov, D., and Strathdee, S. Psychological Distress and Progression to AIDS in a Cohort of IDUs. J Acquir Immune Defic Syndr, 32, pp. 429-434, 2003.
Overcoming Barriers to HIV Testing
Researchers sought to determine strategies to overcome barriers to HIV testing among persons at risk. They developed a survey that elicited testing motivators, barriers, and preferences for new strategies among 460 participants at a needle exchange program, three venues for men who have sex with men, and a STD clinic. Barriers to testing included factors influenced by individual concern (fear and discrimination); by programs, policies, and laws (named reporting and inability to afford treatment); and by counseling and testing strategies (dislike of counseling, anxiety waiting for results, and venipuncture). The largest proportions of participants preferred rapid testing strategies, including clinic-based testing (27%) and home self-testing (20%); roughly equal proportions preferred oral fluid testing (18%), urine testing (17%), and standard blood testing (17%). One percent preferred home specimen collection. Participants who had never tested before were significantly more likely to prefer home self-testing compared with other strategies, and African Americans were significantly more likely to prefer urine testing. These findings suggest that strategies for improving acceptance of HIV counseling and testing include: information about access to anonymous testing and early treatment; expanding options for rapid testing, urine testing, and home self-testing; providing alternatives to venipuncture; making pretest counseling optional; and allowing telephone results disclosure may encourage more persons to learn their HIV status and take steps necessary to reduce their risk behaviors and prevent spread of the infection. Spielberg, F., Branson, B., Goldbaum, G., Lockhart, D., Kurth, A., Celum, C., Rossini, A., Critchlow, C., and Wood, R. Overcoming Barriers to HIV Testing: Preferences for New Strategies Among Clients of a Needle Exchange, a Sexually Transmitted Disease Clinic, and Sex Venues for MSM. J Acquir Immune Defic Syndr, 32(3), pp. 318-327, 2003.
Case Reporting of Acute HBV and HCV Among IDUs
Researchers examined the relationship between hepatitis B (HBV) and hepatitis C (HCV) incidence and case reporting of HBV and HCV in Seattle IDUs to determine the extent to which public health surveillance systems may undercount or misrepresent cases of hepatitis in IDUs. They compared names of participants in a Seattle IDU cohort study who acquired HBV or HCV infection over a 12-month follow-up period to a database of persons with acute HBV and HCV reported to the health department surveillance unit over the same time period. Of 2,208 IDUs enrolled in the cohort study that completed a follow-up visit, 63/759 acquired HBV infection, 53/317 acquired HCV infection, and 3 acquired both HBV and HCV. Of 113 cohort participants who acquired HBV or HCV, only 2 (1.5%) cases were reported; both had acute HBV. The upper 95% confidence interval for case reporting of HCV in the cohort was 5.7%, and for HBV, it was 7.5%. In this study, very few IDUs who acquired HBV or HCV infection were reported to a public health hepatitis surveillance system, raising questions regarding the limitations of community surveillance data to characterize viral hepatitis epidemiology in that population group. Because the majority of study participants who acquired HBV or HCV infection were apparently asymptomatic, they would not have met CDC surveillance case definition. This suggests that alternate methods of hepatitis case finding in IDUs may be needed to monitor incidence in the community. These findings suggest that dependence of routine communicable disease surveillance systems on both access to clinical services and individual clinicians' reporting behavior may lead to under-reporting of IDUs among hepatitis cases, particularly in the case of HCV infection. To the degree that surveillance system data are used to estimate the relative burden of hepatitis diseases borne by drug injectors, there may be under allocation of prevention and care resources. Hagan, H., Snyder, N., Hough, E., Yu, T., McKiernan, S., Boase, J., and Duchin, J. Case Reporting of Acute Hepatitis B and C Among Injection Drug Users. J Urban Health, 79(4), pp. 579-585, 2002.
Service Needs Among IDUs: Needle Exchange and Methadone Maintenance
In this study, researchers compared the prevalence of perceived and unmet needs of HIV-negative IDUs not receiving drug treatment (n=251) and those recruited from a methadone maintenance program (n=312) in 1998. Researchers studied self-reported needs for 6 community services (medical, mental health, housing, income assistance, alcohol treatment, and drug treatment). Respondents reported the highest levels of need for mental health and housing services. Ninety-four percent of out-of-treatment IDUs reported having at least one medical or psychosocial need compared to 62% of methadone clients (p<.001). Across all reported service needs, at least 69% of respondents in both cohorts reported their needs were unmet. While HIV-infected drug users receive assistance through the Ryan White CARE Act, these findings suggest that seronegative drug users may benefit from similar community services. Stein, M. and Friedmann, P. Need for Medical and Psychosocial Services Among IDUs: A Comparative Study of Needle Exchange and Methadone Maintenance. Amer J on Addictions, 11, pp. 262-270, 2002.
HIV+ Drug Users Unaware of Their Status: Who Gets Tested, Who Returns for Results
Researchers analyzed a subset of data collected from out-of-treatment HIV+ drug users (N=1,544) who participated in the NIDA-funded Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research Study. They identified socio-demographic characteristics and drug use and sexual risk behaviors that differentiate HIV+ individuals who had obtained HIV testing in the past and those who had not and, among those who had been tested, what differentiates individuals who had returned to obtain their test results and those who had failed to return. In total, 33.4% of persons who tested HIV+ indicated that they had never been tested for HIV before. Persons who were HIV+ and more likely to have been tested in the past were: female, identified as gay or lesbian, had a history of arrests, were ever in drug treatment, had no IDU sex partner in the past month, and ever had a STD. Among HIV+ persons who reported prior HIV testing, 24.1% never returned for their test results. Persons who were HIV+ and more likely to return to obtain a past HIV test results were: not Hispanic, domiciled (not homeless), married, and recruited in a low HIV prevalence site. These findings suggest that out-of-treatment drug users who do not have contact with institutional systems (e.g., corrections) may need to be targeted for testing through hospital emergency rooms or outreach efforts. Efforts must also be made to shorten the interval between testing and providing test results so that transient individuals may obtain these results before moving on. Clearly, more needs to be done to improve interventions to encourage drug users to obtain HIV testing and counseling and to return for their test results. Strauss, S., Deren, S., Rindskoph, and Falkin, G. HIV-Positive Out-of-Treatment Drug Users Who Are Unaware of Their HIV Status: Predictors of Who Gets Tested and Who Returns for Test Results. J Drug Issues, pp. 1017-1032, Fall 2002.
Anemia in HIV-Infected Drug Abusing Women
Risk factors for anemia and cumulative incidence of anemia were examined in a longitudinal cohort study of 622 injection drug users (IDUs) (8885 visits) in Baltimore, Maryland, from 1988 to 2000. At enrollment, 19.6% subjects were anemic (16.1% of men and 30.5% of women, P<0.0001) and 8.4% had microcytic anemia (6.7% of men and 14.0% of women, P=0.006). Cumulative incidence of anemia was 82.2% (87.9% of men and 100% of women, P<0.0001) during a median of 7.5 years follow-up. Factors associated with anemia included age (per 5 year increase, odds ratio (OR)=1.22; 95% confidence interval (CI): 1.10,1.36), female gender (OR=1.62; 95% CI: 1.16, 2.27), CD4+ lymphocyte count <200 cells/microl (OR 1.85; 95% CI: 1.52, 2.24), weight loss (OR 1.55; 95% CI: 1.26, 1.91), oral thrush (OR 1.53; 95% CI: 1.21, 1.94), Mycobacterium avium complex infection (OR 1.30; 95% CI: 1.04, 1.64), and zidovudine use (OR 1.24; 95% CI: 1.04, 1.48). Higher body mass index (OR 0.92; 95% CI: 0.88, 0.95) and marijuana use (OR 0.75; 95% CI: 0.61, 0.92) were associated with a lower risk of anemia. The cumulative incidence of anemia is high among IDUs, and women are at highest risk of anemia, Semba, R.D., Shah, N., and Vlahov, D., Risk Factors and Cumulative Incidence of Anemia Among HIV-infected Injection Drug Users, Int. J. STD AIDS, 13(2), pp. 119-123, 2002.
Contextual Factors and Other Correlates of Sexual Risk of HIV Among African American Crack-Abusing Women
This study examined differences in contextual factors, substance use, sexual risk behaviors, and comorbid histories between African American, out of treatment crack abusing women who had either a single sexual partner or multiple partners. Bivariate analysis indicated that women with multiple partners were more likely than women with a single partner to be homeless, financially dependent, and to have histories of sexual, physical, and emotional abuse. Women with multiple partners reported higher levels of depression, anxiety and more symptoms of posttraumatic stress disorder. In multiple logistic regression analysis, being unemployed, difficult childhood, and number of days of crack use in the previous 30 days, longer crack runs, and more frequent unprotected fellatio were associated with increased odds of having multiple sexual partners. Being married or living as married was associated with decreased odds of having multiple sexual partners. The importance of assessing contextual and historical factors and implications for future research is discussed. Roberts, A.C., Wechsberg, W.M., Zule, W. and Burroughs, A.R. Contextual Factors and Other Correlates of Sexual Risk of HIV Among African American Crack-Abusing Women. Addictive Behaviors, 28, pp. 523-536, 2003.
Women, AIDS, and Protective Factors
This study compares the characteristics of out-of-treatment, homeless, crack-using African American women with those who are not homeless to determine what risks and protective factors differentiate the two groups. From 1999 to 2001, 683 out-of-treatment, African American crack-using women (of whom 219 were categorized as homeless) were interviewed and serologically tested. Risk factors that were examined include adverse childhood experiences, psychological distress, physical health, violence and victimization, drug use, and risky sex behaviors. Protective factors that were examined include marital status, education, public assistance, and the responsibility of caring for children. Overall, both groups of women started crack use in their mid twenties and started drug use with alcohol in their teenage years. Logistic regression analysis found that that variables associated with increased odds of being homeless are physical abuse before age 18, crack runs greater than 24 hours, income less than $500 in the last 30 days, depression, and current cigarette smoking. Protective factors found are marital status, living with children under 18, having had a physical in the past year, and receiving money from welfare in the last 30 days. Interventions designed for these women need to consider gender, cultural, and contextual issues that not only incorporate aspects of risk reduction related to violence, alcohol use, and comorbid conditions, but also linkages that will address housing issues, education and skills for independence. Wechsberg, W.M., Lam, W.K., Zule, W., Hall, G., Middlesteadt, R., and Edwards, J. Violence, Homelessness, and HIV Risk Among Crack-Using African American Women. Substance Use and Misuse, 38(3-6), pp. 671-701, 2003.
Effectiveness of Risk Reduction Interventions in Drug-Abusing Women
The primary objective of this study was to evaluate the effectiveness of an HIV intervention for African American women who use crack cocaine. Two hundred sixty five women (aged 18-59 years) were randomly assigned to one of two enhanced intervention conditions or to the National Institute on Drug Abuse standard condition. A substantial proportion of women reported no past 30-day crack use at 6-month follow-up (100%-61%, p <.001). Significant (p<.05) decreases in the frequency of crack use; the number of paying partners; the number of times vaginal, oral, or anal sex was had with a paying partner; and sexual risks, such as trading sex for drugs, were reported over time. Significant (p<.05) increases in male condom use with sex partners were observed, as well as decreases in casual partners' refusal of condoms. Findings suggest that combined components of our culturally appropriate, gender-tailored intervention may be most effective at enhancing preventive behavior among similar populations. Sterk, C.E., Theall, K.P. and Elifson, K.W. Effectiveness of a Risk Reduction Intervention Among African American Women Who Use Crack Cocaine. AIDS Education and Prevention, 15(1), pp. 15-32. May 2003.
High Risk Sexual Behaviors among Heroin Sniffers Who Have No History of Injection Drug Use: Implications for HIV Risk Reduction
The purpose of this paper was to assess sexual behaviors which place heroin sniffers (HSs) at high risk for HIV infection. A stratified network-based sample was used to recruit HSs who had no history of injection drug use from the streets of South Florida, USA. HSs displayed a high HIV seroprevalence rate of 12.1%; women (18.1%) were more likely than men (8.7%) to test positive for HIV. Both men and women HSs engaged in considerable high-risk sex behavior, including high-risk sex for money or drugs exchange behavior. The use of crack cocaine was associated with increased sex for money or drugs exchange behavior among women. The need for intervention programs targeted toward HSs is discussed. Sanchez, J., Comerford, M., Chitwood, D.D., Fernandez, M.I. and McCoy, C.B. AIDS Care, 14(3), pp. 391-398, June 2002.
Behavioral Problems in HIV-Infected Children
In an effort to increase understanding of previously-reported behavioral problems among HIV-infected children, investigators have analyzed data from the Women and Infants Transmission Study (WITS), a large multi-site, longitudinal study of maternal-infant HIV infection and the health and developmental outcomes of the children. The analyses examined influences of HIV infection, drug exposure, and family characteristics on behavioral outcomes of 307 children born to HIV-positive mothers (96 HIV-infected and 211 seroreverters). The age range of behavioral outcome assessment was 3 to 8 years. Analyses indicated a high prevalence of behavioral problems in this sample, but the multivariate analyses did not find an association between either HIV status or prenatal drug exposure and poor behavioral outcomes. The strongest associations with increased behavioral problems involved demographic characteristics. Mellins, C.A., Smith, R. and O'Driscoll, P., et al. High Rates of Behavioral Problems in Perinatally HIV-Infected Children Are Not Linked to HIV Disease. Pediatrics, 111, pp. 384-393, 2003.
Factors Affecting Cognitive Functioning in a Sample of Human Immunodeficiency Virus-Positive Injection Drug Users
Dr. Margolin and colleagues at Yale University examined the specific contribution of the multiple factors contributing to cognitive functioning among injection drug users that may affect engagement in, and response to, addiction and HIV-related interventions. The current study examined the independent contributions to neuropsychological test performance of premorbid educational attainment, medical and psychiatric history, long- and short-term drug use, in a sample of 90 HIV-positive injection drug users dually addicted to heroin and cocaine. Assessments were by laboratory, observation, and self-report measures, and plasma HIV-1 RNA viral load and CD4+ count. Fully 88% of the sample showed evidence of impairment on the test battery selected to assess processes associated with successful engagement in the treatment of substance abuse and HIV, such as learning and memory of verbal information, capacity to solve new problems and deal with more than one stimulus at a time, visual-motor coordination, and visual tracking and cognitive flexibility. In addition to drug use, independent predictors of test performance were HIV viral load, educational attainment, and premorbid medical and psychiatric problems. Findings underscore the multiplicity of factors that contribute to cognitive impairment in HIV-positive drug -abusing individuals in addition to drug use. Margolin, A., Avants, S.K., Warburton, L.A., and Hawkins, K.A. AIDS Patient Care STDS, 16(6), pp. 255-267, 2002.