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Director's Report to the National Advisory Council on Drug Abuse
February, 2001

Research Findings

Research on AIDS and Other Medical Consequences of Drug Abuse

Sharing of Drug Preparation Equipment is a Potential Route of Hepatitis C

Transmission Investigators examined the risk of hepatitis C (HCV) transmission in relation to the sharing of cookers used to melt the drug into injectable liquid, of cotton used to filter out particles as the drug is drawn into the syringe, and of water used to rinse the syringe. Injection with a syringe previously used by another injector, and use of a syringe to divide drug doses between users (backloading) were also evaluated. HCV seroconversion was measured in a cohort of IDUs who tested negative for HCV antibody at the time of recruitment to the study. During the recruitment period, 2879 IDUs were enrolled in the overall cohort study, and only 507 (17.6%) tested 8negative for HCV. Follow-up was completed on 317 (62.5%) of the initially HCV-negative IDUs. Fifty-three of the IDUs seroconverted to HCV during the follow-up period, for a cumulative HCV incidence of 16.7%. Among those who did not share syringes, HCV seroconversion was associated with sharing drug cookers and filtration cotton (adjusted risk ratio=5.9; 95% CI=1.1, 31.7); 54% of HCV infections in IDUs who did not share syringes were attributable to cooker/cotton sharing. These findings indicate that, among IDUs who do not share syringes, an important proportion of HCV infections may be attributable to cooker/cotton sharing. Hagan ,H., Thiede, H., Weiss, N., Hopkins, S., Duchin, J. et al. Sharing of Drug Preparation Equipment as a Risk Factor for Hepatitis C. Am J Public Health, 91, pp. 42-46, 2001.

A Comparison of HIV Risk Behaviors Among New and Long-Term Injection Drug Users

The purpose of this study was to characterize the injection and sexual risk behaviors of a cohort of active drug injectors who have initiated injection within the past 4 years and to compare their behaviors with the risk behaviors of long-term injectors who have been injecting drugs since 1984. A stratified, network-based sample was used to recruit injection drug users from the streets in Miami-Dade, Florida. After screening for eligibility, which included a urine test to confirm drug use, participants were administered a structured questionnaire that included basic demographic information, drug use history, and HIV risk behavior practices. Both injector groups displayed a high level of HIV injection risk behavior. Although new initiates into injection demonstrated lower risk behavior than long-term injectors at the first injection episode, the current risk behavior between new and long-term injectors is similar. Other findings of interest include: new heroin injectors are distributed across ethnic and gender sub-populations; are initiating injection at a much later age (on average in their late 20s) than did long-term injectors who on average initiated injection in their late teens. They represent a new cohort of injectors at risk for HIV exposure and transmission. New injectors were more likely than long-term injectors to have sniffed heroin before they initiated heroin injection. Heroin sniffers are at high risk for progression to injection and are a prime target population for prevention efforts. New injectors were less likely than long-term injectors to have used speedball (heroin and cocaine in combination) and less likely to have used Dilaudid. During their first injection episode new injectors were less likely than long-term injectors to have shared syringes and other related equipment such as cookers, cottons and rinse water. Current risk behaviors, however, were quite similar for both injector groups. Chitwood, D.D., Comerford, M., Kitner, K.R., Palacios, W., and Sanchez, J. Substance Use and Misuse, 36(1), pp. 1-21, 2001.

Quality of Life Measures in the Miami HIV-1 Infected Drug Abusers (MIDAS) Cohort: Relationship to Gender and Disease Status

Shor-Posner and colleagues at the University of Miami report that HIV-infected drug abusers, particularly women, have less social support than men. The investigators assessed activity, daily living, health, support and outlook by using the Physician-administered Spitzer Index in 75 HIV-infected drug abusers (51 men; 24 women) enrolled in the Miami HIV Infected Drug Abusers Study (MIDAS). Total composite scores were significantly lower in HIV-infected women than men (p=0.03). Most women (45%) were homeless or marginally housed as compared to 11% of the men. Women with low activity scores had less social support than women with high activity scores. Cocaine use was significantly related to reports of normal activity, and varied across genders; more men used cocaine than women (p=0.03). Compared to non-AIDS participants, AIDS patients were more likely to have lower scores in health (p=0.009) and poor outlook (p=0.03). These findings reveal specific deficits in areas of psychosocial capacity, particularly in HIV-1 infected women who abuse drugs, that may need to be strengthened in order to enhance function and adherence to treatment, as well as well-being. Shor-Posner, G., Lecusay, R., Miguez-Burbano, M.J., Quesada, J., Rodriguez, A., Ruiz, P., O'Mellan, S., Campa, A., Rincon, H., Wilkie, F., Page, B., and Baum, M. Quality of Life Measures in the Miami HIV-1 Infected Drug Abusers (MIDAS) Cohort: Relationship to Gender and Disease Status. Journal of Substance Abuse, 12, pp. 1-10, 2000.

Gonadal Hormone Levels in Injection Drug Users

Dobs group at Johns Hopkins reports preliminary findings showing that HIV-infected IVDUs have low levels of serum testosterone (<410 ng/dl) and may be at risk of hypogonadism. The subjects, 40 African-Americans (20 men, 20 women, mean age of 41.5±5.6 years) were a part of a cohort from an ongoing NIDA-funded ALIVE study (AIDS Linked to Intravenous Drug Experiences). Eight (20%) of these 40 subjects had low levels of testosterone. A larger, more diverse patient population that includes non-injection drug users as controls is underway to determine the relationship between drug use, HIV status and hormones Wahlstrom, J.T., Tang, A., Cofrancesco, J., Shah, N..Jr., Dobs, A. Drug and Alcohol Dependence. 60, pp. 311-313, 2000.

Cocaine, HIV, and Their Cardiovascular Effects: Is there a Role for ACE-inhibitor Therapy?

Margolin and his group at Yale University School of Medicine tested if fosinopril could be used in the treatment of HIV and cocaine-associated cardiovascular complications. Fosinopril is an angiotensin converting enzyme (ACE) inhibitor used in the treatment of hypertension. It also modulates dopamine and corticotropin releasing factor in the brain. The investigators conducted echocardiographic and platelet activation studies in 16 HIV-infected cocaine abusing patients, as well as tolerability and efficacy studies of fosinopril for the treatment of cocaine abuse in both HIV+ (n=6) and HIV- (n=5) methadone-maintained cocaine abusers. Results showed that HIV+ cocaine abusing patients possessed abnormalities of diastolic heart function and platelet activation that are potentially reversible with fosinopril therapy. Findings also suggested that fosinopril was well tolerated regardless of HIV status, does not appear to cause hypotension, and may possess effectiveness for reducing cocaine use. The authors concluded that ACE-inhibitor therapy may offer a new pharmacologic approach to the treatment of cocaine abuse and its complications, and that controlled research of this class of agents may be promising. Margolin, A., Avants, S.K., Setaro, J.F., Rinder, H.M., Grupp, L. Drug and Alcohol Dependence. 61, pp. 35-45, 2000.

Human T-Lymphotropic Virus Type II RFLP Subtypes a0 and b4/b5 are Associated with Different Demographic and Geographic Characteristics in the United States

Murphy's group (Liu et al. 2000) has found that the human T-lymphotropic virus type II (HTLV-II), the prevalence of which is the highest among injection drug users and their sexual partners when compared to general US population and Native American Indians, exists in RFLP (restriction fragment length polymorphism) subtypes a0, a3, a5, a6, a7, b4 and b5 and in different populations. The investigators obtained blood specimens from 493 blood donors from five cities (Baltimore/Washington area, Detroit, Oklahoma, Los Angeles, San Francisco) and obtained the HTLV-II subtypes. HTLV-II subtype a0 was associated with age over 30 and with Black race/ethnicity, while subtype b4 and b5 were more common among Native Americans. The authors state that there may have been at least two transmission foci of HTLV-II in the US: a modest subtype a0 epidemic of unknown source in the 1960s and 1970s spread predominantly among Black persons in several geographic areas and a smaller focus of HTLV-II subtypes b4/b5 among non-Black individuals in Oklahoma and perhaps in other areas (not examined in this study). Liu, H., Leung, P., Glynn, S., and Murphy, E.L. Virology, 279, pp. 90-96, 2001.

HIV Risk Behaviors Differ Among IDUs, Crack Smokers, and IDUs Who Smoke Crack

A study was conducted to assess differences in sex-related risk behaviors between IDUs who did not smoke crack cocaine, crack smokers who did not inject drugs, and drug users who both injected drugs and smoked crack. Current drug users from 22 cities were recruited and assessed. The sample of 26,892 included 28% IDUs only, 42% crack smokers only, and 30% who injected drugs and smoked crack. Results showed that active drug users were at risk of HIV through sexual transmission: in the 30 days prior to the interview, 28% reported sex with two or more individuals, 23% had an IDU sex partner, and 24% exchanged sex for drugs or money. In addition, more than 80% did not use a condom during sex. Crack smokers only, and crack smokers who also injected were more likely than IDUs only to report multiple sex partners and exchanging sex. Because of these high risk behaviors, condom use was of particular importance. The number of days of alcohol use and having an IDU sex partner were independently associated with not using a condom. Crack smoking injectors reported the highest average number of days of alcohol consumption and were the most likely to have had an IDU sex partner. Booth, R.E., Kwiatkowski, C.F., and Chitwood, D.D. Sex-Related HIV Risk Behaviors: Differential Risks Among Injection Drug Users, Crack Smokers, and Injection Drug Users Who Smoke Crack. Drug and Alcohol Dependence, 58, pp. 219-226, 2000.

Relapse to Unsafe Sex Explained by Cognitive Escape Model

A qualitative study was conducted to explore why men who have reduced their sexual behaviors to prevent HIV periodically engage in risky sex, even though they know their lapses put them at risk for acquiring HIV. Men (N=41) who have sex with men participated in semi-structured interviews during the course of the study. Findings indicate that MSM recognize strong normative expectations for using condoms during sex, and usually comply with these expectations. Constant awareness of HIV and the AIDS epidemic and the need to comply with safer sex practices were identified as sources of stress. The men noted that the intoxicating effects from use of illicit drugs and alcohol facilitated cognitive disengagement (a "time out") from the norms of safer sex. A cognitive escape model appears to explain the lapses of MSM who report periodic unprotected sex. Williams, M.L., Elwood, W.N., and Bowen, A.B. Escape from Risk: A Qualitative Exploration of Relapse to Unprotected Anal Sex Among Men Who Have Sex With Men. J Psych Human Sexual., 11(4), pp. 25-49, 2000.

Network Saturation May Explain Continuing Stable HIV Prevalence in IDUs in New York

A study was conducted to consider how HIV incidence could remain moderate at seroprevalence levels that would give maximum incidence. Previous explanations include behavioral risk reduction and network saturation within high-risk groups. Among 767 IDUs studied during a period of stable high seroprevalence in New York City (i.e., from 1991-1993), risk behaviors were common and networks were far from saturated. This study explored a different network-based mechanism: in stable high-prevalence situations, the relatively small sizes of sub-networks of linked seronegatives -- within larger networks of both infected and uninfected persons-- may limit infectious outbreaks. Any primary infection outbreak would probably be limited to members of connected subcomponents of seronegatives, and the largest such subcomponent in the study included only 18 members (of 415 seronegatives). Research and mathematical modeling could explore conditions that may affect the size and stability of subcomponents of seronegatives. Finally, if the existence of small, connected components of seronegatives prevents secondary outbreaks, this protection may weaken, and vulnerability to new outbreaks increase, if HIV seroprevalence falls. Thus, in situations of declining prevalence, prevention programs should be maintained or strengthened. Friedman, S.R., Kottirl, B.J., Neaigus, A., Curtis, R., Vermund, S.H., and Des Jarlais, D. Network-Related Mechanisms May Help Explain Long-Term HIV Seroprevalence Levels That Remain High but Do Not Approach Population Group Saturation. Am J Epidemiol. 152(10), pp. 913-22, 2000.

Study Compares Computer-Administered and Face-to-Face Interviews

Researchers assessed the reliability of responses to HIV risk behavior questions obtained using a voice-enhanced, computer-administered self-interview (audio-CASI) system with touch-screen response compared with those obtained via face-to-face interviews administered by trained and experienced interviewers. Bias that may be attributable to an audio-CASI data collection format was also assessed. A 4-group crossover design was used, with random assignment to one of four study conditions: audio-CASI interview at both intake and retest; face-to-face interview at both intake and retest; audio-CASI interview at intake and face-to-face interview at retest; and face-to-face interview at intake and audio-CASI interview at retest. The study was conducted with a sample of drug users at risk for HIV infection interviewed in nonclinical settings. Data were collected at intake and 48 hours after intake. Analyses show that data obtained using voice-enhanced computer interviewing with touch screen response are reliable and are comparable to data obtained using interviewer administered face-to-face interviews. However, bias was associated with data collection format and may be partially attributable to the complexity of the questionnaire. Williams, M.L., Freeman, R.C., Bowen, A.M., Zhao, Z., Elwood, W.N., et al. A Comparison of the Reliability of Self-Reported Drug Use and Sexual Behaviors Using Computer-Assisted vs. Face-to-Face Interviewing. AIDS Education and Prevention, 12(3), pp. 199-213, 2000.

Syringe Acquisition and Use of SEPs Differ in Puerto Rican IDUs in P.R. and N.Y.

Alternative sources of syringes, including syringe exchange programs (SEPs) were compared for 165 Puerto Rican IDUs in East Harlem, NY and 115 in Baymon, PR. IDUs in PR obtained, on average, 45% of their syringes from "syringe sellers," 18% from pharmacies, and 17.6% from a SEP. By contrast, IDUs in NY obtained 55% of their syringes from SEPs and 23% from "syringe sellers." Compared to their island counterparts, IDUs in NY received significantly more syringes from SEPs (NY, 104.5 vs PR, 9.2) in the prior 30 days, and were more likely to be referred by SEPs to drug treatment and HIV/TB-testing services. The restrictive syringe exchange policies in PR reduce access to new, sterile syringes and enhance HIV risks, indicating that PR should examine and eliminate its restrictive policies, reform drug paraphernalia laws to protect SEP clients, and address police harassment related to carrying syringes. Finlinson, A., Oliver-Velez, D., Colon, H., Deren, S., Robles, R., et al. Syringe Acquisition and Use of SEPs by Puerto Rican IDUs in New York and Puerto Rico: Comparisons Based on Quantitative and Qualitative Methods. AIDS and Behavior, 4(4), pp. 341-351, 2000.

Trends in Crime and the Introduction of a Needle Exchange Program

In this study, researchers determined whether the introduction of a needle exchange program (NEP) was associated with increased crime rates. Trends in arrests were compared in program and nonprogram areas before and after introduction of a NEP in Baltimore. Trends were modeled and compared by way of Poisson regression. No significant differences in arrest trends emerged. Over the study period, increases in category-specific arrests in program and nonprogram areas, respectively, were drug possession, 17.7% and 13.4%; economically motivated offenses, 0.0% and 20.7%; resistance to police authority, 0.0% and 5.3%; and violent offenses, 7.2% and 8.0%. the lack of association of overall and type-specific arrest data with program implementation argues against the role of NEP in increasing crime rates. Marx, M., Crape, B., Brookmeyer, R., Junge, B., Latkin, C. et al. Trends in Crime and the Introduction of a Needle Exchange Program. Am J Public Health, 90, pp. 1933-1936, 2000.

Comparison of Participants and Non-Participants Using Geographic Information System

Comparability of study participants with non-participants is customarily assessed in research studies by contrasting the distributions of sociodemographic characteristics. Such comparisons do not necessarily provide insight into whether or not participants of a given subgroup are similar to non-participants of the same subgroup. A geographical information system (GIS) may provide such insight by visually displaying the spatial distributions of participants and non-participants. In earlier research on heterosexuals at elevated risk for human immunodeficiency virus (HIV), traditional methods suggested distributional differences in the demographic characteristics of participants and non-participants. In this study, researchers used residential address coordinates for each subgroup member and the subgroup's centroid as the origin. They constructed a 360¡ series of overlapping box plots of the distance of subgroups members to the origin, thereby producing closed polygons for each of the box plot demarcators. The rotational box plots revealed similar geographical distributions for most participant and non-participant subgroups, with the exception of African-American men and women. The researchers conclude that observed differences resulted in part from the study design and provide some insight into sampling problems encountered in social network studies. Based on Tobler's supposition that Ônearby things tend to be alike', the rotational box plot represents a useful additional tool for investigating sample bias. Muth, S., Potterat, J. and Rothenberg, R. Birds of a Feather: Using a Rotational Box Plot to Assess Ascertainment Bias, Intl J Epidemiol, 5, pp. 899-904, 2000.

Accuracy of Drug Users' Recall Assessed for Use in Predicting Spread of HIV

To evaluate the accuracy of self-reports on sexual and drug use behaviors, data from a network study of HIV transmission among a sample of drug users and nonusers were used to compare reports of sexual and drug use behaviors by partners who engaged in those behaviors. Partner concordance (self-report agreement between two people) was used as an estimate of validity. Results showed that persons are able to recall and report about 85% of their recent partners (15%-20% less for recent drug use partners). For relationships that were reported by both partners, a high degree of concordance existed about recent behaviors (83%-96%) and variable agreement about frequency (0.48 Naltrexone Administration Attenuates Surgery-induced Immune Alterations in Rats

Surgery is a commonly performed procedure which produces substantial alterations in immune function in both humans and animals. To better understand the mechanism of surgery-induced immunomodulation, the present study investigated the effect of the opioid antagonist naltrexone on surgery-induced immune alterations in rats. Based on previous investigations in our laboratory, rats underwent a 6-cm laparotomy with no internal manipulation and immunological assessments were completed 24 hours following the surgical procedure. Naltrexone was administered at the time of surgery and every 4 hours thereafter until immune assessment. Results showed that naltrexone attenuated the surgery-induced decrease in natural killer cell cyto toxicity, B cell proliferation, T-cell proliferation, and production of the cytokine IFN-gamma. These results are among the first to show that pharmacological antagonism of opioid receptors can prevent deleterious immune changes in the postoperative state, suggesting a detrimental role of the endogenous opioids in surgical procedures. Nelson, C.J., Carrigan, K.A. and Lysle, D.T. Journal of Surgical Research, 94, pp. 172-177, 2000.

Study Examines Stage of Change for Condom Use Among Women Crack Users

Attitudes-norms research (the theories of planned behavior and reasoned action) has been successful in accounting for many types of behavior change. One of the strengths of this approach has been to combine individual beliefs and normative influences in the explanation of behavior change. However, the conceptualization of normative influence in these theories makes very strong assumptions about self-awareness in the selection of normative referents. These assumptions are particularly problematic when applied to female cocaine smokers, who report frequent sex while under duress or while cognitively impaired. In this study the original conceptualization of normative influence and two alternatives (assuming emotion-based and interaction-based selection of normative referents) are operationalized to evaluate stage of change for condom use among women who are heavy crack cocaine users with multiple sex partners. Results show that stage of change for use of condoms with nonmain partners is best accounted for by interaction-based selection of normative referents. Richard, A.J., Bell, D.C., Montoya, I.D. Normative Influence on Condom Use in the Personal Networks of Female Cocaine Smokers. AIDS Educ Prev, 12(4), pp. 357-374, 2000.

Natural History of Hepatitis C Infection: Host, Viral and Environmental Factors

Hepatitis C virus (HCV) infection may resolve through viral clearance, persist with no complications, or progress to end stage liver disease (ESLD). A study to determine the incidence and determinants of viral clearance and ESLD was performed in a cohort of 1667 HCV antibody positive IDUs with median follow-up of 8.8 years. Of 919 patients assessed, persistent viremia was observed in 722 (78.6%), viral clearance in 90 (9.8%), and in 107 (11.6%), viremia was not resolved. Viral clearance occurred more frequently in non-African Americans (OR 5.15), and in those without HIV infection (OR 2.19). Forty cases of ESLD were observed during follow-up, for an incidence rate of 3.1/1000 person years. The risk of ESLD was higher for persons >= 38 years of age (adjusted relative incidence 3.67) and among those who ingested >260 g of alcohol per week (adjusted relative incidence 3.60). Only 1/1667 HCV antibody positive IDUs in this cohort had received treatment for HCV. Further research is important to understand the less frequent clearance of HCV infection among African Americans and to enhance HCV treatment utilization among eligible HCV-infected IDUs. Thomas, D.L., Astemborski, J., Rai, R.M., Anania, F.A., Schaeffer, M., Galai, N., Nolt, K., Nelson, K.E., Strathdee, S., Johnson, L., Laeyendecker, O., Boitnott, J., Wilson, L.E. and Vlahov, D. Journal of American Medical Association, 284, pp. 450-456, 2000.

Childhood Trauma as a Correlate of Lifetime Opiate Use in Psychiatric Patients

Tardiff's group (Heffernan et al. 2000) at Cornell University Medical Center found that the opiate abusers were 2.7 times more likely to have a history of childhood sexual and/or physical abuse than non-opiate users. The investigators examined the relationship between childhood abuse and opiate abuse in particular among 763 men and women consecutively admitted for psychiatric hospitalization between 1991 and 1992. Patients (age 18-59) were interviewed about demographic information, alcohol and drug use, and history of interpersonal violence. About 18% of the patients reported heavy opiate use. Childhood abuse was reported by 41.6% of the sample (17.2% physical abuse only, 9.3% sexual abuse only, and 14.8% both). Opiate use was higher among those reporting physical abuse alone (24%) or both physical and sexual abuse (27%) than among those reporting sexual abuse alone (8.8%) indicating that impact of physical abuse may create greater risk for opiate use. Heffernan, K., Coitre, M., Tardiff, K., Marzuk, P.M., Portera, L. and Leon, A.C. Addictive Behaviors, 25(5), pp. 797-803, 2000.

Prostitution and the Sex Discrepancy in Reported Number of Sexual Partners

Brewer and colleagues report that prostitute women are underrepresented in national household sexual surveys. In their examination of sampling bias to explain previous survey findings that men report more sex partners than women do, the investigators note that the proportion of heterosexual men and women in the United States is roughly balanced and that in the aggregate, men and women in a closed population have relatively the same number of sex partners. The investigators find that prostitutes have been under-represented primarily because their residences or lodgings place them outside sampling frames for household surveys and that when this undersampling is taken into consideration, the discrepancy in sexual behavior survey findings disappears. After adjusting for prostitution-related factors, such as estimated prevalence of prostitutes and their high number of sex partners (Potterat et al., Sexual, drug-using and social networks of persons presumed to be at high risk for HIV infection), the investigators conclude that essentially all the discrepancy is accounted for by undersampling of prostitutes rather than by sex-linked reporting bias such as men's reluctance to report that their partners include prostitutes. Brewer, D.B., Potterat, J.J., Garrett, S.B., Muth, S.Q., Roberts, J.M., Kasprzyk, D., Montano, D.E., and Darrow, W.W. The Proceedings of the National Academy of Sciences, 97(22), pp. 12385-12388, 2000.

Personality, Stress, and Social Support in HIV Risk Prediction

One-hundred and forty-one male veterans in treatment for alcohol and other drugs, were evaluated in terms of whether baseline levels of avoidant, antisocial, and dependent personality features and perceived stress and social support, predict 12-month follow-up levels of unprotected sex. These patients received substance abuse treatment that included an HIV transmission risk reduction component. Pretreatment levels of unprotected sex and dependent personality significantly predicted unprotected sex during follow-up. Avoidant personality was associated with reduced risk linked with lower levels of sexual involvement. Perceived stress and social support did not significantly predict level of unprotected sex during follow-up. Implications for developing personality sensitive HIV prevention interventions are discussed. McMahon, R.C., Malow, R.M., Jennings, T.E. AIDS and Behavior, 4, pp. 399-410, 2000.

Verbal Working Memory in HIV-Seropositive Drug Users

The performance of 30 HIV-seropositive male drug users (mean age 39.4 yrs) and 30 risk-matched seronegative controls (mean age 41.65 yrs) on 2 measures of verbal working memory, the Listening Span and the verbal Self-Ordered Pointing Task, was performed. The results show that impaired working memory performance was significantly more common among HIV-seropositive persons compared to controls, with the highest incidence of deficit among symptomatic participants. These findings indicate that working memory deficits in persons with HIV are not domain-specific and can be demonstrated reliably in drug users. Farinpour, R., Martin, E.M., Seidenberg, M., Pitrak, D.L., Pursell, K.J., Mullane, K.M., Novak, R.M., Harrow, M. Verbal Working Memory in HIV-seropositive Drug Users. Journal of the International Neuropsychological Society, 6(5), pp. 548-555, 2000.

Drug Use, Partner Violence, and HIV Risk

This study analyzed in-depth interviews with women in methadone maintenance treatment programs (MMTPs) who reported having experienced physical or sexual violence by an intimate partner during the past year. 87% of the women reported experiencing a minor physical assault from an intimate partner within the past year, 58% reported experiencing a severe assault, 64.5% reported experiencing minor sexual coercion, and 12.9% reported severe sexual coercion. 40% of the women indicated that both she and her partner were involved in drug-related activities during the most recent occurrence of partner abuse, 35% reported that only the partner was drug-involved, and only 6.4% of the women indicated that they alone were drug-involved. 20% reported using drugs immediately after the violent event because they were upset or in pain. Crack/cocaine was the drug most frequently mentioned by women reporting drug use before, during, or after the most recent violent event. For male partners, alcohol and crack/cocaine use were the most prevalent substances reported in conjunction with the most recent violent event. In terms of HIV risk behavior, 20% of the women reported having unwanted sex after the most recent incident. Few women reported using condoms with their main partners; yet, two-thirds reported that they had outside relationships or suspected their partners of having outside relationships. 20% reported having exchanged sex for money/drugs within the past 90 days. 20% reported injection drug use within the past year. The multiple ways in which drugs of abuse are related to partner violence and HIV risk behaviors suggest the need for specific interventions for preventing drug relapse, and HIV and HCV infection among abused women in MMTPs. Gilbert, L.,El-Bassel, N., Rajah, V. Foleno, A., Fontdevila, J., Frye, V., and Richman, B.L. The Converging Epidemics of Mood-Altering-Drug Use, HIV, HCV, and Partner Violence: A Conundrum for Methadone Maintenance Treatment. Mt. Sinai J. Med., 67(5-6), pp. 452-464, 2000.

HIV Risk Behavior Among Bisexual and Heterosexual Drug Users

This study examined the sexual and drug use behaviors for bisexual and heterosexual drug users (n=11,435 males and n=5,636 females) who participated in the NIDA AIDS Cooperative Agreement study. Results of the study suggest that, for males, bisexuality was highly associated with being homeless, having ever been paid for sex, having five or more sex partners in the month preceding the interview, having an IV drug-using sexual partner in the month preceding the interview, using crack, and sharing injection equipment in the month preceding the interview. For females, bisexuality was associated with ever having been arrested, past substance abuse treatment, ever having been paid for sex, ever having paid for sex, having five or more sexual partners in the month preceding the interview, ever using cocaine, and sharing injection equipment in the month preceding the interview. Overall, results from this study indicate that both male and female bisexuals, when compared to heterosexuals, were at higher risk for HIV and were more likely to be HIV positive. One implication of these results is that a universal prevention message may not be as effective as targeting prevention messages specifically for bisexual males and females. Logan, T. K., Leukefeld, C. J Psychoactive Drugs, 32, pp. 239-48, 2000.

Delivery of HIV Risk-Reduction Services in Drug Treatment Programs

Receipt of services targeted at HIV risk reduction was examined using data from 4,412 participants in the national Drug Abuse Treatment Outcome Study (DATOS). A higher percentage of individuals in long-term residential programs received HIV-related services, compared with clients in short-term inpatient, methadone maintenance, and outpatient drug-free programs. More men than women received HIV services. Although individuals who engaged in sex work had a higher likelihood than others of receiving HIV-related services, individuals with high-risk or multiple sexual partners were no more likely than others to receive HIV services. More comprehensive service delivery is needed in order to reduce the risk for HIV among clients in drug treatment. Grella, C.E., Etheridge, R.M., Joshi, V., and Anglin, M.D. Journal of Substance Abuse Treatment, 19(3), pp. 229-237, 2000.

Antidepressant Treatment and Health Services Utilization Among HIV-Infected Medicaid Patients Diagnosed With Depression

This study identified the prevalence and predictors of diagnosed depression among persons with HIV on Medicaid, determined who among those diagnosed received antidepressant treatment, and compared utilization and costs between depressed HIV-infected individuals treated with and without antidepressant medications. Merged Medicaid and surveillance data were used to compare health services utilized by depressed individuals who were or were not treated with antidepressant medications, controlling for other characteristics. The study population comprised Medicaid recipients in New Jersey who were diagnosed with HIV or AIDS by March 1996 and received Medicaid services between 1991 and 1996. Results indicate that women were more likely and African Americans were less likely to be diagnosed with depression. Women and drug users in treatment were more likely to receive antidepressant treatment. Depressed patients treated with antidepressants were more likely to receive antiretroviral treatment than those not treated with antidepressants. Monthly total expenditures were significantly lower for individuals diagnosed with depression and receiving antidepressant therapy than for those not treated with antidepressants. After controlling for socioeconomic and clinical characteristics, treatment with antidepressant medications was associated with a 24% reduction in monthly total health care costs. The results suggest that depressed HIV-infected patients treated with antidepressants were more likely than untreated subjects to receive appropriate care for their HIV disease. Antidepressant therapy for treatment of depression is associated with a significantly lower monthly cost of medical care services. Sambamoorthi, U., Walkup, J., Olfson, M., Crystal, S. J Gen Intern Med, 15(5), pp. 311-320, 2000.

Burnout in Substance Abuse Counselors - Impact of Environment, Attitudes, and Clients With HIV

Many substance abuse treatment counselors have clients with HIV or AIDS. The contribution of various hypothesized predictors of burnout was studied in 134 substance abuse counselors working with clients with HIV/AIDS. The three burnout dimensions were emotional exhaustion, depersonalization, and personal accomplishment. Emotional exhaustion was significantly predicted by less support, less efficacy, and working in a methadone clinic. Depersonalization was predicted by less efficacy, less support, and working in a methadone clinic. Personal accomplishment was predicted by having a lower percentage of clients with HIV/AIDS, and more efficacy; support, and education. Suggestions for interventions to prevent or limit burnout are presented. Shoptaw, S., Stein, J.A., Rawson, R.A. Journal of Substance Abuse Treatment, 19(2), pp. 117-126, 2000.

Delays in Seeking HIV Care Due To Competing Caregiver Responsibilities

This study described characteristics of HIV-infected persons who delay medical care for themselves because they are caring for others. HIV-infected adults (N = 2864) enrolled in the HIV Cost and Services Utilization Study (1996-1997) were interviewed. Results indicate that the odds were 1.6 times greater for women than for men to put off care. Persons without insurance and with CD4 cell counts above 500 were also significantly more likely to put off care. Those with a child in the household were 1.8 times more likely to put off care. Women or those with a child in the household should be offered services to allow them to avoid delays in seeking their own medical care. Stein, M.D., Crystal, S., Cunningham, W.E., Ananthanarayanan, A., Andersen, R.M., Turner, B.J., Zierler, S., Morton, S., Katz, M.H., Bozzette, S.A., Shapiro, M.F. and Schuster, M.A. Am J Public Health, 90(7), pp. 1138-1140, 2000.

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