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Director's Report to the National Advisory Council on Drug Abuse - February, 2003

Research Findings - Research on AIDS and Other Medical Consequences of Drug Abuse - AIDS Research

Relationship Among Gender, Depression, and Needle Sharing in a Sample of Injection Drug Users

The findings from this study replicate two prior and consistent findings: (a) Women are more likely than men to share needles, and sharers report higher levels of depression than non-sharers. Both of these findings are important in and of themselves; however, the finding that women who share needles reported the highest level of depression of all groups adds new information to the existing literature about this important public health issue. This suggests that the relationships among gender, depression, and needle sharing are more complex than previously assumed, especially for women. Johnson, M.E., Yep, M.J., Brems, C., Theno, S.A., Fisher, D.G Psychology of Addictive Behaviors, 16, pp. 338-341, 2002.

Drug Use, Travel, and HIV Risk

Studies have described how transmission of diseases is socially organized around geographic travel and migration patterns. Sexual and other risk behaviors while traveling abroad have been examined and considered as causal factors in the spread of HIV infection and other STDs. The spread of HIV/AIDS into rural areas has also been linked to high-risk behaviors of rural residents who frequently travel into urban areas. In this study, researchers examined the travel experiences of a community sample of 160 drug users and 44 non-users recruited as part of a social network study of HIV risk. Of the sample, 47% (96 of 204) reported intercity travel in the prior 2 years. Results showed that men were more likely to travel than women, Anglos more than minorities, and young persons more than old. When travelers testing HIV-positive (n=13) were compared with HIV-negative travelers, HIV-positive travelers reported more safe sex (condom use) and more sex partners while traveling than HIV-negative persons. There were no significant differences in sex risk behaviors while traveling between drug users and non-users, or in sex behaviors between IDUs and non-IDUs. Travelers had fewer injection partners while traveling than they had while at home. However, drug-using travelers had a higher rate of drug injection and tended to take longer trips than non-drug users. There was also a significant difference in number of sex partners with whom a condom was not used. At home, there were more sex partners with whom a condom was not used compared to while traveling. Overall, however, this study found that persons who regularly engaged in risky behaviors were not more likely to travel, indicating that more HIV transmission occurs within cities than between cities. Lee, D., Bell, D., and Hinojosa, M. Drug Use, Travel, and HIV Risk. AIDS Care, 14(4), pp. 443-453, 2002.

Peer-Driven Intervention Increases Drug Users' Adherence to HIV Treatment

A feasibility study was conducted to determine whether a peer-driven intervention that was first developed as an HIV prevention mechanism for drug users could be adapted to improve HIV+ drug users' health seeking behaviors. Fifteen HIV+ IDUs were recruited, and 14 were accepted into the study. The feasibility study deliberately sought the most challenging subset of HIV+ IDUs i.e., active IDUs who had prior enrollment in HIV care but, based on a clinician's perceptions, were poorly adherent. Each subject served as a health advocate to a peer of the same sex, and met with the peer once a week to assess how well the peer was keeping up with his or her medical care. Each subject also participated as a peer being served by another health advocate. Results suggest that HIV+ drug users are willing and able to play active roles in helping one another to keep up with their medical treatments. The 14 peers kept 84% of their appointments with primary care providers and HIV-related support services. Altogether, only seven appointments were missed. Although it was not a goal of the study, drug-related HIV risks (sharing syringes and equipment specifically) were found to decrease during the study from 36% to 7%. The researchers conclude from the study that an alternative social support structure to drug treatment is feasible for increasing active drug users' adherence to medical care. Broadhead, R., Heckathorn, D., Altice, F., van Hulst, Y., Carbone, M., Friedland, G., O'Connor, P., and Selwyn, P. Increasing Drug Users' Adherence to HIV Treatment: Results of a Peer-Driven Intervention Feasibility Study. Social Science and Medicine, 55, pp. 235-246, 2002.

Religious Behaviors and HIV-Related Health Care Among IDUs in Baltimore

In many communities, religious institutions are important sources of social support and integration. This study was conducted to examine the relationship among religious behavior and HIV testing, HIV serostatus, and HIV medical care among 1,568 inner-city former and current IDUs in Baltimore, Maryland. Overall, 93% of the participants reported previous HIV testing. About 46% attended church in the past month. Religion or spirituality providing at least some guidance in day-to-day living was reported by 85%. Current drug use was negatively associated with church attendance yet 40% of the active drug users had been to church in the past month and 67% in the past year. There was a significant association between HIV testing and recent church attendance, and participants who reported that they were positive for HIV had higher rates of recent church attendance. Participants who reported currently receiving medical care for HIV were more likely to have attended church recently and more likely to report that religion or spirituality provided them with guidance in their daily lives. This study found that church attendance is frequent and religion is a strong source of guidance among impoverished inner-city drug users. The findings suggest that HIV prevention and treatment strategies that build on prior religious experiences may be useful for this population, for example by incorporating concepts that involve shared behavioral experiences to link HIV prevention, testing, and medical treatment into their histories and social context. Latkin, C., Tobin, K., and Gilbert, S. Shun or Support: The Role of Religious Behaviors and HIV-Related Health Care Among Drug Users in Baltimore, Maryland. AIDS and Behavior, 6(4), pp. 321-329, 2002.

Self-Reported NEP Attendance Among IDUs: Implications for Program Evaluation

Some studies have indicated that needle exchange programs (NEPs) can be effective in reducing drug-related risks for HIV seroconversion, while others have reported higher HIV incidence rates among NEP attendees. Since many studies rely on self-reports of NEP evaluation, researchers investigated the extent to which differential misreporting of NEP attendance could bias risk estimates. That is, they explored the biases that can result from misclassification of exposure assessment and how this can mask true underlying associations between NEP attendance and HIV seroconversion. Over a 3-year period, from 1994 to 1997, self-reports of NEP attendance from participants in a prospective study in Baltimore, MD, were compared with NEP records. Of 1,315 participants, 459 (35%) had registered with the Baltimore NEP. There was 86.7% concordance between self-reported and actual NEP use; 11.0% reported NEP attendance but did not attend (over-reported), and 2.2% reported not attending NEP but did attend (under-reported). In multivariate analyses using generalized estimating equations, persons who over-reported NEP attendance were more likely to have injected frequently, denied needle sharing, and been an HIV seroconverter. With Poisson regression to model predictors of HIV seroconversion, models that included measures of NEP attendance based on self-reports compared with actual program data underestimated a protective association by 18%. From the perspective of evaluating an HIV prevention program, over-reporting of NEP use, particularly among high-risk persons who are at higher risk of HIV, can seriously underestimate the negative association of NEP with HIV seroconversion, especially if the true association is relatively modest. Safaeian, M., Brookmeyer, R., Vlahov, D., Latkin, C., Marx, M., and Strathdee, S. Validity of Self-Reported NEP Attendance Among IDUs: Implications for Program Evaluation. Am. J. Epidemiol., 155(2), pp. 169-175, 2002.

Alcohol Use Among Out-of-Treatment Crack-Using African American Women

This study categorized the quantity and frequency of alcohol use among African American women who were abusing crack cocaine to explore relationships between categories of alcohol use, demographic variables, cocaine use, co-morbidity, and risky sexual behaviors. Data were collected from 635 out-of-treatment crack cocaine using women in Raleigh/Durham, North Carolina. The women were categorized as light (n=272, 43%), moderate (n=216, 34%) or heavy drinkers (n=147, 23%). The groups were similar in age distribution and marital status. Women classified as heavy drinkers were demographically similar to light and moderate drinkers. Heavy drinkers used more crack cocaine, reported longer crack runs (24 hours or longer in length), and were more likely to engage in sexual risk behaviors, including exchanging sex for drugs, money, or shelter, compared to the other two drinking groups. The heavy drinkers also reported greater psychological distress, including anxiety and post-traumatic stress, and were more likely to report histories of physical, sexual, and emotional abuse. Heavy alcohol use among crack-abusing African American women may be a marker for a host of underlying problems that require special attention. The HIV prevention programs and substance abuse treatment programs that provide services to crack-abusing women should screen for heavy drinking. Women identified as heavy drinkers should undergo more in-depth assessments and receive additional referrals as appropriate. Zule, W., Flannery, B., Wechsberg, W., and Lam, W. Alcohol Use Among Out-of-Treatment Crack-Using African American Women. Am J Drug Alcohol Abuse, 28(3), pp. 525-544, 2002.

Social Networks and Forecasting the Spread of HIV Infection

Researchers used network data to forecast the spread of HIV in a large U.S. city. Data were collected from a sample of drug users and socio-demographically matched nonusers in low-income areas of Houston, Texas. Two sample-based HIV prevalence models and two sociological models were combined with three published biological models to yield forecasts of the growth of HIV seroprevalence. The forecasts predict a compounded annual growth in HIV of between 2.4% and 16.5% among low-income residents of Houston's inner city. Accurately forecasting the growth of HIV/AIDS is critical to policy makers, researchers, and clinicians. This study evaluated the relative sensitivity of HIV projections by producing a range of forecasts using 3 hypothetic biological models that were combined with two empiric prevalence models and an empiric sociological model. Results showed that the greatest sensitivity was in the sociological models and that random mixing models, even those that maintain individual levels of activity, tend to overestimate HIV transmission by a factor of 3. The collection of additional social network data is probably the most important requirement for more accurate projections. Bell, D.C., Montoya, I., Atkinson, J.S., and Yang, S. Social Networks and Forecasting the Spread of HIV Infection. J Acquired Immune Deficiency Syndromes, 31, pp. 218-229, 2002.

Syphilis Among IDU Populations in St Petersburg, Russia

An epidemic of syphilis and other STDs in the Russian Federation is believed to be related to the rise in injection drug use. A study was carried out in collaboration with a nongovernmental Russian charity organization, Foundation Vozyrastcheniye ("Return"). The program was aimed at providing medical, social, and educational assistance to IDUs in St Petersburg. It was carried out in the form of a special mobile medical unit where doctors and nurses were able to offer basic medical assistance that included exchange of syringes, drug abuse, STD and infectious disease counseling, and screening blood samples for HIV, syphilis, and hepatitis seromarkers. Nine hundred and ten IDUs participating in the program were tested for syphilis, HIV, HCV, and HBV. Sixty-five participants who had laboratory markers for syphilis and 45 syphilis-negative subjects agreed to participate in a questionnaire study. The results indicated that syphilis, HIV, HBV, and HCV were diagnosed in 12%, 0%, 48%, and 79% of drug users respectively. Prevalence of syphilis seromarkers was nine times higher in females than in males, and highly correlated with sex work. The fact that sex workers in particular would continue to have unprotected sex while having syphilis infection suggests that there may be an economic or other motive for having sex without a condom. Syringe sharing was also common in this population, suggesting the possibility of syphilis transmission via this route of exposure. These results suggest that resources to treat and prevent further infections including HIV should be directed toward risk reduction in IDUs and sex workers in St. Petersburg. Karapetyan, A., Sokolovsky, Y., Araviyskaya, E., Zvartau, E., Ostrovsky, D., and Hagan, H. Syphilis Among IDU Populations: Epidemiological Situation in St. Petersburg, Russia. International J STD & AIDS, 13, pp. 618-623, 2002.

Resource Acquisition Strategies of Inner City Women Who Use Drugs

To better understand how women's HIV risk is influenced by environmental factors, researchers conducted life history interviews and assessed the strategies women adopted for acquiring resources (resource acquisition strategies), as well as the costs and obligations associated with such strategies. Interviews were conducted with 28 women who used drugs in two low-income neighborhoods in New York City. The women were 18 years and older, used heroin, crack, or cocaine, and were recruited from out-of-treatment settings between March and November 2000. The majority of women's resources came from illegal sources or from men with whom they had sexual relationships. Three fourths of the women worked in the drug trade, 68% reported stealing and 68% engaged in street based sex work. Most (89%) women had been arrested. The large majority (79%) had current, male sex partners, from whom they received financial and other benefits, including a diminished risk of incarceration. The implicit or explicit trade of sex for a reliable supply of resources severely limited women's ability to implement sex risk reduction. Avoidance of incarceration, primarily for drug-related offenses, as well as access to substantial and varied resources required both for drug use and for daily survival, favored acquiring resources through establishing sex partnerships with men who could supply at least some level of resources. In the context of economic deprivation, most resource acquisition strategies employed by the women increased HIV risks. Miller, M. and Neaigus, A. An Economy of Risk: Resource Acquisition Strategies of Inner City Women Who Use Drugs. International J Drug Policy, 13(5), pp. 399-408, 2002.

Drug Users' Involvement in the Drug Economy

Researchers examined individual and social characteristics associated with drug users' involvement in the drug economy among a sample of low-income heroin and cocaine users (n=1,288) in Baltimore, MD. The study sample had participated in a network-oriented intervention study of HIV risk behaviors among drug users. Of the sample, 44% (n=569) held at least one role in the drug economy, performing an average of 1.17 roles. A significantly higher percentage of those involved in the drug economy reported being daily drug users (60.6% vs. 40.2%), injecting heroin daily (36.0% vs. 21.8%), injecting speed daily (23.6% vs. 14.7%), and snorting heroin daily (18.3% vs. 13.4%). In terms of social networks, those involved in the drug economy reported a significantly larger social network (9.98 vs. 8.97), greater percentage of active drug users in their social network (47% vs. 44%), greater percentage of active daily drug users in their social network (40% vs. 33%), and larger drug support networks (6.7 vs. 5.6). Drug users involved in the drug economy were significantly more likely to perceive worse withdrawal symptoms and to worry more about getting sick. The study indicates the far-reaching influence of drug use on many aspects of their lives, including their involvement with the drug economy. Reducing drug users' frequency of use could have the consequence of decreasing this involvement. Being a part of the drug economy exposes drug users to many risks, but also places them in a position to influence others. Examining drug users' social networks could provide insights into the composition of their immediate social environment and could inform HIV prevention programs. Sherman, S. and Latkin, C. Drug Users' Involvement in the Drug Economy: Implications for Harm Reduction and HIV Prevention Programs. J Urban Health, 79(2), pp. 266-277, 2002.

Sex Partner Support, Drug Use, and Sex Risk Among Non-Injecting Heroin Users

Researchers examined the extent to which sex partner characteristics, including partner support, influence HIV risk practices among HIV-seronegative non-injecting heroin users. The sample (n=257) was racially/ethnically diverse and predominantly male. More than two-thirds of the respondents reported using heroin with other people in the past 30 days and 30% reported using heroin with sex partners. Three-quarters reported having unprotected sex within the past 30 days; 27% had sex with partners at known risk of being HIV infected. There were no gender differences in terms of sex or drug use practices, but there were differences in sex partner characteristics. Men were significantly less likely than women to have partners who used drugs, receive support from their partners, use heroin with their partners, and have partners at known risk of being HIV infected. For men, increased sex risk was independently associated with having used heroin with sex partners. Women were just as likely to have unprotected sex with partners who provided support as with partners who did not. Moreover, women's partners appeared to pose greater HIV sex risk than men's partners. A disturbing finding was that an awareness of a known increase in HIV risk posed by sex partners was not associated with increased consistent condom use for either men or women. In this analysis, sex partner support was found to discriminate between men who reported unprotected sex and those who did not. Social support may have detrimental as well as beneficial consequences on HIV risk. Miller, M. and Neaigus, A. Sex Partner Support, Drug Use and Sex Risk Among HIV Negative Non-Injecting Heroin Users. AIDS Care, 14(6), pp. 801-813, 2002.

Hepatitis Knowledge is Low and Risks Are High Among IDUs in Three U.S. Cities

In this study, researchers examined the interrelationships among HIV and hepatitis knowledge, risky drug preparation and injection practices, and participation in syringe exchange programs (SEPs) in inner-city neighborhoods of Chicago, Hartford, and Oakland. The study population was a convenience sample of 493 IDUs recruited using street outreach and snowball sampling strategies. Interviews were conducted using a semi-structured questionnaire adapted from the NIDA Risk Behavior Assessment, with measures of hepatitis and HIV knowledge, injection-related risks for virus transmission, associations between the two, and with SEP use. The study found that HIV knowledge was significantly higher than hepatitis knowledge among SEP customers and non-customers alike. A corollary to the lack of knowledge about hepatitis was the finding that many IDUs are unaware that they have been infected with hepatitis. Elevated hepatitis knowledge was associated with a history of substance abuse treatment, hepatitis infection, hepatitis B vaccination, and injection practices that reduced contact with contaminated blood or water but not with SEP use. SEP customers were consistently less likely to engage in risky syringe practices, including syringe re-use and sharing water for drug preparation and syringe rinsing, compared to non-customers. However, SEP users were 2x likelier to staunch blood flow following injection, using alcohol wipes. This places them at higher risk of exposure to blood because isopropyl alcohol inhibits clotting. SEPs need to disseminate information that alcohol wipes should only be used to clean the skin before injection. In this study, increased hepatitis knowledge was not associated with SEP use, but instead with a diagnosed hepatitis infection. These findings suggest that SEPs must also do more to increase hepatitis awareness and prevent hepatitis transmission among IDUs. Heimer, R., Clair, S., Grau, L., Bluthenthal, R., Marshall, P., and Singer, M. Hepatitis-Associated Knowledge is Low and Risks are High Among HIV-Aware IDUs in Three US Cities. Addiction, 97, pp. 1277-1287, 2002.

Syringe Type and Drug Injector Risk for HIV Infection: A Case Study in Texas

Studies of accidental needle stick exposure to HIV-infected blood have shown that the volume of blood in an exposure is a strong predictor of subsequent infection. Injecting drug users use syringes manufactured in two styles, one of which (the integral cannula type) retains substantially less blood after intravenous use than the other (the detachable needle type). Researchers examined some of the factors associated with use of syringes with detachable needles among IDUs in San Antonio, Texas using data from epidemiological surveys, ethnographic studies, and historical observations. They compared history of syringe type use with HIV serostatus in a sample of 501 active IDUs interviewed and screened for HIV in 1997-1998. Ninety-nine percent of these respondents reported that they currently used only integral cannula syringes, but 13% had used a syringe with a detachable needle within the past 2 years, and 37% had used one in their lifetime. Only 9% had ever used one > 20 times in a year. Hispanic (Mexican American) respondents were significantly less likely than other ethnic groups to have ever used a detachable needle syringe. HIV seroprevalence was < 1% among heterosexual IDUs who had never used a detachable needle syringe compared to 4% among those who had used one. Zule, W., Desmond, D., and Neff, J. Syringe Type and Drug Injector Risk for HIV Infection: A Case Study in Texas. Social Science and Medicine, 55, pp. 1103-1113, 2002.

Transmission/Prevention of HIV/STIs in War Settings: Implications for Armed Conflicts

Researchers reviewed the effects of war on HIV/STI transmission and appraised short- and medium-term approaches to prevention. Armed conflicts can influence HIV epidemic dynamics in surrounding countries and beyond, both directly by affecting HIV transmission itself and indirectly through reallocation of health-related public funds toward security and defense measures. Poverty, powerlessness, and social instability, all of which facilitate HIV transmission, are magnified during complex emergencies, but HIV is rarely seen as a priority. During World Wars I and II and in more recent conflicts, high rates of STI were recorded in the military. Changing patterns of sexual behavior, drug use, and increased HIV/STI risk were found in 1998 among young people displaced by the war in Bosnia-Herzegovina. War-related fluctuations in drug supply can lead to widespread HIV transmission in areas of drug transit, as some local residents start taking drugs because of increased drug availability or payment in kind for services rendered. In such situations, which do not lend themselves to safer injection behaviors, other potentially fatal diseases, including hepatitis B and C, can spread among drug injectors and their partners. Large proportions of heroin users in Europe and the US have smoked or snorted the drug since the mid-1980s. Drug market fluctuations may lead significant numbers of them to begin injecting. Moreover, in light of recent events, IDUs in Afghanistan are at particularly high risk of acquiring HIV. This concern is heightened in light of a study reported at the International AIDS Conference in July 2002 that found that, of 143 Afghan drug users in Quetta, Pakistan, none had ever used condoms. The authors discuss the implications of armed conflicts on public health, and identify a range of preventive intervention steps that can be taken to address immediate risks. Hankins, C., Friedman, S., Zafir, T., and Strathdee, S. Transmission and Prevention of HIV and Sexually Transmitted Infections in War Settings: Implications for Current and Future Armed Conflicts. AIDS, 16, pp. 1-8, 2002.

Hepatitis C and Substance Use in a Sample of Homeless People in NYC

Researchers examined the prevalence of hepatitis C antibodies and its association with substance use and sexual behavior among a sample of 139 persons visiting a mobile medical clinic in Manhattan. Ninety percent were unstably housed or were living on the street. The prevalence of HCV antibodies was 32%. Prevalence was also high for hepatitis B core antibodies (47%), HIV antibodies (15%), and syphilis exposure (14%); 76% tested positive for cocaine. Among those who reported ever injecting drugs (20%), 86% were HCV positive; 19% of non-IDUs were HCV positive. In separate logistic regression models that controlled for injection, HCV was predicted by quantitative hair assays for cocaine and self-reported duration of crack cocaine use. There was a clear dose response association of HCV and cocaine use in these results. Alcohol dependence and sexual behavior did not predict HCV. HCV is a significant public health problem among the urban homeless population, with injection drug use and to a lesser extent, cocaine use implicated as risk factors. Rosenbaum, A., Nuttbrock, L., McQuistion, H., Magura, S., and Joseph, H. Hepatitis C and Substance Use in a Sample of Homeless People in New York City. J Addictive Diseases, 20(4), pp. 15- 25, 2002.

Metabolic Abnormalities in HIV Disease and Injection Drug Use

HIV infection is associated with a number of adverse consequences, including metabolic disorders. This article reviews disorders such as wasting, lipid metabolism disorders (including fat redistribution or dyslipidemia), glucose abnormalities, bone disease, and endocrine disorders such as hypogonadism in the presence of HIV infection and/or drug abuse. The issues covered are current estimations of prevalence, risk factors, underlying pathophysiology, diagnosis, and interventions (prevention and treatment) for metabolic complications of HIV and drug abuse Dobs, A., and Brown, T. JAIDS, 31, Suppl 2:S70-S77, 2002.

Adherence to Anti-retroviral Therapy and Viral Load in HIV-infected Drug Abusing Women

Based on results from a prospective observational study of a cohort of HIV-infected drug abusing women in Bronx, NY, Dr. Howard and her colleagues of Montefiore Medical Center/Albert Einstein College of Medicine, report that adherence to antiretroviral therapy is not stable over time and that interventions aimed at monitoring and improving long-term adherence in this population are urgently needed. In a cohort of 161 women studied, about 25% of women had a 10% or greater decrease in adherence between consecutive months. Virologic failure occurred in 17% women with adherence greater than 88%, 28% of those with 45-87% adherence, 43% of those with 13-44% adherence, and 17% of those with less than 12% adherence. Factors such as active drug/alcohol use, shorter duration and more frequent antiretroviral dosing, younger age, and lower initial CD4 lymphocyte count predicted poor adherence. Howard, A.A., Arnsten, J.H., Yungtai, L., Vlahov, D., Rich, J.D., Schuman, P., Stone, V.E., Smith, D.K., and Schoenbaum, E.E. A Prospective Study of Adherence and Viral Load in a Large Multi-Center Cohort of HIV-infected Women, AIDS, 16, pp. 2175-2182, 2002.

HIV and Drug Abuse in the Edinburgh Cohort

The Edinburgh cohort of intravenous drug users (DU) became infected with human immunodeficiency virus (HIV) in 1983/84. Before the era of effective therapy, many of these infected DU displayed cognitive impairments progressing to AIDS and were found to have HIV encephalitis (HIVE). Full autopsies were conducted on these patients, providing an opportunity to study the intersecting pathology of pure HIVE and of drug use. High proviral load in the brain correlated well with the presence of giant cells and of HIV p24 positivity. In presymptomatic HIV infection, drug users were found to have a lymphocytic infiltrate in the central nervous system (CNS). Apart from the expected microglial activation in the presence of HIV infection of the CNS, drug use in its own right was found to be associated with microglial activation. Examination of HIV negative drug users revealed a number of neuropathological features including microglial activation which may underpin HIV-related pathology in the CNS. Bell, J.E., Arango, J.C., Robertson, R., Brettle, R.P., Leen, C., and Simmonds, P. JAIDS, 31[suppl.2]: S35-S42, 2002.

Neuroprotection in HIV+ Drug Users: Implications for Antioxidant Therapy

Impaired neuroprotection, due to oxidative stress, has been implicated in neurodegeneration in a number of pathological conditions of the brain including both subcortical and cortical type dementias. Production of excessive oxidative stress, moreover, can lead to elevated levels of certain proinflammatory cytokines, that are considered to be contributing factors to neuronal injury, and are evident in HIV-related dementia, as well as other neurodegenerative conditions. Inhibitors of oxidative damage could, thus, be promising therapeutic agents for preventing progressive nerve cell death and slowing the advance of neurodegenerative disease. The potential of antioxidant therapy to provide neuroprotection is substantiated by studies demonstrating reduced oxidative stress with supplementation and lower risk for cognitive impairment with higher plasma antioxidant levels. Shor-Posner, G., Lecusay, R., Miguez-Burbano, M-J., Morales, G., and Campa, A. JAIDS, 31(suppl 2): S84-S88, 2002.

Ketamine Injection among High Risk, Street Involved Youth in New York City

Using ethnographic methods, investigators examined 25 young ketamine injectors in New York City. The following practices associated with ketamine injection were identified as risk factors for viral transmission of bloodborne pathogens, such as HIV, HBV, and HCV: (1) ketamine was typically injected in a group setting with up to 10 other injectors; (2) it was typical to inject multiple times, such as 8-10 times over several hours; (3) over half of the participants reported some form of paraphernalia sharing, including syringes and bottles; (4) a large proportion of participants received syringes from indirect sources; and (5) ketamine was frequently obtained for free which often led to spontaneous injection events. Their findings also suggest that, although ketamine is classified as a "club drug," the injection of ketamine occurs in a variety of settings and is typically injected and experienced apart from the club and rave scenes. The investigators conclude that ketamine injection is an emerging trend among hidden populations of injection drug users, particularly among high risk, street-involved youth. Lankenau, S.E. and Clatts, M.C. Ketamine Injection among High Risk Youth: Preliminary Findings from New York City. Journal of Drug Issues, 32, pp. 893 905, Summer 2002.

High Risk Drug Use Sites, Meaning and Practice: Implications for AIDS Prevention

This study presents preliminary findings of drug use in Hartford, CT, to understand the environmental and social conditions with "high-risk sites" where drug users inject drugs or smoke crack, in order to develop AIDS prevention models that build upon the physical and social organization of these locations. By understanding the environmental and social conditions within "high risk sites" where drug users inject drugs or smoke crack, the investigators are able to develop AIDS prevention models that build upon physical and social organization of these locations. A combination of ethnographic, epidemiological, and social network methods are used to document the characteristics, social organizations, natural history, and dynamics of the types of sites used, the network relations of site users, and the various opportunities for, or barriers to, on-site social-level HIV prevention intervention. Weeks, M., Clair, S., Singer, M., Radda, K., Schensul, J., Wilson, D., Martinez, M., Scott, G., and Knight, G. Journal of Drug Issues, 31(1), pp. 781-808, 2002.

An Ethno-Epidemiological Model for the Study of Trends in Illicit Drug Use: Reflections on the 'Emergence' of Crack Injection

National and regional tracking systems along with data from institutionally-derived sources (e.g. emergency departments, drug treatment admissions, and law enforcement data on drug seizures and arrests), have served as a source of sentinel markers about changes in drug use and its consequences. Sentinel marker data can be limiting because they typically fail to capture a number of "hidden populations" evidencing "hidden" drug-related risk behaviors such as patterns of episodic use evidenced in crack injection. This research study incorporates ethnographic methods, including field-based community assessment, semi-structured qualitative interviews, and targeted observation of "natural" venues in which drugs are bought, sold, and used, have potential to overcome some of the limitations from which "systems data" often suffer. Drawing on an ethno-epidemiological approach, the ongoing multi-site research on the use of injection as a mode of administration in the use of crack cocaine is a case in point, and illustrates the potential utility of an ethnographic model for the identification and tracking of emergent and ongoing drug use practices. Clatts, M., Welle, D., Goldsamt, L., and Lankenau, S. International Journal of Drug Policy, 13, pp. 285-295, 2002.

Hepatitis C and Progression of HIV Disease

Conflicting reports exist regarding the impact of hepatitis C virus (HCV) infection on progression of HIV disease. A recent study by researchers at Johns Hopkins University assessed the effects of HCV infection on clinical and immunological progression of HIV disease and immunological response to highly active antiretroviral therapy (HAART) therapy among 1995 HIV-infected patients enrolled in an urban university-based HIV clinic. Median length of follow-up was 2.19 vs. 2.00 years for HCV-infected vs. HCV uninfected patients. No differences were observed in the risk of acquiring an AIDS-defining illness among HCV-infected patients vs. HCV-uninfected patients (231 vs. 164 AIDS-defining events; relative hazard (RH) =1.03) or in survival (153 deaths among HCV-infected patients vs. 168 deaths among HCV-uninfected patients, RH= 1.05). Among a subgroup of HCV-infected patients with low baseline CD4 cell count (between 50 and 200/microL), death was not independently associated with HCV infection after controlling for exposure to effective HAART. Among all patients receiving effective HAART (n=208), there was no difference in increase in CD4 cell count or CD4 percentage by HCV infection status. The authors conclude that in this urban cohort HCV infection was not observed to significantly alter risk of developing AIDS or death, or immunologic response to HAART when differences in its administration and effectiveness were accounted for. Sulkowski, M.S., Moore, R.D., Mehta, S.H., Chaisson, R.E., and Thomas, D.L. JAMA, 288, pp. 241-243, 2002.

Condom Use Among Drug-Using Youth in a High HIV-risk Neighborhood

Friedman and colleagues interviewed 196 18-24 year olds living in Bushwick, New York City, who injected drugs or used heroin, cocaine or crack in the prior year with the objective of assessing predictors of consistent condom use in heterosexual relationships in a high HIV-risk environment. Consistent condom use was reported in 26% of 277 non-commercial relationships and in all of 22 commercial relationships. Consistent condom use is more common in relationships that are described as not "very close" for men (but not women) with peers whose norms are more favorable to condom use, and for subjects who had concurrent sex partners in the last 12 months. The authors conclude that: (1) the lack of relationship between the peer norms of drug-using women and their condom use suggests that they may have little control over condom use in their relationships and this indicates a need for the development of programs to empower young female drug users; (2) the positive association of concurrency to consistent condom use suggests that condom use may be restricting HIV spread in the community and the presence of consistent condom use in all of the commercial sexual relationships may also restrict HIV spread; and (3) prevention efforts should attempt to change peer cultures as a way to develop self-sustaining risk reduction. Friedman, S.R., Flom, P.L., Kottiri, B.J., Neaigus, A., Sandoval, M., Fuld, J., Curtis, R., Zenilman, J.M. and Des Jarlais, D.C. Consistent Condom Use Among Drug-using Youth in a High HIV-risk Neighborhood. AIDS Care. 14(4), pp. 493-507, 2002.

Women, Sex, and HIV: Social and Contextual Factors, Meta-Analysis of Published Interventions, and Implications for Practice and Research

This article is focused on examining social and contextual factors related to HIV-risk behavior for women. Specifically, this article reviews: (1) the literature on selected social and contextual factors that contribute to the risk for the heterosexual transmission of HIV and AIDS, (2) reviews and conduct a meta-analysis of HIV-prevention interventions targeting adult heterosexual populations, and (3) suggests future directions for HIV-prevention intervention research and practice. Results suggest that the HIV-prevention interventions reviewed for this article had little impact on sexual risk behavior; that social and contextual factors are often minimally addressed; and that there was a large gap between research and the practice of HIV-prevention intervention. Logan, T.K., Cole, J., and Leukefeld, C. Women, Sex, and HIV: Social and Contextual Factors, Meta-analysis of Published Interventions, and Implications for Practice and Research. Psychological Bulletin, 128(6), pp. 851-885, 2002.

Coping in Adolescent Children of HIV-Positive and HIV-Negative Substance Abusing Fathers

This study examines the coping techniques of adolescents whose fathers are at risk for contacting the HIV virus or have the HIV virus. Adolescent coping is an important aspect of the adolescent's vulnerability or resilience to drug use and abuse and associated problems. The data for this study was taken from an epidemiological study of fathers who are substance abusers and their adolescent offspring. Adolescents were asked questions regarding their ability to cope with the knowledge that their fathers have AIDS or may contract it. Adolescent adaptive coping was found to be positively related to the adolescents' conventionality, intrapersonal and interpersonal adjustment, and infrequent or no use of marijuana. Adolescent adaptive coping was also associated with paternal adaptive coping, a close father-child bond, and under some conditions, less paternal drug use. Furthermore, for every additional psychosocial risk factor beyond a minimal number, there is a doubling in the odds ratio of the adolescent using maladaptive techniques of coping. Knowledge of such relationships helps guide intervention and policy procedures for adolescents who are at risk because their fathers are HIV-positive or may contract HIV. Brook, D.W., Brook, J.S., Arencibia-Mireles, O., Whiteman, M., Pressman, M. and Rubenstone, E. Coping in Adolescent Children of HIV-Positive and HIV-Negative Substance Abusing Fathers. The Journal of Genetic Psychology, 163(1), pp. 5-23, 2002.


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