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National Institute on Drug Abuse

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

February 1997

Research Findings

AIDS Research

Reducing HIV Risk Behaviors in IV Drug Users Dr. Kelly Avants from Yale University has developed a treatment manual for an intervention, Risk Reduction Therapy (RRT), specifically for HIV-seropositive injection drug users who may not benefit from standard treatment interventions due to cognitive deficits related to HIV and chronic drug use. Though the manual is currently being refined, evaluation of the therapy has occurred in the context of two open label pharmacotherapy trials with HIV-seropositive cocaine- and opioid-dependent patients. One trial investigated bupropion (150 mg/day) plus RRT. Another trial investigated lamotrigine (300 mg/day) plus RRT. Results have been compared to standard treatment (methadone plus standard skills training group). Promising results have been found for both pharmacotherapies plus RRT. Cocaine use, opiate use, cocaine craving, depression, and ASI drug severity scores decreased significantly only for patients receiving the specialized Risk Reduction Program; patients receiving standard treatment showed no significant improvement.

Drug Abuse Among Gay-Bisexual Young Men at Risk for HIV/AIDS The Personal Experience Screening Questionnaire (PESQ) was developed as a brief self-report screening tool for use with adolescents (12-18 years) to identify those who should be referred for a complete chemical dependency evaluation. Winters and colleagues reported on a study designed to assess the utility of the PESQ in a sample of 500 male adolescents and young adults (13-21 years of age) who had sex with men or who otherwise considered themselves to be gay or bisexual regardless of self-reported sexual behavior. All subjects were participating in an HIV prevention program. Study results indicated the PESQ has good internal consistency reliability and convergent validity in this population. Nearly 20% of the subjects met PESQ criteria for needing further drug abuse evaluation and drug use severity was highly associated with subject reports of risky sexual behaviors (e.g., drug use during sex; engaging in unprotected sex; having multiple sex partners). The findings suggest the importance of screening for illicit drug use in gay-bisexual young men who have concerns about HIV/AIDS and provide support for the use of the PESQ to accomplish this aim. Winters et al., Assessing Drug Abuse among Gay-Bisexual Young Men. Psychology of Addictive Behaviors, 10(4): pp. 228-236, 1996.

Successful Adherence to Observed Prophylaxis and Treatment of Tuberculosis Among Drug Users in a Methadone Program
Incomplete antituberculous chemoprophylaxis and treatment are major causes of the resurgence of tuberculosis (TB) among drug users. A study of directly observed prophylaxis and treatment among drug users is ongoing in a methadone program in New York City. Participants are patients in a methadone treatment program with an on-site primary care clinic where patients are screened for TB infection through PPD testing and for active TB on clinical grounds confirmed by mycobacteriologic culture. No material incentives for directly observed treatment were offered to eligible participants and methadone dosing was not contingent upon participation. Directly observed chemoprophylaxis for TB infection was accepted by 88% (90/102) of eligible patients; 75% (9/12) of patients with identified active TB accepted directly observed medication. The majority of patients were HIV infected (57%) and the majority continued active substance abuse (88%) during TB therapy. Patients were administered more than 5 weekly doses of anti-TB therapies during more than 80% of 4740 patient weeks, with >80% adherence and treatment completion. HIV infection and active substance abuse were not associated with diminished adherence. These results indicate that successful adherence to and completion of anti-TB therapy can be attained by drug users in drug treatment, despite ongoing substance use and lack of material incentives. M. Gourevitch et al., J Addictive Med, 15: pp. 93-104, 1996.

Viral Infections in Short-term Injection Drug Users: The Prevalence of Hepatitis C, Hepatitis B, Human Immunodeficiency, and Human T-lymphotrophic Viruses A study of the prevalence and correlates of four blood-borne viral infections was performed among illicit drug users with up to 6 years of injecting history. Data for hepatitis C (HCV), hepatitis B (HBV), HIV, and human T-lymphotropic virus types I and II (HTLV I/II) were analyzed in 6 sequential cohorts defined by duration of drug injection among patients enrolled in a long-term cohort study of HIV and other infectious diseases. Overall seroprevalence of HCV, HBV, HIV and HTLV I/II was 76.9%, 65.7%, 20.5%, and 1.8% for those injecting for up to 6 years. Among those injecting for one year or less, rates were 64.7% for HCV, 49.8% for HBV, 13.9% for HIV and 0.5% for HTLV I/II. Among the newest initiates (one year or less), HCV and HBV were associated with injecting variables in the prior 6 months (injection frequency once or more daily, any cocaine injection, use of non-sterile needles), and duration of injection >6 months: HIV was associated with sexual variables (high number of sex partners, never married, homosexual or bisexual orientation). The high rates of HCV, HBV, and HIV infections among short-term injectors emphasizes the need to target both parenteral and sexual risk reduction interventions early. Garfein, R., Vlahov, D., Galai, N., et al., Am J Pub Health, 86: pp. 655-661, 1996.

Outreach, Referral, and Assistance Improve Treatment Entry and Retention
A study was conducted to assess the effect of client characteristics and community interventions on treatment entry and retention, and to evaluate the relative effectiveness of treatment, compared to other interventions, in reducing drug use and crime among out-of-treatment opiate injectors. Data were analyzed for 2,973 opiate injectors from 15 cities participating in NIDA's Cooperative Agreement for AIDS Community-Based Outreach Intervention Research Program (CA). The IDUs were randomly assigned to NIDA's standard or enhanced interventions, and had participated in both baseline and 6-month follow-up behavioral risk assessments. IDUs who entered treatment and those who did not reduced drug use at follow up. However, those who remained in treatment for at least 90 days reported significantly greater reductions in drug injection and crack smoking (corroborated by urinalysis), and were less likely to have been arrested, compared to IDUs who did not enter treatment. Treatment entry and retention were associated with the enhanced intervention plus active treatment referral and assistance (e.g., scheduling intake, providing transportation, and waiving admission fees); IDUs contacted by community outreach workers were also more likely to have entered treatment than subjects lacking outreach-facilitated interventions. The results show that substance abuse treatment can reduce drug use, risk for HIV infection, and arrests among not-in-treatment IDUs. Treatment entry and retention are improved by outreach worker-facilitated interventions, active referral, and assistance with the treatment entry process. Booth, R., Crowley, T., and Zhang, Y. Substance Abuse Treatment Entry, Retention, and Effectiveness: Out-of-Treatment Opiate Injection Drug Users. Drug and Alcohol Dependence, 42: pp. 11-20, 1996.

Protective Effect Against HIV Infection Linked to Participation in Syringe Exchange
Meta-analytic techniques were used to examine whether participation in syringe exchange programs leads to individual-level protection against incident HIV infection. HIV incidence data from injecting drug users were combined for three studies: the Syringe Exchange Evaluation (n=280); the Vaccine Preparedness Initiative Cohort (n=133 continuing exchangers, n=188 non-exchangers); and very-high-seroprevalence cities in the National AIDS Demonstration Research (NADR) program (n=1029). HIV incidence among continuing exchangers in the Syringe Exchange Evaluation was 1.58 per 100 person-years at risk (95% CI 0.54, 4.65) and among continuing exchange users in the Vaccine Preparedness Initiative, it was 1.38 per 100 person-years at risk (95% CI 0.23, 4.57). Incidence among non-users of the exchange in the Vaccine Preparedness Initiative was 5.26 per 100 person-years at risk (95% CI 2.41, 11.49) and in the NADR cities, 6.23 per 100 person-years at risk (95% CI 4.4, 8.6). When the data were pooled, not using the syringe exchanges was associated with a hazard ratio of 3.35 (95% CI 1.29, 8.65) for incident HIV infection compared with using the exchanges. The findings indicate that an individual-level protective effect against HIV infection is associated with participation in syringe exchange programs. Des Jarlais, D.C., Marmor, M., Paone, D., et al. HIV Incidence among Injecting Drug Users in New York City Syringe-Exchange Programmes. Lancet, 348: pp. 987-991, 1996.

The Value of Combining Qualitative and Quantitative Methods in AIDS Prevention Research
Ethnographers working with injection drug users in U.S. AIDS prevention projects have found that drug users generally prefer not to use each other's needles and do not conceive of needle "sharing" (transfer) as a key dimension of their identity. These findings to date have been based on qualitative ethnographic methods. Drug injector values toward needle transfer were operationalized, and a questionnaire was administered to 276 active injectors recruited in 1993 at the Dayton/Columbus, Ohio site participating in NIDA's Cooperative Agreement. Results from the questionnaire confirmed the qualitative evidence: 96% of the respondents disagreed with the statement: "When shooting up with other people, I feel like I have to use the same outfit everyone else uses." Only 16.3% perceived new needles were inaccessible, while 72.8% feared carrying needles because of drug paraphernalia laws. This study demonstrates the value of combining qualitative and quantitative methods in AIDS prevention research. Carlson, R.G., Siegal, H.A., Wang, J., and Falck, R.S. Attitudes toward Needle "Sharing" among Injection Drug Users: Combining Qualitative and Quantitative Research Methods. Human Organization, 55 (3): pp. 361-369, 1996.

Risk Acts, Health Care and Medical Adherence Among HIV+Youths in Care Over Time The level and consistency of HIV-related sexual and substance-use risk acts, health status, and medical adherence were examined among 102 HIV+ youths aged 14-23 who had lifetime high risk sexual and substance abuse behaviors. When current risk behaviors were assessed twice over two 3-month periods, almost a third had been sexually abstinent. Among youths who were currently sexually active, most had multiple sexual partners and used condoms (72%-77% sexual acts protected). Use of drugs was substantial: alcohol (63%), marijuana (41%), hard drugs (36%), and injecting drugs (12%), and remained relatively consistent over 3 months. Youths were relatively healthy and attended about one third of their medical appointments. While all youths were linked to adolescent AIDS programs, unhealthy behavior and risk acts remained common. More effective and intensive intervention appears required. Rotheram-Borus, M.J., Murphy, D. Coleman, C., Kennedy, M., Reid, H., Cline, T., Birnbaum, J.M., Futterman, D., Levin, L., Schneir, A., Chabon, B., O'Keefe, Z., and Kipke, M. Risk Acts, Health Care and Medical Adherence Among HIV+Youths in Care Over Time. AIDS and Behavior, In Press.

Improving the Understanding and Effectiveness of HIV Risk Interventions for Drug Users.
Fen Rhodes and Kevin Malotte provide a review of modes of HIV transmission among IDUs and crack users, behavioral research and collaborative studies, needle exchange programs, and community-based HIV intervention approaches. They describe details of NIDA's Cooperative Agreement as implemented in Long Beach, California, and show that relatively brief interventions which incorporate HIV testing have proven efficacy in reducing drug-related risks, but are less so in reducing sexual risk behaviors. By contrast, research to date suggests that more intensive, longer-term interventions have been disappointing in demonstrating any incremental effectiveness beyond that of brief interventions. An intervention-oriented model of behavior change which adheres to a well-defined set of principles for designing interventions holds great promise for improving HIV intervention effectiveness and power. Rhodes, F. and Malotte, K. HIV Risk Interventions for Active Drug Users: Experience and Prospects. In: Oskamp, S. and Thompson, S. (Eds.), Understanding and Preventing HIV Risk Behavior: Safer Sex and Drug Use. Thousand Oaks, California: Sage Publications, pp. 207-236, 1996.

Measures Identified to Explain Variation in HIV Seroprevalence Rates Across Cities.
By analyzing the national database from NIDA's Cooperative Agreement, Isaac Montoya and John Atkinson identified subsets of behavioral variables which would, within three subgroups of drug users, distinguish 16 Cooperative Agreement cities by HIV seroprevalence levels. Baseline interview and HIV serostatus data from 4,595 heterosexual non-crack-using IDUs, 4,187 noninjecting crack users, and 2,203 crack-using IDUs in the 16 cities were used to classify the sites according to high, medium, and low HIV seroprevalence levels. Among non-crack-using IDUs, high seroprevalence rate sites were associated with males, African Americans or Hispanics, frequency of injection (particularly of cocaine), and eastern geographic location. Among noninjecting crack users, sites were distinguished by the frequency of sex-for-money exchanges, number of sexual partners, local seroprevalence rates among IDUs, and location. Among crack-using IDUs, the sites were distinguished by frequency of sex-for-drug exchanges and again by location, significantly correlated with the eastern U.S. This analysis demonstrates that subsets of behavioral variables can be used to explain variance in HIV seroprevalence rates within drug user groups and across cities. Further analysis of these and other data may help to predict whether cities may be facing higher rates, especially since the regional differences found here are likely related to differences in the time of HIV introduction. Montoya, I.D., and Atkinson, J.S. Determinants of HIV Seroprevalence Rates Among Sites Participating in a Community-Based Study of Drug Users. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 13: pp. 169-176, 1996.

Behavioral Settings and Personal Network Characteristics as Correlates of Needle Sharing.
Social and environmental factors were examined as possible correlates of needle sharing in a sample of 330 drug users who participated in an HIV prevention study in Baltimore, Maryland. The respondents were administered a survey on two occasions 5.2 months apart. Higher total network density, larger drug network size, and injecting at friends' residences were positively associated with reports of sharing needles that had been cleaned with bleach. Sharing of needles that had not been disinfected with bleach was positively associated with reports of injecting in semipublic areas (streets, rooftops, parks, cars, public bathrooms, and abandoned buildings). These data support ecological and resource models of needle sharing and suggest the potential utility of network-oriented strategies for reducing needle sharing among IDUs. Latkin, C., et al. People and Places: Behavioral Settings and Personal Network Characteristics as Correlates of Needle Sharing. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 13: pp. 273-280, 1996.

Evaluating Outreach Services Using Both Qualitative and Quantitative Techniques
The development of effective HIV interventions requires rigorous evaluations that, to date, have been noticeably lacking in the field. In particular, assessments of HIV prevention efforts have considered interventions as "black boxes," with little attention to the actual services delivered. This paper presents issues related to evaluating outreach interventions, and recommends an evaluation strategy to measure the delivery of outreach services, using both quantitative and qualitative techniques. Booth, R.E. and Koester, S.K. Issues and Approaches to Evaluating HIV Outreach Interventions. Journal of Drug Issues, 26(3): pp. 525-539, 1996.

Reaching and Enrolling At-Risk Drug Users for Prevention Studies
The St. Louis EachOneTeachOne (EOTO) is a NIDA-funded Cooperative Agreement project aimed at examining rates of HIV risk behaviors and studying HIV risk reduction interventions among out-of-treatment IDUs and crack users. This paper describes findings related to the effect of street outreach on HIV risk behavior involvement, including (1) men reported more HIV risk behaviors than did women, but there were no racial/ethnic differences; (2) women street contacts were largely ineligible to enroll in EOTO, but the program was able to enroll women; and (3) actual EOTO enrollees, compared with street contacts and eligible street contacts, engaged in fewer HIV risk behaviors. These results imply that strategies in addition to street outreach may be needed to enlist more individuals, particularly whites and women who are engaging in the highest risk drug and sexual behaviors. Cunningham, R.M., Cottler, L.B., and Compton, W.M. Are We Reaching and Enrolling At-Risk Drug Users for Prevention Studies? Journal of Drug Issues, 26(3): pp. 541-560, 1996.

Outcomes of an AIDS Prevention Program for African American and Latino IDUs

This paper discusses preliminary outcomes from a community-based AIDS prevention program for drug users participating in the NIDA-funded Cooperative Agreement in Hartford, Connecticut. The efficacy of two culturally targeted, enhanced interventions, one for African Americans and one for Puerto Ricans, was compared with the NIDA standard. The data suggest that attendance in culturally targeted enhanced interventions may increase the likelihood of positive program outcome, including drug-related risk reduction for some populations. However, subgroups of IDUs, such as extremely high risk injectors or persons who drop out before initiating or completing the program, appear to require different intervention approaches. Weeks, M.R., Himmelgreen, D.A., Singer, M., et al. Community-Based AIDS Prevention: Preliminary Outcomes of a Program for African American and Latino Injection Drug Users. Journal of Drug Issues, 26(3): pp. 561-590, 1996.

The Efficacy of Network-Based Risk Reduction Programs in Mid-Sized Towns
Three HIV and drug abuse intervention approaches were compared in two mid-sized towns: an intensive outreach program using indigenous outreach workers providing reinforcement of an HIV risk reduction program; a low intensity outreach program combined with a more intensive office-based HIV risk reduction program, and the NIDA standard intervention. A total of 579 drug users participated in the study. Each of the enhanced interventions were effective in reducing both drug-related and sexual risks for HIV transmission in active drug users. The intensive outreach combined with office intervention and the intensive office intervention without outreach reinforcement each produced significant reductions in sexual risk taking in active drug users, beyond the reductions found in the standard intervention. Gender differences were also found, with intensive outreach having a significant effect on the reduction of sexual risk behaviors of men but not of women, and the more intensive office-based risk reduction program significantly related to improvement in the sexual risk behavior of women but not of men. Trotter, R.T., Bowen, A.M., Baldwin, J.A., and Price, L. The Efficacy of Network-Based HIV/AIDS Risk Reduction Programs in Mid-Sized Towns in the U.S. Journal of Drug Issues, 26(3): pp. 591-605, 1996.

Assessing Intervention Efficacy From Change Profiles of Unprotected Sex Among Drug Users
Over 700 active drug users recruited in East Harlem to participate in an AIDS prevention program were interviewed on 2 occasions 6 months apart to assess relative changes in HIV-related risk behaviors as a result of participation in the NIDA standard and an enhanced intervention. The number of unprotected sex acts reported in the 30 days prior to each interview reflected five distinct patterns of risk over time (i.e., a decrease, an increase, remaining at low risk, remaining at high risk, or no sexual activity at either time). Bivariate and multivariate analyses indicated that (1) compared to persons at high levels of unprotected sex at follow-up, those who remained at low level or decreased were more likely to be HIV positive; and (2) age, living alone, and having a stable source of income were also significant predictors of risk pattern. Sexual risk pattern was not associated with type of risk reduction intervention (standard or enhanced) nor with drug treatment between baseline and follow up. These findings suggest that knowledge of HIV serostatus can contribute to or has an effect on risk-behavior change. The findings also have implications for improving the design and implementation of behavioral interventions to address sexual risks as well as drug-related risks from injecting drugs and the smoking crack cocaine. Beardsley, M., Goldstein, M.F., Deren, S., and Tortu, S. Assessing Intervention Efficacy: An Example Based on Change Profiles of Unprotected Sex Among Drug Users. Journal of Drug Issues, 26(3): pp. 635-648, 1996.

Effective Facilitation into Drug Treatment Does Not Affect Retention
Seven hundred thirty-eight active IDUs were recruited to participate in the NIDA Cooperative Agreement in Portland, Oregon from September 1992 to June 1994. HIV-negative IDUs were randomly assigned to the NIDA standard intervention or the enhanced intervention; those assigned to the latter group also received interventions designed to facilitate entry into drug treatment or self-help. For the 266 IDUs in the enhanced intervention who participated in both the baseline and follow up assessments, initial attendance at drug treatment or self-help was increased by the procedures designed to facilitate treatment entry. However, clients tended to drop out of both after an average of only four assisted sessions, and their outcomes were no different from those clients who attended no sessions at all; i.e., they were no more likely to stop injecting than IDUs who went to no sessions. The incentive (a $10 food coupon following each of the first four sessions) may have motivated clients to attend the first four sessions, but the intrinsic value of the drug treatment or self-help program may not have been sufficient to continue. Twenty-four percent of the IDUs ceased injecting drugs in the 30 days prior to the 6-month follow-up interview and, after adjusting for confounders, the data showed this to be significantly associated with attendance at five or more drug treatment or self-help sessions. IDUs who continued to inject also showed a reduction in needle sharing from baseline to follow up. Other factors associated with attending five or more drug treatment or self-help sessions were living with children under age 18, not residing in a regular place at the time of the baseline interview, and having a high school education. This study indicates that effective facilitation into drug treatment does not, in and of itself, increase the likelihood that clients will continue in the treatment program or cease their drug injecting or needle use behavior. Drug treatment and self-help programs need to address the ambivalence held by a large percentage of active drug users toward entering and continuing in drug treatment. He, H., Stark, M., Fleming, D., et al. Facilitation into Drug Treatment or Self-Help Among Out-of-Treatment IDUs in Portland: You Can Lead a Horse to Water, But... Journal of Drug Issues, 26(3): pp. 649-661, 1996.

Enhanced Treatment Adds to Behavior Improvement Beyond Standard HIV Intervention
At the Detroit site of NIDA's Cooperative Agreement, two outreach interventions were compared on effectiveness in decreasing the AIDS-related high risk behaviors of 539 active IDUs and crack cocaine users not in treatment. Half of the drug users were assigned to NIDA's standard intervention, and half to the enhanced intervention, a nursing intervention called Personalized Nursing LIGHT Model. An optional component of this intervention was a weekly "Tuesday Group," when care givers and clients would meet as a group to discuss client concerns and provide peer support and encouragement. Follow-up evaluations indicated a dose-response relationship, with participants in the enhanced intervention plus weekly Tuesday Group showing significantly more improvement in reducing their use of drugs and in engaging in unprotected sex, followed by clients in the enhanced only, then by clients in the standard intervention. The findings show the importance of positive peer support and encouragement, group counseling, and consistent, planned opportunities to participate in group sessions for reducing drug use and sexual risk behaviors, and for preventing relapse. Andersen, M.D., Hockman, E.M., and Smereck, G. Effect of a Nursing Outreach Intervention to Drug Users in Detroit, Michigan. Journal of Drug Issues, 26(3): pp. 619-634, 1996.

Simulating the Complex Dynamics of HIV Transmission in IDUs
Although the use of mathematical modeling as a tool for studying HIV transmission is well established, it is also problematic. The assumptions of the classical epidemiological model may not be appropriate in modeling the spread of HIV because homogeneous mixing and susceptibility to infection cannot be assumed. Using the General Purpose Simulation System, which is based on concepts of system analysis, a hypothetical cohort of IDUs was created, drawing from a common needle supply. Following the introduction of an index case, the HIV infection rate was followed over 5 simulated years to examine effects from systematic variation in the frequency of injection with contaminated needles and needle-cleaning behavior. While simplifying assumptions (specifically "other things being equal") were used in these models, greater complexity can be introduced (e.g., by specifying variable probabilities of passing contaminated needles and by including effects of sexual risks behaviors and more variable in and out migration mixing patterns). Nonetheless, the preliminary model captures the essential characteristics of an IDU system and the dynamics of HIV transfer within this group. Atkinson, J. A Simulation Model of the Dynamics of HIV Transmission in Intravenous Drug Users. Computers and Biomedical Research, 29: pp. 338-349, 1996.

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