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National Institute on Drug Abuse

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

February, 1998

Research Findings

AIDS Research

The Influence of Drug Use Patterns on the Rate of CD4+ Lymphocyte Decline Among HIV Infected IDUs

An analysis to assess the relationship between injecting drug use patterns (e.g., frequency, duration, continuous vs. intermittent) and the rate of CD4+ lymphocyte decline (change in CD4 count per month as compared with previous CD4 count) was performed in a cohort of active IDUs. Among 605 IDUs, the median initial CD4 count was 513 and the mean change in CD4 count was -3.2 cells x 10(6)/l per month. The rate of CD4 decline was higher in those with a higher level of CD4 (p<.01) and greater with length of drug use (p<.01), but did not vary by injection frequency or injection intensity by drug type, or by pattern of administration (intermittent vs. continuous). Although animal studies have suggested that the pattern of drug administration and episodes of withdrawal or overdose might have an impact on the rate of CD4 decline, injection patterns by self-report were not associated with the rate of CD4 decline in this study of active injectors. Lyles, C.M., Margolick, J.B., Astemborski, J. et al., AIDS, 11: pp. 1255-1262, 1997.

HIV Seroprevalence Rates Among Homicide Victims in New York City: 1991-1993

Tardiff and his team (Cornell) assessed HIV seroprevalence in homicide victims killed in New York City in 1991-1993, using data from the Office of Chief Medical Examiner. Among 5,852 homicide victims, there were 344 (5.9%) victims who were HIV+. Females were just as likely as males to be HIV+. For females, the rates were 11.7% and 12.6% in the 25-34 and 35-44 year age group, respectively. The highest rates of HIV infection for homicide victims were among those using both opiates and cocaine (males:23.0%; females:27.3%). The rate of HIV infection among women using cocaine was 18.4%. In comparison, the victims not using these drugs had rates of HIV infection around 2%. According to the investigators, the high risk of HIV among homicide victims may be due to the use of cocaine and associated risky use of needles and risky sex practices. Tardiff, K., Marzuk, P.M., Leon, A.C., Hirsch, C.S., Stajic, M., Portera, L., Hartwell, N. J Forensic Sci., 42(6), pp. 1070-1073, 1997.

HIV Seroprevalence Among Suicide Victims in New York City, 1991-1993

Marzuk, Tardiff and others (Cornell) determined the HIV seroprevalence among suicide victims in New York City for the period of 1991 through 1993, using the data from the Office of Chief Medical Examiner. HIV-seropositive suicide victims were assessed for pathological findings suggestive of HIV-related illnesses. Over 90% of all HIV+ suicide victims were aged 25-54 years, and almost 90% were men. Among black and Hispanic men aged 35-54 years who committed suicide, the proportion who were HIV seropositive was 0.252, the highest seropositive rate of any demographic group. More than 66% of HIV+ suicide victims had no HIV-related pathology or AIDS-indicator conditions at autopsy. The authors concluded that the demographically adjusted proportion of suicide victims who were HIV+ (approx. 0.038 to 0.059), contrasted with the HIV seroprevalence estimates for the New York City general population (approx. 0.014 to 0.032), the absence of HIV-related pathology among suicide victims, and the likelihood that many HIV+ individuals had other risk factors for suicide, such as substance abuse, suggests that a positive HIV serostatus is associated, at most, with a modest elevation in suicide risk. Marzuk, P.M., Tardiff, K., Leon, A.C., Hirsch, C.S., Hartwell, N., Portera, L., and Iqbal, M.I. Am J Psychiatry, 154, pp. 1720-1725, 1997.

HIV Infection Among Victims of Accidental Fatal Drug Overdoses in New York City

Tardiff and his colleagues at Cornell determined the factors associated with HIV seroprevalence rates for victims (n=2,159; over 15 years of age) of drug overdoses in New York City (population 7,322,564) in 1991-1993, using data from the Office of Chief Medical Examiner. There were 646 (29.9%) victims who were HIV positive. Women (37.5%) were more likely than men (27.9%) to be HIV+. African-Americans (39.4%) had a higher rate of HIV infection than Latinos (27.5%), whites (19.2%) or Asians (8.3%). The rates of HIV positive seroprevalence were 38.8%, 33.7% and 20.4% among victims aged 35-44, 45-54, and 25-34, respectively. Dying from opiates overdose was associated with a 24 times increase in the likelihood of being HIV positive. Women who died of drug overdoses were more likely than men to be HIV positive. The authors stated that this may be related to risky sex practices as well as sharing needles (Inciardi et al.1993 and Beveer et al. 1995). They suggest that harm reduction programs should address risky sex as well as needle programs. Tardiff, K., Marzuk, P.M., Leon, A.C., Hirsch, C.S., Portera, L., Hartwell, N. Addiction, 92(8), pp. 1017-1022, 1997.

Hepatitis A (HAV) among Homosexual Men and Injection Drug Users: More Evidence for Vaccination

Serum samples from 292 IDUs, 294 homosexual men, and 300 blood donors were tested for the presence of total antibody to Hepatitis A virus (anti-HAV). Anti-HAV was detected in 66% of IDUs, 32% of homosexual men, and 14% of blood donors. The prevalence of anti-HAV among IDUs was not associated with any specific drug use practice, including the duration of injection drug use, the frequency of injection, needle sharing, or injection in a shooting gallery (p>.10). Exposure to HAV was not correlated with serologic evidence of hepatitis B or C, syphilis, or HIV infection (p>.05), nor did the presence of anti-HAV correlate with reported number of sexual partners or a history of a sexually transmitted disease (p>.10). Anti-HAV was more prevalent among IDUs with annual incomes <$5000 (p<.02). The data indicate that IDUs are at increased risk for HAV infection but that factors related to low socioeconomic status, such as poor hygiene or overcrowding, contribute more to the occurrence of HAV infection than does injection drug use. Further study is needed to clarify routes of HAV transmission among IDUs. The high prevalence of anti-HAV among IDUs in this study suggests that IDUs are an important reservoir of HAV infection, and indicates the need for HAV vaccination of IDUs and persons at risk for injection drug use. Villano, S.A., Nelson, K.E., Vlahov, D. et al., Clin Infect Dis, 25, pp. 726-728, 1997.

Impact of AIDS Prevention Intervention on Risky Behaviors and Drug Use

This study examined the impact on specific risky behaviors of two randomly assigned cognitive-behavioral community-based AIDS interventions for high-risk impoverished African-American (N = 353) and Latina (N = 31) women residing in homeless shelters or drug treatment facilities. The study participants were contrasted with untreated, newly recruited controls. An in-depth Specialized program provided AIDS information, and psychosocial and behavioral skill enhancement; a shorter Traditional program provided basic AIDS information. Both treatment groups received information about community resources. At follow-up, women exposed to either program reported significant decreases from their baseline scores in unprotected sexual activity, illegal activities (providing sex for drugs or money), cocaine use, heroin use, and high risk drug-related behaviors such as sex with injection drug users and needle-sharing. After controlling for pre-existing differences between the groups and whether they were in drug treatment, the Specialized group reported less cocaine use and fewer illegal activities. Further comparisons with the untreated newly-recruited control group supported findings of improvement across the two years for both treatment groups. Community-based AIDS health education efforts are discussed. Stein. J.A., Nyamathi, A., and Kington, R. Journal of Community Psychology, 25, pp. 519-533, 1997.

Adolescent Conduct Disorder Predictive of HIV Risk Taking Behaviors

A study was conducted to assess the prevalence of conduct disorder among runaway and homeless adolescents and to investigate associations between conduct disorder and HIV risk behaviors. The Diagnostic Interview Schedule for Children and a standardized HIV risk assessment questionnaire were administered to 219 runaway and homeless adolescents recruited from a drop-in center serving high risk youth. One half of the males and 60% of the females were diagnosed with conduct disorder. In multivariate analyses, conduct disorder was the strongest predictor of lifetime use of heroin and/or cocaine and exchanging sex for money, drugs, food or shelter, as well as the number of drugs used and the number of sex partners in the last 3 months. The high rate of conduct disorder in this population, and the association between conduct disorder and both drug and sex-related HIV risk behaviors, indicate a need for interventions that consider the influence of psychiatric diagnosis on high risk behaviors. Booth, R.E. and Zhang, Y. Conduct Disorder and HIV Risk Behaviors among Runaway and Homeless Adolescents. Drug and Alcohol Dependence, 48: pp. 69-76, 1997.

High HIV Seroprevalence in Street-Recruited IDUs and Crack Users in 16 U.S. Cities

Researchers conducted an analytical assessment of the national database from NIDA's Cooperative Agreement program to determine the seroprevalence of HIV and the risk factors for HIV among street-recruited IDUs and crack cocaine smokers. The analysis examined data on HIV serologies and self-reported risk behaviors of 6,402 IDUs and 3,383 crack smokers from 16 U.S. municipalities, collected in 1992 and 1993. Among the IDUs, HIV seroprevalence was 12.7%, and among crack smokers, HIV seroprevalence was 7.5%. The highest seroprevalence municipalities were along the eastern seaboard of the U.S. The key predictors of HIV among injectors were having injected cocaine, having injected speedball, and unsafe sex; among crack smokers, sexual risk behaviors were most predictive of HIV seropositivity. This study provides a national-level assessment of HIV seroprevalence among IDUs and crack smokers. All of the study participants were recruited from street settings (i.e., community-based), and not-in-drug treatment, suggesting that the risks for HIV continue at very high levels for IDUs and crack users in community, street, and nonclinical locations. Kral, A.H., Bluthenthal, R.N., Booth, R.E., Watters, J.K., et al. HIV Seroprevalence among Street-Recruited IDUs and Crack Cocaine Users in 16 U.S. Municipalities. Amer. J. Public Health, In Press.

Psychosocial Risk Factors for HIV Transmission in Female Drug Abusers

This cross- sectional study examined the influences of domains of psychosocial risk factors on needle-sharing with familiar people and with strangers in a cohort of female injecting drug users (IDUs). Subjects were 119 female IDUs, 46% of whom were HIV+. Subjects were given individually administered questionnaire interviews. Using Pearson correlation coefficients and multiple hierarchical regression analyses, personality, family, and peer attributes related to needle-sharing in women were similar to those found in men, with certain exceptions. Specifically, in males, the family was more distal in its effect on needle-sharing behavior. The role of the family, particularly the significant other, was more important and proximal in its effect on needle-sharing behavior in women than in men. The data suggest that women's resilience and resistance to self-destructive behavior are closely related to ties with others. There was a main effect as well as mediating effects of protective family factors in women, buffering the risk factors leading to needle-sharing. Brook, D.W., Brook, J.S., Whiteman, M., Win, P.T., Gordon-Maloul, C., Roberto, J., Amundsen, F., Masci, J.R., de Catalogne, J. Psychosocial Risk Factors for HIV Transmission in Female Drug Abusers. The American Journal on Addictions, 6 (2), pp. 1-12, 1997.

HIV-Risk Behaviors and Mental Health Characteristics Among Homeless or Drug Recovering Women and their Supportive Person

This paper describes risky drug and sexual behavior and mental health characteristics in a sample of 240 homeless or drug-recovering women and their most immediate source of social support. Women and their closest support sources both reported a great deal of recent non-injection drug use (56% and 52%, respectively) and lesser, though similar, amounts of recent injection drug use (12% and 14%, respectively). Over a third of both groups reported a history of STD and sexual activity with multiple partners. Fifty-one percent of the women and 31% of their companions had CES-D scores of 27 or greater, suggesting a high level of depressive disorders in both samples. Similarly, 76% of the women and 59% of their friends had psychological well-being scores below a standard clinical cutpoint. These data suggest that homeless and impoverished women are turning to individuals who are themselves at high risk for emotional distress and risky behaviors as their main source of support. Implications relating to the importance of integrating the dyad in interventions and introducing alternate sources of support are discussed. Nyamathi, A., Flaskerud, J., and Leake, B. Nursing Research, 46 (3), pp. 133-137, 1997.

Coping with AIDS: A Longitudinal Study

The three goals of this longitudinal, prospective study were: (1) to examine coping strategies of HIV positive and HIV negative IDUs; (2) to study the relationship of earlier social support to later coping in HIV positive men; and (3) to examine the effects of earlier coping strategies on later psychosocial functioning. The authors studied 287 HIV positive and negative men who were patients in an AIDS or a methadone maintenance clinic in an urban hospital. Subjects were given a structured questionnaire at two points in time by ethnically matched interviewers. HIV positive subjects scored higher that HIV negative subjects on measures of AIDS-related adaptive coping (social support) and AIDS-related maladaptive coping (aggression), but not on general coping. General coping was not specifically AIDS-related, but was correlated positively with adaptive coping and negatively with maladaptive coping. These results suggest that earlier general coping is related to the later avoidance of maladaptive coping, with specific implications for teaching preventive strategies. AIDS-related adaptive or maladaptive coping techniques may be used simultaneously, and coping behavior may change over time. Earlier social support is related positively to aspects of later coping in HIV positive men. Thus, social support should enhance later coping in HIV positive men and should be included in intervention programs. Brook, J.S., Brook, D.W., Win, P.T., Whiteman, M., Masci, J.R., de Catalogne, J., Roberto, J., Amundsen, F. Coping with AIDS: A Longitudinal Study. The American Journal on Addictions, 6 (1), pp. 11-20, 1997.

Relative Impact of Two AIDS Education Programs among High-Risk Women on Cognitive, Behavioral, and Psychosocial Variables

Changes in cognitive, psychological, and risky behavior latent variables after traditional or specialized AIDS education were assessed using structural equation modeling in a sample of impoverished at-risk African American women (N = 300). The traditional group watched an AIDS videotape and received a 1-hour basic AIDS education program. In addition to the videotape, the specialized group received a 2-hour program in which they received a demonstration of risk-reducing behaviors, discussion of problem-focused coping, and techniques to enhance self-esteem. Also, they received individualized responses to their concerns such as referrals to drug rehabilitation programs or shelters. Both groups reported significant improvement at two years in their self-esteem and social resources. They also reported less threat perception, avoidant coping, emotional disturbance, HIV risk behavior, and drug use behavior. Also, when compared with the traditional group at two years, women in the specialized group reported more social resources, more reduced emotional distress, less use of an avoidant coping style, and less drug use. The advantages of culturally sensitive HIV risk reduction programs and the importance of connecting women with social services available in their communities are discussed. Nyamathi, A.M. and Stein, J.A. AIDS Education and Prevention, 9, pp. 253-273, 1997.

Participant Observation Fieldwork Provides Contextual Understandings of Individual HIV Risks

Extensive field observations of homeless heroin injectors in San Francisco underscore the importance of context in understanding individual behaviors and the transmission of HIV. Relationships between and among individuals and their personal, demographic, sexual, social, political, economic, and geographic environments shape risky behaviors. For example, substance use and HIV risk behaviors are influenced by addicts' income-generating strategies as well as by hierarchies of respect and identity. Individual risks for HIV transmission increase when addicts who have no money engage in sex-for-drug or money exchanges, pool resources to buy drugs and/or to obtain drug injection equipment, or when there is a need to win personal respect (e.g., by acting on a dare or by aggression). Recognizing the power and dynamics of relationships and the contexts in which they occur provides for a full understanding of the who, why, how, and where of HIV infection. Bourgois, P., Lettiere, M., and Quesada, J. Social Misery and the Sanctions of Substance Abuse: Confronting HIV Risk Among Homeless Heroin Addicts in San Francisco. Social Problems, 44(2): pp. 155-173, 1997.

Factors which Introduce HIV into Drug Injector Networks in Low Seroprevalence Cities

Although many are knowledgeable about how HIV is transmitted, IDUs today continue to be at high risk for infection, particularly those who reside in cities where HIV seroprevalence levels are low. This study examined factors which facilitate the introduction of HIV into networks of IDUs in low HIV seroprevalence cities by analyzing data from a large (n=9492) multi-site sample of IDUs recruited in 9 low seroprevalence cities between June 1988 and June 1991 as part of NIDA's National AIDS Demonstration Research (NADR) project. The results of univariate and multivariate analyses indicate that, after male-to-male sexual contact, having sex at least twice in an AIDS epicenter was the strongest predictor of HIV infection. Higher odds of HIV seropositivity were also associated with the African American and Puerto Rican racial/ethnic groups, daily drug injection, and injecting drugs in an AIDS epicenter. Traveling to an AIDS epicenter and having sex or injecting drugs play a large role in the introduction of HIV into drug injector networks in low seroprevalence cities. Williams, M.L., et al. Introduction of HIV into Drug Injector Networks Outside AIDS Epicenters. International J. STDs & AIDS, 8: pp. 629-635, 1997.

Behavioral Change in HIV+ Adolescents

This study examined whether HIV+ adolescents (N=102) linked to care then change risk and health-related behaviors subsequent to learning their HIV serostatus, and to document the stability of their current behavior patterns over a 6-month period. Over their lifetime, youths engaged in unprotected sexual acts with multiple partners (M=284; median=44; consistent condom protection, 5%) and substance use (21% injecting drug use; 68% hard drugs). When current risk behaviors were assessed twice over two consecutive 3-month periods, almost one third had been sexually abstinent. Among youths who were currently sexually active, most had multiple sexual partners (M=5.7, time 1; 4.9, time 2) and used condoms (72-77% sexual acts protected); most of the youths (63-64%) always used condoms. Use of alcohol (63%), marijuana (41%), hard drugs (36%), and injecting drugs (12%) was substantial. There were gender difference among sexual behavior (females had fewer sexual partners) and substance use behavior (fewer females injected drugs or shared needles). Youths were relatively healthy (M T cells=521.4; 14% T cells < 200; 1.9 diseases and 3.7 physical symptoms in the previous 3 months). There was an exceptionally high rate of adherence, about 66% for appointment over 3-6 months. Rotheram-Borus M.J., Murphy D.A., Coleman C.L., Kennedy M., Reid H.M., Cline T.R., Birnbaum J.M., Futterman D., Levin L., Schneir A., Chabon B., O'Keefe Z., & Kipke M. Risk Acts, Health Care, and Medical Adherence among HIV+ Youths in Care Over Time. AIDS and Behavior, 1, pp. 43-51, 1997.

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