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National Institute on Drug Abuse

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

May, 1997

Research Findings

AIDS Research

Salmonella Infections, HIV and Opiates

There is a substantial literature identifying Salmonella as an opportunistic infection in patients with HIV infection, of whom a substantial portion are drug abusers. A recent review (Angulo, F.J. and D.L. Swerdlow. Bacterial Enteric Infections in Persons Infected with Human Immunodeficiency Virus. Clinical Infectious Diseases, 21, Suppl l:S84, 1995) summarized recent findings on bacterial enteric infection in patients with HIV and concluded that Salmonella is a leading cause of such infections and that they are likely to be more severe, recurrent or persistent, and extra-intestinal. The fact that more extra-intestinal infections occur suggests that Salmonella can move from their portal of entry, the gastrointestinal tract, to other areas and organs, a phenomenon described in a publication in press on opioid treatment of mice. A paper entitled Morphine Induces Sepsis in Mice by Mary E. Hilburger, Martin W. Adler, Allan L. Truant, Joseph J. Meissler, Jr., Vilas Satishchandran, Thomas J. Rogers, and Toby K. Eisenstein from Temple University School of Medicine describes studies which examine the role of morphine in inducing sepsis. Mice administered morphine by the subcutaneous implantation of a slow-release pellet developed colonization of the liver, spleen and peritoneal cavity with Gram-negative and other enteric bacteria. In addition, the mice became hyper-susceptible to sublethal endotoxin challenge. The effects were blocked by the simultaneous implantation of a pellet containing the opioid antagonist naltrexone. These findings show that morphine pellet implantation in mice results in the escape of Gram-negative organisms from the gastrointestinal tract, leading to the hypothesis that morphine used post-operatively or chronically for analgesia or by drug abusers may serve as a co-factor in the precipitation of sepsis and shock. Additionally, morphine-induced sepsis may provide a physiologically-relevant model of Gram-negative sepsis and endotoxic shock.

Virus Load as a Marker of Disease Progression in HIV-Infected Children

Savita Pahwa and colleagues at North Shore University Hospital, Manhasset, New York, report that HIV-1 proviral DNA load, as determined in peripheral blood mononuclear cells by the quantitative competitive DNA polymerase chain reaction assay, is predictive of disease outcome in HIV infected children at three months of age or before. They also found that a very early dysregulation of CD95T-cell surface marker expression in such infants may have profound implications for the progression of HIV/AIDS. Tetali, S., Abrams, E., Bakshi, S., Paul, M., Oyaizu, N., and Pahwa, S. AIDS Res. Hum. Retroviruses, 12(8), pp. 669-675, 1996.

Dietary Intake of Community-Based HIV-1 Seropositive and Seronegative Injecting Drug Users

Research shows that the dietary habits of HIV-1 positive individuals are subnormal. Smit and colleagues from Johns Hopkins studied a cohort of 104 inner-city African American injecting drug users (67 men and 37 women); 45 were seropositive and 59 were negative for HIV-1. The food frequency questionnaire and a 24-hour recall were administered to assess dietary intake of calories, fat, protein, carbohydrates, vitamins and macro- and micronutrients (e.g., selenium). HIV-1 seropositives reported higher intake of proteins, fat, B2, B12, pantothenic acid, phosphorous, and selenium as compared to the seronegatives. The intake of zinc, vitamins A and E were below the daily recommended allowances among both groups. Additional research is underway to understand the implication of dietary habits and nutritional status in the HIV-1 infected and non-infected IDUs. Smit, E., Graham, N.M.H., Tang, A., Flynn, C., Soloman, L., and Vlahov, D. Nutrition, 12, pp. 496-501, 1996.

High Risk of Mortality in HIV Infections Is Associated with Selenium Deficiency

Baum and her colleagues at the University of Miami find that selenium deficiency is an independent predictor of survival in HIV-1 infection. In a longitudinal study, a cohort of 125 HIV-1 seropositive drug-using men and women in Miami, Florida were studied over a period of 3.5 years. CD4 T-cell count, anti-retroviral treatment and plasma levels of vitamins A, E, B6, B12, selenium, and zinc were determined. Immune parameters and nutrients known to affect immune function were evaluated at 6 month intervals. A total 21 of the HIV-1 participants died from HIV related causes during the study period. Subclinical malnutrition (deficiency of vitamin A, B12, zinc, and selenium) over time, but not AZT treatment, was associated with HIV-1 related mortality independent of CD4 cell counts <200 at baseline, and CD4 over time. Data suggest that CD4 over time (RR=0.69, p<0.04) and selenium deficiency (RR=10.8, p<0.002) were significantly associated with mortality. Baum, M.K., Shor-Posner, G., Lai, S., Zhang, G., Lai, H., Fletcher, M.A., Sauberlich, H., and Page, J.B. J. Acquired Imm Def Synd and Hum Retrovir. In press.

Risk for Human Immunodeficiency Virus (HIV) Infection Among Persons With Severe Mental Illness

Kate Carey, a NIDA FIRST awardee and her colleagues at Syracuse University have found that individuals diagnosed with serious mental illness (SMI; e.g., schizophrenia, schizo affective disorder, bipolar disorder) are at enhanced risk for infection with HIV. A review of the published literature shows that 54-74% of adults who report mental illness are sexually active, and one-third report having two or more partners. Among the sexually active, condom use was inconsistent. About 4-35% also report a history of injection drug use. Overall, the data indicate that the severely mentally ill engage regularly in practices known to involve increased risk for HIV transmission (Carey, M.P., Carey, K.B., and Kalichman, S.C., Clinical Psychology Review, In press). Carey and her co-workers further piloted a six-session HIV-risk reduction intervention for 9 women and 8 men (average age of 39.8 yrs) with serious mental illness. The intervention and assessment were based on Fisher & Fisher's Information-Motivation Behavioral Skills model of HIV-preventive behavior (Psychological Bulletin, 1992). Data were collected pre-and post-intervention, and at one-month follow-up. Results showed that this brief intervention resulted in enhanced HIV-related knowledge, and trends toward enhanced skills at condom use negotiation and condom use self-efficacy. Overall, a modest decrease in risk behavior among participants was observed suggesting that HIV-related risk of the serious mental illness can be reduced through traditional behavioral skills and education methods. According to the authors, further research employing intensive interventions and baseline screening for high risk is needed. Weinhardt L.S., Carey, M.P., and Carey, K.B. HIV Risk Reduction for the Seriously Mentally Ill: A Pilot Investigation and Call for Research. J. Behav. Ther. and Exp. Psychiat., 22(2), pp. 1 10, 1997.

Factors that Impact Street Risks Through Sexual Income Generation

Drug addicted women whose economic and social base is the urban street have limited choices for income generation. These limitations often put such women in danger of predation, assault, arrest, and illness. In this context, an important source of income will often become the exchange of sex for drugs or money. Because of the legal, social, interpersonal, and safety risks associated with these exchanges, drug addicted women may not always be able to practice safe sex, raising their chances of contracting or transmitting HIV infection. These complex conditions may pressure women engaged is sexual exchanges for drugs or money to respond in a variety of ways. Street-recruited women drug users participating in NIDA's Cooperative Agreement AIDS research program in Hartford, Connecticut report a range of protective and risk behaviors when exchanging sex for drugs or money. This article discusses some of the ethnic, economic, and drug use differences among women from the street, analyzes how these differences may affect their drug and sexual risk behaviors, and describes the various approaches and significant efforts of many of these women to reduce their HIV risks. Weeks, M. Grier, M., Romero-Daza, N., et al. Streets, Drugs, and the Economy of Sex in the Age of AIDS. Women and Health, 7, In press.

Social Gatherings Facilitate HIV Risk Reduction among Drug Users

As part of an HIV risk reduction intervention for out-of-treatment drug injectors and crack smokers, the Center for Behavioral Research and Services of California State University has instituted regularly scheduled social gatherings in the Long Beach community as a means to provide social support for modifications of HIV risk behaviors. These events are one component of a 4-to-6 month HIV risk reduction intervention that also includes HIV counseling and testing, individual and group risk reduction sessions, "support buddies," and follow-up by outreach workers. The monthly HIV focused social gatherings provide peer support and opportunities for social modeling by staff and peers, influence perceived social norms, and increase personal self-efficacy for reducing HIV risks. The socials last about 2 hours and include lunch. They are structured around risk reduction activities, including highly effective role model panels, in which outreach workers and staff with prior drug experience and clients who have successfully reduced their risk behaviors discuss a variety of topics, such as the role of social support in modifying risk behaviors, techniques for dealing with relapse and backsliding, and techniques for quitting drugs and maintaining sobriety. Over a 3-year period, 345 of the 510 active clients in the intervention program (68%) attended at least one social event, and 66% attended more than one. At follow-up, significant differences were found between clients who attended social events and those who did not: the former were more likely to report that the program helped them get off drugs, that they had discussed staying safe from AIDS with friends and family members, that they had asked an outreach worker for assistance with a personal problem, and that they were acquainted with other program participants. The popularity of these social events, which are relatively cost effective and easily implemented, makes this intervention mechanism especially valuable for maintaining the participation of active drug users in programs of this type. Wood, M. and Rhodes, F. Using Social Gatherings to Encourage HIV Risk Reduction among Drug Users. American Journal of Public Health (Notes from the Field), 86 (12), pp. 1815-1816, 1996.

Factors Related to Safe Sex Among Heterosexual Drug Injectors

Researchers in Dayton, Ohio conducted a study to determine factors which affect the self-reported use of condoms among heterosexual injection drug users and crack cocaine smokers. A total of 354 drug users (70% male and 30% female) who were enrolled in the Dayton/Columbus site of NIDA's Cooperative Agreement for AIDS Outreach/Intervention Research Program also participated in this study. Most of the study participants were single (90.1%). The largest group were current injection drug and crack cocaine users (40.1%), followed by crack users who did not inject drugs (33.1%), and injection drug users who did not use crack (26.8%). More than 70% of the participants reported that they frequently used drugs when having sex. Persons who were high when they had sex were significantly less likely to use condoms than persons who were not high, but those whose partners got high when having sex were more likely to report condom use. Individuals said that they were less likely to use condoms when they had sex with a main partner. Those who believed it was important to use condoms were more likely to use them, while persons who believed condoms reduced sexual pleasure were significantly less likely to use them. A key result of this research is that drug users frequently use substances before and during sex, which presents a significant impediment to the employment of safer-sex techniques that rely on condoms. While it is important to be sensitive to partner characteristics, it is also critical that sexual risk reduction interventions which target heterosexual users of injection drugs or crack address the widespread practice of simultaneous use of psychoactive drugs. Until such dually focused interventions are in place, access to drug abuse treatment continue to play a critical role in preventing the spread of HIV and other sexually transmitted diseases in this population. Falck, R., Wang, J., Carlson, R., and Siegal, H. Factors Influencing Condom Use Among Heterosexual Users of Injection Drugs and Crack Cocaine. Sexually Transmitted Diseases, 24(4), pp. 1-7, 1997.

Effects of Attrition on the Evaluation of an HIV Prevention Program

Attrition impacts the effectiveness of prevention interventions as well as the external validity of efficacy analyses. A recent article examines the effects of attrition on the evaluation of an HIV prevention program for out-of-treatment drug users who participated in the Cooperative Agreement for AIDS Prevention in Philadelphia. Of the 1,115 injecting drug and crack cocaine users in the program, 967 (87%) completed the 2-session HIV prevention intervention. Of these, 679 (69%) also completed the 6-month follow-up assessment. Factors related to completing the 2-session prevention intervention were different from those related to completing the longer term, 6-month follow-up assessment. Results from multiple logistic regression identified three predictors for completing the 2-session intervention, all of which were related to HIV risk behaviors: testing HIV seronegative, engaging in high risk use of needles/syringes, and ever having had a sexually transmitted disease. By contrast, predictors for completing the study (i.e., to the end of the 6 month follow-up assessment) were not related to HIV risk behaviors, but were representative of a more stable lifestyle. In particular, being a female, receiving public assistance, and living with a partner were predictive of study completion. Persons with high HIV risks, including those who were homeless and those who injected more frequently in the past 30 days, were significantly more likely to drop out from the research project. The authors suggest that research attrition analysis such as this is important for improving the appeal of interventions which target high risk and hard to-reach subgroups, for developing better procedures to track and stay in touch with clients, and for enhancing data collection methods. Lauby, J., Kotranski, L., Feighan, K., et al. Effects of Intervention Attrition and Research Attrition on the Evaluation of an HIV Prevention Program. Journal of Drug Issues, 26(3), pp. 663-677, 1996.

Risk Factors for HIV Seropositivity Among Migrant Workers in Southern Florida

As part of a NIDA Cooperative Agreement, a study was conducted to identify variables associated with HIV seropositivity among migrant workers in rural southern Florida. From 1993 to 1995, researchers enrolled 543 male and female migrant workers into the study, of whom 369 (68%) were born in the U.S. and 32% were from other countries. All of the migrant workers currently used drugs, primarily crack cocaine. Overall, 61 (11.2%) of the participants were HIV positive, including 18% of African Americans born in the U.S. as well as 8.0% of non-Hispanic Whites born in the U.S., Blacks from the Caribbean, and persons from Central or South America. Although 3.4% of Hispanic persons from Mexico were HIV seropositive, none of the U.S. or Caribbean-born Hispanics were. From logistic regression analysis, the authors identified race/ethnicity, gender, and age as significantly associated with being HIV positive. Immigration status, current drug use, and current sexual activity were not related to HIV seropositivity. These findings indicate that HIV prevention programs must address risks associated with heterosexual transmission of HIV as well as drug use both locally and where migrants travel and work. Weatherby, N., McCoy, V., Bletzer, K. et al. Immigration and HIV Among Migrant Workers in Rural Southern Florida. Journal of Drug Issues, 27(1), pp. 155-172, 1997.

Preventing AIDS in Communities of Color

Working in predominately Puerto Rican and African American communities of the inner cities, researchers in Hartford, Connecticut are witness to a widening divide between the spread of HIV among non-Hispanic whites -- generally white men who have sex with men -- and the spread of HIV in communities of color. This article describes the dramatic and increasing over-representation of AIDS cases diagnosed each year in the U.S. among communities of color, despite the work of public health and community-based educators. The authors suggest that the increases in HIV/AIDS among persons of color reflect specific shortcomings in current AIDS prevention work. For example, risk group categories may have a role in tracking and predicting the course of the epidemic, but they have little utility when used to lump individuals of differing ethnicities, cultures, and experiences into the same social category because they share a common potential route of infection. In addition, the theoretical models of motivation and behavioral change which predominate in AIDS prevention tend to focus on the individual level, with little consideration of family, communities, and the broader society. The researchers propose that the lessons learned from their work in AIDS prevention serve as guideposts for the development of new approaches to combat the epidemic in communities of color. Key among these is the need to refocus AIDS prevention as social prevention, with decreased attention on individual level prevention models and epidemiologic risk exposure categories, and much greater emphasis on three emergent contexts of AIDS risk reduction: networks, neighborhoods, and natural social groups. Singer, M. and Weeks, M. Preventing AIDS in Communities of Color: Anthropology and Social Prevention. Human Organization, 55(4), pp. 488-492, 1996.

A Systematic Method to Improve Data Collection from a Large Network of Drug Injectors

As part of the Multicultural AIDS Prevention Program in Flagstaff, Arizona -- one of the sites participating in NIDA's Cooperative Agreement for AIDS Outreach Intervention Program -- researchers have employed psychosocial and network interventions to provide knowledge, skills, and incentives to injection drug users to reduce their HIV-related risk behaviors. A major component of the study involved administration of a 27-item network questionnaire to each member of a drug network. When the researchers attempted to use the instrument with a network of more than 40 members, the problems of respondent burden and complexity of data analysis became apparent (i.e. each member in the network was asked to fill out a matrix with more than 1080 cells (27 items x 40 members) -- a condition which produced fatigue and irritation among respondents and risked a loss of precision in the data). To remedy the situation, the researchers applied Principle Components Analysis with VARIMAX rotation to systematically identify co-occurring sets of questions across eight network factor solutions, and then to identify the questions in each set which made the strongest contribution to the various factors. In this way, they were able to determine the best representative questions to keep in the questionnaire without destroying either the theoretical underpinnings for the matrix or the factors found in the empirical administration of the questions. As a result, it was possible to significantly reduce the burden on respondents from large networks, preserve the richness and complexity of the network data, and simplify the analytical computations required. Trotter, R. T., Bowen, A.M., and Hurlbert, H.J. A Method for Systematic Reduction of the Number of Questions in a Network Matrix Questionnaire. Journal of Quantitative Anthropology, 6, pp. 35-47, 1996.

Multicultural AIDS Prevention Programs

A recent volume of Drugs and Society is devoted to HIV and drug use prevention research, beginning with the initial identification of injection drug use as a key transmission vector for HIV infection, and continuing through today. Eleven of the 12 articles are by principal investigators and co-investigators in NIDA's National AIDS Demonstration Research projects (NADR) and Cooperative Agreement for AIDS Outreach/ Intervention Research Program, including, among others, John Anderson, Robert Trotter, Sherry Deren, Antonio Estrada, Mike Stark, Clyde McCoy, Isaac Montoya, Rafaela Robles, and Robert Booth. As such, the articles provide a direct historical link to "first generation" research in community-based AIDS prevention, with its successes, failures, and methodological and practical ambiguities, while also moving the science of prevention forward, into the "second generation." The presentations discuss, and in some instances resolve, key issues that will need to be addressed in the future, as the epidemiology of HIV changes and as treatment approaches improve. For example, as individuals become saturated with information about HIV transmission, it is important that they don't "tune out" and lower their behavioral risk thresholds. Trotter, R.T. (ed.). Multicultural AIDS Prevention Programs, (published also as a Special Issue of Drugs and Society, 9 ( ), 1996.

AIDS Prevention Education in a Puerto Rican Community

In a recent article, the Associate Director of the Hispanic Health Council (HHC), a community-based health research and services organization in Hartford, Connecticut, provided (1) an update and expansion of an earlier report on the 12-year evolution of AIDS prevention education work at the HHC; (2) a further examination of the contribution of applied medical anthropology to community-based AIDS prevention; and (3) a critique of assertions by some researchers about the impact of local, State, and Federal government funding on local AIDS prevention efforts and the surmountability of barriers to community-based work. The author describes how, through the application of "action anthropology," it has been possible at the HHC to focus on the twin goals of science and a specific culturally defined community. As a result, HHC has been addressing both the underlying structural causes of ill health in the Hispanic community as well as the more immediate social, cultural, medical, and environmental causes. Singer, M. The Evolution of AIDS Work in a Puerto Rican Community Organization. Human Organization, 55(1), pp. 67-75, 1996.

IDUs Understand and Retain Knowledge about Preventing Risk of HIV

A study was conducted from 1988 to 1989 in Dade County, Florida to evaluate the recall and performance skills for cleaning syringes/needles among a sample of 393 out-of-treatment IDUs. The study was guided by a question about the extent of correct cleaning of syringes. A free recall procedure, combining cognitive and psychomotor testing, provided a means of verifying knowledge and skills. Results from the study indicate that IDUs learn and retain the knowledge and skills necessary to prevent risk of HIV infection from the use of syringes/needles. Tests of knowledge and performance 6 months after training showed high retention of the material learned. The population at risk is capable of reducing the spread of HIV. Even with partial compliance with the correct cleaning procedures, some preventative impact could be assumed provided exposure time to bleach exceeds 30 seconds. McCoy, V., Chitwood, D., Page, B. et al. Skills for HIV Risk Reduction: Evaluation of Recall and Performance in IDUs. Substance Use and Misuse, 32(3), pp. 229-247, 1997.

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