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National Institute on Drug Abuse

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

May, 1998

Research Findings

AIDS Research

Vitamin A Supplementation and Human Immunodeficiency Virus Load in Injection Drug Users

The use of vitamin A therapy in HIV infection has been under investigation for its potential efficacy in modulating replication of HIV. A randomized, double-masked, placebo-controlled clinical trial was performed in drug users to determine the impact of a single high-dose vitamin A supplementation, 60-mg retinol equivalent (200,000 IU), on HIV viral load and CD4 count. One hundred-twenty HIV-infected injection drug users were randomly assigned to receive vitamin A or placebo. Plasma vitamin A levels, CD4 lymphocyte counts, and HIV viral load were assessed at baseline and at 2 weeks and 4 weeks post-treatment. Vitamin A supplementation had no significant impact on viral load or on CD4 count at 2 weeks or at 4 weeks post-treatment. Study results indicate that high-dose vitamin A supplementation does not influence viral load in HIV infection. Semba, R.D., Lyles, C.M., Margolick, J.B., Caiaffa, W.T., Farzadegan, H., Cohn, S., and Vlahov, D. J Infect Dis, 177, pp. 611-616, 1998.

Prognostic Indicators for AIDS and Infectious Disease Death in HIV-Infected Injection Drug Users: Plasma Viral Load and CD4+Cell Count

Plasma HIV viral load and CD4 count, markers used to predict prognosis in HIV-infected individuals, were analyzed to determine whether these markers in combination improve prognostic accuracy and whether they predicted prognosis in a predominantly African-American population of HIV-infected IDUs. Plasma HIV RNA and CD4 cell count were measured at baseline and compared with time to first clinical AIDS diagnosis and time to death due to an infectious disease in 522 subjects (96% African-American, 80% male, median age 33, 96% active injectors in prior 6 months). A total of 146 cases of AIDS and 119 infectious disease deaths occurred during a median follow-up period of 6.4 years. Baseline levels of viral load and CD4 cell count were independent predictors of progression to AIDS and infectious disease deaths, but in proportional hazards models, viral load had better predictive value than CD4 cell count. Analysis of time to AIDS and to infectious disease deaths by viral load categories (<500; 500-9999; 10,000-29,000; >=30,000 copies/mL) at 3 levels of CD4 cell count (<200; 200-499; >=500/mm3) was reduced to a 5-stage classification scheme. The 5-year cumulative probabilities for AIDS and infectious disease deaths ranged from 0% and 0%, respectively, for those with viral load <500 copies/mL and CD4 count >=500/mm3 (stage 1) to 81% and 76%, respectively, for those with viral load >=10,000 copies/mL and CD4 cell count 200-499/mm3 (stage 5). This study demonstrated that plasma HIV viral load independently and in combination with CD4 cell count measurements provided powerful prognostic information for progression to AIDS and to death caused by infectious disease in this population of IDUs. Combining categories of both markers provided a simple method for prognostically staging HIV disease. Vlahov, D., Graham, N., Hoover, D., Flynn, C., Bartlett, J.G., Margolick, J.B., Lyles, C.M., Nelson, K.E., Smith, D., Holmberg, S., and Farzadegan, H. JAMA, 279, pp. 35-40, 1998.

Temporal Trends in the Progression of HIV Disease in a Cohort of Drug Users

Changes over time in rates of progression to AIDS, mortality, and distribution of AIDS-defining illnesses were evaluated in a prospective cohort of HIV+ drug users. Study participants attended a methadone maintenance program with on-site primary care and were enrolled between 1986 and 1995. Data were analyzed among 524 HIV-infected drug users (42% female, 64% Hispanic, 23% black, 14% white); 92% reported illicit drug use during follow-up and 77% reported injection. No specific drug or route of administration was prominently associated with progression to AIDS. AIDS-defining illnesses occurred in 98/524 persons (18%), an overall rate of 5.5/100 person years (PY). Among those with an initial CD4 cell count <=200/mm3, the AIDS rate was 17.5/100 PY vs. 3.8/100 PY in those with initial CD4 cell count >200/mm3. Those who enrolled after 1990, compared to earlier enrollees, demonstrated greater AIDS-free time: progression to AIDS declined from 19.9/100 PY to 15.0/100PY for those with CD4 cell count <=200 vs. 4.7/100PY to 2.5/100PY for those with CD4 cell count >200). The proportionate morbidity due to Pneumocystis carinii pneumonia (PCP) as the initial AIDS-defining illness declined from 33% of AIDS cases before 1990 to 17% after 1990. TB also declined, from 20% to 13% after 1990, while recurrent bacterial pneumonia increased from 10% to 20% after 1990. Recent enrollees (1994-95) had approximately one-fifth the hazard ratio (HR) of progression to AIDS compared with the reference group of participants enrolled between 1986 and 1987, after controlling on CD4 cell count and age. Overall mortality, however, did not differ significantly by year of study entry (8.9/100 PY before 1990 to 8.5/100PY after 1990). The mortality HR did not differ by year of study enrollment, controlling on age and CD4 cell count. The reduction in morbidity and greater AIDS-free time was associated with implementation of a comprehensive on-site primary care program. Webber, M.P., Schoenbaum, E.E., Gourevitch, M.N., Bouno, D., Chang, C.J., Klein, R. Epidemiology, In Press.

Assessing the Impact of HIV Risk Reduction Counseling

Changes in cognitive, psychological, and risky behavior latent variables after Traditional or Specialized AIDS education was assessed after two years using structural equation modeling (SEM) in a sample of impoverished at-risk African-American women (N=300). Both groups reported significant improvement at 2 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. There was an advantage to Specialized group membership. When compared to the Traditional group at two years, women in the Specialized group reported enhanced social resources, reduced emotional distress, less use of an avoidant coping style and less drug use. Advantages of culturally sensitive HIV risk reduction program and the importance of connecting women with social services available in their communities is discussed. Nyamathi, A.M., and Stein, J.A. AIDS Education and Prevention, 9(3), pp. 253-273, 1997.

Study Identifies Sexual Risk Behaviors among Native American Drug Users

This study describes patterns of sexual behavior and condom use in a sample of Native American drug-using men and women (N=114). Data were collected on self-reported sexual behaviors in the past 30 days, including descriptions of the most recent sex partners (up to five partners). There were 157 sex partner pairs, of which at least one partner was a drug user. Native American women (55%) were more likely than Native American men (23%) to report never using condoms for vaginal and anal sex in the last 30 days. Compared with other ethnic pair combinations, sex partner pairs composed of Native American women and white men (n=18) were least likely to use condoms (6% of pairs) and the most likely to report an injection drug user sex partner (33% of pairs). These results suggest a potential vector of HIV and other STDS between white male IDUs and Native American women and highlight the need for further qualitative and quantitative research to examine the factors underlying this pattern of sexual risk behavior. Fenaughty, A.M., et al. Sex Partners of Native American Drug Users. Journal of AIDS & Human Retrovirology, 17(3); pp. 275-282, 1998.

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 a 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.

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 were assessed after traditional or specialized AIDS education after 2 years 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 2 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. When compared with the traditional group at 2 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 is discussed. Nyamathi, A.M., and Stein, J.A. AIDS Education and Prevention, 9, pp. 253-273, 1997.

Ethnographic Study Characterizes HIV Risk Behaviors of High Risk Men

An exploratory ethnographic study was conducted in Seattle, Washington to characterize the drug use and sexual risk behaviors, social and ecological contexts, and service needs of men who use drugs and who have sex with men (DUMSM). Three ethnographic methods were used for this research: unobtrusive observations, focus group interviews, and individual interviews. Thirty DUMSM ranging between 20 to 56 years of age were interviewed for the study, 80% of whom were white, and 20% of whom were Native American, Latino, African American, and multi-racial. Nearly all of the men were HIV positive or had an AIDS diagnosis, and almost all identified themselves as gay or bisexual. A number of common themes emerged from the interviews: almost all of those interviewed injected methamphetamine and used other drugs (cocaine, MDMA, alcohol, marijuana, and heroin); almost all described an intense association between methamphetamine use and sex; and some of the men said they had moved to Seattle specifically because it had a reputation as "the hot spot" for DUMSM. Although some respondents had completed treatment and remained abstinent from methamphetamine for a period of time, most had also relapsed, explaining that they were unable to enjoy sex without it. Abstaining from methamphetamine was perceived as equivalent to abstaining from sex, and therefore made treatment entry and compliance options of last resort. The authors learned that methamphetamine was sometimes used by respondents to manage the depression they felt from being HIV positive or having AIDS. At the same time, they learned that needle sharing and unprotected sex were common among the men who reported being HIV seropositive or having AIDS, either because they assumed their injecting drug and sexual partners were also HIV positive, or because they would become so intoxicated that they'd forget they were HIV positive. Gorman, M.E., et al. Speed, Sex, Gay Men, and HIV: Ecological and Community Perspectives. Medical Anthropology Quarterly, 11(4), pp. 505-515, December 1997.

Longitudinal Theory-Based Study Predicting Needle-Disinfection by IVDUs who Share Needles

Working from the AIDS risk reduction model (ARRM) and other theories of behavior change such as the theory of reasoned action, the authors tested psychosocial antecedents of needle/syringe disinfection by 136 injection drug users who admitted sharing needles in both waves of a longitudinal study. Latent variables were developed as predictors. High perceived self-efficacy for risk reduction had a positive effect on needles/syringe disinfection attempts one year later. Self-efficacy was, in turn, related to less perceived infection risk, peer norms more favorable to risk reduction, and greater knowledge of AIDS. Behavioral intention had no significant effect on subsequent disinfection attempts. These results suggest that disinfecting needles/syringes is partly nonvolitional, that high perceived infection risk may be counter- productive to injection risk reduction, and that perceived self-efficacy, but not intention to change behavior, may be a useful leverage point for AIDS preventive intervention. Longshore, D., Stein, J.A., and Anglin, M.D. AIDS Education and Prevention, 9, pp. 443-460, 1997.

Study Provides Guidance on Interpreting Indeterminate HIV Test Results in Prisoners

A study was conducted in Rhode Island to evaluate the significance of indeterminate HIV test results in the prison setting and to develop specific information and guidelines to direct HIV counseling of incarcerated persons with an indeterminate test result. Medical chart review was conducted for all prisoners incarcerated at the Rhode Island State Prison who had received indeterminate HIV test results between the inception of mandatory testing of inmates in 1990 and October 1996. There were 35 inmates who had an indeterminate HIV Western blot result and 31 who had follow-up HIV testing. Of the 31 with follow-up testing, 23 (74%) seroconverted. Factors strongly associated with seroconversion were drug/alcohol use, including crack cocaine and injection drug use, as well as injection drug use only. Of research studies on seroconversion rates among persons with indeterminate HIV test results, this is the highest rate ever reported. The authors suggest that many of the behaviors that put people at risk of HIV also put them at risk of incarceration, particularly drug-related activities and prostitution. In addition, many people may become infected near the time of incarceration when HIV risk behaviors are escalating. The findings indicate that indeterminate HIV test results taken on entrance to correctional institutions are more likely to represent true HIV infections in prison populations than in other groups. For this reason, counseling of prisoners with indeterminate test results should acknowledge the likelihood of seropositivity and encourage immediate confirmatory viral loading tests. Rich, J.D., et al., Interpretation of Indeterminate HIV Serology Results in an Incarcerated Population. Journal of AIDS and Human Retrovirology, 17 (4), pp. 376-379, 1998.

Needle Sharing and Sexual Risk Behaviors Among IDUs in Rio de Janeiro

This paper characterizes HIV seroprevalence and risk behaviors of IDUs in Rio de Janeiro, Brazil between 1990 and 1996. Three separate cross-sectional samples of IDUs in Rio de Janeiro were compared on the basis of demographic characteristics, HIV risk behaviors, and HIV seroprevalence, and combined analyses were performed to determine the factors associated with injection drug use risk behaviors, sexual risk behaviors, and HIV seropositivity. There were a total of 727 IDUs from the three samples, and the overall HIV seroprevalence among the combined samples was 25%. Persons recruited in the latest years (1995-1996) had lower levels of needle sharing and lower HIV seroprevalence in one of the three samples composed mainly of less educated, poorer IDUs living in deprived neighborhoods. There were no trends toward safer behavior for sexual risk, however, with younger age being the primary factor associated with high risk. The study shows that levels of needle sharing and sexual risks among IDUs in Rio de Janeiro remain high, demonstrating an urgent need to increase the limited preventive measures undertaken so far. Seroprevalence levels for HIV remain significantly lower in the most deprived sample, arguing for the fundamental importance of prompt and effective HIV prevention strategies to keep infection rates from rising among the poorest and largest population strata of Rio's IDUs. Telles, P.R., et al., Risk Behavior and HIV Seroprevalence Among IDUs in Rio de Janeiro, Brazil. AIDS, 11(suppl 1), pp. S35-S42, 1997.

Determinants of Syringe Sharing in Communities With Illegal/ Underground Needle Exchange Programs

Between 1992-1995, researchers administered the NIDA Cooperative Agreement Risk Behavior Assessment and Follow-Up Assessment instruments to 1,304 IDUs in Oakland, California. To determine the factors related to syringe and injection supply sharing among the IDUs, who lived in a community with an illegal/underground needle exchange program (NEP), researchers recently re-examined seven semi-annual waves of interviews from both the baseline and follow-up assessments. Since some of the respondents were interviewed on more than one occasion, the researchers statistically adjusted for correlations between multiple observations on the same person. They also controlled for several potentially confounding variables, including drug treatment, marital status, gender, and income, as well as for possible temporal trends in use of NEPs and syringe sharing (i.e., "calendar time" or interview "waves"). There were substantial declines in syringe sharing over the seven waves of interviews: in 1992, 52% of respondents shared syringes compared to only 28% in 1995. Conversely, use of the NEP increased from 5% of the IDUs at Wave 1 (in 1992) to 36% in 1995 despite arrests of program volunteers during the study period. When temporal trends in behavior were controlled, researchers were able to distinguish the independent impact of a temporal trend toward less syringe sharing over the study period from the significant impact of the NEP on syringe sharing among study participants. They also found an individual protective effect from use of an NEP on needle sharing among consumers of an illegal/underground NEP. The data from this analysis indicate that use of an illegal/underground NEP is associated with lower rates of syringe sharing, suggesting that, regardless of legal status, NEPs can be effective for HIV prevention among IDUs. Bluthenthal, R.N., Kral, A.H., Erringer, E.A., and Edlin, B.R. Use of an Illegal Syringe Exchange and Injection-Related Risk Behaviors among Street-Recruited Injection Drug Users in Oakland, California, 1992-1995. Journal of AIDS and Human Retrovirology, In Press.

An Examination of Substance Abuse, HIV Seropositivity, and the Role of Partner Notification

In this article, researchers discuss a recent pilot study on partner notification with drug users and the social policy implications of implementing notification programs to inform HIV positive drug-using and sexual partners of drug users about their potential exposure to HIV. The pilot study was conducted in Washington, D.C., with 53 out-of-treatment injecting drug users (29 males, 24 females) between 30 and 49 years old. About 75% of the respondents were sexually active and about 33% of persons being sexually active also reported being the sexual partner of an IDU. More than one in six had tested positive for HIV. A questionnaire was given to each respondent concerning 4 types of partners: close drug using, casual drug using, close sexual, and casual sexual. The majority of respondents said they would desire to disclose their HIV positive serostatus to all 4 types of partners (96% for close drug using, 78% for casual drug using, 100% for close sexual, and 86% for casual sexual). Most also preferred to self-notify than to have outreach worker or provider assistance, with 72% saying this for close drug using partners, compared to 67% for casual drug using partners, 71% for close sexual partners, and 55% for casual sexual partners. Only 2% said they would fear being harmed if they disclosed their status to close drug users, but 19% said they would fear harm in telling casual drug using partners; 10% feared harm from close sexual partners compared to 31% for casual sexual partners. The findings from this pilot suggest that partner notification by self-disclosure is preferred for close drug using and sexual partners, but less so for casual partners and that self-disclosure is preferred over and above outreach/ provider-assisted notification. While these findings are generally favorable for partner notification, there are difficult barriers that must be addressed before a partner notification program could be implemented. These include personal issues such as fear of losing the partner, fear of losing support, and not knowing how to initiate the conversation, as well as legal and ethical concerns about confidentiality, the extent to which contacts should be traced, and the types of information, services, and support that should be available once a person learns about his/her potential exposure. Hoffman, J.A. and Klein, H. Social Policy Implications of Partner Notification for Substance Abusers Who Test HIV Positive. Research on Social Policy, 6, May 1998.

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