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National Institute on Drug Abuse

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

May, 1999

Research Findings

AIDS Research

Plasma Virus Load Evaluation in Relation to Disease Progression in HIV-Infected Children

Savita Pahwa and colleagues at North Shore University Hospital, Manhasset, New York, observed that high levels of HIV RNA (measured retrospectively by nucleic acid sequence-based amplification assay) in infancy is associated with increased mortality, although no correlation was observed between levels of cellular HIV DNA and plasma HIV RNA. Tetali, S., Bakshi, S., Than, S., Pahwa, S., Abrams, E., Romano, J., and Pahwa, S. G. Plasma Virus Load Evaluation in Relation to Disease Progression in HIV-Infected Children. AIDS Res. Hum. Retroviruses, 14(7), pp. 571-577, 1998.

Direct Comparison of Time to AIDS and Infectious Disease Death Between HIV Seroconverter IDUs in Italy and the U.S.: Results from the ALIVE and ISS Studies

The rate of HIV disease progression was compared in two cohorts: one a U.S. cohort of active polysubstance injectors (ALIVE) and the other an Italian cohort of predominantly opiate injectors (ISS). Data from the two cohorts were combined and the seroconversion date was estimated as the midpoint between the last negative and first positive HIV test. Time to AIDS or infectious disease death was calculated, adjusting for age at seroconversion, gender, and year of seroconversion. Of the 1003 IDUs, 226 progressed to AIDS and 146 died after AIDS diagnosis or from an infectious disease. Although the univariate analysis suggested possible differences for progression to AIDS or to infectious disease death between cohorts, multivariate analyses which adjusted for age showed no significant differences by cohort, gender, race, or time of seroconversion. The median time to AIDS for 25 year old persons in ALIVE was 12.3 years vs. 11.8 years in the ISS; for 35 year old persons the median time to AIDS 8.5 and 8.2 years, respectively. These estimates were similar to those for non-IDUs observed in the ISS and for homosexual men in a large U.S. cohort study. These results confirm the importance of accounting for age in considering the incubation period for HIV infection. Despite differences in drug use characteristics, the similar median times to AIDS, for each age, between the two cohorts of IDUs and between the IDUs and the non-IDUs, suggest a negligible effect of active injection drug use on HIV progression. Pezzotti, P., Galai, N., Vlahov, D., Rezza, G., Lyles, C.M., and Astemborski, J. Direct Comparison of Time to AIDS and Infectious Disease Death between HIV Seroconverter IDUs in Italy and the U.S.: Results from the ALIVE and ISS Studies. J Acqir mmune Defic Syndr Hum Retrovirol 20, pp. 275-282, 1999.

HIV Among Trauma Patients in New York City

The Cornell University Medical College investigators, Tardiff and his colleagues conducted a descriptive survey to determine the HIV seroprevalence rates in relation to the demographic characteristics of victims, cause of death, and toxicology findings in a sample of victims of violence and accidents who presented to emergency departments before death. The survey was conducted in 5 boroughs of New York City (population, 7.3 million). Persons 15 years of age and older injured by intentional violence or accidents (excluding drug overdoses, falls, and suicides) who presented to hospitals, died and were sent to the medical examiner were included. Plasma and sera were analyzed for HIV and cocaine and its metabolites. Logistic regression and other appropriate statistical tests analyzed the data. Among the 1,242 subjects in the sample, 90 (7.2%) had positive findings: male patients (8%) having higher rates of HIV than females (3.4%). Among the various age groups, HIV rates were 20.8%, 9.6% and 8.1% among patients 35-44, 45-54, and 25-34-year age groups, respectively. Further, HIV rates among victims of homicides, accidents, and motor vehicle crashes were 8.2%, 10.5%, and 4%, respectively. Patients with positive results for cocaine (16.3%) were more likely than those with negative results (5.8%) to be HIV positive. Logistic regression analyses found that only age and positive cocaine results, not sex race, were related to increased risk of HIV infection. The investigators concluded that the rate of HIV infection among victims of fatal trauma was significant, especially in those with evidence of cocaine use. The results further emphasize the need for use of universal precautions in the care of trauma patients. Tardiff, K., Marzuk, P., Leon, A.C., Hirsch, C.S., Portera, L., and Hartwell, N. Human Immunodeficiency Virus Among Trauma Patients in New York City. Annals of Emergency Medicine, 32, pp. 151-154, 1998.

Effects of Chronic Opioid Dependence and HIV-1 Infection on Pattern Shift Visual Evoked Potentials

Bauer (University of Connecticut) examined the effects of opioid dependence, alone and in combination with asymptomatic HIV-1 infection, on the transmission of visual information from the retina to occipital cortex via measurements of the pattern shift visual evoked potential (PSVEP). For this purpose, three groups of patients were evaluated, including patients characterized by: (1) a past history (2-4 months abstinent) of DSM-IIIR opioid dependence (i.e., in partial remission); (2) a recent history (7 days abstinent) of opioid dependence with ongoing methadone maintenance; and (3) a recent history of opioid dependence, ongoing methadone maintenance, and asymptomatic HIV-1 infection. A group of healthy, non-drug-dependent volunteers was also evaluated. The data analysis revealed no PSVEP differences between patients with a past history of opioid dependence and healthy volunteers. There were also no PSVEP differences between methadone-maintained patients with or without HIV-1 infection. Collectively, however, the two methadone maintenance groups exhibited significant delays in the N75 and P100 components of the PSVEP relative to the other two groups. The delay in N75 latency was strongly correlated with self-reported years of heroin abuse, but not with years of cocaine, alcohol, or other drug abuse. The nonsignificant trend toward delayed N75 latencies among asymptomatic HIV-1 seropositive drug abusers is better explained by their greater exposure to the neurotoxic effects of heroin than by coincident HIV-1 infection. Bauer, L.O. Effects of Chronic Opioid Dependence and HIV-1 Infection on Pattern Shift Visual Evoked Potentials. Drug and Alcohol Dependence, 50, pp. 147-155, 1998.

Viable, Proliferating HIV-1 Recovered From Syringes in Excess of Four Weeks Later

Using a microculture assay to detect viable virus in volumes of blood typical of those commonly found inside used syringes, and modeling the worse-case scenario, researchers determined the duration of survival of HIV-1 in syringes typically used by injectors of illicit drugs. They recovered viable, proliferating HIV-1 from syringes that have been maintained at room temperature for periods in excess of four weeks. The percentage of syringes with viable virus varied with the volume of residual blood and the titer of HIV-1 in the blood. Syringes with detachable needles were found to harbor more blood between their plunger and base, indicating that they may be riskier for HIV transmission than syringes with needles that do not detach. The likelihood of encountering a potentially infectious syringe decreased with time but remained finite for an extended period. The researchers suggest that, in the absence of bleach, postinjection flushing with clean water may lessen chances of HIV transmission. Abdala, N., Stephens, P.C., Griffith, B.P., and Heimer, R. Survival of HIV-1 in Syringes. J AIDS Hum Retroviol, 20, pp. 73-80, 1999.

Researchers Examine Use of Syringe Exchange and Incidence of Viral Hepatitis Infections

Using data from a cohort study among Seattle IDUs, researchers assessed whether participation in a syringe exchange program was associated with incidence of hepatitis B (HBV) and hepatitis C (HCV) infection. Susceptible IDUs included 187 who were seronegative for HCV and 460 who were seronegative for HBV between June 1994 and January 1996. They were followed for seroconversion one year later. There were 39 HCV infections and 46 HBV infections, and no apparent protective effect against either HBV or HCV from participation in the syringe exchange. The authors hypothesize that changes in the injecting behaviors of IDUs using the syringe exchange may account for these findings. For example, needle exchange programs typically attract drug injectors who practice high risk behaviors for transmission of blood-borne infections such as more frequent injections and sharing of needles and syringes. At the same time, lower risk IDUs who don't use an exchange can get sterile syringes from pharmacies and other sources. If exchange users are at higher risk for transmission of hepatitis, this may explain why the rates of infection are higher than expected and similar to non-exchange users who may be at a lower risk of infection. Hagan, H., McGough J.P., Thiede, H., Weiss, N.S., et al. Syringe Exchange and Risk of Infection with Hepatitis B and C Viruses. Am J Epidemiol, 149 (3), pp. 203-213, 1999.

Very Recent and New Injectors in NYC Have Very High Risks of Acquiring the HIV Infection

This paper examines HIV risk behavior and HIV infection among new initiates into illicit drug injection in New York City. Cross-sectional surveys were conducted of IDUs recruited from a large detoxification treatment program (n=2489) and a street store-front research site (n=2630) in New York City from 1990 through 1996. The interviews covered demographics, drug use history, and HIV risk behavior; serum samples were also collected for HIV testing. Subjects were categorized into two groups of newer injectors: very recent initiates (just began injecting to 3 years of injecting) and recent initiates (injecting 4 to 6 years); and long-term injectors (injecting more than or at least 7 years). Of the 5119 study subjects, 954 (19%) were newer injectors, all of whom had begun injecting after knowledge about AIDS had become widespread among IDUs in the City. New injectors were more likely to be female and white than long-term injectors, and new injectors were more likely to have begun injecting at an older age (median age at first injection for very recent initiates, 27 years; median age at first injection for recent initiates, 25 years; these compare to the median age at first injection for long-term injectors, 17 years). Newer injectors generally matched long-term injectors in frequencies of HIV risk behavior. No significant differences were found among these groups on four measures of injection risk behavior. HIV infection was substantial among the newer injectors: HIV prevalence was 11% among very recent initiates and 18% among recent initiates. Among new injectors, African Americans, Hispanics, females, and men who had sex with men were more likely to be infected. New injectors appear to have adopted the reduced risk injection practices of long-term injectors in the City. HIV infection among new injectors, however, must still be considered a major public health problem in New York City. Des Jarlais, D.C., Friedman, S.R., Perlis, T., Chapman, T.F., et al. Risk Behavior and HIV Infection Among New Drug Injectors in the Era of AIDS in New York City. J AIDS and Human Retrovirol, 20(1), pp. 67-72, 1999.

Study Finds Expanded Number, Size, and Scope of Syringe Exchange Programs in the U.S.

In November 1996, researchers surveyed 101 syringe exchange programs (SEPs) and conducted telephone interviews with SEP program directors in the U.S. Data were collected on the number of syringes exchanged, SEP program operations, legal status, and services offered. The findings were compared with those of a similar survey conducted in 1994. Of the 101 SEPs contacted, 87 (86%) responded. Almost all that did not respond were small and/or "underground" (operating in states that have no prescription law and formal support from local officials). The 87 SEPs that responded operated in 71 cities in 28 states and one territory; 44 were in four states (California, New York, Connecticut, and Washington). About 14 million syringes were exchanged by the SEPs in 1996, compared to 8 million syringes by 55 SEPs in 1994. Program size was directly related to the provision of services other than syringe exchange. All 87 SEPs provided IDUs with information about safer injection techniques and/or use of bleach to disinfect injection equipment; 84 provided referrals to clients to substance abuse treatment programs, information about safer use of condoms to prevent sexual risks for HIV and other STDs; and 70 offered education about STD prevention. Just over half (46) of the SEPs were legal, 20 (23%) were illegal but tolerated, and 21 (24%) were illegal/underground. Legal programs were more likely to offer on-site HIV counseling and testing and tuberculosis testing than were other programs, and to have a steady source of funds and adequate staffing. Secondary exchange was reported as a widespread and important way to distribute sterile syringes to IDUs unable to obtain them directly from the SEP. SEPs have expanded in size, geographic distribution, numbers of syringes exchanged, and types of services offered since 1994. These changes have occurred with support from local and state governments and/or from contributions of organizations, private citizens, and volunteers, but without funding from the U.S. government. Paone, D., Clark, J., Qiuhu, S., Purchase, D., and Des Jarlais, D.C. Syringe Exchange in the United States, 1996: A National Profile. Am J Public Health, 89(1), pp. 43-46, 1999.

Psychoactive Drug Use Does Not Appear to Have Important Effects on the Course of HIV

Early in the history of the AIDS epidemic there was clear evidence of differences in the outcomes of HIV infection between injecting drug users and men who have sex with men. There were also some indications that high levels of nonsterile drug injection equipment may increase the progression of the HIV infection. Recent epidemiologic studies indicate no differences in rates of progression to AIDS among drug injectors, men who have sex with men, or persons infected through heterosexual contact. In vitro and animal studies suggest that the effects of different psychoactive drugs on HIV infection may be negative, positive, or mixed, and that the effects of a psychoactive drug on immune functioning may differ among acute administration, chronic administration, or cessation of chronic administration. Although the current epidemiologic data do not provide support for the hypothesis that psychoactive drug use will have any important effects on the course of HIV infection, possible interactions between psychoactive drugs and antiviral medications and medication adherence issues among drug users are important and promising areas for AIDS research. Des Jarlais, D.C. Psychoactive Drug Use and Progression of HIV Infection. J AIDS and Human Retrovirol, 20(3), pp. 272-274, 1999.

Gender Differences in an Impoverished Minority Population

Gender differences among impoverished minority females (n = 205; 87% African-American, 13% Latina) and males (n = 203; 89% African-American, 11% Latino) were examined using associations among latent variables representing stress, self-esteem, avoidant and active coping strategies, and health outcomes of depression, escapist drug use, and sexual risk behaviors. Subjects were selected from individuals participating in a community-based educational AIDS prevention program in 9 homeless shelters and 11 residential drug recovery programs in Los Angeles. Among both men and women, drug use and depression were positively related to each other. A large and significant relationship between stress and sexual risk behaviors among women was not evidenced for men. In multiple group latent means comparison models, women reported significantly more stress, depression, and avoidant coping styles than men. In predictive path models, an avoidant coping style predicted escapist drug use among men whereas greater stress predicted escapist drug use among women. Greater stress, and lower self-esteem predicted depression in both groups. Greater stress and less active coping predicted more sexual risk behaviors for women. No predictor construct in this model was significantly associated with elevated sexual risk behavior among the men. These results suggest gender-specific leverage points for AIDS-risk reduction interventions. Stein, J.A., and Nyamathi, A. Gender Differences in Relationships Among Stress, Coping, and Health Risk Behaviors in Impoverished Populations. Personality and Individual Differences, 26, pp. 145-157, 1999.

Higher Levels of HIV Risk Behaviors Found in IDUs Who Use Crack vs. Those Who Don't

The baseline characteristics and HIV risk behaviors were compared in two groups of out-of-treatment IDUs in South Philadelphia, one of 366 IDUs who concurrently smoked crack (smoking IDUs) and one of 212 IDUs who did not smoke crack in the past 30 days. Temporal trends in recent risk behaviors were also assessed for each drug user group over an 18-month period, January 1992 to June 1994. Although both groups were economically disadvantaged and at high risk of HIV infection, smoking injectors had fewer economic resources and were at a moderately greater risk of HIV because of higher levels of sexual risk behaviors and higher rates of ever having an STD compared to IDUs only. Analysis of temporal trends revealed few reductions in drug risk behaviors and none in sexual risk behaviors. This study points to the need for examining differences between types of drug users. Understanding the characteristics of different types of drug users and their communities is essential to develop tailored, maximally effective interventions and appropriate treatment programs for persons who use multiple drugs. Semaan, S., Kotranski, L., Collier, K., Lauby, J., et al. Temporal Trends in HIV Risk Behaviors of Out-of-Treatment Injection Drug Users and Injection Drug Users Who Smoke Crack. J AIDS and Human Retrovirol, 19, pp. 274-281, 1998.

Risk Behavior Change in HIV Positive and HIV Negative Drug Users

This research sought to examine the effectiveness of an HIV intervention program among out-of-treatment IDUs and crack users who were HIV+ and HIV-, and to identify risk behaviors of seropositive drug users that may require more intensive or targeted intervention efforts. A total of 225 IDUs (31% HIV+) and 316 crack users (15% HIV+) were administered a baseline interview, received HIV testing and test results, and participated in a 6-month follow up interview. There were significant differences between injectors and crack smokers by demographic characteristics: injectors were more likely to be Puerto Rican and crack smokers more likely to be African American; injectors were more likely to be male, and living on the street or in a shelter. About 40% of both groups were homeless, only 5% were employed, and illegal activity was the primary source of income for 46% of the injectors and 23% of the crack smokers. Injectors were significantly more likely to be HIV+ than crack smokers. Both HIV-positive and negative drug users reported reductions in risk behaviors over time. For both injection-related and sex-related risks, seropositive subjects reported significantly greater reductions from baseline to follow-up than seronegatives. It appears that seropositives may have already reduced risk behaviors based on knowledge of their serostatus at baseline, underscoring the utility of HIV testing and counseling; i.e., knowledge of serostatus can lead to reductions in sex- and injection-related risks. The researchers also suggest that the changes in risk behaviors in the drug users may have been influenced by multiple factors, including participation in the intervention study, receiving pre- and post- HIV test counseling, and benefiting from community-wide outreach efforts and more widely available needle exchange programs. Deren, S., Beardsley, M., Tortu, S., and Goldstein, M. HIV Serostatus and Changes in Risk Behaviors Among Drug Injectors and Crack Users. AIDS and Behavior, 2(2), pp. 171-176, 1998.

Older Substance Abusers, Age-Related Factors, and HIV/AIDS

A study was conducted to examine the role of HIV counseling, testing, and partner notification in the lives of street addicts of all ages, with a subsample of the addicts being older injectors (N=53) ranging between 50 to 86 years. About 75% of the sample were African American and the rest were White or Latino; there were 11 women and 42 men. Ten of the 53 (19%) were positive for HIV. Six of the 10 seropositive IDUs lived alone, compared to only nine of the 43 seronegative IDUs. Heroin was the drug of choice, and one injection a day was the average. All of the IDUs reported polydrug use, with the major drugs used being downers, amphetamines, and cocaine. Six of the seven males who were HIV positive had been crack smokers at one time or another. All but one of the women and half the men reported having had heterosexual sex in the past six months, but nearly 60% said they never used a condom. A lot of time was spent by the IDUs to procure drugs and money to buy drugs, by stealing, engaging in "street hustles," or by assisting drug dealers in supplying their customers. The paper reviews issues related to the illness trajectory for HIV/AIDS in older drug users, social support and social networks, access to old age benefits and public assistance, and the need for age appropriate interventions to facilitate older drug users to adopt strategies of risk reduction and AIDS prevention. Levy, J.A. AIDS and Injecting Drug Use in Later Life. Research on Aging, 20(6), pp. 776-797, 1998.

Unprotected Sex Among Drug-Using Men and Women

Using the AIDS risk reduction model as a conceptual framework, a multivariate prospective test of psychosocial antecedents of unprotected sex was conducted using 155 female and 134 male heterosexual injection drug users. For both women and men, stronger intentions to use condoms predicted subsequent reduction in unprotected sex. For women, but not men, higher perceived self-efficacy also led to reductions in unprotected sex. These results suggest that explicit formation of risk-reduction intentions is an important antecedent to sexual behavior change by drug users of either gender and that change by drug-using women is also influenced by their perceived control over sexual risk-taking. Longshore, D., Stein J.A., Anglin, M.D., and Kowalewski, M.R. Psychosocial Antecedents of Unprotected Sex by Drug-Using Men and Women. AIDS & Behavior, 2, pp. 293-306, 1998.

Two-index Method for Evaluating Models

This article extends work on the use of fit indices to evaluate models, and proposes use of a two-index evaluation strategy based on the standardized root mean squared residual and supplementing it with one of several well-known indices. A series of empirically determined cut-off values are developed for the various indices to replace ad-hoc rules such as the requirement that a model fit exceed an arbitrary value (e.g., .9) before the model is considered adequate. It was determined that a cutoff value closer to .95 for several indices is required before one can conclude that there is a relatively good fit between the hypothesized model and the observed data. The proposed two-index presentation strategy is required to reject reasonable proportions of various types of true-population and misspecified models. This work will ultimately lead to the development of improved statistical models (such as structural equation models) used in drug abuse research. Hu, L. and Bentler, P.M. Cutoff Criteria for Fit Indices in Covariance Structure Analysis: Conventional Criteria Versus New Alternatives. Structural Equation Modeling, 6, pp. 1-55, 1999.

Correlates of High Risk Sexual Activity Are Identified Among STD Patients Who Use Crack

Crack-smoking sexually transmitted disease (STD) patients are at high-risk for contracting HIV. To examine the effects of cocaine use and other correlates on high-risk sexual behavior among STD clinic patients, a cross-sectional study was conducted. The sample included 1,490 consecutive patients attending three Los Angeles County STD clinics between 1992 and 1994. Logistic regression analysis found high-risk sexual activity was associated with being male and of younger age. Among women, high-risk sexual behavior was associated with crack cocaine use and a perceived need for help. Among men in the study, ethnicity (being black) and having an arrest history were associated with high-risk behavior. Effective intervention strategies should address cocaine use among STD patients and provide them with referrals to drug treatment. Hser, Y.I., Chou, C.P., Hoffman, V., Anglin, M.D. Cocaine Use and High-Risk Sexual Behavior Among STD Clinic Patients. Sex Transm Dis, 26(2), pp. 82-86, 1999.

Computer-Assisted HIV Risk Assessment Interviewing is Acceptable to Drug Users

Researchers assessed the acceptability of a computer HIV risk assessment instrument administered to not-in-treatment drug users. The study differed from other assessments of the acceptability of computer-assisted data collection in that the population of interest had relatively little experience in use of computers and only limited education. The study was also implemented under field conditions. Three questions were asked related to acceptability (are drug users comfortable responding to HIV risk questions using the computer assessment; do they feel they possess the requisite skills to respond to questions using a computer; and do they believe that their responses will remain private and confidential). Only slight modifications were made to the content of the instrument. Data collection was facilitated using audio enhancement and touch screen, and three scales were used to measure comfort, skill, and perceived privacy. The findings suggest that drug users are comfortable responding to an HIV risk assessment using computer assisted interviewing. Drug users perceived they possessed the requisite skill to successfully complete the interview. Study participants also reported that they believed their responses would remain private and confidential. Their favorable attitudes seemed to be in evidence even though some of the questions were lengthy for some of the respondents. The average time for completing the risk assessment was 60 minutes. The results of this study suggest that computer interviewing has potential for collecting HIV risk information from drug users under field conditions, even though conditions in field settings are often far less manageable than conditions in clinical or institutional settings. Williams, M.L., Freeman, R.C., Bowen, A.M., and Saunders, L. The Acceptability of a Computer HIV/AIDS Risk Assessment to Not-In-Treatment Drug Users. AIDS Care, 10 (6), pp. 701-711, 1998.

Results of the Cooperative Agreement Studies Indicate Intervention Efficacy

In this article, researchers examine the NIDA Cooperative Agreement HIV intervention studies for active drug users relative to the constructs of prevention efficacy and effectiveness. Conservatively interpreting the outcome findings indicates they fall within the domain of efficacy rather than effectiveness, owing to the high degree of control and organization that occurred with respect to intervention recruitment, participation, process monitoring, and staff training. Because the interventions were implemented and evaluated in community-based, noninstitutional settings with many real-world constraints, minimal shrinkage of their effects would occur if they were implemented in uncontrolled community settings. The CA intervention studies also have attributes of structure, content, process, dose, and participant characteristics that are related to intervention efficacy. Rhodes, F., Wood, M.M., and Booth, R.E. Efficacy and Effectiveness Issues in the NIDA Cooperative Agreement: Interventions for Out-of-Treatment Drug Users. J Psychoactive Drugs, 30(3), pp. 261-269, 1998.

Building Bridges for Community Involvement in Drug and HIV Research among Minority Populations

This paper proposes methods for developing a community base for drug abuse research with minority populations. Recommendations are based on 6 years of research in communities with a high prevalence of prostitution and/or drug use in New York City and Atlanta. Researchers employed a qualitative methodology that included participant observation, in-depth interviewing, and focus groups. The participant observation involved data collection in the subjects' natural setting. The main stages in participant observation, also referred to as ethnographic mapping, were to gain access, develop a role in the field, identify key respondents, and build trust relationships. The open-ended structured interviews facilitated the development of trust and permitted discovery of the subjects' perspective of his/her own salient issues. Sterk, C.E. Building Bridges: Community Involvement in Drug and HIV Research Among Minority Populations. Drugs & Society 14, 1/2, pp. 107-121, 1999.

Incidence and Duration of Hospitalizations Among Persons with AIDS: An Event History Approach

The hospitalization patterns of persons with AIDS (PWAs) in a multi-state/multi-episode continuous time duration framework were examined using Medicaid claims history data from 1,401 AIDS patients in New Jersey. Differences in the use of inpatient services by race/ethnicity, gender, AIDS risk group, region, severity of illness, and year of services were studied. Participation in a Medicaid waiver program offering case management and home health care was associated with hospital stays 1.3 days shorter than non-participants. African-American race and Hispanic ethnicity were associated with hospital stays 1.2 days and 1.0 day longer respectively than for non-Hispanic whites. African Americans also experienced more frequent hospital admissions. Residents of the high HIV-prevalence area of the state had more frequent admissions and stays two days longer than those residing elsewhere in the state. Older PWAs experience less frequent hospital admissions but longer stays, with hospitalizations of 55-year-olds lasting 8.25 days longer than those of 25-year-olds. Crystal, S., Lo Sasso, A.T., & Sambamoorthi. Health Services Research 33(6), pp. 1611-1638, February 1999.

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