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Director's Report to the National Advisory Council on Drug Abuse
September, 2001

Research Findings

Research on AIDS and Other Medical Consequences of Drug Abuse

Association Between Methamphetamine and High-Risk Behaviors among Gay and Bisexual Men in Los Angeles

This report explored the association between abuse of methamphetamine, high-risk behaviors, and HIV-status among a sample of gay and bisexual men in Los Angeles. Results from a 12-page admission form distributed to 163 gay and bisexual men seeking treatment for methamphetamine abuse indicate that men who reported being HIV-positive were significantly more likely to report that their use of crystal was always associated with sexual behavior (62%) compared to 44% of HIV-negative men indicating that crystal use was always associated with sexual behavior. HIV-positive men were also significantly more likely to report injection as route of administration (48%) compared to 25% of HIV-negative men reporting any injection behaviors. Methamphetamine abuse and its strong association with high-risk sexual and drug use behaviors represent an important public health problem for gay and bisexual men. Hucks-Ortiz, C., Shoptaw, S., and Reback, C.J. Drug and Alcohol Dependence, 63, pp. 1-202, 2001.

HCV Risk Not Limited to Injection Drug Users

A study in New York City examined the prevalence of hepatitis C (HCV) infection among non-injecting drug users residing in East Harlem and the Lower East Side of Manhattan neighborhoods. As many as 17% percent of the subjects who denied a history of injection drug use were found to be infected, compared to a 2% infection rate in the general population. Among women from one of the study sites in East Harlem who reported use of non-injection heroin, the rate of infection was as high as 26%, compared to 14% among women recruited from the Lower East Side. This discrepancy may be attributed at least in part to differences in age between the two study samples. Older women (>35) were found to have a higher anti-HCV prevalence than do younger women (<35). Rates of anti-HCV prevalence were substantially higher for former injectors than for never injectors and, in contrast to never injectors, former injectors exhibited anti-HCV rates that were quite similar across study locations, non-injecting drug use categories, and gender. The researchers posit that the considerable prevalence of HCV among never injectors could be, in part, from some never injectors misrepresenting past injection histories, although study procedures were designed to minimize underreporting. A particular concern is the possibility that the prevalence of HCV among never injectors is related to non-injecting routes of transmission. A pool of HCV-infected non-injecting drug users may be a residual source for the transmission of HCV to other populations. These findings have relevance for HCV testing and treatment policies, as well as for future research focused on the risk factors for HCV transmission among those with no history of injecting drug use. Tortu, S., Neaigus, A., McMahon, J., and Hagen, D. Hepatitis C Among Non-injecting Drug Users: A Report. Substance Use and Misuse, 36(4), pp. 523-534, 2001.

Gender Differences in Condom Usage Among Rural Crack-Using Men and Women

This study explores gender differences in attitudes and motivations to use condoms within a rural, economically disadvantaged sample. Qualitative data analysis identified recurrent themes regarding condom use and assessed how themes varied among men and women. Analyses showed that men and women exhibit different rationales for condom use, while both reported inconsistencies between their knowledge about safe sex, receptivity to condom use, and applications in practice. The findings suggest that prevention programs should be tailored to increase consistent condom use among main partners of crack smokers at risk for HIV. McCoy, H.V. and Wasserman, A. Women and Health, 33, pp. 1-2, 2001.

HIV-1 Seroconversion in Street-Recruited IDUs is Associated With Sexual Behavior

Many new HIV-1 infections in the U.S. occur among IDUs. HIV-1 seroconversion among IDUs is mainly associated with injection-related risk factors. Harm reduction programs concentrate on injection risk behaviors. In this study, researchers sought to establish whether injection or sexual risk factors, or both, were associated with HIV-1 antibody seroconversion of street-recruited IDUs in San Francisco from 1986 to 1998. IDUs were enrolled every 6 months from four community sites. The researchers used a nested case-control design to compare 58 respondents who seroconverted between visits with 1134 controls who remained seronegative. Controls were matched with cases by sex and date. Adjusted odds ratios and 95% C.I.s were calculated for men and women by use of conditional logistic regression. Men who had sex with men were 8.8 times as likely to seroconvert (95% CI 3.7-20.5) as heterosexual men. Women who reported having traded sex for money in the past year were 5.1 times as likely as others to seroconvert (95% CI 1.9-13.7). Women younger than 40 years were 2.8 times more likely to seroconvert than women 40 years and older (95% CI 1.05-7.6), and women who reported a steady sex partner who injected drugs were 0.32 times less likely to seroconvert than other women (95% CI 0.11-0.92). The researchers conclude that HIV-1 seroconversion among street-recruited IDUs in San Francisco is strongly associated with sexual behavior. HIV-1 risk might be reduced by incorporation of innovative sexual-risk reduction strategies into harm reduction programs. Kral, A.H., Bluthenthal, R.N., Lorvick, J., Gee, L., Bacchetti, P., and Edlin, B. Sexual Transmission of HIV-1 Among IDUs in San Francisco, USA: Risk-Factor Analysis. The Lancet, 357, pp. 1397-1401, 2001.

Factors Associated With Readiness to Change Drug Use Among Needle Exchange Users

In this study, researchers sought to determine if frequent needle exchange program (NEP) use is associated with lower readiness to change drug use. They interviewed 168 NEP clients in Providence, RI regarding drug use, HIV risk, health, and past use of treatment services in 1997 and 1998. Readiness to change was assessed using a 9-step decision ladder. Based on this assessment, 14.3% of the sample were classified as pre-contemplators, 29.2% were in the contemplation stage, and 56.5% were in the determination or readiness to change stage. The researchers found that the mean number of NEP visits was 25.5 among pre-contemplators, 28.7 among contemplators, and 22.5 among those in the determination stage. In multivariate analysis, an inverse relationship between having ever been in alcohol treatment and higher readiness to change drug use was the only significant association. More frequent NEP participation did not impact readiness to change drug use among IDUs. Given the high proportion of NEP clients ready to change drug use, improving linkages between NEP and substance abuse treatment appears warranted. Bluthenthal, R.N., Goginen, A., Longshore, D., and Stein, M. Factors Associated With Readiness to Change Drug Use Among Needle-Exchange Users. Drug and Alcohol Dependence, 62(3), pp. 225-230, 2001.

Longitudinal Study Identifies Sex Differences in HIV Risks Among Injecting Drug Users

Injection drug use directly or indirectly accounts for nearly half the annual HIV infections in the United States today. The changing dynamic of the HIV/AIDS epidemic has also had a significant impact on women and minorities: in 1999, women accounted for 23% of all reported adult AIDS cases in the U.S. and African American and Hispanic ethnic groups accounted for 55% of the cumulative total number of AIDS cases and 77% of AIDS cases in women and girls. Researchers in Baltimore, MD followed a cohort of 1874 IDUs from 1988 to 1998 to investigate drug-related and sexual risk factors for HIV. Participants were 1447 male (77%) and 427 female (23%) HIV-negative IDUs. The median age at enrollment was 35 years; 91% of the participants were African American. Incidence of HIV was 3.14 per 100 person years (95% CI, 2.78-3.53) and did not significantly differ by sex. Younger age independently predicted HIV seroconversion for both men and women. Among men, less than a high school education, recent needle sharing with multiple partners, daily injection, and shooting-gallery attendance independently predicted HIV seroconversion. HIV incidence was double among men who recently engaged in homosexual activity and cocaine injection. Among women, the incidence of HIV was more than double for those recently reporting sexually transmitted diseases. HIV incidence has remained high among IDUs in Baltimore over the past decade. Risk factors for HIV seroconversion differed markedly by sex, with homosexual activity and needle sharing predominant among men and heterosexual activity predominant among women. These findings underscore the importance of interventions for IDUs that are sex-specific and incorporate sexual risk factors. Strathdee, S.A., Galai, N., Safaiean, M., Celentano, D.D., Vlahov, D., Johnson, L., and Nelson, K.E. Sex Differences in Risk Factors for HIV Seroconversion Among Injection Drug Users. Arch Intern Med, 161, pp. 1281-1288, 2001.

Risk Factors Are Compared for Transitions to Injecting In Noninjecting Heroin Users

Researchers sought to compare potential risks for transitioning to injection drug use among noninjecting heroin users with different injecting histories. They recruited 575 noninjecting heroin users for a prospective study on drug use transitions and conducted baseline interviews between March 1996 and July 1998. Of the 575 heroin users, 385 (67%) had never injected (mean age 33 years), 89 (16%) had injected 1-9 times (mean age 33 years), and 101 (18%) had injected "frequently" or at least 10 or more times (mean age 36 years). To be eligible for the study, none of the former injectors had injected drugs at least 6 months prior to the baseline interview. More African Americans had never injected heroin, and more Latinos had injected 10 or more times in the past. Compared to never injectors and those who injected fewer than 10 times, frequent former injectors were more likely to be homeless, unemployed, to be long-time heroin users, to be younger at first heroin use, to have initiated heroin through injecting drug use, to be unafraid of injecting themselves with needles, to sniff heroin with former IDUs, and to have sex partners who were former IDUs. Frequent and infrequent former injectors were twice as likely as never injectors to perceive that their friends thought that it was "OK" to inject drugs. The data suggest the importance of prevention interventions that target risk factors among never and former noninjectors that may lead to transitions or a resumption of injecting. A significant proportion of such risk factors involve these individuals' peers, their relationships, and their social networks. Neaigus, A., Miller, M., Friedman, S., Hagen, D., et al. Potential Risk Factors for the Transition to Injecting Among Noninjecting Heroin Users: A Comparison of Former Injectors and Never Injectors. Addiction, 96, pp. 847-860, 2001.

Improving the Quality of Life Among Young People Living with HIV

A three-module intervention was designed to address the multiple needs of young persons living with HIV (YPLH): (1) Staying Healthy, (2) Acting Safe, and (3) Being Together. YPLH from three cities were assigned by small cohort to either an Immediate Intervention Condition or a Control Condition. Building on the positive effects of the Staying Healthy and Acting Safe Modules, this paper reports the effects of the Being Together Module, an eight-session cognitive-behavioral intervention aimed at improving YPLHs quality of life. The YPLH (n=104) were aged 14-23 (M=21.03); 73% were male; most were Latino (43%) or African American (24%). YPLH in the Immediate Intervention Condition were significantly less emotionally distressed on multiple indices than those in the Control Condition, and those who attended the intervention showed decreasing emotional distress even when controlling for HIV symptomatology. HIV preventive interventions must promote emotional well-being, as well as reduce risk acts and promote health behaviors. Rotheram-Borus, M.J., Murphy, D.A., Wight, R.G., Lee, M.B., Lightfoot, M., Swendeman, D., Birnbaum, J.M., and Wright, W. Improving the Quality of Life Among Young People Living with HIV. Evaluation and Program Planning, 24, pp. 227-237, 2001.

Drug Use, HIV-related Risk Behaviors and Dropout Status of New Admissions and Re-admissions to Methadone Treatment

New entrants to methadone maintenance treatment programs (MMTP) have been reported to have different drug use patterns than readmissions. This study assesses differences between 211 re-admissions and 128 new admissions to a NYC MMTP. Those new to MMTP were found to be less likely to have ever injected drugs (although those who are injecting appear to be engaging in riskier behaviors than re-admissions who are injectors), have used more types of drugs, and used heroin at higher frequencies in the 30 days prior to admission. Within the first three months of treatment, new admissions dropped out at a higher rate than the re-admissions (31% vs. 20%, p <0.05). The most frequent reasons for dropout, for both groups, included "lost to contact" and incarceration. Further research on strategies to address polydrug use of MMTP admissions is needed. Efforts to identify concerns of new admissions early in treatment, and programs to continue drug treatment services to incarcerated clients, are indicated. Deren, S., Goldstein, M.F., Des Jarlais, D.C., Richman, B.L., Kang, S.Y., and Flom, P.L. Drug Use, HIV-Related Risk Behaviors and Dropout Status of New Admissions and Re-admissions to Methadone Treatment, Journal of Substance Abuse Treatment, 20(2), pp. 185-189, Mar 2001.

Methadone Maintenance as HIV Risk Reduction with Street-Recruited Injecting Drug Users

The objective of this study was to compare changes in HIV risk behaviors between street-recruited opiate injectors who entered and remained in methadone maintenance treatment and those who did not. Three hundred sixteen participants were interviewed at baseline, received outreach interventions, and were interviewed again 6 months later. Significant (p <.001) reductions in HIV-related risk behaviors, including frequency of injecting, injecting with used (dirty) needles, and sharing injection paraphernalia, were demonstrated. Participants (31%) who entered and remained in methadone maintenance treatment for at least 90 days before follow-up showed a significantly greater reduction in heroin injections than those who did not. They did not show a greater reduction in using dirty needles or sharing other injection paraphernalia. These findings suggest that although methadone maintenance may reduce injection frequency, it does not reduce other HIV-related risk behaviors beyond what can be accomplished through outreach interventions. Treatment facilities and outreach intervention programs should collaborate to provide a comprehensive approach to reducing HIV risk behaviors among drug injectors both in and out of drug treatment. Kwiatkowski, C.F., and Booth, R.E. Methadone Maintenance as HIV Risk Reduction with Street-Recruited Injecting Drug Users., J Acquir Immune Defic Syndr., 26(5), pp. 483-489, April 2001.

Regular Outpatient Medical and Drug Abuse Care and Subsequent Hospitalization of Persons Who Use Illicit Drugs

Patients and the public could benefit from identification of factors that prevent drug users' heavy reliance on inpatient care. However, optimal health care delivery models for illicit drug users remain ill defined. This paper reports on an evaluation of associations of outpatient medical and drug abuse care with drug users' subsequent hospitalization rates. A retrospective cohort study of data from longitudinally linked claims for all ambulatory physician/clinic services and drug abuse services covered by the New York State Medicaid program was conducted. Participants totaled 11,556 human immunodeficiency virus positive and 46,687 HIV-negative drug users. The following outcome measures were used: hospitalization in federal fiscal year (FFY) 1997 compared by 4 patterns of care in FFY 1996: regular drug abuse care (>/=6 months in 1 program), regular medical care (>35% of care from 1 clinic, group practice, or individual physician), both, or neither. Data indicated that hospitalization occurred in 55.6% of HIV+ and 37.5% of HIV- drug users, with a mean of 27.5 and 24.5 inpatient days, respectively. In HIV+ drug users, the adjusted odds ratio (AOR) for hospitalization was lowest among those with both regular medical and drug abuse care (AOR, 0.76; 95% confidence interval [CI], 0.67-0.85) followed by those with regular medical care alone (AOR, 0.82; 95% CI, 0.74-0.91) and regular drug abuse care alone (AOR, 0.85; 95% CI, 0.76-0.96) versus those with neither. In HIV- drug users, the AOR of hospitalization was lower for those with regular medical and drug abuse care (AOR, 0.73; 95% CI, 0.68-0.79), regular drug abuse care alone (AOR, 0.71; 95% CI, 0.66-0.76), and regular medical care (AOR, 0.91; 95% CI, 0.86-0.95) versus those with neither. Both types of care showed favorable effects for all but drug abuse-related hospitalizations. Study data suggest that regular drug abuse care with regular medical care is associated with less subsequent hospitalization. Laine, C., Hauck, W.W., Gourevitch, M.N., Rothman, J., Cohen, A., and Turner, B.J. Regular Outpatient Medical and Drug Abuse Care and Subsequent Hospitalization of Persons Who Use Illicit Drugs. JAMA., 285(18), pp. 2355-2362, May 9, 2001.

Social Relationships and Intravenous Drug Use Among Methadone Maintenance Patients

This study examined the extent to which social relationships were associated with continued injection drug use and needle sharing among 252 methadone maintenance patients. Logistic regression analyses indicated that drug use was highest among persons who had a substance using live-in partner and among those with more drug-using social relationships. Among injectors, whites and those who had more people present during IV drug use were more likely to share needles, while those with more emotional support were less likely to do so. These findings suggest that personal relationships strongly influence continued injection drug use and that methadone programs should help patients develop social networks of non-users. In this study of persons on methadone maintenance, findings extend the previous literature by indicating the importance of personal relationships, in particular, live-in partners' and friends' drug use in continued opiate use. Investigators found that the existence of both live-in partners and drug-using social relationships influenced continued drug injection. Furthermore, among persons who continued to inject drugs, social circumstance, such as number of people present during injecting was associated with needle-sharing. Nearly one-third of MMTP patients who received high doses of methadone continued to inject illicit drugs. With nearly one-third of these persons sharing needles, many persons in MMTP are at high risk for HIV infection and transmission of HIV. Gogineni, A., Stein, M.D., and Friedmann, P.D. Social Relationships and Intravenous Drug Use Among Methadone Maintenance Patients. Drug and Alcohol Dependence, 64(1), pp. 47-53, September 1, 2001.

Developing Language Skills of Cocaine-Exposed Infants

In a prospective, longitudinal, quasi-experimental, matched cohort design, Singer et al. assessed the association between level of fetal cocaine exposure and auditory comprehension skills underlying speech-language skills at 1 year corrected age. Maternal self-report and meconium assay were used to define 3 cocaine exposure groups, including nonexposure (n = 131), heavy exposure (n = 66), and light exposure (n = 68). After controlling for drug, medical, and environmental factors, several differences among the exposure groups emerged indicating an association between amount of cocaine exposure and poor infant outcomes. Infants in the heavy exposure group received lower total language scores than infants in the light exposure and nonexposure groups. And, in comparison to infants in the nonexposure group, infants in the heavy exposure group received lower auditory comprehension scores and were more likely to be classified as mildly delayed by total language scores. These findings document significant behavioral teratogenic effects of heavy prenatal exposure to cocaine on developmental precursors of speech-language development. Singer, L.T., Arendt, R., Minnes, S, Salvator, A., Siegel, A.C., and Lewis, B.A. Developing Language Skills of Cocaine-Exposed Infants. Pediatrics, 107, pp. 1057-1064, 2001.

The Search for Congenital Malformations in Newborns With Fetal Cocaine Exposure

Using a prospective longitudinal design, Behnke et al. assessed the association between prenatal cocaine exposure and congenital anomalies in a sample of 272 infants of 154 prenatally identified crack/cocaine users and 154 nonusing matched controls (perinatal deaths and infants not examined within 7 days of birth were not included). Mothers' cocaine use during pregnancy was measured using repeated in-depth histories and urine screens. Measured infant outcomes included 16 anthropometric measurements and a checklist of 180 physical features. In comparison to nonexposed infants, exposed infants were more likely to be born prematurely and to have lower mean birthweights, lengths, and head circumferences. Exposed and nonexposed infants did not differ on remaining anthropometric measurements. Timing and amount of cocaine exposure were not associated with infant outcomes, nor was a consistent pattern of abnormalities associated with prenatal exposure identified. Behnke, M., Eyler, F.D., Garvan, C.W., and Wobie, K. The Search for Congenital Malformations in Newborns with Fetal Cocaine Exposure. Pediatrics, 107, e74, 2001.

Drug Use in One's Social Network and Neighborhood Predicts Use of Heroin and Cocaine

Researchers sought to examine the influence of competing social environmental factors on substance abuse. They conducted a longitudinal study to determine the relative power of social network and neighborhood characteristics in predicting continuing illicit drug use. Adults with a history of injecting drug use (N=342) were followed for one year. Their heroin and cocaine use were assessed semiannually. Multiple logistic regression models were fit to determine the degree to which social network and neighborhood characteristics, assessed at baseline, predicted continuing heroin and/or cocaine use throughout the study period. Of the 342 participants, 236 (69%) reported continuing heroin and/or cocaine use. Drug use by members of the social network was a stronger predictor of participants' continuing drug use (OR=4.31, 95% CI 2.51, 7.40) than was a high level of drug-related arrests in the participant's neighborhood (OR=2.41, 95% CI 1.24, 4.71), after adjusting for drug treatment and demographic variables. Both seemed to have independent effects on study participants' drug use. These findings underscore the importance of breaking social ties with drug-using associates, even for those who reside in high-risk environments. Dissociating from drug-using peers and/or developing relationships with nonusers are generally regarded as important treatment goals and incorporated into drug treatment approaches with demonstrated efficacy. The practical application of these findings is to target the social environment for intervention in the context of drug abuse treatment counseling, but further work will be needed to develop substance abuse treatment and prevention strategies that build coping and social skills to minimize drug abuse in high-risk environments. Schroeder, J.R., Latkin, C.A., Hoover, D.R., Curry, A.D., Knowlton, A.R., and Celantano, D.D. Illicit Drug Use in One's Social Network and in One's Neighborhood Predicts Individual Heroin and Cocaine Use. Ann Epidemiol, 11, pp. 389-394, 2001.

Researchers Identify Predictors of Accidental Fatal Drug Overdose Among IDUs

Researchers sought to evaluate factors associated with accidental fatal overdose among a cohort of 2849 injection drug users in King County, Washington. They used a prospective cohort design and identified 72 deaths by electronically merging subject identifiers with death certificate records. Univariate and multivariate Cox regression analyses were performed to identify predictors of overdose mortality. Thirty-two of the 72 deaths (44%) observed were due to accidental overdose. Independent predictors of overdose mortality were bisexual orientation (relative risk [RR]=4.86; 95% CI=2.30,13.2), homelessness (RR=2.30; 95% CI = 1.06, 5.01), infrequent injection of speedballs (RR=4.84; 95% CI= 1.13, 20.8), and daily use of poppers (RR=22.0; 95% CI=1.74,278). This is consistent with other studies among IDUs, which have found that, even with the competing risk of HIV/AIDS, deaths due to accidental overdose remain a major cause of mortality. Bisexual sexual orientation, homelessness, and drug use, including non-injecting use of powdered cocaine and poppers and recent infrequent injection of speedballs, were found to be important, independent predictors of fatal overdose in this cohort. These characteristics identify high-risk IDUs who may benefit from targeted, educational and risk reduction interventions. Driscoll, P.T., McGough, J., Hagan, H., Thoede, H., Critchlow, C., and Alexander, E.R.. Predictors of Accidental Fatal Drug Overdose Among a Cohort of Injection Drug Users. Am J Public Health, 91, pp. 984-987, 2001.

Study Links Recalled Adolescent Peer Norms About Drug Use With Current Drug Use

Drug use among adolescents is a significant social and public health problem in the U.S. and in many other countries. This study explored the relationship between the drug use norms of young adult peers (recalled from age 15) and subjects' current drug use in the past 12 months. Subjects included two samples of 18-24 year olds from a low income, minority neighborhood in New York City, a probabilistically selected household sample, and a targeted sample of users of cocaine, heroin, crack or injected drugs. Norms varied by drug, and were least for marijuana, and increasingly negative for cocaine, heroin, crack, and injected drugs. There was a strong relationship between recalled norms and current use for both individual drugs and a hierarchically defined level of drug use; this relationship remained significant after controlling for socio-demographics and parental and sibling drug use. Intervention programs for young teens that influence peer selection and norms of groups of adolescents should be developed and tested. Research is also needed on the social, economic, political, and other determinants of norms in the neighborhood and community context. Flom, P.L., Friedman, S.R., Kottiri, B.J., Neaigus, A., and Curtis, R. Recalled Adolescent Peer Norms Towards Drug Use in Young Adulthood in a Low-Income, Minority Urban Neighborhood. Journal of Drug Issues, pp. 425-444, Spring 2001.

Improved Antioxidant Status Among HIV-infected Injecting Drug Users on Potent Antiretroviral Therapy

Tang and her colleagues from Tufts examined serum antioxidant levels (retinal, alpha-and gamma-tocopherols, alpha-and beta-carotenes, lycopene, lutein/zeanthin, and beta-cryptoxanthin) in 175 HIV-positive and 210 HIV-negative IVDUs in Baltimore, MD. Of these patients, 30 were receiving antiretroviral therapy (ART) including a protease inhibitor (PI), 43 ART without a PI, 22 on montherapies, and 80 were not on any ART. Among HIV+ subjects, there were significant differences in antioxidant levels by ART regimen. In multivariate models adjusting for injecting drug use, dietary intake, supplement intake, gender, and alcohol intake, significant overall differences by ART regimen were observed for alpha-tocopherol, beta-carotene, and beta-cryptoxanthin. Serum levels of these three antioxidants were significantly higher in the PI group than in the other three ART groups combined. These data provide indirect evidence of the effectiveness of PIs in lowering oxidative stress levels in HIV+ IDUs. Tang, A. Smit, E., Semba, R., Shah, N., Lyles, C.M., Li, D., and Vlahov, D. JAIDS, 23 (4), pp. 321-326, 2000.

Study Links Joint Drug Purchases With Drug Preparation Risk Behaviors Among IDUs

In the process of preparing jointly purchased drugs, IDUs may share drug preparation materials and use a single syringe to distribute injectable drugs. The aim of this study was to examine the association of joint drug purchasing with drug preparation risk behaviors among Puerto Rican IDUs. The study sample comprised 555 IDUs from New York City and 297 from Puerto Rico. IDUs reported pooling money for 12% of the injection episodes in New York, and for 14% of the injection episodes in Puerto Rico. In both study sites, correlation coefficients between frequency of pooling money and drug preparation behaviors were .30 or larger. After controlling for sociodemographics, drugs injected, and injection frequency, pooling money was significantly related to all four drug preparation behaviors in both study sites: using rinse water before or after someone else, drawing the drug from the cooker before or after someone else, transferring drugs from one syringe to another, and squirting the drug solution back into the cooker. Results of this study show that during the preparation and division of injectable drugs, IDUs practice other behaviors beyond the shared use of syringes (i.e., needle sharing) that can expose them to infection with HIV and other blood-borne pathogens. HIV prevention interventions need to be cognizant of the joint purchasing of drugs and its relationship to drug preparation risk behaviors. Colon, H.M., Finlinson, H.A., Robles, R.R., Deren, S., Andia, J., K, S.Y., and Oliver-Velez, D. Joint Drug Purchases and Drug Preparation Risk Behaviors Among Puerto Rican Injection Drug Users. AIDS and Behavior, 5(1), pp. 85-96, 2001.

Study Examines Needle Exchange Program Attendance as Correlate of Injection Risk

Needle sharing has long been recognized as a primary route of HIV infection, but research has also shown that HIV antibody is detectable in injection supplies other than needles. In this study, researchers tested the frequency of attendance at a Providence, Rhode Island needle exchange program (NEP) as a correlate of injection risk, including not just sharing needles, but also sharing cookers, cottons filters, cleaning the skin before injecting, and using bleach as a needle disinfectant. Between 1997 and 1998, they asked 354 individuals seen at the NEP to enroll in the study, of which 248 (70%) consented. All of the respondents reporting injecting on a daily basis in the past month, and most were injecting at least three times a day. Most were injecting cocaine only. Over half of the respondents (56%) reported NEP attendance five or more times per month; most of the less frequent attendees (33% of the sample) reported using the NEP two to four times a month; and the remaining 11% attended the NEP not more than once per month. Results showed that drug users who attended the NEP less frequently were more likely to report needle sharing, less likely to report always cleaning their skin, and more likely to report sharing cookers. The Providence NEP is one at which alcohol swabs and cookers are distributed along with clean needles. These findings suggest that, as part of a comprehensive approach to HIV prevention, NEPs represent a valuable and under-exploited opportunity to promote risk reduction efforts beyond the avoidance of needle sharing. In particular, NEPs should be distributing risk reduction supplies in addition to clean needles and educational information about HIV/AIDS. They should also adopt strategies (e.g., outreach and expanded days and hours of operation) to access persons who are hard-to-reach and at highest risk and to encourage more frequent attendance. Longshore, D., Bluthenthal, R.N., and Stein, M.D. Needle Exchange Program Attendance and Injection Risk in Providence, Rhode Island. AIDS Education and Prevention, 13(1), pp. 78-90, 2001.

Patterns of Needle Acquisition and Correlates of NEP Attendance in Baltimore

Researchers examined factors associated with obtaining syringes from a needle exchange program (NEP) and other safer sources in Baltimore, Maryland. They conducted a cross-sectional, face-to-face survey of 741 drug injectors recruited by snowball sampling techniques. They also conducted a brief open-ended interview with a subsample of respondents. Most of the participants (85%) obtained needles from street needle sellers. Only 8% obtained their needles exclusively from safer sources (NEPs, pharmacies, hospitals, or patients with diabetes). Cocaine use was associated with obtaining needles from the NE but not from exclusively safer sources. Obtaining needles from only safer sources was associated with being female and less frequent needle sharing and shooting gallery attendance. Among HIV-seropositive participants, those who were diagnosed before the year that the NEP began were more likely to obtain needles from safer sources. Participants who sold needles reported that it was easy to make used needles appear to be unused and some admitted selling used needles as new. Street needle sellers are an important source of needles for drug injectors and few injectors appear to be able to determine whether these needles are clean. Individual sealing of diabetic syringes may reduce the risk of blood-borne infections by enabling drug injectors and patients with diabetes to better judge the sterility of the needles they purchase. Latkin, C.A. and Forman, V.L.. Patterns of Needle Acquisition and Sociobehavioral Correlates of Needle Exchange Program Attendance in Baltimore, Maryland. J Acquir Immune Defic Syndr, 27(4), pp. 398-404, 2001.

HIV Risks Among IDUs in Low, Medium, and High Seroprevalence Communities

Researchers compared HIV-related risk behaviors for IDUs across communities with low, moderate, and high seroprevalence rates among IDUs. They analyzed interview data collected from 12,072 seronegative IDUs who participated in a large, 22-site HIV prevention program (i.e., NIDA's Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research Program). The 22 sites were categorized according to seroprevalence among IDUs: sites with seropositive rates of 5% or less were classified as having low seroprevalence, sites with 6%-19% were classified as moderate, and sites with rates of 20% or higher were classified as high seroprevalence; 10 sites were classified as low, 8 sites as moderate, and 4 sites as high. Data on injection risk behaviors showed significantly higher rates of injection in high seroprevalence communities, almost 2.5 times higher than in low and moderate seroprevalence communities (186.0 vs 79.2 [low] and 60.7 [moderate]). Higher percentages of IDUs in low seroprevalence communities reported using other syringes (52%) and paraphernalia (59%) compared with sites having moderate and high seroprevalence levels. IDUs in low seroprevalence sites also reported the highest rate of giving or loaning their used syringes (45% vs 33% in moderate and high seroprevalence level communities). IDUs from high seroprevalence communities were least likely to report engaging in sex in the 30 days prior to the interview (54% vs 75% in the sites with lower seroprevalence levels). Among those who reported engaging in sex, IDUs in lower seroprevalence sites reported the highest rates of having sex with another IDU during the preceding 30 days (51% vs 41% and 30% in moderate and high seroprevalence sites, respectively). Injection- and sex-related risk behaviors were significantly higher in low seroprevalence communities. These differences have implications for developing risk reduction messages and deploying HIV intervention strategies on a continual basis across all IDU communities. Deren, S., Beardsley, M., Coyle, S., Singer, M., and Kang, S. HIV Risk Behaviors Among Injection Drug Users in Low, Medium, and High Seroprevalence Communities. AIDS and Behavior, 5(1), pp. 45-50, 2001.

Concurrence of Drug Users' Self-Reports of Current HIV Status and Serotest Results

This study examined the concurrence of drug users' self-reports of current HIV status with serotest results. The analyses are based on data obtained from face-to-face interviews with 7,256 out-of-treatment injection drug and/or crack users in 10 sites that participated in NIDA's Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research Program. Although the degree of concurrence between HIV-negative individuals' self-reports of their current HIV status and their serostatus results was high (specificity, 99%), this was not the situation for persons who tested positive for HIV (specificity 44%). Lack of concurrence between self-report of HIV status and serotest results was most pronounced among individuals who tested positive for HIV. HIV-seropositive persons who injected drugs but did not use crack were more likely than crack users to report that they were HIV-positive. In this study, prevalence estimates based on self-report were found to significantly underestimate the number of individuals who were infected with HIV. These results suggest the importance of empirically assessing current HIV status among drug users through biologic testing for the virus. In addition, more attention needs to be given to the placing and wording of questions used to elicit self-report of current HIV status; for example, disclosure of HIV status may be more socially acceptable if questions that elicit HIV status are prefaced with a statement that many individuals in the community have the virus. Strauss, S.M., Rindskopf, D.M., Deren, S., and Falkin, G.P. Concurrence of Drug Users' Self-Report of Current HIV Status and Serotest Results, J Acquir Imm Defic Syndr, 27(3), pp. 301-307, 2001.

Predictors of Condom Use Among Young Adults in High-Risk Neighborhoods

Researchers sought to determine predictors of condom use in the heterosexual non-commercial sexual relationships of young adults who neither inject drugs nor use cocaine, heroin, or crack, in a neighborhood with widespread drug-use-connected HIV. They analyzed data from a sample of 279 young adults, aged 18-24, who have never injected drugs or used heroin, cocaine, or crack in the last year. The subjects were recruited from the Bushwick neighborhood of New York City from July 1997 to September 1999. A face-to-face interview included items about sociodemographic background, substance use, and sexual networks. The focus of the analysis was on self-reported sexual relationships and consistent (100%) condom use over the prior year with the partner. Subjects had 337 heterosexual non-commercial relationships. Consistent condom use was reported in 32% of the relationships. In multiple logistic regression, consistent condom use was more likely in relationships that were not "very close" (odds ratio[OR]=3.92, 95% CI=2.08, 7.52); and in relationships of subjects whose peer norms support condom use (OR=1.94, 95% CI=1.43, 2.69) and who are not problem drinkers (OR=8.70, 95% CI=2.22, 58.8). Consistent condom use remains uncommon among youth in this high-risk neighborhood. It is important to keep HIV from entering the sexual networks of youth in communities such as this through programs aimed at drug injectors and their sexual partners. Programs to increase condom use among young adults should focus on strengthening norms that promote safer sex to protect oneself and others. In addition, because problem drinking is related to less condom use among young adults in this study, assistance should be given to youth who are problem drinkers. Friedman, S.R., Flom, P.L., Kottiri, B.J., Neaigus, A., Sandoval, M., Curtis, R., Des Jarlais, D.C., and Zenilman, J.M. Consistent Condom Use in the Heterosexual Relationships of Young Adults Who Live in a High-HIV-Risk Neighborhood and Do Not Use "Hard Drugs." AIDS Care, 13(3), pp. 285-296, 2001.

HIV Risk Networks and HIV Transmission Among Injecting Drug Users

This research sought to demonstrate how injecting drug users' HIV risk networks affect their risk for HIV infection and influence their HIV risk behaviors. Concepts utilized in a network approach were specified, including (1) the distinction between risk networks (the people with or among whom IDUs, or others at risk of infection with HIV, engage in HIV risk behaviors) and social influence networks (the people who shape each others behavior), (2) the extent to which risk networks and social influence networks overlap, and (3) three levels of network analysis i.e., the dyad, personal networks, and sociometric networks. The role of IDUs' risk networks in the transmission of HIV and their influence on promoting and preventing HIV risk behaviors have been demonstrated in a number of studies of IDUs in New York City and other locations. By studying IDUs risk networks as conduits of HIV infection, network analysis can help in the identification of network structures that promote HIV transmission, such as bridge populations and concurrent partnerships. Network analysis can also help to identify and locate socially identifiable groups, such as "core groups," that may perpetuate the HIV epidemic among IDUs and may also be a major source for the heterosexual spread of HIV to other populations. The identification of such high-risk groups and network structures can help to target interventions where they have the most effect. Neaigus, A., Friedman, S.R., Kottiri, B.J., and Des Jarlais, D.C. HIV Risk Networks and HIV Transmission Among Injecting Drug Users. Evaluation and Program Planning, 24, p. 226, 2001.

Sexual Transmission of HIV-1 Among Injection Drug Users in San Francisco, USA: Risk Factor Analysis

Many new HIV-1 infections in the USA occur in injection drug users (IDUs). HIV-1 seroconversion of IDUs is mainly associated with injection-related risk factors. Harm reduction programs concentrate on injection-risk behavior. The aim of this study was to establish whether injection or sexual risk factors, or both, were associated with HIV-1 antibody seroconversion of street-recruited IDUs in San Francisco, from 1986 to 1998. IDUs were enrolled every 6 months from four community sites. Investigators did a nested case control study comparing 58 respondents who seroconverted between visits with 1134 controls who remained seronegative. Controls were matched with cases by sex and date. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated for men and women by use conditional logistic regression. Men who had sex with men were 8.8 times as likely to seroconvert (95% CI = 3.7, 20.5) as heterosexual men. Women who reported having traded sex for money in the past year were 5.1 times as likely as others to seroconvert (95% CI = 1.9, 13.7). Women younger than 40 years were more likely to seroconvert than those 40 years or older (AOR=2.8; 95% CI=1.05, 7.6), and women who reported having a steady sex partner who injected drugs were less likely to seroconvert than other women (AOR=0.32; 95% CI=0.11, 0.92). HIV-1 seroconversion of street-recruited IDUs in San Francisco is strongly associated with sexual behavior. HIV-1 risk might be reduced by incorporation of innovative sexual-risk reduction strategies into harm-reduction programs. Kral, A.H., Bluthenthal, R.N., Lorvick, J., Gee, L., Bacchetti, P., and Edlin, B.R. Sexual Transmission of HIV-1 Among Injection Drug Users in San Francisco, USA: Risk Factor Analysis. Lancet, 357, pp. 397-401, 2001.

Gender Differences in HIV-related Sexual Risk Behavior among Urban African American Youth: a Multivariate Approach

Alcohol and other drug (AOD) use during sexual encounters, sexual partner's age, perceived HIV risk and perceived condom effectiveness were studied among 388 sexually active African American youth. Cluster analysis of condom use, number of partners, and frequency of sexual intercourse identified four groups: low risk, monogamy strategy, condom strategy, and high risk. Low-risk youth used condoms consistently and had few partners. High-risk youth used condoms inconsistently with many partners. Monogamy strategy youth used condoms inconsistently but had few partners. Condom strategy youth used condoms consistently with a moderate number of partners. The high-risk group included more males and the monogamy group included more females. High-risk males reported more AOD use during sexual activity than all females, and low-risk or condom strategy males. Females had older partners, rated condoms as less effective and perceived lower HIV/AIDS risk than males. Results suggest differential HIV risk mechanisms by gender. Implications for gender-specific HIV prevention are discussed. Newman, P.A., and Zimmerman, M.A. Gender Differences in HIV-related Sexual Risk Behavior among Urban African American Youth: A Multivariate Approach. AIDS Educ Prev,12(4), pp. 308-325, 2000.

Perspectives on Use of Vaginal Microbicides Among Drug-Involved Women

A study was conducted to obtain potential users' perspectives on vaginal microbicides from a population of women at high risk for HIV. Using street outreach sampling techniques, researchers interviewed 743 drug-using women and female sexual partners of male IDUs in Bridgeport, Connecticut, Providence, Rhode Island, and San Juan, Puerto Rico. All of the women were current users of heroin and/or cocaine. Ninety percent of the women said they would be very likely to use micobicides with paying partners (who paid for sex with money or drugs) and 78% with primary partners (p=0.001). Even after potential product characteristics were rated as unacceptable, such as irritation or burning, women expressed a high likelihood of potential use. Latinas had significantly higher predicted likelihood of use with primary (p=0.001) and paying partners (p=0.018) than blacks and whites. Eighty percent of respondents preferred products that provided additional lubrication. More than 80% of respondents said they would want their primary partners to know of their microbicide use and 42% (p=0.001) said that they would want their paying partners to know. Women's concern about a paying partner's violent response to suggested use of risk reduction measures was inversely related to predicted likelihood of microbicide use (p=0.045). Microbicides should be assessed in the context of the potential users' actual relationships and cultures. Achieving broad acceptability among drug-involved women will require a range of products. Hammett, T.M., Norton, G.D., Mason, T.H., Langenbahn, S., Mayer, K.H., Robles, R.R., Feudo, R., and Seage, G. Drug-Involved Women as Potential Users of Vaginal Microbicides for HIV and STD Prevention: A Three-City Survey. Journal of Women's Health and Gender-Based Medicine, 9(10), pp. 1071-1080, 2000.

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