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Director's Report to the National Advisory Council on Drug Abuse - September, 2003

Research Findings - Research on AIDS and Other Medical Consequences of Drug Abuse - AIDS Research

Psychological Burden in the Era of HAART: Impact of Selenium Therapy

Shor-Posner and her colleagues at the University of Miami conducted a randomized, double-blind, placebo-controlled selenium therapy (200g/day) trial in HIV+ drug users to determine the impact of nutritional (selenium) chemo-prevention on levels of psychological burden (anxiety, depression, and mood state) in HIV/AIDS. Psychosocial measures (STAI-State and Trait anxiety, BDI-depression, and POMS- mood state), clinical status (CD4 cell count, viral load), and plasma selenium levels were determined at baseline and compared with measurements obtained at the 12-month evaluation in 63 participants (32 men, 31 women). Results showed that the majority of the study participants reported elevated levels of both State (68%) and Trait (70%) anxiety. Approximately 25% reported overall mood distress (POMS >60) and moderate depression (BDI > 20). Psychological burden was not influenced by current drug use, antiretroviral treatment, or viral load. At the 12-month evaluation, participants who received selenium reported increased vigor (p = 0.004) and had less anxiety (State, p = 0.05 and Trait, p = 0.02), compared to the placebo-treated individuals. No apparent selenium-related affect on depression or distress was observed. The risk for state anxiety was almost four times higher, and nearly nine times greater for trait anxiety in the placebo-treated group, controlling for antiretroviral therapy, CD4 cell decline (> 50 cells) and years of education. The authors concluded that selenium therapy may be a beneficial treatment to decrease anxiety in HIV+ drug users who exhibit a high prevalence of psychological burden. Shor-Posner, G., Lecusay, R., Miguez, M.J., Moreno-Black, G., Zhang, G., Rodriguez, N., Burbano, X., Baum, M.and Wilkie, F. Psychological Burden in the Era of HAART: Impact of Selenium Therapy, Int'l. J. Psychiatry in Medicine, 33, pp. 55-69, 2003.

The Association of Hepatitis C Prevalence, Activity, and Genotype with HIV Infection in a Cohort of New York City Drug Users

Factors associated with serum HCV antibody, HCV RNA level, and HCV genotype were assessed in 557 current and former drug users. Additional assays included HIV antibody, CD4+ lymphocyte counts, HIV viral loads, and hepatitis B markers. Seventy-five percent of subjects were anti-HCV positive, of whom 75% had detectable HCV RNA (median, 5.04 x 10(5) IU/mL; range, 1020-15.7 x 10(6)). On multivariate analysis HCV seropositivity was associated with history of drug injection, HIV seropositivity, and increased age and inversely with drug snorting. Among anti-HCV-positive persons, detectable HCV RNA was independently associated with HIV seropositivity, male gender, and history of injection and inversely associated with hepatitis B surface antigen positivity. Among persons with detectable HCV RNA, higher levels were independently associated with higher HIV viral load, increased age, and genotypes 2a and 2b. These findings demonstrate an association of HCV RNA level with HIV viral load, independent of the level of immunosuppression. However, a substantial degree of the person-to-person variability in the prevalence and level of detectable HCV RNA remains unexplained. Strasfeld, L., Lo, Y., Netski, D., Thomas, D.L. and Klein, R.S. J Acquir Immune Defic Syndr. 33(3), pp. 356-364, July 1, 2003.

Prevalence of and Risk Factors for Viral Infections Among Human Immunodeficiency Virus (HIV)-Infected and High-Risk HIV-Uninfected Women

Viruses that can persist in the host are of special concern in immunocompromised populations. Among 871 human immunodeficiency virus (HIV)-infected and 439 high-risk HIV-uninfected women, seroprevalences of cytomegalovirus, hepatitis B virus, hepatitis C virus, and herpes simplex virus types 1 and 2 and prevalence of human papillomavirus DNA in cervicovaginal lavage fluids were all >50% and were 2-30 times higher than prevalences in the general population. Prevalences were highest among HIV-infected women, of whom 44.2% had >or=5 other infections, and were relatively high even among the youngest women (age 16-25 years). In multivariate analyses, viral infections were independently associated not only with behaviors such as injection drug use and commercial sex but also with low income, low levels of education, and black race. Disadvantaged women and women who engage in high-risk behaviors are more likely to be coinfected with HIV and other viruses and, thus, may be at high risk of serious disease sequelae. Stover, C.T., Smith, D.K., Schmid, D.S., Pellett, P.E., Stewart, J.A., Klein,,R.S., Mayer, K., Vlahov, D., Schuman, P. and Cannon, M.J. HIV Epidemiology Research Study Group. J Infect Dis., 187(9), pp. 1388-1396, May 1, 2003. Epub April 15, 2003.

Clinical and Immunologic Progression in HIV-Infected US Women Before and After the Introduction of Highly Active Antiretroviral Therapy

The objective of this study was to examine factors associated with clinical and immunologic HIV disease progression in a cohort of US women. Data from a prospective, longitudinal, case-control study of HIV-infected women followed every 6 months for 7 years in four urban clinical centers in the United States were analyzed. Participants were 648 HIV-infected women who did not have AIDS at time of entry into the study. Structured clinical and behavioral interviews, protocol-directed physical examinations, CD4 lymphocyte counts, plasma HIV RNA, and infectious pathogen serologies were performed. With 2304 women-years of follow-up, 46.1% of the women developed AIDS; however, 93.3% of the diagnoses were based on CD4 counts dropping to <200 cells/mm3. Only 10.6% of the women with CD4 counts <200 cells/mm3 developed an opportunistic infection. Baseline CD4 count was the strongest predictor of subsequent clinical progression. Illicit substance use, multiple pregnancies, demographic variables, and other infections were not associated with progression. Among women with CD4 counts >500 cells/mm3 at baseline, those who were anemic or had hepatitis C were more likely to progress to AIDS. By the end of the study, only 52% of the participants were on highly active antiretroviral therapy (HAART). Despite underutilization of HAART in this multicenter cohort of urban women, opportunistic infections were uncommon, despite CD4 declines. Mayer, K.H., Hogan, J.W., Smith, D., Klein, R.S., Schuman, P., Margolick, J.B., Korkontzelou, C., Farzedegan, H., Vlahov, D. and Carpenter, C.C. HIV Epidemiology Research Study (HERS) Group. J Acquir Immune Defic Syndr. 33(5), pp. 614-624, August 15, 2003.

Home Intervention for Mothers and their Drug-Exposed Infants

This longitudinal randomized cohort study assessed the effects of a home intervention and ongoing maternal drug use on developmental outcomes of drug-exposed infants. Participants included 108 low-income, inner-city, drug-exposed children and their biological mothers (control, 54; intervention, 54). Results suggest that, compared to control infants, intervention infants had significantly higher Bayley Scales of Infant Development (BSID) Mental Development Index (MDI), and BSID Psychomotor Developmental Index (PDI) scores during the first 18 months post partum. Furthermore, ongoing maternal drug use was associated with worse developmental outcomes for both groups. Schuler, M.E., Nair, P., and Kettinger, L. Drug Exposed Infants and Developmental Outcome: Effects of a Home Intervention and Ongoing Maternal Drug Use. Archives of Pediatrics & Adolescent Medicine, 157, pp. 133-138, 2003.

Increased Density of Neurons Containing NADPH Diaphorase and Nitric Oxide

Synthase in the Cerebral Cortex of Patients with HIV-1 Infection and Drug Abuse To determine whether nitrogen monoxide (nitric oxide; NO) synthase (NOS) and NADPH diaphorase (NDP) co-containing cerebrocortical neurons (NOSN) are affected in patients infected with human immunodeficiency virus type 1 (HIV 1) with and without associated intake of drugs of abuse, authors examined the temporal neocortex of 24 individuals: 12 HIV-1 positive (including 3 drug users, 9 non-drug users) and 12 HIV-1 negative (including 6 drug users and 6 non-drug users). Histochemical labeling for NDP-an enzymatic domain co-expressed in the NOS enzyme was employed to visualize NOSN. Drug abuse and HIV-1 infection cause independently an increase in NOSN density, but combined they result in up to a 38-fold increase in NOSN density, suggesting that the combination of these factors induces NOS expression powerfully in neurons that normally do not synthesize NDP/NOS. This is associated with an increase in the proportion of NOSN displaying dystrophic changes, indicating that NOSN undergo massive degeneration in association with NOS synthesis induction. The increase in density of NOSN in HIV-1 infected drug abusers may be among the important sources of NO mediating cerebrocortical dysfunction, and the degeneration of NOS containing local circuit neurons in patients with HIV-1 infection or drug abuse may underlie in part their neuropsychiatric manifestations. Kuljis, R.O., Shapshak, P., Alcabes, P., Rodr’guez, de la Vega, P., Fujimura, R. and Petito, C. Journal of NeuroAIDS. 2(3), pp. 19-36, 2002.

The Role of Macrophase/Microglia and Astrocytes in the Pathogenesis of Three Neurologic Disorders: HIV Associated Dementia, Alzheimer's Disease, and Multiple Sclerosis

Macrophage/microglia (M∅) are the principal immune cells in the central nervous system (CNS) concomitant with inflammatory brain disease and play a significant role in the host defense against invading microorganisms. Astrocytes, as a significant component of the blood -- brain barrier, behave as one of the immune effecter cells in the CNS as well. However, both cell types may play a dual role, amplifying the effects of inflammation and mediating cellular damage as well as protecting the CNS. Interactions of the immune system, M∅, and astrocytes result in altered production of neurotoxins and neurotrophins by these cells. These effects alter the neuronal structure and function during pathogenesis of HIV-1 associated dementia (HAD), Alzheimer disease (AD), and multiple sclerosis (MS). HAD primarily involves subcortical gray matter, and both HAD and MS affect sub-cortical white matter. AD is a cortical disease. The process of M∅ and astrocytes activation leading to neurotoxicity share similarities among the three diseases. Human Immunodeficiency Virus (HIV)-1 infected M∅ are involved in the pathogenesis of HAD and produce toxic molecules including cytokines, chemokines, and nitric oxide (NO). In AD, M∅s produce these molecules and are activated by _-amyloid proteins and related oligopeptides. Demyelination in MS involves M∅ that become lipid laden, spurred by several possible antigens. In these three diseases, cytokine chemokine communications between M∅ and astrocytes occur and are involved in the balance of protective and destruction actions by these cells. This review describes the role of M∅ and astrocytes in the pathogenesis of these three progressive neurological diseases, examining both beneficent and deleterious effects in each disease. Minagar, A., Shapshak, P., Fujimura R., Ownby, R., Heyes, M., and Eisdorfer, C. Journal of the Neurological Sciences, 202, pp. 13-23, 2002.

Brain Macrophage Surface Marker Expression with HIV-1 Infection and Drug Abuse: A Preliminary Study

The goal of this study was to determine the heterogeneity of surface marker expression of macrophages in the temporal lobe of patients who died with AIDS who were also drug abusers (DAs). Authors studied the expression of macrophage surface markers CD11c, CD14, CD68, and HLA-DR and T cell surface markers CD4 and CD8. The macrophage is the prime locus for HIV-1 associated pathology, the most frequently infected cell in the brain, and has the highest virus load compared to other cells. The current authors previously described the heterogeneity of macrophage surface maker expression and performed morphometric analysis in peripheral nerves of patients who died from AIDS compared to HIV-1 negative individuals and showed that the HIV-related neuropathy in AIDS is a multifocal process. It is similarly important to determine the expression of macrophage surface markers in brain. Temporal lobe tissue was selected for this preliminary study because authors previously found elevated HIV-1 proviral DNA load and inflammatory processes in this neuroanatomic location for subjects who died with AIDS. There is a high prevalence of drug abuse in Miami, Florida, associate with AIDS that may interactively affect HIV-associated pathology. Temporal lobe tissue was examined from 17 HIV-1-seropositive patients (4 with drug abuse and 13 without drug abuse) and 11 HIV-seronegative individuals (5 with drug abuse and 6 without drug abuse). Standard immunohistochemistry utilized alkaline phosphatase conjugate secondary antibody and fuchsin substrate. Authors found that HIV-1 infection and the interaction of HIV-1 infection and drug abuse produced changes in macrophage surface marker expression. Macrophage surface markers, CD11c, CD14, CD68, and HLA-DR, and T-cell marker CD4 were increased with statistical significance due to HIV-1 infection (all p<.001) whereas CD8 remained unchanged. Changes due to drug abuse alone were not significant. Interaction of drug abuse and HIV-infected individuals showed increased expression of CD68 (p=.011), HLA-DR (p=.001), CD4 (p=.027), and CD8 (p=.016). The authors concluded that drug abuse and HIV-1 infection are factors that differentially and interactively result in multiple macrophages surface marker effects. In HIV-1 infected individuals, drug abuse stimulates surface marker expression. Since brain macrophage surface markers do not change uniformly as a result of drug abuse and HIV infection, these cells may be heterogeneous and contain sub-types (sub-sets). It remains to be determined which macrophage sub-types may be most pathognomic for pathology. Shapshak, P., Stewart, R.V., Rodriguez de la Vega, P., Dom’nguez, B., Fujimura, R., Segal, D.M., Sun, N.C.J., Delgado, S. and Petito, C. Journal of NeuroAIDS, 2(3), pp. 37-50, 2002.

HIV and Hepatitis C Virus Risk in New and Longer-Term IDUs in Oslo, Norway

Research has focused on understanding injecting drug use initiation in the era of HIV/AIDS. However, differences between new and longer-term injecting drug users (IDUs) have not received as much attention. This study examined injecting initiation experience, risk and risk reduction practices, and self-reported HIV and hepatitis C virus (HCV) testing practices and infection among new (injecting < or =4 years) and longer-term IDUs. Data from 3 cross-sectional surveys in 1992, 1994, and 1997 of syringe exchange program (SEP) users in Oslo, Norway, were used. Approximately one fifth of IDUs were new injectors. New IDUs were increasingly indistinguishable from longer-term IDUs in terms of socio-demographics, risk practices, and HIV and HCV testing. The prevalence of HIV infection remained low (5%); in contrast, approximately two thirds of all SEP users reported being HCV-infected. Known HCV infection status had no impact on syringe sharing; most HCV-infected SEP users reported sharing syringes, regardless of the duration of injecting. The only variable associated with HCV infection was injecting < or =4 years (adjusted odds ratio = 0.2; 95% confidence interval = 0.1-0.4). Increased similarity in age between new and longer-term IDUs may have contributed to the rapid spread of HCV infection by facilitating mixing patterns between HCV-infected and -susceptible IDUs. Miller, M., Mella, I., Moi, H. and Eskild, A. HIV and Hepatitis C Virus Risk in New and Longer-Term Injecting Drug Users in Oslo, Norway. JAIDS, 33(3), pp. 373-379, July 1, 2003.

Staphylococcus Aureus Colonization in a Community Sample of HIV+/- Drug Users

HIV-infected individuals, especially those with a history of injecting drug use, are at high risk of S. aureus infection. Moreover, the use of antimicrobial agents for opportunistic infections may increase nasal colonization by antimicrobial-resistant S. aureus in this population and, subsequently, levels of infection with multidrug-resistant S. aureus in the community. From February 1999 and March 2000, 500 subjects from a community-based cohort of drug users completed an interview and underwent a physical exam. Risk factors for colonization by S. aureus were examined, the antibiotic susceptibility profiles of all strains were determined, and DNA strain analysis was performed. One hundred twenty (24%) subjects had positive S. aureus nasal cultures. Only HIV infection and homelessness were associated with S. aureus colonization. Ten (8%) isolates were methicillin-resistant S. aureus. Methicillin-resistant S. aureus isolates were found more frequently among HIV-infected than HIV-uninfected respondents (14% vs. 3%, P=0.04). Among those colonized and HIV infected, the mean number of resistant isolates was higher for those currently reporting antibiotic use (5.0 vs. 2.3, P<0.001) and for those with CD4+ counts

Intervention Response Rates Among Drug-Using Women

Injection drug users (IDUs) who also smoke crack may be at greatest risk for infection with HIV as well as other blood-borne and sexually transmitted infections and in most need of positive behavioral changes. In this study, researchers randomly assigned 333 women (aged 18-59 years) to one of two enhanced gender- and culturally specific HIV intervention conditions or to the NIDA standard condition. Of primary interest were baseline risk and intervention response rates among three groups of drug users--IDUs who did not smoke crack, IDUs who did smoke crack, and crack smokers who did not inject. Using univariate and multivariate methods, including generalized estimating equations, the study found that the intervention produced positive behavioral changes over time, but that response rates varied according to drug-using group. Women in the crack smoking IDU group were found to be less responsive to the intervention than women in the other drug-using groups, and participants in the crack smoking only group were less responsive than those in the IDU only group. These findings indicate that there is a continuing need to develop and target improved, effective interventions to particular subgroups of high-risk individuals who may be most resistant to change. Sterk, C., Theall, K. and Elifson, K. Who's Getting The Message? Intervention Response Rates Among Women Who Inject Drugs and/or Smoke Crack Cocaine. Prev Med., 37(2), pp. 119-128, August 2003.

Migration and HIV Risk Behaviors: Puerto Rican Drug Injectors in New York City and Puerto Rico

Researchers compared injection-related HIV risk behaviors of Puerto Rican current injection drug users living in New York City and in Puerto Rico who also had injected in the other location with those who had not. They recruited 561 Puerto Rican IDUs in New York and 312 in Puerto Rico. Of the former, 39% were newcomers, having previously injected in Puerto Rico; of the latter, 14% were returnees, having previously injected in New York. Risk behaviors were compared within each sample between those with and without experience injecting in the other location. Newcomers reported higher levels of risk behaviors than other New York IDUs. Newcomer status (adjusted OR= 1.62) and homelessness (adjusted OR = 2.52) were significant predictors of shooting gallery use; newcomer status also predicted paraphernalia sharing (adjusted OR = 1.67). Returnee status was not related to these variables. These findings underscore the importance of targeting HIV intervention services to reach mobile populations who move between environments characterized by high-risk and low-risk behaviors. Deren, S., Kang, S.Y., Colon, H., Andia, J., Robles, R., Oliver-Velez, D. and Finlinson, A. Migration and HIV Risk Behaviors: Puerto Rican Drug Injectors in New York City and Puerto Rico. Amer J Public Health, 93, pp. 812-816, 2003.

HIV Prevalence, Risk Behaviors, and High-Risk Sexual and Injection Networks Among Young Women Injectors Who Have Sex With Women

Women who inject drugs and have sex with women constitute 20% to 30% of American women IDUs. Compared with other women IDUs, this group has higher prevalence and incidence of HIV, and a greater likelihood of engaging in high-risk injection and sexual practices with men. In this study, researchers examined HIV risk among women who inject drugs and have sex with women, and compared their social situations, injection and social networks, and behaviors with those of other young women IDUs. A sample of 803 women IDUs was recruited from 5 U.S. cities between July 1997 and March 1999, of which 274 reported having had sex with a woman in the past 6 months or identifying as lesbian or bisexual. Compared to the other women IDUs, those who had sex with women were more likely to have been recently homeless, to have ever been institutionalized in a mental health facility, and to have been incarcerated. They were more likely to receive most of their income from selling sex than from other sources. Women who inject drugs and have sex with women were more likely to have injected drugs with a person who was HIV positive, and to be positive for hepatitis B and HIV (but not hepatitis C, chlamydia, or gonorrhea), in high prevalence but not low prevalence sites. They were also more likely to have engaged in receptive syringe sharing, and to have shared rinse water. These differences cannot be accounted for by their greater involvement in sex work. The findings show that sexual identity and sex between women are important in studies of women drug users, and may help explain variations in homelessness, institutionalization, behavior, networks, and infection rates. Friedman, S.R., Ompad, D., Maslow, C., Young, R., Case, P., Hudson, S., Diaz, T., Morse, E., Bailey, S., Des Jarlais, D., Perlis, T., Hollibaugh, A. and Garfein, R. HIV Prevalence, Risk Behaviors, and High-Risk Sexual and Injection Networks Among Young Women Injectors Who Have Sex With Women. Amer J Public Health, 93, pp. 902-906, 2003.

Rapid Assessment of the HIV/AIDS Crisis in Racial and Ethnic Minority Communities: An Approach for Timely Community Interventions

In 1998, the US Department of Health and Human Services, in collaboration with the Congressional Black Caucus, created a new initiative to address the disproportionate ongoing HIV/AIDS crisis in racial/ethnic minority populations. The initiative included deploying technical assistance teams through the Office of HIV/AIDS Policy. The teams introduced rapid assessment and response (RARE) methodologies and trained minority communities in their use. The first 3 eligible cities (Detroit, Miami, and Philadelphia) focused assessments in small geographic areas, using multiple methodologies to obtain data. The data indicate that high-risk drug and sexual behavior result in local and commuter mixing of risk groups and produce concurrent and sequential exposure to multiple and overlapping HIV transmission risk among bridge populations. RARE is a useful strategy for rapidly obtaining local data about changes in an epidemic in small geographic areas. It helps to focus on persons at risk in specific environments. It also provides a mechanism to link assessment data to the rapid deployment of new intervention strategies based on site- and culture-specific risk taking. Needle, R.H., Trotter, R.T., Singer, M., Bates, C., Page, B., Metzger, D., and Marcelin, L. Rapid Assessment of the HIV/AIDS Crisis in Racial and Ethnic Minority Communities: An Approach for Timely Community Interventions. Amer J Public Health, 93, pp. 970-979, 2003.

Failure to Return for HIV Posttest Counseling in an STD Clinic Population

Researchers assessed the extent of and characteristics associated with failure to return (FTR) for HIV posttest counseling in persons undergoing an HIV test during their visit to a sexually transmitted disease (STD) clinic. The study population included all 101 newly diagnosed HIV-infected subjects and 411 matched HIV-uninfected subjects, identified over a 5-year period in a publicly funded STD clinic in the southeastern United States. Overall, 55% of subjects failed to return for their test results. HIV testing history, demographic characteristics, and STD diagnosis were associated with FTR. Of clients testing HIV-positive, 58% failed to return. A median of 12 days was required for disease intervention specialists (DIS) to locate HIV-infected subjects who failed to return. Clients with a history of drug use, including injection drug use, were unlikely to return for their posttest counseling appointment (66% vs 34% for those without a history of drug use; p=.02). FTR was least likely among MSM and clients who engaged in other high-risk behaviors (sex for drugs or money, sex with an IDU, sex with an HIV+ contact or recipient of blood products). This study found that the proportion of persons returning for HIV antibody test results is low among patients tested while seeking STD services. Considerable time and effort is required to find and notify those subjects testing HIV-positive who fail to return. To maximize the potential benefit of counseling and testing, interventions need to be designed to target those at highest risk of not returning. Hightow, L., Miller, W., Leone, P., Wohl, D., Smurzynski, M., and Kaplan, A. Failure to Return for HIV Posttest Counseling in an STD Clinic Population. AIDS Educ Prev., 15(3), pp. 282-290, June 2003.

Drug-Scene Roles and HIV Risk Among Puerto Rican Injection Drug Users in East Harlem, New York and Bayamon, Puerto Rico

This article describes and compares distributions of drug-scene roles, frequency of engaging in role behaviors, and relationships of roles, high-risk behaviors, and sexual partnerships among Puerto Rican injection drug users in New York and Puerto Rico. For this study, 561 street-recruited injection drug users in East Harlem, New York, and 312 in Bayamon, Puerto Rico were asked the number of days (in the last 30) in which they earned money or drugs in each of seven drug-scene roles; and about behaviors and egocentric risk partner characteristics in the last 30 days. East Harlem subjects were more likely to get resources by selling drugs and syringes, and buying drugs for someone else; Bayamon subjects were more likely to be "hit doctors," buy needles for others, operate a shooting gallery, or escort others to shooting galleries. All roles were part-time except shooting gallery management in East Harlem. About 27% of respondents at each site engaged in two or more roles. Many roles were associated with increased odds of injecting more than twice a day, receptive syringe sharing, distributive syringe sharing, receptive paraphernalia sharing, and having a drug-injecting sex partner. Drug-scene role structures vary between cities. Most roles are part-time pursuits. Role-holders have higher-risk behaviors and sexual partnerships than other drug injectors. Although further research is needed, drug-scene role-holders should be targeted for interventions to affect their own risk and their communications with others. Friedman, S., Kang, S., Deren, S., Robles, R., Colon, H., Andia, J., Oliver-Velez, D. and Finlinson, A. Drug-Scene Roles and HIV Risk among Puerto Rican Injection Drug Users in East Harlem, New York and Bayamon, Puerto Rico. J Psychoactive Drugs, 34(4), pp. 363-369, October-December 2003.

Violence, Homelessness, and HIV Risk Among Crack-Using African-American Women

This study compares the characteristics of out-of-treatment, homeless, crack-using African-American women with those who are not homeless to determine what risks and protective factors differentiate the two groups. From 1999 to 2001, researchers interviewed and serologically tested 683 out-of-treatment, African-American crack-using women (of whom 219 were categorized as homeless). They examined risk factors (adverse childhood experiences, psychological distress, physical health, violence and victimization, drug use, and risky sex behaviors) as well as protective factors (marital status, education, public assistance, and the responsibility of caring for children). Overall, both groups of women started crack use in their mid-twenties and started drug use with alcohol in their teenage years, though differed significantly on each risk factor examined. Logistic regression analysis found that variables associated with increased odds of being homeless are physical abuse before age 18, crack runs greater than 24 hours, income less than 500 dollars in the last 30 days, depression, and current cigarette smoking. Protective factors found are marital status, living with children under 18, having had a physical in the past year, and receiving money from welfare in the last 30 days. Being sexually assaulted in the past 90 days was marginally associated with homelessness in the model. These findings, specific to crack-using African-American women, suggest that not only do these women overall report painful histories and currently stressful lives, but homeless women are more likely than women who are not homeless to have experienced childhood abuse and are more involved with drug use. Interventions designed for these women need to consider gender, cultural, and contextual issues that not only incorporate aspects of risk reduction related to violence, alcohol use, and comorbid conditions, but also linkages that will address housing issues, education, and skills for independence. Wechsberg, W., Lam, W., Zule, W., Hall, G., Middlesteadt, R. and Edwards, J. Violence, Homelessness, and HIV Risk Among Crack-Using African-American Women. Subst Use Misuse, 38(3-6), pp. 669-700, February-May 2003.

Methamphetamine Use Among HIV-Positive Men Who Have Sex With Men

This study compared the social and behavioral characteristics of binge users and non-binge users of methamphetamine (meth) in a sample of 90 HIV-positive men who have sex with men. Forty-one participants (46%) self-identified as a binge user. Meth binges ranged from 2 to 33 days (mean = 5.6), and average consumption was 3.1 grams. Binge users were significantly more likely than non-binge users to be ethnic minority and to have lower education. The two groups did not differ in terms of the total amount of meth used in the past 30 days; however, binge users reported significantly more social difficulties, more mental and physical health problems, and more sexual risk behaviors as compared with non-binge users. These findings, though preliminary, have implications for drug treatment approaches and the development of behavioral interventions. Semple, S., Patterson, T. and Grant, I. Binge Use of Methamphetamine Among HIV-Positive Men Who Have Sex With Men: Pilot Data and HIV Prevention Implications. AIDS Educ Prev, 15(2), pp. 133-147, April 2003.

HIV Risk Behaviors Among Older American Drug Users

Despite increasing numbers of Americans older than 50 years of age, little is known about the impact of HIV/AIDS on aging drug users. The current study assesses the drug-related and sex-related HIV risk behaviors of older and younger injection drug users and crack smokers. Structured interview responses from 1508 out-of-treatment active drug users older than 50 years of age were compared with those of 1515 out-of-treatment active drug users who were 50 years old or younger. Comparisons were also made within the older cohort to examine differences in risk behaviors between crack smokers and nonsmokers, men and women, and users older than 60 years of age and those in their 50s. Results indicated that although older drug users (older than 50 years of age) were less likely to have had sex in the prior month, those who did were as risky as their younger counterparts with regard to sex-related risk behaviors. They were, however, significantly less risky in their needle sharing practices than those 50 years old or younger. Among the older cohort, those who smoked crack were extremely risky. Men older than 50 years of age were riskier than women older than 50 years of age; however, users older than 60 years of age were no less risky than those in their 50s. The findings show that interventions designed for older drug users should focus on sex risk behaviors, especially among those who smoke crack. Kwiatkowski, C. and Booth, R. HIV Risk Behaviors Among Older American Drug Users. JAIDS, 33 (Supplement 2), S131-S137, June 1, 2003.

Late-Onset Crack Users: An Emergent HIV Risk Group

This article explores late-onset crack use among midlife and older adults as an emerging risk factor for HIV infection. Most research on illicit drug use and HIV infection/AIDS has focused on younger drug users, typically those who inject. The initiation into crack use during later adulthood challenges this narrow view. The analysis the authors present was drawn from qualitative and quantitative data collected as part of their ongoing research on illicit drug use. The subsample consisted of 27 men who began using crack at the age of 50 or older and 40 women who started using crack at the age of 35 or older. The findings suggest a typology of late-onset users with differing forms of HIV risk and prevention needs. The authors end the article with recommendations for effective HIV risk reduction programs for late-onset crack users. Johnson, W. and Sterk, C. Late-Onset Crack Users: An Emergent HIV Risk Group. JAIDS, 33 (Supplement 2), S229-S232, June 1, 2003.

Safer Sex by Type of Relationship Following an HIV Intervention Among Women

Predictors of increased male condom use were investigated following a recent, gender-specific HIV intervention among African-American women. Data were analyzed from 138 women (aged 18 to 59), recruited from inner-city Atlanta neighborhoods. Predictors of condom use with steady and casual paying partners were examined separately. Increased condom use with steady partners was associated with drug-using status, intervention assignment, sexual relationship characteristics, age at first condom use, and HIV testing history. An increased ability to communicate openly and honestly with one's sex partner was another partner-specific factor that predicted increased condom use over time. Condom use with casual paying partners was associated with having sex while high and the frequency of crack cocaine use. Personalized norms regarding condom use were not salient factors in predicting increased rates of condom use with either partner type. These findings indicate the continued need to consider sex in the context of drug use, and reveal the importance of measuring such influences and all antecedents of condom use separately for steady vs. casual sexual relationships. Theall, K., Sterk, C. and Elifson, K. Male Condom Use by Type of Relationship Following an HIV Intervention Among Women Who Use Illegal Drugs. J Drug Issues, pp. 1-28, 2003.

Religiosity and HIV Risk Behavior Among "At Risk" Women

During the past decade, increased attention has been given to the role that religious and faith-based organizations can play in enhancing health behaviors. In this study, researchers examined the role that religiosity plays in women's involvement in HIV risk behaviors. They analyzed data from an intergenerational drug use study with 250 mother/daughter dyads, collected from August 1997 to August 2000 in Atlanta, Georgia. Three measures of religiosity were used: frequency of attending worship services, belief in the role of religion in influencing personal behavior, and an interaction term that combined these 2 variables. They found that religiosity was a strong predictor of women's involvement in HIV-related risky behaviors, even when the effects of other demographic/background variables, childhood maltreatment experiences, psychosocial measures, experiences and relationships with other persons, exposure to substance abusers, and condom related beliefs and attitudes were considered. The more frequently women attended worship services and the more influential they perceived their religion to be on their behaviors, the less involved they tended to be in HIV-related risky behaviors. Elifson, K., Klein, H., and Sterk, C. Religiosity and HIV Risk Behavior Involvement Among 'At Risk' Women. J Religion and Health, 42(1), pp. 47-65, Spring 2003.

Perceived Temptation To Use Drugs And Actual Drug Use Among Women

Much research has been conducted to examine the relationship between various psychological and psychosocial factors and substance use/abuse. Where as such topics as depression, bipolar disorder, anxiety, self-esteem, optimism/pessimism, coping, and stress/tension have been studied fairly extensively others have received much less attention. One such understudied psychosocial factor is perceived level of temptation to use drugs under specified circumstances. This research is based on a study of 125 adult women drug users residing in the Atlanta, Georgia metropolitan area, interviewed between August l997 and August 2000. Street outreach efforts were used to identify potential study participants, with further expansion of the sample done via targeted sampling and ethnographic mapping procedures. The present study examines 16 specific items assessing temptations to use drugs. After describing which circumstances people think will be most likely to bring about greater illegal drug usage, the authors compare perceptions to actual drug use behaviors. Multivariate analyses are conducted to examine the role that perceived temptations to use drugs play in predicting actual drug use when the effects of demographic variables, background experiences, childhood maltreatment experiences, other psychosocial measures, and exposure to substance abusers are taken into account. A multivariate model explaining nearly one-half of the variance in actual drug abuse is derived, and retained several of the temptations-to-use-drugs items. Klein, H., Elifson, K.W. and Sterk, C.E Journal of Drug Issues, pp. 161-192, 2003.

Effectiveness Of A Risk Reduction Intervention Among African American Women Who Use Crack Cocaine

The primary objective of this study was to evaluate the effectiveness of an HIV intervention for African American women who use crack cocaine. Two hundred sixty-five women (aged 18-59 years) were randomly assigned to one of two enhanced intervention conditions or to the national institute on drug abuse standard condition. A substantial proportion of women reported no past 30-day crack use at 6-month follow-up (100%-61%, p <.001). Significant (p < .05) decreases in the frequency of crack use; the number of paying partners; the number of times vaginal, oral, or anal sex was had with a paying partner; and sexual risks, such as trading sex for drugs, were reported over time. Significant (p < .05) increases in male condom use with sex partners were observed, as well as decreases in casual partners' refusal of condoms. Findings suggest that combined components of our culturally appropriate, gender-tailored intervention may be most effective at enhancing preventive behavior among similar populations. Sterk, C.E., Theall, K.P. and Elifson, K.W. AIDS Education and Prevention, 15(1), pp. 15-32, 2003.

HIV Risk Reduction Among African-American Women Who Inject Drugs: A Randomized Controlled Trial

A community-based HIV intervention for African-American women who are active injection drug users (IDUs) was evaluated. Seventy-one women (aged 20-54 years) were randomly assigned to one of two enhanced gender- and culturally specific intervention conditions or to the NIDA standard condition. Substantial decreases (p < .001) were found in the frequency of drug use and the frequency of drug injection as well as in the sharing of injection works or water and the number of injections. Trading sex for drugs or money, having sex while high, as well as other sexual risk behaviors were also reduced significantly. Furthermore, women in both enhanced intervention conditions were more likely to reduce their drug-using and sexual risk behaviors than were women in the standard condition. Results indicate the value of including additional components in interventions designed to reduce the risk of infection with HIV among women who inject drugs. Sterk, C.E., Theall, K.P., Elifson, K.W., and Kidder, D., AIDS and Behavior, 7(1), pp. 73-85, March 2003.

Increased Glial Metabolites Predict Increased Working Memory Network Activation in HIV Brain Injury

Deficits in attention and working memory are common in HIV-1+-infected individuals, but the pathophysiology of these deficits is poorly understood. Modern neuroimaging techniques, such as proton magnetic resonance spectroscopy (1H MRS) and functional MRI (fMRI), can assess some of the processes underlying HIV brain injury. To evaluate the model that attentional deficits in early HIV brain disease are related to brain inflammation, 1H MRS and fMRI were performed by researchers at Brookhaven National Laboratory in 14 HIV+ subjects with AIDS dementia complex stage 1 or less. Increasing attentional load on three working memory tasks was assessed with fMRI, and the concentrations of brain metabolites were measured with 1H MRS in the frontal gray and white matter, and basal ganglia. Metabolite concentrations were correlated with fMRI blood oxygenation level-dependent (BOLD) signals. Several positive correlations were observed between the BOLD signal strength in the working memory network (posterior parietal cortex and lateral prefrontal cortex) and the concentrations of frontal white matter and basal ganglia metabolites that are predominant in glial cells. In contrast, BOLD signals in the working memory network were not correlated with the concentration of N-acetyl compounds or with metabolite concentrations in the frontal gray matter. These findings are consistent with previous results that mild HIV brain injury is associated with increased glial activation without major involvement of neuronal abnormalities. Ernst, T., Chang, L. and Arnold, S. NeuroImage, 19(4), pp. 1686-1693, 2003.

Working Memory Deficits in HIV-Positive Polydrug Abusers

HIV-seropositive (HIV+) individuals are often plagued by working memory (WM) deficits that can be exacerbated by manipulating a variety of task parameters, such as increasing memory load or information complexity. Researchers at UIC investigated the role of timing in HIV-associated WM defects by varying the amount of time required to maintain information online while holding memory load and information complexity constant. Fifty HIV+ and 35 HIV-seronegative (HIV-) polydrug abusers abstinent at testing and well matched on demographic variables were tested. The HIV- group outperformed the HIV+ group across all stimulus-response time delays. HIV-associated WM defects are not critically dependent on the amount of time stimulus representations must be maintained and might be attributed to impaired encoding or retrieval of stimulus representations. Martin, E.M., Pitrak, D.L, Rains, Niles, R., Grbesic, S. Pursell, K, Nunnally, G. and Bechara, A. Delayed Nonmatch-to-Sample Performance in HIV-Seropositive and HIV-Seronegative Polydrug Abusers. Neuropsychology, 17, pp. 283-288, April 2003.


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