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Director's Report to the National Advisory Council on Drug Abuse - September, 2004

Research Findings - Research on Medical Consequences of Drug Abuse

HIV Incidence Among High-Risk Puerto Rican Drug Users: A Comparison of East Harlem, New York, and Bayamon, Puerto Rico

Significant differences in HIV-related risk behaviors have been found between Puerto Rican drug users in New York City (NY) and Puerto Rico (PR). This study examined HIV incidence rates and characteristics of seroconverters in each location. Baseline and follow-up interviewing and HIV testing were conducted in 1998 to 2002 with seronegative Puerto Rican IDUs and crack smokers from East Harlem, NY (n = 455) and Bayam—n, PR (n = 268). There were a total of 32 seroconverters, 9 in NY and 23 in PR, for seroconversion rates of 0.88/100 person-years at risk (pyr; 95% CI, 0.31—1.45) in NY and 3.37/100 pyr (95% CI, 2.02—4.72) in PR (P < 0.001). In PR, variables significantly related to seroconversion were younger age and using shooting galleries. Being in methadone treatment was protective against seroconversion. In NY, crack use was significantly related to seroconversion. The higher seroconversion rate found in PR indicates a need to enhance HIV prevention efforts, including increasing methadone treatment and access to sterile syringes. The findings also underscore the importance of interventions that target sexual risk behaviors in both locations. Efforts to reduce HIV transmission in the Caribbean should address the significant role of high-risk drug use in the epidemic in Puerto Rico. Deren, S., Kang, S.Y., Colon, H., Andia, J. and Robles, R. HIV Incidence Among High-Risk Puerto Rican Drug Users: A Comparison of East Harlem, New York, and Bayamon, Puerto Rico. J Acquir Immune Defic Syndr, 36(5), pp. 1067-1107, 2004.

Effects of Changes in Perceived Self-Efficacy on HIV Risk Behaviors Over Time

This study examined the impact of changes in self-efficacy over time on HIV-related injection and sex risk behaviors among Puerto Rican drug injectors and crack smokers. Baseline (T1) and 6-month follow-up (T2) data were collected between 1998 and 2000 in New York and Puerto Rico (follow-up rate=79%, 952/1199). Differences in scores on self-efficacy (for risk behaviors) between T1 and T2 were first computed and dichotomized (negative change vs. no/positive change). Those with negative change in self-efficacy were more likely than those with no/positive change to engage in HIV injection and sex risk behaviors at T2. The relationships were significant in multiple logistic regressions after controlling for the effects of potential confounding variables. The findings indicate that improving perceived self-efficacy for risk reduction can help reduce HIV transmission behaviors in high-risk drug users, and have implications for the development of effective HIV/AIDS prevention. Kang, S.Y., Deren, S., Andia, J., Colon, H.M. and Robles, R. Effects of Changes in Perceived Self-Efficacy on HIV Risk Behaviors Over Time. Addict Behav, 29(3), pp. 567-74, 2004.

Detection of Hepatitis C Virus in the Nasal Secretions of an Intranasal Drug User

Hepatitis C virus (HCV) is a major cause of liver-related morbidity and mortality worldwide, with an estimated global prevalence of 170 million chronic infections. HCV-induced liver disease is the most common indication for liver transplantation and it has emerged as a leading cause of death among hospitalized HIV-infected patients treated during the HAART era. Although much is known about the routes of HCV transmission, nearly 15% of infected individuals report no identifiable source of exposure. Unexplained cases are particularly high among drug-users who have no history of injection risk and no other identifiable risk factors. One hypothesis that might account for the high number of unexplained HCV infections among noninjection drug users is the sharing of contaminated implements, such as straws or spoons, to nasally inhale cocaine and other powdered drugs. An essential precondition for this mode of transmission is the presence of HCV in the nasal secretions of intranasal drug users. In this preliminary study, researchers recruited five patients from clinics in East Harlem, New York. All subjects were male between 46 to 56 years of age and HIV-1 seropositive, had previously tested HCV seropositive, and reported a history of intranasal drug use. Blood and nasal secretion samples were collected and tested for HCV RNA using RT-PCR. HCV was detected in each of the five blood samples and in the nasal secretions of the subject with the highest serum viral load. This finding does not confirm intranasal viral transmission, but it does lend virological support to previous indications that intranasal drug use poses a risk by confirming an important precondition for this route of infection. McMahon, J., Simm, M., Milano, D. and Clatts, M. Detection of Hepatitis C Virus in the Nasal Secretions of an Intranasal Drug User. Ann Clin Microbiol Antimicrob, 73(1), pp. 6-10, 2004.

HIV Risk, Seropositivity, and Predictors of Infection Among Homeless and Non-Homeless Women Sex Workers in Miami

Although homelessness has frequently been associated with substance abuse, and has been established as a predictor of HIV risk among substance abusers, little is known about the impact of homelessness on HIV risk among female sex workers. This analysis investigated the contribution of homelessness to sexual risk taking among a sample of 485 female sex workers recruited into an HIV prevention program in Miami, Florida, 41.6% of whom considered themselves to be currently homeless. In comparison to non-homeless sex workers, significantly more homeless sex workers were daily users of alcohol and crack, and their past month sex work reflected more frequent vaginal and oral sex acts, higher levels of unprotected vaginal sex and more numerous sexual activities while 'high' on drugs. At the same time, a significantly greater proportion of homeless sex workers encountered customers that refused to use condoms than did the non-homeless sex workers. There were no significant differences in HIV seropositivity between the homeless and non-homeless women (22.5 and 24.9%, respectively), primarily because the majority of the women in the study cycled in and out of homelessness. These findings show how urgent it is to break the continuing cycle of homelessness in the lives of these women. Such cost-effective approaches as specialized HIV/AIDS interventions, intensive outreach to the homeless sex worker community to increase willingness to participate and retention in intervention programs, improved referral linkages to substance abuse treatment facilities, and readier access to treatment and other community services, would have tremendous public health benefit both to the women and to society as a whole. Surratt, H. and Inciardi, J. HIV Risk, Seropositivity, and Predictors of Infection Among Homeless and Non-Homeless Women Sex Workers in Miami. AIDS Care, 16(5), pp. 594-604, 2004.

Prevalence and Incidence of HIV, Hepatitis B Virus, and Hepatitis C Virus Infections Among Males in Rhode Island Prisons

Concerns exist that jails and prisons could serve as reservoirs that could amplify transmission of infectious diseases in the wider community as inmates who become infected while behind bars are released. Such reservoirs would be formed by the high prevalence of infections such as HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) among inmates, particularly those with a history of injection drug use. In this study, researchers evaluated the prevalence and intraprison incidence of HIV, HBV, and HCV among male prison inmates by observing intake prevalence for 4269 sentenced inmates at the Rhode Island Adult Correctional Institute between 1998-2000 and incidence among 446 continuously incarcerated inmates (incarcerated for 12 months or more). They found that HIV, HBV, and HCV prevalences were 1.8%, 20.2%, and 23.1%, respectively, and that infections were significantly associated with injection drug use (odds ratio =10.1, 7.9, and 32.4). Incidence per 100 person-years was 0 for HIV, 2.7 for HBV, and 0.4 for HCV. These findings are a cause for continuing public health concern. Although HIV infection was relatively low, the infection rate was similar to what has been previously reported from Rhode Island. These data are indicative of significant HBV transmission. They underscore the importance of offering HBV vaccinations in prisons as a cost-effective public health priority, particularly given the impact of infected individuals on the incarcerated population and, beyond the prison walls, on the transmission of HIV, HBV, and HCV in the communities to which inmates return. Macalino, G., Vlahov, D., Sanford-Colby, S., Patel, S., Sabin, K., Salas, C. and Rich, J. Prevalence and Incidence of HIV, Hepatitis B Virus, and Hepatitis C Virus Infections Among Males in Rhode Island Prisons. Am J Public Health, 94, pp. 1218-1223, 2004.

Prevention Myths and HIV Risk Reduction by Active Drug Users

A survey was conducted among 526 drug injectors and crack smokers in South Florida to explore beliefs concerning the effectiveness of 14 HIV prevention strategies used in sexual situations, with a focus on the relationship between these beliefs and reported use of condoms. Each of 14 identified sexual risk reduction strategies was believed to be an effective method of HIV prevention by at least 25%, and condom use was endorsed as an effective HIV prevention strategy by 95%. Substantial numbers of sexually active drug users believed in alternative, ineffective strategies for preventing the spread of HIV, and those who subscribed to such "prevention myths" were also more likely to report inconsistent or non-use of condoms. However, HIV prevention strategies that would generally be considered "safe" or "safer," such as condom use, abstinence, and having sex with only one partner, were most likely to be endorsed as effective, indicating that drug users have general knowledge about the correct set of prevention strategies but that their prevention arsenals also include a variety of prevention myths. Given the public health importance of stemming the spread of HIV through reduction in risk behaviors, and the apparent prevalence of misconceptions regarding effective risk reduction strategies, interventions conducted among all risk groups should take into account the roles that risk reduction beliefs and perceived social norms play in shaping risk practices of drug users. Metsch, L.R., McCoy, C.B., Miles, C.C. and Wohler, B. Prevention Myths and HIV Risk Reduction by Active Drug Users. AIDS Educ and Prev, 16(2), pp. 150-159, 2004.

Efficacy of a Woman-Focused Intervention to Reduce HIV Risk and Increase Self-Sufficiency Among African American Crack Abusers

Researchers compared 3- and 6-month outcomes of a woman-focused HIV intervention for crack abusers, a revised NIDA standard intervention, and a control group. Outreach workers in the community were trained to refer out-of-drug-treatment African American women (n=620) who used crack to field sites for participation in a randomized field experiment. The results showed that all 3 groups significantly reduced crack use and high-risk sex at each follow-up, but only woman-focused intervention participants consistently improved on measures of employment and housing status. Compared with control subjects at 6 months, woman-focused intervention participants were least likely to engage in unprotected sex; revised standard intervention women reported greatest reductions in crack use. The results of this study are consistent with previous research that out-of-treatment African American women who use crack and are at high risk of HIV successfully reduce drug use and sex risk behaviors when they receive tailored educational and skill-building interventions. Moreover, the women who received the women-focused intervention also improved in measures of employment and housing status. These changes can provide greater stability to the daily lives of these women and thereby help to reduce the frequency of drug use and unprotected sex in the longer term. Wechsberg, W., Lam, W., Zule, W. and Bobashev, G. Efficacy of a Woman-Focused Intervention to Reduce HIV Risk and Increase Self-Sufficiency Among African American Crack Abusers. Am J Public Health, 94, pp. 1165—1173, 2004.

HIV Risk Behaviors Among Male-to-Female Transgender Persons of Color in San Francisco

Researchers examined HIV risk behaviors among drug-using African American, Asian/Pacific Islander (API), and Latina male-to-female (MTF) transgender persons to identify factors that can be addressed in behavioral prevention interventions aimed at reducing HIV and other infections and transmissions. They conducted individual survey interviews with MTF transgender persons of color (n=332; 112 African Americans, 110 Latinas, and 110 APIs), and found that the prevalence and correlates of receptive anal sex and unprotected receptive anal sex (URAS) varied by type of partner (primary, casual, or commercial sex partners). In addition, URAS with primary partners was associated with drug use before sex; URAS with casual partners was associated with HIV-positive status and drug use before sex; and URAS with commercial sex partners was associated with African American ethnicity and low income. Of major public health concern was the finding that HIV-positive participants were 3.8 times more likely to have recently engaged in URAS with casual partners than HIV-negative participants. Findings on ethnic differences in HIV-related sexual risk behaviors under the influence of drugs and with commercial partners were consistent with previous findings. The extremely high-risk behaviors found among MTF transgender persons in this study demonstrate the important need for community outreach, drug treatment, and social service programs to target and reach MTF transgender persons to participate in HIV prevention interventions. Nemoto, T., Operario, D., Keatley, J., Han, L. and Soma, T. HIV Risk Behaviors Among Male-to-Female Transgender Persons of Color in San Francisco. Am J Public Health, 94, pp. 1193—1199, 2004.

Intravenous Drug Users' HIV-Risk Behaviors with Primary/Other Partners

The objective of this study was to determine how injection drug users' (IDUs) HIV-risk behavior differs with primary and other sex partners. Interviews were conducted with IDUs from a needle exchange program (n = 243). The sample was composed of 79 women and 164 men; their ages ranged from 18 to 67 (M = 35.02, SD = 9.25). The ethnic make-up of the sample was 86% (209) Caucasian, 9% (22) African American, 3% (7) Hispanic, and 2% (5) Other. There were significant differences in age (w 2=34.58, df =4, p < 0.0001) and marital status (w 2 = 23.26, df =4, p = 0.0001) among those who reported no partners, those who reported one partner, and those who reported more than one partner in the past six months. Age was negatively related to the number of sexual partners (i.e., those with no partners were older than those with one partner, who, in turn, were older than those with more than one partner). Those with one sexual partner were more likely to report never using condoms with primary partners than were those with more than one partner (74% vs. 54%, p < 0.001). Those with more than one partner differed in their disclosure of HIV and IDU status, condom use, and drug use in combination with sex between their primary and other partners. These findings indicate that primary sexual partners of IDUs are placed at risk from IDUs' risk behavior with other sexual partners. Given that IDUs behave differently with primary partners than with other partners, HIV-risk reduction interventions for IDUs should address risk behavior with primary partners separately from behavior with other partners. In addition, when resources for risk-reduction prevention are scarce, a particular focus should be given to reducing HIV risk behaviors among those IDUs who report both primary and other partners. Rosenberg, C., Anderson, B. and Stein, M. Intravenous Drug Users' HIV-Risk Behaviors with Primary/Other Partners. Amer J Drug Alc Abuse, 30(2), pp. 225—236, 2004.

Medication Compliance and Satisfaction with Treatment for HIV Disease in a Sample of African-American Crack Cocaine Smokers

The development of treatment regimes for African-American HIV-infected crack cocaine users has often been based on assumptions about compliance with medication regimes rather than evidence. This study sought to obtain baseline information on the adherence to antiretroviral medications among 137 members of this important risk population in Houston, Texas. The median age of respondents was 40 years, with half (51%) aged 40 years and older; one-fourth (27%) were women. All participants in the sample were smoking crack or injecting drugs at the time they were interviewed. Most who reported smoking crack (82%) reported smoking daily. About one-fifth (18%) of injectors were injecting daily. Of those who were injecting, 18% had shared needles and 82% had shared paraphernalia used for preparing drug solution. Length of time since HIV diagnosis ranged among the respondents from less than 1 year to 18 years. It was found that for only 5 of a range of 16 antiviral medications was there a significant correlation between levels of compliance and beliefs as to how effective these medications are. Medication compliance was also found not to be associated with frequency of crack cocaine use in the month prior to interview. Irrespective of gender and reported extent of medication compliance, the respondents tended to report positive relationships with their treating physicians, with higher levels of satisfaction reported by women. These results suggest that the majority of African-American crack cocaine users are able to comply with HIV treatment regimes, with more than half (53%) claiming full compliance for one or more medications, and a further one third (31%) claiming compliance more than half the time. Medication compliance, which presumably reflects responsibility and desire to maximize both the quality and the length of one's life, seems to be at odds with reports of HIV-infected cocaine users engaging in irresponsible and high-risk behaviors, yet these findings suggest that they will continue to take antiretroviral medications even if they have doubts about the effectiveness of these medications. Crisp, B., Williams, M., Timpson, S. and Ross, M. Medication Compliance and Satisfaction with Treatment for HIV Disease in a Sample of African-American Crack Cocaine Smokers. AIDS and Behavior, 8(2), pp. 199-206, 2004.

Cocaine's Effect on HIV Expression Can Be Modulated by the Kappa Opioids

The HIV virus acts on chemokine receptors to enter macrophages, glia and lymphocytes. Opiates and other drugs have been shown to compete with these sites and modify the toxicity of the virus. Therefore, many laboratories are focusing on the nature of this interaction to clarify the role of drugs in HIV toxicity or in the development of (HIV)-1-associated dementia (HAD). Cocaine abuse, for example, has been implicated as a cofactor in HAD. In this study, investigators tested the hypothesis that exposure of microglial cells, the resident macrophages of the brain, to cocaine would increase HIV-1 expression. Because kappa-opioid receptor (KOR) agonists have been shown to suppress neurochemical and neurobehavioral responses to cocaine and to inhibit HIV-1 expression in microglial cell cultures, the investigators hypothesized that KOR ligands would inhibit cocaine-induced HIV-1 expression. In this experiment, microglial cells were infected with HIV-and viral expression was quantified. Treating the microglia with the KOR inhibited viral expression. Consistent with the hypothesis, treatment of microglia with cocaine increased HIV-1 expression, and pretreatment of microglia with these KOR agonists as well as with the KOR-selective antagonist abolished cocaine-induced potentiation of HIV expression. Further analysis suggested that KOR ligands inhibit cocaine's stimulatory effect on viral expression by suppressing cocaine-induced activation of extracellular signal-regulated kinase1/2, reducing cocaine-enhanced up-regulation of the HIV-1 entry chemokine co-receptor CCR5. These findings suggest that in addition to its neurotoxic effects, cocaine could foster development of HAD by increasing viral expression in the brain and, importantly, this process is inhibited by KOR ligands. Gekker, G., Hu, S.X., Wentland, M.P., Bidlack, J.M., Lokensgard, J.R. and Peterson, P.K. Kappa-opioid Receptor Ligands Inhibit Cocaine-induced HIV-1 Expression in Microglial Cells. Journal of Pharmacology and Experimental Therapeutics,309, pp. 600-606, 2004.

Drug Interactions Between Opioids and Antiretroviral Medications: Interaction Between Methadone, LAAM, and Nelfinavir

Understanding drug interactions between antiretrovirals and opiate therapies may decrease toxicities and enhance adherence, with improved HIV outcomes in injection drug users. Dr. McCance-Katz and her colleagues report results of a clinical pharmacology study designed to examine the interaction of the protease inhibitor, nelfinavir, with methadone and LAAM (N = 48). Nelfinavir decreased methadone exposure, but no withdrawal was observed over the 5-day study period. LAAM and dinorLAAM concentrations were decreased, while norLAAM concentrations were increased, with minimal overall change in LAAM/metabolite exposure. Methadone and LAAM did not affect nelfinavir concentrations, but methadone decreased M8 metabolite exposure. The authors stated that while no toxicities were observed, clinicians should be aware of the potential for drug interactions when patients require treatment with nelfinavir and these opiate medications. McCance-Katz, E.F., Rainey, P.M., Smith, P., Morse, G., Friedland, G., Gourevitch, M. and Jatlow, P. Am. J. Addict., 13(2), pp. 163-180, 2004.

Abuse Experiences in a Community Sample of Young Adults: Relations with Psychiatric Disorders, Sexual Risk Behaviors, and Sexually Transmitted Diseases

This study documents significant associations among lifetime abuse experiences, psychiatric diagnoses, and sexual risk behaviors in a multiethnic community sample of young men and women (N = 1803) in South Florida. Self-report data were collected via structured interviews as part of a longitudinal follow-up of a larger school-based study. Participants were grouped according to extent of lifetime abuse experiences. Cumulative lifetime abuse experiences were associated with increased risk for a broad range of individual lifetime psychiatric disorders, as well as cumulative lifetime psychiatric disorders. Both cumulative abuse experiences and cumulative psychiatric disorders were independently associated with (a) higher levels of sexual risk behaviors and (b) higher risk for lifetime sexually transmitted diseases (STDs). Implications for selective prevention of sexual risk behaviors and STDs among young adults with histories of abuse and psychiatric disorders are discussed. Tubman, J.G., Montgomery, M.J., Gil, A.G., and Wagner, E.F. Abuse Experiences in a Community Sample of Young Adults: Relations with Psychiatric Disorders, Sexual Risk Behaviors, and Sexually Transmitted Diseases. American Journal of Community Psychology. 34(1/2), pp. 147-162, September 2004.

Substance Use and Sexual Risk: A Participant- and Episode-level Analysis Among a Cohort of Men Who Have Sex with Men

Researchers determined whether substance use during sex was independently associated with sexual risk during recent sexual episodes, as reported by 4,295 HIV—negative men who have sex with men. Prior reports associating substance use with sexual risk behavior have generally used summary measures and have not adjusted for participants' background levels of substance use. In this 1999—2001 US study, the main outcome measure was serodiscordant unprotected anal sex (i.e., with an HIV-positive partner or a partner whose serostatus is unknown). The influence of participant-level characteristics was examined by using repeated-measures logistic models, such that the influence of participant-level characteristics, including 6-month substance use, was removed by using conditional logistic regression (in effect making each participant his own control). Eleven percent of participants reported heavy alcohol use, 37% used poppers, 19% sniffed cocaine, and 13% used amphetamines. In the participant-level analysis, use of poppers, amphetamines, and sniffed cocaine as well as heavy alcohol use in the prior 6 months were independently associated with unprotected anal sex. In the conditional analysis, consumption of alcohol or use of poppers, amphetamines, or sniffed cocaine just before or during sex was independently associated with serodiscordant unprotected anal sex. These findings underscore the importance of HIV prevention interventions and the influence that substance use during sex can have on increased risk behavior. Colfax, G., Vittinghoff, E., Husnik, M., McKirnan, D., Buchbinder, S., Koblin, B., Celum, C., Chesney, M., Huang, Y., Mayer, K., Bozeman, S., Judson, F., Bryant, K., Coates, T., and the EXPLORE Study Team. Substance Use and Sexual Risk: A Participant- and Episode-level Analysis among a Cohort of Men Who Have Sex with Men. Amer J Epidemiol, 159(10), pp. 1002- 1012, 2004.

Mortality in a Long-term Open Cohort of Prostitute Women

In this study, the authors estimated overall and cause-specific mortality among prostitute women. They recorded information on prostitute women identified by police and health department surveillance in Colorado Springs, Colorado, from 1967 to 1999. The authors assessed cause-specific mortality in this open cohort of 1,969 women using the Social Security Death Index and the National Death Index, augmented by individual investigations. They identified 117 definite or probable deaths and had sufficient information on 100 to calculate a crude mortality rate (CMR) of 391 per 100,000 (95% confidence interval (CI): 314, 471). In comparison with the general population, the standardized mortality ratio (SMR), adjusted for age and race, was 1.9 (95% CI: 1.5, 2.3). For the period of presumed active prostitution only, the CMR was 459 per 100,000 (95% CI: 246, 695) and the SMR was 5.9 (95% CI: 3.2, 9.0). Violence and drug use were the predominant causes of death, both during periods of prostitution and during the whole observation period. The CMR for death by homicide among active prostitutes was 229 per 100,000 (95% CI: 79, 378), and the SMR was 17.7 (95% CI: 6.2, 29.3). Deaths from AIDS occurred exclusively among prostitutes who admitted to injecting drug use or were inferred to have a history of it. Potterat, J., Brewer, D., Muth, S., Rothenberg, R., Woodhouse, D., Muth, J., Stites, H. and Brody, S. Mortality in a Long-Term Open Cohort of Prostitute Women. Am J Epidemiol, 159(8), pp. 778-785, 2004.

Urging Others to be Healthy: "Intravention" by IDUs as a Community Prevention Goal

In this article, researchers present data on a culture of support for risk reduction and risk avoidance among IDUs in Bushwick, within New York City—a city in which an enormous HIV/AIDS epidemic killed tens of thousands of IDUs in the 1980s and 1990s, but also a city in which HIV prevalence among IDUs has declined from about 50% to about 10% to 15%, and HIV incidence among IDUs has declined from about 13% per person per year at risk to about 1% to 2%. They describe "intravention" activities that are conducted by and sustained through ongoing actions of members of communities-at-risk and present data from 120 IDUs to show how their supportive efforts may influence others to engage in one or more self-protective actions. These findings suggest that the common image of IDUs as sources of social and medical problems is inaccurate. They also have a number of implications for public health practice. First, they suggest that many IDUs are active participants in trying to reduce HIV transmission and other problems that afflict themselves and others. Second, they suggest that even in the context of strong stigmatization of drug users, there is at least a subset of IDUs who are involved in community agencies and activities in various ways. Although only a small proportion, they may nonetheless be important allies for public health prevention and drug treatment. Friedman, S., Maslow, C., Bolyard, M., Sandoval, M., Mateu, P. and Neaigus, A. Urging Others to be Healthy: "Intravention" by IDUs as a Community Prevention Goal. AIDS Educ and Prev, 16(3), pp. 250-263, 2004.

Long-Term Effects of Syringe Exchange on Risk Behavior and HIV Prevention

The purpose of this study was to assess stability of population-level injection risk behavior over time among participants in a syringe exchange program and compare factors affecting syringe sharing at two points in time. Participants of the Tacoma Syringe Exchange Program (SEP) were interviewed in 1997 and 2001 using audio computer assisted self-interviewing technology. In each wave of data collection, a random cross section of participants was recruited and interviewed, with no attempt made to follow respondents over time. Rates of injection risk behavior remained stable across the 4-year period, despite increases in factors associated with syringe sharing. Homelessness, rates of depression symptoms, and injection of amphetamines all increased from 1997 to 2001. The central factors associated with syringe sharing in both 1997 and 2001 were depression symptoms and the interaction of younger age with amphetamine injection. The data indicate that the syringe exchange program has helped to stabilize risk among a high-risk population of drug injectors for a substantial period of time, and confirms previous findings about the significant role that SEPs play in the prevention of HIV in marginal and impoverished communities. Braine, N., Des Jarlais, D., Ahmad, S., Purchase, D. and Turner, C. Long-Term Effects of Syringe Exchange on Risk Behavior and HIV Prevention. AIDS Educ and Prev, 16(3), pp. 264-275, 2004.

Public Funding of US Syringe Exchange Programs

Although there has been no federal government funding of syringe exchange, there is substantial state and local government funding. This paper describes program characteristics associated with receiving state and local government funding. Annual telephone surveys were made of program directors of syringe exchange programs known to the North American Syringe Exchange Network. The number of syringe exchange programs (SEPs) known to this network has increased from 63 in 1994—1995 to 127 in 2000. Approximately 80% of programs participated in each of the surveys. The results indicate that approximately 50% of programs receive state and local government funding, which has remained constant from 1994 to 2000. Receiving state and local government funding was associated with larger numbers of syringes exchanged per year, which is a fundamental purpose of SEPs, and with providing more on-site services, including HIV counseling and testing so that clients can learn their serostatus and seek appropriate treatment and medical services. Among the programs that received state or local government funding, this funding accounted for a mean of 87% of the budget for syringe exchange services. In the absence of federal funding, state and local government support is associated with better syringe exchange performance. Des Jarlais, D., McKnight, C. and Milliken, J. Public Funding of US Syringe Exchange Programs. J Urban Health, 81(1), pp. 118-121, 2004.

Attachment Style, Childhood Adversity, and Behavioral Risk Among Young Men

In a study of young men who have sex with men (YMSM), researchers sought to examine relationships among childhood adversity, attachment style (core beliefs regarding the self and others), and homelessness, daily substance use, participation in sex work, involvement in the criminal justice system, and being out of school or work. They used a targeted sampling approach to recruit and then interview 569 YMSM aged 17-28 years in New York City. After controlling for demographic characteristics and childhood adversity, YMSM with a fearful attachment style were more likely to have been homeless (OR 2.93, 95% CI 1.65-5.18), to have participated in sex work (OR 2.35, 95% CI 1.44-3.85), to use substances daily (OR 2.79, 95% CI 1.29-6.03), to have been involved in the criminal justice system (OR 2.04, 95% CI 1.38-3.01), and to be out of school/work (OR 2.47, 95% CI 1.47-4.15). YMSM who identified as heterosexual, or bisexual, and/or transgender were especially vulnerable. These findings suggest that a fearful attachment style contributes to some YMSM remaining outside of the protective systems of family, school, and work, and is associated with risky contexts where they are less likely to encounter prosocial peers and adults. It is also associated with high-risk drug use and sexual behavior. Attachment theory has potential for guiding the development of more effective interventions by elucidating the links between an individual's experience of relationships and management of developmental transitions. Gwadz, M.V., Clatts, M.C., Leonard, N.R. and Goldsamt, L. Attachment Style, Childhood Adversity, and Behavioral Risk Among Young Men Who Have Sex With Men. J Adolesc Health, 34(5), pp. 402-413, 2004.

Psychosocial Factors Associated with Adherence to Antiretroviral Medication in a Sample of HIV-Positive African American Drug Users

Researchers sought to investigate factors affecting antiretroviral adherence among African American drug users to identify associations between self-reported adherence levels and psychosocial measures (from the Transactional Model of Stress and Coping). The study used data from 137 HIV-positive drug users who were receiving antiretroviral medications at the time they were interviewed. Multiple regression analysis showed only perceived self-efficacy of antiretrovirals and one measure of perceived barriers, simply forgetting to take medications, to be independently related to adherence. These findings suggest that theoretical approaches to understanding antiretroviral adherence among HIV-positive African American drug users need to consider and address a range of variables including but not limited to behavioral practices, cognitive appraisals, affective responses, and social support. Harzke, A., Williams, M., Nilsson-schšnnesson, L., Ross, M., Timpson, S. and Keel, K. Psychosocial Factors Associated with Adherence to Antiretroviral Medication in a Sample of HIV-Positive African American Drug Users. AIDS Care, 16(4), pp. 470, 2004.

Relation of Coronary Artery Calcium to Left Ventricular Mass in African-Americans

Both coronary artery calcium (CAC) deposits and increased ventricular (LV) mass are important risk factors for coronary heart disease, but the relation between these two factors has rarely been studied. The investigators (Dr. Shenghan Lai and his colleagues at Johns Hopkins) examined the correlation of coronary artery calcium and left ventricular mass in 159 young to middle-aged African-Americans, and found that the average left ventricular mass indices were bigger in the CAC-positive groups than in CAC-negative groups in both genders [p=0.0004 in men and p=0.08 in women]. Studies are in progress to examine if drug abuse (e.g., cocaine) has an impact on cardiovascular disease (coronary artery calcium/ventricular function) in African-Americans. Tong, W., Lima, J.A., Lai, H., Celentano, D.D., Dai, S. and Lai, S. Am J. Cardiol., 93, pp. 490-492, 2004.

Bioavailabilities of Rectal and Oral Methadone in Healthy Subjects

Rectal administration of methadone may be an alternative to intravenous and oral dosing in cancer pain, but the bioavailability of the rectal route is not known. Dr. Kharash and his colleagues compared the absolute rectal bioavailability of methadone with its oral bioavailability in healthy humans. Seven healthy subjects (six males, one female, aged 20-39 years) received 10 mg d(5)-methadone-HCl rectally (5 ml in 20% glycofurol) together with either d(0)-methadone intravenously (5 mg) or orally (10 mg) on two separate occasions. Blood samples for the LC-MS analyses of methadone and it's metabolite EDDP were drawn for up to 96 h. Noninvasive infrared pupillometry was performed at the same time as blood sampling. Data showed that the mean absolute rectal bioavalability of methadone was 0.76 (0.7, 0.81), compared to 0.86 (0.75, 0.97) for oral administration (mean (95% CI)). Rectal absorption of methadone was more rapid than after oral dosing with Tmax values of 1.4 (0.9, 1.8) vs. 2.8 (1.6, 4.0) h. The extent of formation of the metabolite EDDP did not differ between routes of administration. Single doses of methadone had a duration of action of at least 10 h and were well tolerated. Rectal administration of methadone resulted in rapid absorption, a high bioavailability and long duration of action. No evidence of pre-systemic elimination was seen. Data suggested that rectal methadone has characteristics that make it a potential alternative to intravenous and oral administration, particularly in cancer pain and palliative care. Dale, O., Sheffels, P., Kharasch, E.D., Br. J. Clin. Pharmacol. 58(2), pp. 156-162, 2004.

Marijuana Withdrawal in Humans: Effects of Oral THC or Divalproex

Abstinence following daily marijuana use can produce a withdrawal syndrome characterized by negative mood (e.g. irritability, anxiety, misery), muscle pain, chills, and decreased food intake. Two placebo-controlled, within-subject studies investigated the effects of a cannabinoid agonist, delta-9-tetrahydrocannabinol (THC: Study 1), and a mood stabilizer, divalproex (Study 2), on symptoms of marijuana withdrawal. Participants (n=7/study), who were not seeking treatment for their marijuana use, reported smoking 6-10 marijuana cigarettes/day, 6-7 days/week. Study 1 was a 15-day in-patient, 5-day outpatient, 15-day in-patient design. During the in-patient phases, participants took oral THC capsules (0, 10 mg) five times/day, 1 h prior to smoking marijuana (0.00, 3.04% THC). Active and placebo marijuana were smoked on in-patient days 1-8, while only placebo marijuana was smoked on days 9-14, that is, marijuana abstinence. Placebo THC was administered each day, except during one of the abstinence phases (days 9-14), when active THC was given. Mood, psychomotor task performance, food intake, and sleep were measured. Oral THC administered during marijuana abstinence decreased ratings of 'anxious', 'miserable', 'trouble sleeping', 'chills', and marijuana craving, and reversed large decreases in food intake as compared to placebo, while producing no intoxication. Study 2 was a 58-day, outpatient/in-patient design. Participants were maintained on each divalproex dose (0, 1500 mg/day) for 29 days each. Each maintenance condition began with a 14-day outpatient phase for medication induction or clearance and continued with a 15-day in-patient phase. Divalproex decreased marijuana craving during abstinence, yet increased ratings of 'anxious', 'irritable', 'bad effect', and 'tired.' Divalproex worsened performance on psychomotor tasks, and increased food intake regardless of marijuana condition. Thus, oral THC decreased marijuana craving and withdrawal symptoms at a dose that was subjectively indistinguishable from placebo. Divalproex worsened mood and cognitive performance during marijuana abstinence. These data suggest that oral THC, but not divalproex, may be useful in the treatment of marijuana dependence. Haney, M., Hart, C.L., Vosburg, S.K., Nasser, J., Bennett, A., Zubaran, C. and Foltin, R.W. Neuropsychopharmacology, 29(1), pp. 158-170, 2004.


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