Faculty Bibliography

OBJECTIVE: To study prospectively injection behavior of injecting drug users (IDU) who did and did not utilize a local needle exchange in the Bronx, New York City. DESIGN: Since 1985, IDU attending a methadone maintenance program have been enrolled in a prospective study of HIV-related risk behaviors. Since 1989, when a needle exchange opened near the methadone program, data have been collected from study participants regarding utilization of the exchange. PARTICIPANTS: Study participants (n = 904) who injected between 1985 and 1993. RESULTS: Of 904 IDU, 21.9% used the needle exchange. Male gender [adjusted odds ratio (AOR), 1.57], HIV seropositivity (AOR, 1.39) and younger age (AOR per 10 years of age, 1.66) were independently associated with needle exchange attendance. The percentage injecting declined each year, preceding the opening of the needle exchange and concurrent with its operation (from 64.6% in 1985 to 43.6% in 1993). Among the 329 participants who injected in the year before the exchange opened, 1988, 53 out of 124 (42.7%) needle exchange users and 168 out of 205 (81.9%) non-users reduced or stopped injecting by 1993 (P < 0.001). Exchange users shared needles less than non-users (P < 0.05 in 1993). HIV infection was unrelated to these reductions in injection. CONCLUSIONS: Methadone-treated IDU with access to a needle exchange reduced injecting and needle-sharing. This pattern of harm reduction, which began at least 4 years before the needle exchange opened, occurred in both those who did and did not utilize the needle exchange. Needle exchange, as a strategy to reduce injection-related harm, should not be viewed as discordant with methadone treatment

Nationally and globally the HIV/AIDS pandemic shows little sign of abating as it arrives at the midpoint of its second decade. In many communities, however, successful steps have been taken to limit its progression. The challenge of the years ahead lies in engaging individuals and communities to join in arresting and ultimately reversing the tide of this plague

Smaller tuberculin test induration sizes suggest eligibility for tuberculosis chemoprophylaxis in HIV-seropositive than in HIV-seronegative persons. To determine whether human immunodeficiency virus (HIV) infection is associated with induration size among tuberculin reactors, a cross-sectional study of HIV-seropositive and -seronegative drug users was performed. Twenty-four of 160 (15%) HIV-seropositive and 68 of 284 (24%) HIV-seronegative patients had reactions to purified protein derivative (PPD) of > or = 2 mm (OR = 0.56, 95% CI 0.32 to 0.96). However, the prevalence of tuberculin reactivity was equal among nonanergic subjects with and without HIV infection. Median induration size was similar among HIV-seropositive (20.5 mm) and -seronegative (17.5 mm) reactors. Thus, although HIV-seropositive patients were less likely, due to cutaneous anergy, to be PPD reactors, induration size was not associated with HIV infection among reactors. Although using a reduced cutpoint to determine suitability of chemoprophylaxis in HIV-seropositive persons may be prudent, the logical assumption that the loss of specificity this entails is accompanied by an increase in sensitivity for detecting Mycobacterium tuberculosis infection remains to be proved

OBJECTIVES. The purpose of this study was to assess the relationship between syphilis and human immunodeficiency virus (HIV) infection in injection drug users. METHODS. A 6-year prospective study of 790 injection drug users receiving methadone maintenance treatment in the Bronx, NY, was conducted. RESULTS. Sixteen percent (4/25) of HIV-seroconverting patients, 4.8% (16/335) of prevalent HIV-seropositive patients, and 3.5% (15/430) of persistently HIV-seronegative patients was diagnosed with syphilis. Incidence rates for early syphilis (cases per 1000 person-years) were 15.9 for HIV-seroconverting patients, 8.9 for prevalent HIV-seropositive patients, and 2.9 for persistently HIV-seronegative patients. Early syphilis incidence was higher among women than men (8.4 vs 3.2 cases per 1000 person-years). Independent risks for early syphilis included multiple sex partners, HIV seroconversion, paid sex, and young age. All HIV seroconverters with syphilis were female. CONCLUSIONS. Diagnosis of syphilis in drug-using women reflects high-risk sexual activity and is associated with acquiring HIV infection. Interventions to reduce the risk of sexually acquired infections are urgently needed among female drug users

Incomplete antituberculous chemoprophylaxis and treatment are major causes of the resurgence of tuberculosis, often drug-resistant, among drug users. We offered directly observed antituberculous chemoprophylaxis (n = 102) or treatment (n = 12) to tuberculous chemoprophylaxis (n = 102) or treatment (n = 12) to eligible methadone maintenance treatment patients. Methadone dosing was not contingent upon ingestion of antituberculous medication(s). No material incentives were provided. Ninety (88%) prophylaxis and 9 (75%) treatment patients were administered > or = 5 weekly doses of antituberculous medications during > or = 80% of 4740 patient-weeks. The majority of patients were HIV-seropositive. Active substance abuse was not associated with diminished adherence. Over 80% of patients completed or were still receiving therapy at the end of the study. Adherence to and completion of directly observed antituberculous therapy can thus be attained by drug users in treatment, despite ongoing drug misuse. Substance abuse treatment programs provide opportunities for enhanced compliance, and should thus be viewed as critical components of strategies to address the tuberculosis epidemic in drug users

OBJECTIVE: To describe the effects of human immunodeficiency virus (HIV) infection on the serologic manifestations and response to treatment of syphilis in intravenous drug users. DESIGN: Cohort study of intravenous drug users. SETTING: Medical clinic in a hospital-based methadone maintenance treatment program in New York City. PATIENTS: Fifty patients with syphilis, of whom 31 were HIV seropositive and 19 HIV seronegative. MEASUREMENTS: Serologic tests for syphilis and clinical manifestations. RESULTS: Stage of syphilis at presentation was not associated with HIV serologic status. No unusual or fulminant manifestations of early syphilis or neurosyphilis were noted among HIV-seropositive cases. Maximum nontreponemal titers were higher among HIV-seropositive (median, 1:128) than among HIV-seronegative (median, 1:32) patients with syphilis (P = 0.05); this difference was present only among patients with first-episode syphilis. All 26 evaluable, HIV-seropositive patients treated for syphilis responded appropriately, including 13 patients given standard or less-than-standard doses of penicillin. Seven of 43 patients (16%) showed reversion to negative treponemal antibody assay results after treatment for syphilis; this finding was not associated with HIV infection, CD4 count, or stage of syphilis. Low nontreponemal titer was weakly associated with treponemal test reversion. CONCLUSIONS: Infection with HIV did not alter the stage at presentation, clinical course, serologic manifestations, or response to treatment of syphilis in this cohort of intravenous drug users