Faculty Bibliography

OBJECTIVES: We tested the hypothesis that higher rates of previous hard drug-related arrests predict lower rates of injection drug use. METHODS: We analyzed drug-related arrest data from the Federal Bureau of Investigation's Uniform Crime Reporting Program for 93 large US metropolitan statistical areas in 1992 to 2002 to predict previously published annual estimates of the number of injection drug users (IDUs) per 10,000 population. RESULTS: In linear mixed-effects regression, hard drug-related arrest rates were positively associated (parameter = +1.59; SE = 0.57) with the population rate of IDUs in 1992 and were not associated with change in the IDU rate over time (parameter = -0.15; SE = 0.39). CONCLUSIONS: Deterrence-based approaches to reducing drug use seem not to reduce IDU prevalence. Alternative approaches such as harm reduction, which prevents HIV transmission and increases referrals to treatment, may be a better foundation for policy.

This study examined engagement in treatment in substance abuse treatment programs that treated primarily either African American or White clients. Findings showed higher levels of engagement in White programs; however, engagement of African Americans in White programs was similar to that of Whites and was greater than Whites in African American programs. No significant differences emerged when a mixed model analysis considered additional variables of staff consensus (regarding treatment elements), treatment climate, acceptance of Medicaid clients, the proportion mandated to treatment, and the quality of the physical space. Although African American programs may show poorer levels of engagement than White programs, attribution of engagement in treatment to client level race/ethnicity should be made with caution.

This study examined commuting patterns among 23,141 methadone patients enrolling in 84 opioid treatment programs (OTPs) in the United States. Patients completed an anonymous one-page survey. A linear mixed model analysis was used to predict distance traveled to the OTP. More than half (60%) the patients traveled < 10 miles and 6% travelled between 50 and 200 miles to attend an OTP; 8% travelled across a state border to attend an OTP. In the multivariate model (n = 17,792), factors significantly (P < .05) associated with distance were, residing in the Southeast or Midwest, low urbanicity, area of the patient's ZIP code, younger age, non-Hispanic white race/ethnicity, prescription opioid abuse, and no heroin use. A significant number of OTP patients travel considerable distances to access treatment. To reduce obstacles to OTP access, policy makers and treatment providers should be alert to patients' commuting patterns and to factors associated with them.

As we begin the fourth decade of the epidemic, it is clear that, as demonstrated by the articles in this Special Issue, much has been learned about factors contributing to the decline in HIV prevalence among drug users in New York. However, there are a number of outstanding research questions that remain or are emerging. Following is a summary of some of the topics requiring further research. While this summary does not represent a comprehensive list, it is based on many of the questions raised in the articles in this Special Issue and identifies some of the directions to be investigated during the next decade.

Deaf adolescents who use American Sign Language (ASL) as their main communication mode are, like their hearing age peers, at risk for acquiring HIV. Many sources of HIV information (radio and television) are not accessible to these adolescents. Little is known about HIV knowledge base and risk behaviors of this group. The objective of this study was to develop and administer, on laptop computer, an HIV knowledge and risk survey in ASL. Findings among 700 deaf adolescent participants attending high schools for the deaf throughout the United States showed that, on average, students knew correct answers to approximately half (x = 7.2) of 14 knowledge items (median: 7.0; range: 0-14; sd = 3.8) on a highly reliable knowledge scale (alpha = .83). Knowledge score was found in multivariable analysis to be strongly related to receiving HIV information in school. This population is clearly in need of linguistically and culturally accessible HIV prevention education delivered in school.

Persons living with HIV/AIDS (PLHA) of color are under-represented in AIDS clinical trials (ACTs), which may limit the generalizability of research findings and denies many individuals access to high levels of care and new treatments available through ACTs. Disproportionately low rates of recruitment in health care settings and by providers are a major barrier to ACTs for this group. Moreover, PLHA of color are more likely than their white peers to decline to participate, mainly due to fear and mistrust (although willingness is also high), negative social norms about ACTs, and difficulty navigating the unfamiliar ACT system. We describe a small number of successful behavioral and structural interventions to increase the participation of PLHA of color in screening for and enrollment into ACTs. HIV care settings, clinical trials sites, and trial sponsors are uniquely positioned to develop procedures, supports, and trials to increase the proportion of PLHA of color in ACTs.

OBJECTIVES: Injection drug users (IDUs) are at high risk for HIV, hepatitis, overdose and other harms. Greater drug treatment availability has been shown to reduce these harms among IDUs. Yet, little is known about changes in drug treatment availability for IDUs in the U.S. This paper investigates change in drug treatment coverage for IDUs in 90 metropolitan statistical areas (MSAs) during 1993-2002. METHODS: We define treatment coverage as the percent of IDUs who are in treatment. The number of IDUs in drug treatment is calculated from treatment entry data and treatment census data acquired from the Substance Abuse and Mental Health Service Administration, divided by our estimated number of IDUs in each MSA. RESULTS: Treatment coverage was low in 1993 (mean 6.7%; median 6.0%) and only increased to a mean of 8.3% and median of 8.0% coverage in 2002. CONCLUSIONS: Although some MSAs experienced increases in treatment coverage over time, overall levels of coverage were low. The persistence of low drug treatment coverage for IDUs represents a failure by the U.S. health care system to prevent avoidable harms and unnecessary deaths in this population. Policy makers should expand drug treatment for IDUs to reduce blood-borne infections and community harms associated with untreated injection drug use.

The study's aims were to describe rapid and conventional HIV testing practices and referrals/linkages to services posttest among homeless youth in New York City. We also examined variation among service-involved youth, street youth, and "nomads." Respondent-driven sampling was used to recruit 217 homeless youth who participated in structured interviews. Almost all youth were tested in the past year (82%). Most received pretest/posttest counseling (> 77%). Rapid testing was common and conducted in diverse settings. However, youth reported that rates of referral/linkage to services posttest were low (< 44.4%). Service-involved youth were significantly more likely to receive rapid testing, be tested in the past year, and be tested at a high frequency. Street youth and nomads, those at highest risk for poor health outcomes, had less access to testing and may require creative, low-threshold services. Further, a better understanding of barriers to the use of referrals/linkages to services posttest is needed.

This paper presents the results of a meta-analysis for a single investigator examining the effectiveness of the modified therapeutic community (MTC) for clients with co-occurring substance use and mental disorders (COD). The flexibility and utility of meta-analytic tools are described, although their application in this context is atypical. The analysis includes 4 comparisons from 3 studies (retrieved N = 569) for various groups of clients with COD (homeless persons, offenders, and outpatients) in substance abuse treatment, comparing clients assigned either to an MTC or a control condition of standard services. An additional study is included in a series of sensitivity tests. The overall findings increase the research base of support for the MTC program for clients with COD, as results of the meta-analysis indicate significant MTC treatment effects for 5 of the 6 outcome domains across the 4 comparisons. Limitations of the approach are discussed. Independent replications, clinical trials, multiple outcome domains, and additional meta-analyses should be emphasized in future research. Given the need for research-based approaches, program and policy planners should consider the MTC when designing programs for co-occurring disorders.