Faculty Bibliography

OBJECTIVES: To describe prevention activities and risk behavior in cities where human immunodeficiency virus (HIV) was introduced into the local population of injecting drug users (IDUs), but where seroprevalence has nevertheless remained low (< 5%) during at least 5 years. DESIGN AND SETTING: A literature search identified five such cities: Glasgow, Scotland; Lund, Sweden; Sydney, New South Wales, Australia; Tacoma, Wash; and Toronto, Ontario. Case histories were prepared for each city, including data on prevention activities and current levels of risk behavior among IDUs. PARTICIPANTS: Injecting drug users recruited from both drug treatment and non-treatment settings in each city. INTERVENTIONS: A variety of HIV prevention activities for IDUs had been implemented in each of the five cities. RESULTS: There were three common prevention components present in all five cities: (1) implementation of prevention activities when HIV seroprevalence was still low, (2) provision of sterile injection equipment, and (3) community outreach to IDUs. Moderate levels of risk behavior continued with one third or more of the IDUs reporting recent unsafe injections. CONCLUSIONS: In low-seroprevalence areas, it appears possible to severely limit transmission of HIV among populations of IDUs, despite continuing risk behavior among a substantial proportion of the population. Pending further studies, the common prevention components (beginning early, community outreach, and access to sterile injection equipment) should be implemented wherever populations of IDUs are at risk for rapid spread of HIV.

From 1988 to 1991, 6,882 drug injectors in 15 US cities were interviewed and had serum samples collected. The interviews and samples were analyzed for determination of significant predictors of human immunodeficiency virus (HIV) seroconversion in the 10 low seroprevalence cities and the five high seroprevalence cities. The unit of analysis was the period of observation between consecutive paired interviews/blood samples. In Cox proportional hazards regression, significant predictors of seroconversion in the low seroprevalence cities were: not being in drug treatment, injecting in outdoor settings or abandoned buildings, using crack cocaine weekly or more frequently, engaging in woman-to-woman sex, being of non-Latino race/ethnicity, and city seroprevalence. Predictors in high seroprevalence cities were: injecting with potentially infected syringes, not being in drug treatment, and having a sex partner who injected drugs. These findings suggest that HIV may be concentrated in sociobehavioral pockets of infection in low seroprevalence cities. For reducing HIV transmission, these results suggest: 1) in low seroprevalence cities, localized monitoring to detect specific emerging sociobehavioral pockets of infection, and quick implementation of appropriate targeted interventions if necessary; 2) in high seroprevalence cities, relatively more emphasis on locality-wide outreach and syringe-exchange projects to reduce risky behavior; and 3) in both types of cities, considerable expansion of drug treatment programs.

While most studies of AIDS risk behavior rely on self-reports, few studies have assessed the reliability of these reports. The present study examines self-reports of drug-related and sexual risk behavior among pairs of injecting drug users (IDUs) recruited from the streets in New York City. Since both members of the pair were interviewed, it was possible to compare their responses in order to assess reliability. Subjects reported on their contacts' demographic data (age, gender, race/ethnicity) and on shared risk behaviors, including syringe sharing. Despite the private and/or illegal nature of AIDS risk behaviors, IDU subjects were generally reliable in their reports of both demographic and AIDS risk behaviors.

OBJECTIVES/OBJECTIVE:To identify factors associated with effective AIDS behavior change among injecting drug users (IDU) in different national settings. DESIGN/METHODS:Cross-sectional surveys of IDU, with determination of HIV status. Trends in city HIV seroprevalence among IDU also used to validate effectiveness of behavior change. SETTING AND PARTICIPANTS/METHODS:Subjects recruited from drug-use treatment programs and outreach efforts in Bangkok, Thailand (n = 601), Glasgow, Scotland (n = 919), New York City, USA (n = 2539), and Rio de Janeiro, Brazil (n = 466). RESULTS:Evidence for the effectiveness of self-reported risk reduction was available for all cities. Univariate followed by multiple logistic regression analyses were used to identify factors associated with self-reported AIDS behavior change. Separate analyses were conducted for each city. Talking about AIDS with drug-using friends was significantly associated with behavior change in all four cities. Talking with sex partners about AIDS, educational level, knowing that someone can be HIV-infected and still look healthy, and having been tested previously for HIV were each significantly associated with behavior change in three of the four cities. CONCLUSIONS:Despite the substantial differences in these national settings, there were common factors associated with effective risk reduction. In particular, risk reduction appears to occur through social processes rather than through individual attitude change. HIV prevention programs need to explicitly incorporate social processes into their work.

HIV among injecting drug users (IDUs) has now been documented in over 60 countries in the world, and there are an additional 40 countries where injecting drug use has been reported including widespread epidemics in Southeast and southern Asia and in Latin America. At present HIV infection is almost always fatal, and there is no promise that a preventive vaccine will become available soon. Given the enormity of the HIV epidemic among IDUs and the critical need to reduce the spread of HIV transmission to and from IDUs, prevention efforts are essential. Syringe-exchange programs have become a major component of HIV prevention strategies in most developed countries and work within the philosophy of harm reduction. Increasing access to sterile syringes has been met with considerable controversy. Opponents of syringe exchange have generally argued that increasing access to sterile syringes would simultaneously increase the number of injecting drug users, increase the frequency of injection for already active IDUs, and appear to "condone" an illegal behavior. To date many research studies and four major reviews of syringe exchange literature have been conducted. All studies thus far have shown no increase in illicit drug injection associated with syringe exchanges, and significant decrease in drug risk behaviors.