Faculty Bibliography

This paper examined correlates of consistent condom use with a main partner among heterosexual male injection drug users (IDUs). Using data from a multi-site sample of young IDUs, we identified 1770 sexually active men of whom 24% (429/1770) reported an exclusive main female sex partner and 49% (862/1770) reported both main and casual female sex partners. Consistent condom use with a main partner was low among men with an exclusive main partner and those with multiple partners (12% and 17%, respectively). In multivariate analysis, consistent condom use with a main partner across partnership patterns was directly associated with anticipating a positive response to requests for condom use and by partner support of condom use; consistent condom use was inversely associated with a main partner's pregnancy desires. Among men with an exclusive main partner, consistent condom use was also inversely associated with needle sharing with a main partner. Among men with multiple partners, consistent condom use with a main partner was inversely associated with injecting with a used needle and intimate partner violence. The low prevalence of consistent condom use with main female partners among heterosexually active male IDUs indicates an increased risk for HIV transmission between men and their primary sex partners. Interventions for heterosexual males that are geared toward increasing condom use in primary relationships are warranted.

Using cross-sectional analysis we examined residential status and associated differences in HIV risk behaviors among 3266 young IDUs enrolled in an HIV prevention trial. A three-level outcome (homeless (37%), equivocally housed (17%), housed (46%)) was defined based on responses to two questions assessing subjective and objective criteria for homelessness: "equivocally housed" participants were discordant on these measures. In multivariate analysis, antecedents of homelessness were having lived in an out-of-home placement, been thrown out of the home or in juvenile detention, and experienced childhood abuse; while correlates included receiving income from other and illegal sources, drinking alcohol or using methamphetamine at least daily, using shooting galleries, backloading, and sex work. A subset of these variables was associated with being equivocally housed. HIV risk varies by housing status, with homeless IDUs at highest risk. Programs for IDUs should utilize a more specific definition of residential status to target IDUs needing intervention.

BACKGROUND: We examined the interaction of illicit drug use and depressive symptoms, and how they affect the subsequent likelihood of highly active antiretroviral therapy (HAART) use among women with HIV/AIDS. METHODS: Subjects included 1710 HIV-positive women recruited from six sites in the U.S. including Brooklyn, Bronx, Chicago, Los Angeles, San Francisco/Bay Area, and Washington, DC. Cases of probable depression were identified using depressive symptom scores on the Center for Epidemiologic Studies Depression Scale. Crack, cocaine, heroin, and amphetamine use were self-reported at 6-month time intervals. We conducted multivariate random logistic regression analysis of data collected during 16 waves of semiannual interviews conducted from April 1996 through March 2004. RESULTS: We found an interaction effect between illicit drug use and depression that acted to suppress subsequent HAART use, controlling for virologic and immunologic indicators, socio-demographic variables, time, and study site. CONCLUSIONS: This is the first study to document the interactive effects of drug use and depressive symptoms on reduced likelihood of HAART use in a national cohort of women. Since evidence-based behavioral health and antiretroviral therapies for each of these three conditions are now available, comprehensive HIV treatment is an achievable public health goal.

BACKGROUND: New injection drug users (IDUs) are at high risk for blood-borne viral infections. Given U.S. policy to only fund proven-effective HIV prevention interventions, insights into conducting intervention trials among young IDUs are provided here by describing methods and participants' characteristics in the CIDUS III/DUIT study. METHODS: In 2002-2004, 15-30-year-old IDUs in Baltimore, Chicago, Los Angeles, New York, and Seattle were recruited through community outreach, advertising and coupon-based participant referrals. Baseline interviews assessed sociodemographics, injection, and sexual behaviors. Antibody tests for HIV and hepatitis A, B, and C viruses (HAV, HBV, and HCV) were conducted. IDUs who were HIV and HCV antibody negative at baseline were eligible to participate in a randomized controlled HIV/HCV prevention trial. Follow-up assessments were conducted 3 and 6 months post-intervention. Data were analyzed to identify participant differences at baseline by city, trial enrollment, and trial retention. RESULTS: Baseline assessments were completed by 3285 IDUs. Participants were mean age 23.8 years, 69% male, 64% White, 17% Hispanic, and 8% Black. Seroprevalence of HIV, HCV, HBV, and HAV antibodies were 2.9, 34.4, 22.4, and 19.3%, respectively. Of the 2062 (62.7%) baseline participants who were HIV and HCV antibody negative, 859 (41.7%) were randomized. At least one follow-up assessment was completed by 712 (83%) randomized participants. Contextual factors, primarily homelessness, were associated with lower enrollment and retention. CONCLUSIONS: Recruitment and retention of young-adult IDUs for complex intervention trials is complicated, yet feasible. Risk behaviors among participants enrolling in and completing the trial reflected those eligible to enroll.

BACKGROUND: Sharing of drug paraphernalia to prepare, measure and divide drugs for injection remains an important residual risk factor for hepatitis C and other blood-borne infections among injection drug users (IDUs) especially as sharing of syringes for injection decreases. METHODS: We analyzed data from five U.S. cities to determine the prevalence and independent correlates of non-syringe paraphernalia-sharing (NSPS) and syringe-mediated drug-splitting (SMDS) among 15-30-year-old IDUs who reported not injecting with others' used syringes (receptive syringe-sharing, RSS). RESULTS: NSPS was reported by 54% of IDUs who did not practice RSS and was independently associated (p<0.05) with having > or =5 injection partners, injecting with sex partners or regular injection partners, injecting in shooting galleries, peers' sharing behaviors, lower self-efficacy for avoiding NSPS, and less knowledge of HIV and HCV transmission. SMDS was reported by 26% of IDUs who did not practice RSS, and was independently associated with having > or =5 injection partners, injecting in shooting galleries, and inversely associated with unknown HIV status. CONCLUSIONS: NSPS and SMDS were common among young adult IDUs. Increased efforts to prevent these risky practices should address social and environmental contexts of injection and incorporate knowledge and skills building, self-efficacy, and peer norms.

OBJECTIVES: To evaluate whether a behavioral intervention, which taught peer education skills, could reduce injection and sexual risk behaviors associated with primary HIV and hepatitis C virus infection (HCV) among young injection drug users (IDU). DESIGN: We conducted a randomized controlled trial involving HIV and HCV antibody-negative IDU, aged 15-30 years, recruited in five United States cities. A six-session, small-group, cognitive behavioral, skills-building intervention in which participants were taught peer education skills (n = 431) was compared with a time-equivalent attention control (n = 423). Baseline visits included interviews for sociodemographic, psychosocial, and behavioral factors during the previous 3 months; HIV and HCV antibody testing; and pre/posttest counselling. Procedures were repeated 3 and 6 months postintervention. RESULTS: The intervention produced a 29% greater decline in overall injection risk 6 months postintervention relative to the control [proportional odds ratio 0.71; 95% confidence limit (CL) 0.52, 0.97], and a 76% decrease compared with baseline. Decreases were also observed for sexual risk behaviors, but they did not differ by trial arm. Overall HCV infection incidence (18.4/100 person-years) did not differ significantly across trial arms (relative risk 1.15; 95% CL 0.72, 1.82). No HIV seroconversions were observed. CONCLUSION: Interventions providing information, enhancing risk-reduction skills, and motivating behavior change through peer education training can reduce injection risk behaviors, although risk elimination might be necessary to prevent HCV transmission.

Hepatitis C virus (HCV) is hyperendemic among injection drug users (IDUs). However, few scientifically proven interventions to prevent secondary transmission of HCV from infected IDUs to others exist. This report describes the design, feasibility, and baseline characteristics of participants enrolled in the Study to Reduce Intravenous Exposure (STRIVE). STRIVE was a multisite, randomized-control trial to test a behavioral intervention developed to reduce distribution of used injection equipment (needles, cookers, cottons, and rinse water) and increase health-care utilization among antibody HCV (anti-HCV) positive IDUs. STRIVE enrolled anti-HCV positive IDU in Baltimore, New York City, and Seattle; participants completed behavioral assessments and venipuncture for HIV, HCV-RNA, and liver function tests (LFTs) and were randomized to attend either a six-session, small-group, peer-mentoring intervention workshop or a time-matched, attention-control condition. Follow-up visits were conducted at 3 and 6 months. At baseline, of the 630 HCV-positive IDUs enrolled (mean age of 26 years, 60% white, 76% male), 55% reported distributive needle sharing, whereas 74, 69, and 69% reported sharing cookers, cottons, and rinse water, respectively. Health-care access was low, with 41% reporting an emergency room as their main source of medical care. Among those enrolled, 66% (418/630) were randomized: 53% (222/418) and 47% (196/418) to the intervention and control conditions, respectively. Follow-up rates were 70 and 73% for the 3- and 6-month visits, respectively. As distributive sharing of used injection equipment was common while reports of receiving HCV care were low, these findings indicate an urgent need for HCV-related interventions with IDUs and demonstrate the acceptability and feasibility to do so.

OBJECTIVE: This study was conducted to assess the accuracy of self-reported hepatitis C virus (HCV) antibody (anti-HCV) serostatus in injection drug users (IDUs), and examine whether self-reported anti-HCV serostatus was associated with recent injection risk behavior. METHODS: In five U.S. cities (Baltimore, Chicago, Los Angeles, New York, and Seattle), 3,004 IDUs from 15 to 30 years old were recruited for a baseline interview to determine eligibility for a randomized controlled trial of a behavioral intervention. HIV and HCV antibody testing were performed, and subject data (e.g., demographics, drug and sexual risk behavior, and history of HIV and HCV testing) were collected via audio computer-administered self-interview. Risk behavior during the previous three months was compared to self-reported anti-HCV serostatus. RESULTS: Anti-HCV prevalence in this sample of young IDUs was 34.1%. Seventy-two percent of anti-HCV-positive and 46% of anti-HCV-negative IDUs in this sample were not aware of their HCV serostatus. Drug treatment or needle exchange use was associated with increased awareness of HCV serostatus. Anti-HCV-negative IDUs who knew their serostatus were less likely than those unaware of their status to inject with a syringe used by another IDU or to share cottons to filter drug solutions. Knowledge of one's positive anti-HCV status was not associated with safer injection practices. CONCLUSIONS: Few anti-HCV-positive IDUs in this study were aware of their serostatus. Expanded availability of HCV screening with high quality counseling is clearly needed for this population to promote the health of chronically HCV-infected IDUs and to decrease risk among injectors susceptible to acquiring or transmitting HCV.