Faculty Bibliography

Infective endocarditis is a potentially fatal consequence of illicit injection drug use. We estimate that the number of hospitalization for injection drug use-related infective endocarditis increased by 38%-66% in the United States between 2000-2001 and 2002-2003, a period during which the number of at-risk persons (i.e., injection drug users) remained stable. Increasing methamphetamine use and/or drug injection frequency may have increased the incidence of infective endocarditis among active injection drug users.

Significant advances have been made in preventing HIV infection among injectors but we still know little about preventing hepatitis C (HCV). Both prevalence and incidence of hepatitis C can remain high among IDUs even in the context of widespread implementation of harm reduction programmes. We need to develop new ways to fill the knowledge gap regarding HCV prevention. One way is to learn from the experts--those IDUs who, after long-term injection in social milieus of high hepatitis C prevalence, nonetheless remain uninfected. We describe a recently commenced program of research that focuses on understanding the strategies, behaviours, and environmental factors associated with "staying safe". This represents a 180-degree turn in IDU research where the focus has traditionally been on risk. Since social, cultural and environmental factors, as well as the vagaries of human strategic discovery by drug users can vary among localities, researchers in four different contexts--New York City, Valencia, Sydney and London--are collaborating in parallel Staying Safe studies. These studies aim to provide the conceptual basis for developing a new generation of HCV prevention programs to assist both new and experienced IDUs to remain uninfected over the long run.

OBJECTIVES/OBJECTIVE:We analyzed the relations of two 1990 dimensions of racial residential segregation (isolation and concentration) with 1998 injection drug use prevalence among Black adult residents of 93 large US metropolitan statistical areas (MSAs). METHODS:We estimated injection drug use prevalence among Black adults in each MSA by analyzing 3 databases documenting injection drug users' encounters with the health care system. Multiple linear regression methods were used to investigate the relationship of isolation and concentration to the natural logarithm of Black adult injection drug use prevalence, controlling for possible confounders. RESULTS:The median injection drug use prevalence was 1983 per 100000 Black adults (interquartile range: 1422 to 2759 per 100000). The median isolation index was 0.48 (range: 0.05 to 0.84): in half the MSAs studied, the average Black resident inhabited a census tract where 48% or more of the residents were Black. The multiple regression model indicates that an increase of 0.50 in the isolation index was associated with a 23% increase in injection drug use prevalence among Black adults. Concentration was unrelated to the outcome. CONCLUSIONS:Residential isolation is positively related to Black injection drug use prevalence in MSAs. Research into the pathways linking isolation to injection drug use is needed.

OBJECTIVES/OBJECTIVE:To examine gender differences in drug injection equipment sharing at injecting initiation. METHODS:Young injecting drug users (IDUs) in New York City February 1999-2003 were surveyed about injection risk behaviors and circumstances at initiation. Analyses were gender-stratified and excluded participants who initiated alone. Multiple logistic regression estimated adjusted odds ratios. RESULTS:Participants (n=249) were 66% male and 82% White. Mean initiation age was 19.2; mean years since initiating was 3.0. Women were significantly more likely to cite social network influence as a reason for initiating, to have male and sex partner initiators, and to share injecting equipment than men. Among women, sharing any injection equipment was associated with initiation by a sex partner and having > or =2 people present. Among men, being injected by someone else predicted sharing any injection equipment, while using a legally obtained syringe was protective. CONCLUSIONS:Social persuasion stemming from sexual and/or social relationships with IDUs may increase women's risk of sharing injection equipment at initiation, and consequently, their early parenteral risk of acquiring blood-borne infections. Interventions should focus on likely initiates, especially women in injecting-discordant sex partnerships, and IDUs (potential initiators).

"Social capital" has been critiqued as distracting attention from inequalities and policies that produce ill health. We support this critique insofar as social capital refers to the degree of trust and consensus in a locality, but find value in another dimension often included in the concept of social capital--social network ties and their associated communication patterns. We present a case study of Bushwick, a community of 100,000 people in Brooklyn NY, to suggest that the network aspect of "social capital" is useful to understand the active, on-the-ground processes by which residents of some neighborhoods beset by poverty, racial/ethnic subordination, and internal divisions (that themselves arise from inequalities and state policies) work out ways to defend their own and others' safety and health. We use a combination of population-representative survey data for young adults; sexual network survey data; and ethnography to show that Bushwick residents (including drug users and dealers) have used social network ties, communication, and normative pressures to reduce the extent to which they are put at risk by the drug trade and by drug-use-related HIV/AIDS in spite of conflicting interests, disparate values, and widespread distrust both of other community members and of dominant social institutions. This was done by "intravention" health communications, development of protective norms, informal negotiations, and other forms of adjustments within and among various groups--but it occurred in the absence of trust or consensus in this community. We conclude both (1) that social network interpretations of "social capital" might be better conceptualized in dialectic terms as collective action to survive in a harsh social order, and (2) that the social capital theory emphasis on trust and consensus as important causal factors for lowering drug-related risks at the community level may be a romanticized and erroneous perspective.

Syringe exchange programs (SEPs) aim to reduce the harm associated with injection drug use (IDU). Although they have been accepted as critical components of HIV prevention in many parts of the world, they are often unwelcome and difficult to set up and maintain, even in communities hardest hit by IDU-related HIV transmission. This research examines socio-cultural and political processes that shape community and institutional resistance toward establishing and maintaining SEPs. These processes are configured and reinforced through the socio-spatial stigmatizing of IDUs, and legal and public policy against SEPs. Overarching themes the paper considers are: (1) institutional and/or political opposition based on (a) political and law enforcement issues associated with state drug paraphernalia laws and local syringe laws; (b) harassment of drug users and resistance to services for drug users by local politicians and police; and (c) state and local government (in)action or opposition; and (2) the stigmatization of drug users and location of SEPs in local neighborhoods and business districts. Rather than be explained by "not in my back yard" localism, this pattern seems best conceptualized as an "inequitable exclusion alliance" (IEA) that institutionalizes national and local stigmatizing of drug users and other vulnerable populations.

Risk networks can transmit HIV or other infections; social networks can transmit social influence and thus help shape norms and behaviors. This primarily-theoretical paper starts with a review of network concepts, and then presents data from a New York network study to study patterns of sexual and injection linkages among IDUs and other drug users and nonusers, men who have sex with men, women who have sex with women, other men and other women in a high-risk community and the distribution of HIV, sex at group sex events, and health intravention behaviors in this network. It then discusses how risk network microstructures might influence HIV epidemics and urban vulnerability to epidemics; what social and other forces (such as "Big Events" like wars or ecological disasters) might shape networks and their associated norms, intraventions, practices and behaviors; and how network theory and research have and may continue to contribute to developing interventions against HIV epidemics.

We examine injecting and sexual risk correlates of hepatitis B (HBV) and hepatitis C (HCV) seroprevalence among new injecting drug users (IDUs) (age 18-30 years, injecting < or =6 years). Participants were interviewed/serotested (HIVab, HBVcAb, HCVab) in New York City, February 1999-February 2003. Gender-stratified, multivariate logistic regression was conducted. Participants (N=259) were: 68% male; 81% white. Women were more likely to test HCV seropositive (42% versus 27%) and men HBV seropositive (24% versus 12%); HIV seroprevalence was low (3%). Among both men and women, HBV seropositivity was associated with ever selling sex, and HCV seropositivity with ever having had infected (HIV, HBV or HCV) sex partners (among those ever sharing injecting equipment). Among women only, HBV seropositivity was associated with ever having had infected sex partners (regardless of ever sharing injecting equipment), and HCV seropositivity with > or =300 lifetime drug injections. Among men only, HCV seropositivity was associated with > or =40 lifetime number of sex partners (among those never sharing injecting equipment). In this new IDU sample, HBV and HCV seroprevalence differed by gender and were considerably higher than HIV seroprevalence. Early interventions, targeting injecting and sexual risks and including HBV vaccination, are needed among new IDUs to prevent HBV, HCV and, potentially, HIV epidemics.