The epidemic of acquired immunodeficiency syndrome (AIDS) and suggestions for its control in drug abusers

Longitudinal HIV risk behavior among the Drug Abuse Treatment Outcome Studies (DATOS) adult sample

Longitudinal trajectories for HIV risk were examined over 5 years following treatment among 1,393 patients who participated in the nationwide Drug Abuse Treatment Outcome Studies. Both injection drug use and sexual risk behavior declined over time, with most of the decline occurring between intake and the first-year follow-up. However, results of the application of growth mixture models for both sets of trajectories indicated that a subgroup of individuals reverted to a high-risk behavior over time, with a higher level of risk at the 5-year follow-up than their original risk level at intake. Of clients who were engaged in regular injection drug use at intake, 76% continued to inject drug at a moderate-stable or increased rate during the 5-year follow-up.

The impact of New York City's 1975 fiscal crisis on the tuberculosis, HIV, and homicide syndemic

In 1975, New York City experienced a fiscal crisis rooted in long-term political and economic changes in the city. Budget and policy decisions designed to alleviate this fiscal crisis contributed to the subsequent epidemics of tuberculosis, human immunodeficiency virus (HIV) infection, and homicide in New York City. Because these conditions share underlying social determinants, we consider them a syndemic, i.e., all 3 combined to create an excess disease burden on the population. Cuts in services; the dismantling of health, public safety, and social service infrastructures; and the deterioration of living conditions for vulnerable populations contributed to the amplification of these health conditions over 2 decades. We estimate that the costs incurred in controlling these epidemics exceeded 50 billion US dollars (in 2004 dollars); in contrast, the overall budgetary saving during the fiscal crisis was 10 billion US dollars. This history has implications for public health professionals who must respond to current perceptions of local fiscal crises.

Substance abuse in HIV-positive women

Early in the U.S. HIV/AIDS pandemic, the role of substance abuse in the spread of AIDS was clearly established. However, the relationship of HIV and substance abuse is more complex than simply noting that injection drug use is a mode of transmission for the virus. HIV infection and substance abuse disorders interact in a complex fashion, with each acting as a potential catalyst or obstacle in the treatment of the other. In this article, we report the results of a qualitative metasynthesis of studies containing information on substance abuse among HIV-positive women, using 74 published and unpublished reports. The data on 1,548 women, who were primarily mothers from minority groups, allowed us to construct a trajectory that describes the events of their lives with regard to substance abuse and its intersection with HIV infection.

Predictors of Self-Reported HIV Infection Among Drug Injectors in Ukraine

OBJECTIVE

To identify characteristics, including current high-risk drug and sex behaviors, associated with self-reported HIV infection among injection drug users (IDUs) in Ukraine.

DESIGN

Targeted sampling of IDUs from Kiev, Odessa, and Makeevka/Donetsk, Ukraine.

METHODS

From June through August 2002, 100 IDUs from each site were recruited through street outreach, including 212 who had previously been tested for HIV and knew their serostatus. Subjects were administered a standardized computer-assisted interview assessing HIV-related drug and sex risk behaviors and history of HIV testing.

RESULTS

Twenty six percent of the 212 participants reported they were HIV-positive. Univariate followed by multiple logistic regression analyses were used to identify factors associated with HIV infection. In the 30-day period before their interview, HIV-infected IDUs were significantly more likely to have injected with a needle previously used by another injector without disinfecting, frontloaded and/or backloaded, and shared the drug solution from a common container. In addition, they had higher prevalence rates for hepatitis B virus and hepatitis C virus than those not infected with HIV. On the other hand, they were more likely to have reported no sex partners and, if sexually active, more likely to have used a condom.

CONCLUSION

The high HIV seroprevalence among IDUs in Ukraine, combined with their continued engagement in needle-related risk behaviors, assures the continuance of the epidemic in this region, a region that is the epicenter of HIV in Europe.

Improving entry to methadone maintenance among out-of-treatment injection drug users

This study of 577 out-of-treatment drug injectors was designed to assess predictors of methadone maintenance treatment entry, including offering free treatment coupons. Using targeted sampling methods, participants were recruited through street outreach; randomly, they were either assigned a coupon for 90 days of free treatment or required to pay for their treatment. Regardless of assignment, all subjects who desired treatment were provided transportation, rapid intake, and a waiver of the treatment entry fee. Overall, 33% entered treatment, including 66% of those who received a free coupon. Other factors associated with treatment entry included desire for treatment, heroin use, prior treatment experience, associating with fewer drug-using friends, and injecting with a previously used unsterile needle/syringe. Injecting cocaine and smoking crack reduced the probability of treatment entry. Findings lend support to street outreach efforts designed to increase rates of treatment entry among chronic out-of-treatment drug injectors. Additional treatment options are required for those abusing cocaine.

Partial characterization and tissue distribution of the feline mu opiate receptor

Heroin abuse is a common route of acquiring HIV-1 infection. However, the effects of opiates on lentivirus disease progression are not well understood. Feline immunodeficiency virus is recognized as a good animal model for HIV-1, but characterization of the opiate receptor system in cats is lacking. Here we report the partial sequencing of the feline mu opiate receptor (MOR) and demonstrate a homology of 92 and 93% to the published human MOR sequences. Additionally, MOR transcripts were detected in the feline brain and tonsil but not in the spleen. Also, specific receptor ligand interactions were observed using microphysiometry.

Maturity of human immunodeficiency virus infection and incubation period of acquired immunodeficiency syndrome in injecting drug users

This study was aimed at estimating the maturity of the human immunodeficiency virus (HIV) epidemic in cohorts of injecting drug users with existing HIV infection at the time of first observation, and using this information to estimate the incubation period of acquired immunodeficiency syndrome (AIDS) in this population group. The method imputed the "missing" time from seroconversion to first observation for seroprevalent subjects in a combined cohort including injecting drug users from New York (n = 246) and Baltimore (n = 621). Imputation relied on a probability model predicting time since seroconversion on the basis of two markers of maturity of HIV infection: percent of CD4+ lymphocytes and platelet count. The model was developed from data observed in a combined cohort of subjects from New York (n = 24) and Baltimore (n = 112) who had incident HIV infections. The estimates of median time since seroconversion for the Baltimore and Bronx seroprevalent subcohorts were 28 and 39 months, respectively. The total time from seroconversion to AIDS was then estimated for the incident plus completed-prevalent cohorts using a modified version of the nonparametric product-limit method. The results showed that approximately 95% (95% confidence interval: 90 to 98%) of drug users remained AIDS-free 2 years after seroconversion; 83% (74-91%), 4 years after seroconversion; and 72% (61-82%), 6 years after seroconversion. Median time to AIDS was 10.2 years, with an estimated 95% confidence interval of 7.9 to 12.3 years. Consistency of these results with those derived from large cohorts of homosexual men indicate that the HIV incubation distributions for drug users and homosexual men are similar.

Knowledge of AIDS and HIV among various groups

To date, no cure has been found for HIV/AIDS. Prevention has therefore been the immediate principal aim and a didactic approach has been given a primary role. Studies from the USA indicate that knowledge level may be dictated by membership of particular subcultural groups and the perceived relevance of HIV/AIDS to these groups. This study investigates knowledge among four groups: homosexual; single heterosexual; IV drug users; and a 'married' group. Results indicate some gaps in knowledge and a greater knowledge base among one of the high risk groups, the homosexual group.

Self-Report Interview Data for a Study of HIV-1 Infection among Intravenous Drug Users: Description of Methods and Preliminary Evidence on Validity

This article presents a description and preliminary evidence on validity of self-report interview methods being used in a study of HIV-1 infection and AIDS among intravenous drug users (IVDUs). The study population includes 2,616 currently active IVDUs living in or near Baltimore City, Maryland (USA), many of them reporting no prior treatment for drug dependence, and many with no history of criminal arrest or incarceration. These IVDUs were recruited in 1988–89 by extensive community outreach efforts; most learned of the study by word-of-mouth. To study IV drug use and HIV-1 infection in relation to onset of AIDS, the subjects are being interviewed, examined, and tested at baseline (recruitment), and periodically thereafter. This report compares information from the self-report baseline interview with independently collected data on physical stigmata of drug injection, T-lymphocyte cell subsets, and HIV-1 serostatus. The evidence generally supports the validity of these self-report data on IV drug use, including data from a year-by-year history of sharing injection equipment, obtained by retrospection at baseline.

The Alive Study: A Longitudinal Study of HIV-1 Infection in Intravenous Drug Users: Description of Methods

To identify risk factors for infection with the human immunodeficiency virus (HIV) and for progression to the acquired immunodeficiency syndrome (AIDS) among intravenous drug users, we established a cohort in Baltimore Maryland in 1988–1989. Intravenous drug users were recruited by extensive community outreach to undergo interview and confidential HIV testing in a special study site. During 13 months of recruitment, 2,921 intravenous drug users were enrolled of whome 24 percent were HIV seropositive; 90 percent returned to receive test results. Methodological issues for enhancing recruitment and retention of drug users are discussed.

Intravenous drug users and AIDS: risk behaviors

Risk-taking behaviors were studied in this assessment of 345 intravenous drug users from Baltimore, El Paso, and Denver. Over 50% reported injecting drugs daily and 70% shared needles with others, averaging 6.3 partners. In addition, 86% had shared a "cooker" and nearly 50% injected in a "shooting gallery." More than half of the males sampled had two or more sex partners, including 18% with five or more. Females averaged 19 sex partners in the preceding 6 months, with 22% reporting sex with five or more. Two-thirds of the total sample never used a condom, while only 6% always used this form of protection. On the other end of this risk continuum were those subjects who did not share needles or always cleaned their needles with an effective agent, had no sexual relations or always used a condom. Subjects following such practices could be considered low risk if they adopted safe behaviors in other associated areas of their lives. However, in an analysis of total risk, it was found that only 14 subjects (4%) practiced safe needle use and safe sex. Despite these findings, some encouraging results were seen. In an analysis of risk according to location, Baltimore subjects were significantly less at risk according to number of needle-sharing partners, borrowing needles, sharing a "cooker," injection in a "shooting gallery," cleaning needles, use of disinfectants, number of sexual partners, and use of condoms than either their cohorts in El Paso or Denver. Street outreach to modity risk behaviors among IVDUs began in Baltimore approximately 2 years prior to funding in El Paso and Denver. These results suggest that there may be a potential to moderate risk through intervention.

Needle Sharing among Male Prostitutes: Preliminary Findings of the Prospero Project

To date there is only sketchy information about the needle-sharing practices of IV drug users. This article reviews the existing literature on needle-sharing practices and presents quantitative findings on IV drug use, needle-sharing practices and the utilization of shooting galleries of male sex workers. Self-reports of 178 street hustlers, male prostitutes who sell sexual favors in public places, indicate a high incidence of IV drug use, particularly methamphetamines, cocaine and heroin. They also report considerable syringe sharing, as well and needle sharing in social settings such as shooting galleries, bath houses and sex clubs. Pragmatic issues, such as availability of syringes and convenience, are said to be the principle reasons to share needles. Race and ethnicity were not important factors for this group. It would appear from this preliminary data that a sizeable percentage of street hustlers in San Francisco are at risk to contract the HIV virus because of their needle-sharing practices.

The Lexington addicts, 1971-1972: demographic characteristics, drug use patterns, and selected infectious disease experience

The demographics, drug habits, and medical complications of a cohort of 1,129 addicts treated at Lexington in the period 1971-1972 were studied. These patients, admitted from 41 different states, had a mean period of addiction of 5.4 years. Over one-third of the sample had engaged in pimping or prostitution, and there were no differences by gender in terms of involvement. Eight-eight percent had shared injection equipment, and surprisingly, 78% admitted to some effort at sterilizing their "works." Hepatitis was the most common associated medical condition: 87% had serologic markers of hepatitis B virus (HBV) infection, 60% had evidence of hepatitis A virus (HAV) exposure, and 47% had abnormal liver function parameters. Gynecomastia was evident in 2% of male subjects. Thirteen percent of the sample had a reactive VDRL assay, but 64% of these were biologically false positive. Subtle abnormalities of immune function were also observed; 18% of the patients had recent unexplained weight loss, 6% had lymphadenopathy, 8% had leukopenia, and 2% had lymphocytopenia. We conclude that both HBV and HAV were important infectious disease risks in these addicts, and that many evidenced deficiencies in immune function well before AIDS became a major public health concern.

AIDS and IV Drug Use among Ethnic Minorities

Blacks and Hispanics have a higher prevalence and incidence of cases of Acquired Immunodeficiency Syndrome (AIDS) associated with intravenous (IV) drug use than do whites. Further transmission of the AIDS virus to sexual partners of IV drug users increases the possibility of a secondary epidemic of AIDS, especially among non-white females. This report presents data on differences in IV drug cases of AIDS among white and non-white IV drug users in the United States, offers possible explanations for differences in transmission patterns, and suggests the implications of these differences for the prevention of further transmission of the AIDS virus among minority populations.

Acquired Immunodeficiency Syndrome (Aids): A Survey of Substance Abuse Clinic Directors' and Counselors' Perceived Knowledge, Attitudes and Reactions

As Acquired Immunodeficiency Syndrome (AIDS) continues to affect intravenous drug abusers, providing AIDS-related counseling to this population is becoming increasingly critical. Substance abuse clinic directors and counselors within the Chicago area were surveyed to examine, respectively, clinic policies and practices concerning AIDS and self-reported knowledge, attitudes, and reactions associated with AIDS. Across clinics, policies and practices were found to be inconsistent and frequently incomplete, inadequate and at times, questionable. Many directors either would not admit or were uncertain if they would admit persons with AIDS (PWAs) for treatment. Most had incomplete AIDS infection control policies; a few had questionable and several had none. Clearer and nondiscriminatory federal and state AIDS guidelines need to be established and implemented at the clinic level. Counselors, similar to the general population, held apprehensions concerning AIDS. Unlike the fears of the general population, these fears did not translate into negative attitudes, prejudices, or active discrimination, but they did seem to translate into inaction and indecision. Many counselors reported not being knowledgeable nor comfortable enough to counsel PWAs. AIDS counselor education needs to deal with these AIDS-elicited emotional reactions.

Geographic distribution of human immunodeficiency virus markers in parenteral drug abusers

Drug abuse treatment programs in six regions of the United States collaborated in a study aimed at monitoring trends in the seroprevalence of human immunodeficiency virus (HIV) antibodies. The wide disparities in HIV seroprevalence in the face of similarities in drug using behavior have important implications for prevention. In the New York City area (Harlem, Brooklyn), 61 per cent of samples (N = 280) obtained in late 1986 were positive, up from 50 per cent of samples (N = 585) in early 1985. In Baltimore, Maryland, 29 per cent of samples (N = 184) representing 11 programs were positive. In contrast, samples from programs distant from the Northeast corridor had far lower rates: Denver, Colorado 5 per cent (N = 100); San Antonio, Texas 2 per cent (N = 106); Southern California, 1.5 per cent (N = 413); and Tampa, Florida, 0 per cent (N = 102). Contrary to expectations, there was no corresponding difference in reported lifetime needle sharing experiences, which ranged from 70 per cent in New York to 99 per cent in San Antonio. HIV seropositivity was associated only with geographic location and ethnicity; however, because needle sharing is practiced by parenteral drug abusers in areas where seroprevalence is still relatively low, these areas are potentially vulnerable to the same catastrophic spread seen in the Northeast. A window of opportunity exists where prompt, vigorous, and aggressive efforts at prevention could have major impact.

AIDS and addiction in New York City

The association between AIDS and intravenous drug abuse is emerging as a critical component of the AIDS epidemic due to several factors: the high rate of infection of this group with the HTLV-III virus-approximately 50%; the risk of infection to others through shared needles, sexual contact, and intrauterine transmission to the fetus; and the impact of large numbers of new cases of AIDS among addicts on the health care services of a few urban areas. This paper outlines the projected dimensions of the AIDS epidemic among intravenous drug abusers in New York City and its implications for hospital utilization and local health care expenditures. These considerations indicate the urgent need for a rapid expansion of addiction treatment services and modification of treatment objectives to deal with this new problem.