Alcohol use among out-of-treatment crack using African-American women

Sex Differences, Cocaine Use, and Liver Fibrosis Among African Americans in the Miami Adult Studies on HIV Cohort

Background: HIV infection disproportionally affects African Americans. Liver disease is a major cause of non-HIV morbidity and mortality in this population. Substance abuse accelerates HIV disease and may facilitate progression of liver disease. This study investigated the relationship between sex differences and cocaine use with liver injury, characterized as hepatic fibrosis. Materials and Methods: A cross-sectional study was conducted on 544 African Americans [369 people living with HIV (PLWH) and 175 HIV seronegative] from the Miami Adult Studies on HIV (MASH) cohort. Cocaine use was determined with a validated self-reported questionnaire and confirmed with urine screen. Fasting blood was used to estimate liver fibrosis using the noninvasive fibrosis-4 (FIB-4) index. Results: Men living with HIV had 1.79 times higher odds for liver fibrosis than women living with HIV (p = 0.038). African American women had higher CD4 count (p = 0.001) and lower HIV viral load (p = 0.011) compared to African American men. Fewer women (PLWH and HIV seronegative) smoked cigarettes (p = 0.002), and fewer had hazardous or harmful alcohol use (p < 0.001) than men. Women also had higher body mass index (kg/m²) (p < 0.001) compared to men. No significant association was noted among HIV seronegative participants for liver fibrosis by sex differences or cocaine use. Among African Americans living with HIV, cocaine users were 1.68 times more likely to have liver fibrosis than cocaine nonusers (p = 0.044). Conclusions: Sex differences and cocaine use appear to affect liver disease among African Americans living with HIV pointing to the importance of identifying at-risk individuals to improve outcomes of liver disease.

Instruments of Policy and Administration for Improving Substance Abuse Treatment Practice and Program Outcomes

The call for practice improvement in substance abuse treatment is motivated by the ultimate goal of achieving consistently positive post-treatment outcomes. A central hypothesis of the empirical investigation in this study is that consumer-level outcomes are affected either directly or indirectly through clinical practice, by factors originating at the policy and organizational level. Four broad categories of policy and program administration (funding, service technology and delivery, organizational structure, and leadership) that facilitate or hinder the implementation of practice improvements are investigated. Models hypothesizing that the effects of policy and program administration will vary according to the treatment goals and corresponding measurement of outcomes are tested. Using newly available data that link program- and consumer-level measures, the empirical analysis shows statistically significant direct effects of program and policy factors on outcomes as well as effects of these variables on treatment practices that have significant implications for treatment outcomes.

Genders and the concurrent use of cocaine and alcohol: Pharmacological aspects

AIMS

Gender-related differences in the pharmacological effects of addictive drug are an emerging issue. This review examines gender differences in both pharmacokinetic and pharmacodynamic aspects of alcohol and cocaine intake since they cause complex pharmacological interactions, not least the formation of the active metabolite cocaethylene.

METHODS

The MEDLINE database was searched from 1990 to 2014 in order to find articles related to gender differences in alcohol, cocaine and cocaethylene pharmacokinetics and pharmacodynamics.

RESULTS

Besides the well known gender differences in alcohol pharmacokinetics, women appear more susceptible to alcohol-mediated brain damage and seem to suffer more than men the acute effects of alcohol on hepatic and gonadal hormones. No significant gender differences have been found in the pharmacokinetics of cocaine taken alone; yet, in women pharmacological sensitivity to the drug seems to vary in relation to menstrual cycle; moreover, progesterone attenuates subjective effects of cocaine in women. Higher ratings at a subjective measure of mental/physical well-being have been observed in women when given cocaine and alcohol, alone or in combination. Finally, among subjects dependent on both alcohol and cocaine, men only benefit from naltrexone, whereas women used more cocaine during the trial and were less compliant to therapy than men.

CONCLUSIONS

The observed subtle gender differences in the pharmacokinetics and pharmacodynamics of both alcohol and cocaine may have no subtle influence on the natural history of the co-abuse of the two drugs by women.

The association between alcohol use and sexual risk behaviors among African American women across three developmental periods: a review

BACKGROUND

African American women experience increased rates of sexually transmitted diseases and HIV. The use of alcohol may increase sexual risk behaviors among this population.

PURPOSE

This paper provides a review and critique of the literature examining the association between alcohol use and sexual risk behaviors among African American females including a: (a) synthesis of research findings from adolescent, college-aged/early adulthood, and adult samples; (b) methodological critique of the literature; and (c) guidance for future research.

METHODS

We reviewed 32 studies examining the association between alcohol use and sexual risk behaviors among African American females across developmental periods.

RESULTS

Similar to previous association studies, results suggest that increased use of alcohol is associated with increased sexual risk practices among African American females. Further, even non-abuse levels of drinking among African American females, at all ages, were related to increased sexual risk-taking.

CONCLUSIONS

Future studies should seek to recruit samples that more fully reflect the diversity of African American women's experiences across the lifespan. Given the association between alcohol use and/or abuse and the prevalence of STI/HIV-associated risk behaviors and adverse biological outcomes (i.e., STIs, including HIV) among African American females across the lifespan, there is a clear need to develop and evaluate prevention research efforts tailored for this subgroup.

Initial feasibility of a woman-focused intervention for pregnant african-american women

African-American women who use crack are vulnerable to HIV because of the complex social circumstances in which they live. Drug-abuse treatment for these women during pregnancy may provide time for changing risk behaviors. This paper examines the initial 6-month feasibility of a women-focused HIV intervention, the Women's CoOp, adapted for pregnant women, relative to treatment-as-usual among 59 pregnant African-American women enrolled in drug-abuse treatment. At treatment entry, the women were largely homeless, unemployed, practicing unsafe sex, and involved in violence. Results indicated marked reductions in homelessness, use of cocaine and illegal drugs, involvement in physical violence, and an increase in knowledge of HIV from baseline to 6-month followup for both conditions. Findings suggest that the Women's CoOp intervention could be successfully adapted to treat this hard-to-reach population. Future studies should examine the efficacy of the pregnancy-adapted Women's CoOp for women not enrolled in drug-abuse treatment.

A prospective study of alcohol consumption and HIV acquisition among injection drug users

OBJECTIVE

to estimate the effect of alcohol consumption on HIV acquisition while appropriately accounting for confounding by time-varying risk factors.

DESIGN

african-American injection drug users in the AIDS Link to Intravenous Experience cohort study. Participants were recruited and followed with semiannual visits in Baltimore, Maryland between 1988 and 2008.

METHODS

marginal structural models were used to estimate the effect of alcohol consumption on HIV acquisition.

RESULTS

at entry, 28% of 1525 participants were women with a median (quartiles) age of 37 (32-42) years and 10 (10-12) years of formal education. During follow-up, 155 participants acquired HIV and alcohol consumption was 24, 24, 26, 17, and 9% for 0, 1-5, 6-20, 21-50, and 51-140 drinks per week over the prior 2 years, respectively. In analyses accounting for sociodemographic factors, drug use, and sexual activity, hazard ratios for participants reporting 1-5, 6-20, 21-50, and 51-140 drinks per week in the prior 2 years compared to participants who reported 0 drinks per week were 1.09 (0.60-1.98), 1.18 (0.66-2.09), 1.66 (0.94-2.93), and 2.12 (1.15-3.90), respectively. A trend test indicated a dose-response relationship between alcohol consumption and HIV acquisition (P value for trend = 9.7 × 10).

CONCLUSION

a dose-response relationship between alcohol consumption and subsequent HIV acquisition is indicated, independent of measured known risk factors.

Risk behaviors for HCV- and HIV-seroprevalence among female crack users in Porto Alegre, Brazil

Several studies have shown a high prevalence of HIV-seropositive status among crack users, though most refer to North American populations. Few studies evaluate HCV prevalence among female crack users. In addition, there is a particular lack of data about risk behaviors and HIV/HCV prevalence in this population around the world. In order to ascertain the HIV/HCV serostatus and associated risk behaviors for infection of female crack users of Porto Alegre, Brazil. A cross-sectional study of a convenience sample of 73 current female crack users was conducted. Subjects answered NIDA's Risk Behavior Assessment and an AIDS Information Questionnaire. In addition, blood was collected from subjects for HIV/HCV tests. The overall prevalence of HIV was 37.0%; HCV seroprevalence was 27.7%; of 15.1% the sample was co-infected with HIV and HCV. Four years of schooling or fewer (OR 4.72-CI 95%; 1.49-14.99) and having three or more HIV tests in one's lifetime (OR 4.26-CI 95% (1.29-14.04)) were associated with HIV infection (after multivariate logistic regression). The single greatest risk factor for HCV infection was having 4 years of schooling or fewer (OR 4.51-CI 95%; 1.18-17.27). We found a very high prevalence of HIV and HCV infection among female crack users, and low education was the most significant risk factor associated with both infections.

Effects of time-varying exposures adjusting for time-varying confounders: the case of alcohol consumption and risk of incident human immunodeficiency virus infection

OBJECTIVE

Discuss issues related to time-varying exposures using as an example the recently meta-analyzed literature (Baliunas et al. in Int J Public Health, 2009) on alcohol consumption and risk of HIV infection.

METHODS

Cataloged sources of bias and imprecision in the context of time-varying exposures.

RESULTS

Confounding, selection, or measurement bias may occur when standard regression approaches are used to estimate effects of time-varying exposures. The reviewed literature on alcohol consumption and HIV infection suffer from one or more of these biases.

CONCLUSIONS

Detailed prospective data and thoughtful implementation of appropriate statistical methods are needed to obtain unbiased estimates of time-varying exposures, such as alcohol consumption.

The social context of homeless women's alcohol and drug use

BACKGROUND

Substance use poses a significant threat to the health of women, and homeless women are more likely to use alcohol and drugs than other women. Addressing risk factors in this population requires a focus on the social context of substance use among homeless women.

METHODS

Participants were 445 homeless women who were randomly sampled and interviewed in shelter settings about the characteristics of their personal networks. Binomial logistic regressions predicted days of binge drinking and of using marijuana, crack, cocaine, and methamphetamine or other amphetamines in the past 6 months.

RESULTS

Homeless women with a greater proportion of heavy alcohol users in their personal networks had greater odds of engaging in binge drinking, and women with a greater proportion of drug users in their networks had greater odds of using marijuana, cocaine, crack, and methamphetamine or other amphetamines. Women with a greater proportion of individuals in their networks that they had met in school or through work had lower odds of marijuana, cocaine, and crack use.

CONCLUSIONS

Findings suggest the importance of structural solutions in addressing homeless women's alcohol and drug use, including greater access to treatment and recovery support for alcohol and drug problems as well as depression, and enhancing employment and educational opportunities for homeless women.

Risk of alcohol-exposed pregnancies among low-income, illicit drug-using women

OBJECTIVES

Poor women of childbearing age who use crack, cocaine, marijuana, and heroin may be at risk for having an alcohol-exposed pregnancy because of concurrent alcohol use. Women who use illicit drugs may not know the harmful effects of fetal alcohol exposure. Fetal alcohol exposure is a leading cause of developmental disabilities and mental retardation.

METHODS

We report findings of a survey administered to 2672 women 18-44 years of age in settings serving low-income women, including an urban jail, a drug treatment facility, and healthcare facilities in Florida, Virginia, and Texas. We compared women who reported using more than one illicit drug (drug users) and women who reported never using illicit drugs (nonusers) for frequent alcohol consumption, binge drinking, failure to use contraception, unplanned pregnancies, and drinking during pregnancy.

RESULTS

Of women interviewed, 75% (2000) reported using more than one illicit drug. Drug users were more likely to report frequent drinking (33%, relative risk [RR] 12.73, 95% confidence interval [CI] 7.9-20.4, binge drinking (39%, RR 5.7, 95% CI 4.9-7.6), and drinking during pregnancy (37%, RR 2.10, 95% CI 1.75-2.53) compared with nonusers (3%, 7%, 17%, respectively, p < 0.0001). Greater proportions of drug users (27%, RR 2.20, 95% CI 1.75-2.53) also failed to used contraception compared with nonusers (19%, p < 0.05). Notable proportions of both groups, drug users (91%) and nonusers (82%), reported unplanned pregnancies.

CONCLUSIONS

The findings suggest that poor women who reported ever using more than one illicit drug were at greater risk for having an alcohol-exposed pregnancy. Unplanned pregnancies in both groups surpassed national averages. Poor women likely require enhanced education about the hazards of drinking during pregnancy and methods to reduce unplanned pregnancies.

Predictors of substance abuse treatment entry for crime-involved, cocaine-dependent women

A health services utilization model was used to examine predictors of treatment entry among a large sample (N=659) of crime-involved, cocaine-dependent women. Previous research in this area has focused on women already in treatment and resultantly excluded a critical population of drug-dependent women who are actively using but not in treatment. Thus, interviews were completed with women who were participating in substance abuse treatment programs and with women who were not currently in treatment to examine what factors may have inhibited or facilitated their entering treatment. The predisposing characteristics, enabling resources, and service needs of these women were assessed in relation to their treatment utilization status. Findings indicated that variables within each of the three categories of the health services model were related to treatment entry including race/ethnicity and education (predisposing characteristics), and alcohol use and having multiple chronic health problems (need). But, overall, enabling factors, such as being legally employed, having health insurance, having custody of children, and knowing where to go to get treatment, appeared to be the most influential predictors. Implications of this research include employing multiple tactics for increasing the likelihood of treatment entry such as aggressive outreach efforts focusing on at-risk women who have the fewest social ties and who are the least integrated into mainstream society.

Psychiatric Distress in Incarcerated Women With Recent Cocaine and Alcohol Abuse

PURPOSE

Women frequently abuse cocaine and alcohol before incarceration. Research indicates that women in criminal justice settings also suffer high rates of psychiatric distress. This study aimed to determine how preincarceration abuse of alcohol and cocaine affected current psychiatric distress among female jail detainees held for 10-14 days.

METHODS

A probability sample of women in a large urban jail (n = 469) were assessed for use of alcohol and cocaine during the 6 months before incarceration and for their current psychiatric distress. They were grouped based on their level of alcohol consumption and cocaine use: high cocaine/high alcohol; high cocaine/low alcohol; low cocaine/high alcohol; and low cocaine/low alcohol. Profile analysis was used to examine the relation of psychiatric distress, as measured by the Brief Symptom Inventory, to levels of recent alcohol and cocaine use.

RESULTS

Psychiatric distress is highest (and similar) among women in the high cocaine groups, regardless of alcohol use, and psychiatric distress is lowest among those who used both substances infrequently. Characteristics of psychiatric distress differed based on level of alcohol use, but only when cocaine use was low. High alcohol and cocaine use alone and together also predict the likelihood of psychiatric distress reaching a diagnosable level of severity.

CONCLUSIONS

High cocaine, alcohol, or combined use is related to higher levels of psychiatric distress among incarcerated women in this jail. Women should be screened at the time of incarceration, and women who have alcohol and other drug problems should receive treatment that includes mental health services.

Expanding research on the role of alcohol consumption and related risks in the prevention and treatment of HIV/AIDS

This article is a review of some of the major epidemiological, behavioral, biological, and integrative prevention research issues and priorities in the area of HIV/AIDS and alcohol consumption. Drinking alcohol increases both the risk for infection with HIV and related illnesses and the morbidity and mortality of patients who progress to AIDS. New and improved measurement procedures have helped in assessment of the complex patterns of alcohol use, identification of intervening explanatory mechanisms for risk behaviors and contexts, and determination of intervention outcomes. Both the direct and indirect effects of alcohol misuse appear to be major contributors to both the risk for infection with HIV and the transmission of HIV/AIDS at the individual and population levels. There is increasing evidence that perhaps no level of alcohol consumption is "safe" for those who are HIV infected and receiving antiretroviral treatment. Interdisciplinary basic behavioral and biomedical research is needed to develop comprehensive culturally appropriate strategies for programs that can be effectively delivered in community contexts in the United States and abroad and that focus on the integration of our understanding of individual behaviors, high-risk group membership, biological mechanisms, and the social and physical environments that place individuals at risk for HIV infection. High-priority topics include improving adherence to antiretroviral medications, prevention of infection in young minority women in the United States, and treatment of HIV+ pregnant women who are alcohol abusers to prevent adverse fetal outcomes, which is an international focus in under-resourced settings in Africa.

Violence against substance-abusing South African sex workers: intersection with culture and HIV risk

The Republic of South Africa has become an epicentre of heterosexual HIV transmission among Black women, and the interface between violence against women, substance abuse, and HIV risk is becoming evident. This paper describes the characteristics of Black South African women who engage in sex work in Pretoria and examines their intersecting experiences of high-risk sexual behaviour, substance abuse, and victimization. Ninety-three women were recruited into the study. Field staff collected biological measures of drug use and administered a structured, self-report interview. Findings indicate that young South African women who engage in sex work and use drugs rely on this activity as their main source of income and are supporting other family members. The majority of sample women reported experiencing some victimization at the hand of men, either clients or boyfriends, with many reporting childhood abuse histories; young women also report great fear of future victimization. Findings also suggest that as a result of their decreased likelihood of using protection, women who reported any sexual or physical victimization are at increased risk for HIV and other STIs. Results support the critical need for targeted, comprehensive interventions that address substance abuse, sexual risk, and violence as interrelated phenomena.

Mental disorders and drug abuse in persons living with HIV/AIDS

This article reviews the literature on the prevalence of mental and substance use disorders among persons living with HIV/AIDS. Drug use, both injection and non-injection, substantially increases the risk for HIV infection. While injection drug users have the highest prevalence rates for HIV, substantially elevated rates of HIV infection are also present among crack cocaine users and individuals with substance use disorders generally. Persons with HIV/AIDS and a mental and/or substance use disorder have highly variable patterns of accessing services. Persons with HIV/AIDS who have a serious mental illness are more highly involved with services than other groups. Most individuals with co-occurring disorders report some involvement with outpatient primary medical care, although ancillary services such as mental health and substance abuse treatment, transportation assistance, and case management improve involvement in medical care. Women with HIV/AIDS and co-occurring mental and substance use disorders experience unique vulnerabilities, particularly those related to exposure to traumatic events. Given the complexity of needs with which triply or multiply diagnosed individuals present, effective treatment programmes are likely to be those that provide some degree of integrated care.

Efficacy of a woman-focused intervention to reduce HIV risk and increase self-sufficiency among African American crack abusers

OBJECTIVES

This study compares 3- and 6-month outcomes of a woman-focused HIV intervention for crack abusers, a revised National Institute on Drug Abuse standard intervention, and a control group.

METHODS

Out-of-drug-treatment African American women (n = 620) who use crack participated in a randomized field experiment. Risk behavior, employment, and housing status were assessed with linear and logistic regression.

RESULTS

All groups significantly reduced crack use and high-risk sex at each follow-up, but only woman-focused intervention participants consistently improved employment and housing status. Compared with control subjects at 6 months, woman-focused intervention participants were least likely to engage in unprotected sex; revised standard intervention women reported greatest reductions in crack use.

CONCLUSIONS

A woman-focused intervention can successfully reduce risk and facilitate employment and housing and may effectively reduce the frequency of unprotected sex in the longer term.