Sex, drugs and HIV counseling and testing: a prospective study of behavior-change among methadone-maintenance clients in New England

Who Leaves Early? Factors Associated With Against Medical Advice Discharge During Alcohol Withdrawal Treatment

OBJECTIVE

To determine if certain patient, clinical, and disease factors are associated with against medical advice (AMA) discharge among patients admitted for treatment of alcohol withdrawal.

METHODS

Data from admissions to a dedicated unit for treatment of substance withdrawal were collected over a 6-month period. Patients with AMA and planned discharge were compared with regard to demographics, clinical data, and substance use disorder disease characteristics. A stepwise logistic regression was used to find the best model.

RESULTS

The study population included 655 patient encounters. A total of 93 (14%) discharges were AMA. Bivariate analysis showed patients with AMA discharge were younger (mean age 43 vs 46 years; P < 0.05), more likely to leave on a Tuesday to Thursday, and to have an initial withdrawal score at or above the median (AMA 69% vs planned 56%; P = 0.02). Emergency department (ED) admissions had an AMA discharge rate of 21% compared with 10% of community admissions (P < 0.05). Regression analysis found AMA discharge was significantly associated with admission from the ED (odds ratio [OR] 2.03, confidence interval [CI] 1.27-3.25) and younger age (OR 0.97, CI 0.95-0.99). There was no significant difference in discharge disposition among patients with concurrent opioid use disorder who were on opioid agonist therapy.

CONCLUSIONS

AMA discharges occurred in 1 of every 7 admissions. Being admitted from the ED and younger age was associated with AMA discharge. No other patient or clinical factors were found to be associated with AMA discharge.

Potential cost-effectiveness of supervised injection facilities in Toronto and Ottawa, Canada

BACKGROUND AND AIMS

Supervised injection facilities (legally sanctioned spaces for supervised consumption of illicitly obtained drugs) are controversial public health interventions. We determined the optimal number of facilities in two Canadian cities using health economic methods.

DESIGN

Dynamic compartmental model of HIV and hepatitis C transmission through sexual contact and sharing of drug use equipment.

SETTING

Toronto and Ottawa, Canada.

PARTICIPANTS

Simulated population of each city.

INTERVENTIONS

Zero to five supervised injection facilities.

MEASUREMENTS

Direct health-care costs and quality-adjusted life-years (QALYs) over 20 years, discounted at 5% per year; incremental cost-effectiveness ratios.

FINDINGS

In Toronto, one facility cost $4.1 million and resulted in a gain of 385 QALYs over 20 years, for an incremental cost-effectiveness ratio (ICER) of $10,763 per QALY [95% credible interval (95CrI): cost-saving to $278,311]. Establishing one facility in Ottawa had an ICER of $6127 per QALY (95CrI: cost-saving to $179,272). At a $50,000 per QALY threshold, three facilities would be cost-effective in Toronto and two in Ottawa. The probability that establishing three, four, or five facilities in Toronto was cost-effective was 17, 21, and 41%, respectively. Establishing one, two, or three facilities in Ottawa was cost-effective with 13, 35, and 41% probability, respectively. Establishing no facility was unlikely to be the most cost-effective option (14% in Toronto and 10% in Ottawa). In both cities, results were robust if the reduction in needle-sharing among clients of the facilities was at least 50% and fixed operating costs were less than $2.0 million.

CONCLUSIONS

Using a $50,000 per quality-adjusted life-years threshold for cost-effectiveness, it is likely to be cost-effective to establish at least three legally sanctioned spaces for supervised injection of illicitly obtained drugs in Toronto, Canada and two in Ottawa, Canada.

Patients receiving opioid maintenance treatment in primary care: successful chronic hepatitis C care in a real world setting

Background

Injection drug users (IDUs) represent a significant proportion of patients with chronic hepatitis C (CHC). The low treatment uptake among these patients results in a low treatment effectiveness and a limited public health impact. We hypothesised that a general practitioner (GP) providing an opioid maintenance treatment (OMT) for addicted patients can achieve CHC treatment and sustained virological response rates (SVR) comparable to patients without drug dependency.

Methods

Retrospective patient record analysis of 85 CHC patients who received OMT for more than 3 months in a single-handed general practice in Zurich from January 1, 2002 through May 31, 2008. CHC treatment was based on a combination with pegylated interferon and ribavirin. Treatment uptake and SVR (undetectable HCV RNA 6 months after end of treatment) were assessed. The association between treatment uptake and patient characteristics was investigated by multiple logistic regression.

Results

In 35 out of 85 CHC patients (52 males) with a median (IQR) age of 38.8 (35.0-44.4) years, antiviral therapy was started (41.2%). Median duration (IQR) of OMT in the treatment group was 55.0 (35.0-110.1) months compared to the group without therapy 24.0 (9.8-46.3) months (p<0.001). OMT duration remained a significant determinant for treatment uptake when controlled for potential confounding. SVR was achieved in 25 out of 35 patients (71%).

Conclusion

In addicted patients a high CHC treatment and viral eradication rate in a primary care setting in Switzerland is feasible. Opioid substitution seems a beneficial framework for CHC care in this “difficult to treat” population.

Is monogamy or committed relationship status a marker for low sexual risk among men in substance abuse treatment? Clinical and methodological considerations

BACKGROUND

HIV prevention interventions often promote monogamy to reduce sexual risk. However, there is little consensus about how to define monogamy.

OBJECTIVE

To determine the extent to which recent monogamy and/or being in a committed relationship serve as markers for low sexual risk among men in substance abuse treatment.

METHODS

Participants were 360 men enrolled in the National Institute on Drug Abuse Clinical Trials Network "Real Men Are Safe" protocol who completed all assessments (baseline, 3 months, and 6 months). Self-reported behaviors included number of sexual partners, type of relationships, frequency of vaginal/anal intercourse, and percentage of condom use.

RESULTS

The rate of self-reported monogamy in the prior 90 days was stable across assessments (54.2%, 53.1%, 58.3%). However, at each assessment 7.5-10% of monogamous men identified their partner as a casual partner, and only 123 (34.2%) reported being monogamous at every assessment. Of these, 20 (5.6%) reported being monogamous with different partners across assessments. Men with both committed relationship and casual partners reported more condom use with their committed relationship partners than men with only a committed relationship partner.

CONCLUSION

Clinicians and researchers should consider individual relationship context and behavior and avoid assuming that recent monogamy or being in a committed relationship denotes low risk.

SCIENTIFIC SIGNIFICANCE

This study provides evidence that, in male drug users, monogamy does not necessarily reflect low sexual risk. Rather, "monogamous" men actually encompass various combinations of partner types and levels of risk behavior that are unstable, even over brief time periods. Clinicians and researchers must take these variations into account.

Oral substitution treatment of injecting opioid users for prevention of HIV infection

BACKGROUND

Injecting drug users are vulnerable to infection with Human Immunodeficiency Virus (HIV) and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour

OBJECTIVES

To assess the effect of oral substitution treatment for opioid dependent injecting drug users on risk behaviours and rates of HIV infections

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and PsycINFO to May 2011. We also searched reference lists of articles, reviews and conference abstracts

SELECTION CRITERIA

Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered. Two authors independently assessed each study for inclusion

DATA COLLECTION AND ANALYSIS

Two authors independently extracted key information from each of the included studies. Any differences were resolved by discussion or by referral to a third author.

MAIN RESULTS

Thirty-eight studies, involving some 12,400 participants, were included. The majority were descriptive studies, or randomisation processes did not relate to the data extracted, and most studies were judged to be at high risk of bias. Studies consistently show that oral substitution treatment for opioid-dependent injecting drug users with methadone or buprenorphine is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection. However, because of the high risk of bias and variability in several aspects of the studies, combined totals were not calculated.

AUTHORS' CONCLUSIONS

Oral substitution treatment for injecting opioid users reduces drug-related behaviours with a high risk of HIV transmission, but has less effect on sex-related risk behaviours. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review.

Determinants of successful chronic hepatitis C case finding among patients receiving opioid maintenance treatment in a primary care setting

AIMS

Injection drug users are at high risk for chronic hepatitis C virus infection (CHC). Opioid maintenance treatment (OMT) offers a unique opportunity to screen for CHC. This study proposed the hypothesis that a general practitioner (GP) with special interest in addiction medicine can achieve CHC screening rates comparable to specialized centres and aimed to investigate determinants for a successful CHC case finding in a primary care setting.

DESIGN AND PARTICIPANTS

Retrospective medical record analysis of 387 patients who received opioid maintenance therapy between 1 January 2002 and 31 May 2008 in a general practice in Zurich, Switzerland.

MEASUREMENTS

Successful CHC assessment was defined as performance of hepatitis C virus (HCV) serology with consecutive polymerase chain reaction-based RNA and genotype recordings. The association between screening success and patient characteristics was assessed using multiple logistic regression. findings: Median (interquartile range) age and duration of OMT of the 387 (268 males) patients was 38.5 (33.6-44.5) years and 34 (11.3-68.0) months, respectively. Fourteen patients (3.6%) denied HCV testing and informed consent about screening was missing in 13 patients (3.4%). In 327 of 360 patients (90.8%) with informed consent a successful CHC assessment has been performed. Screening for HCV antibodies was positive in 136 cases (41.6%) and in 86 of them (63.2%) a CHC was present. The duration of OMT was an independent determinant of a successful CHC assessment.

CONCLUSIONS

In addicted patients a high CHC assessment rate in a primary care setting in Switzerland is feasible and opioid substitution provides an optimal framework.

Substitution treatment of injecting opioid users for prevention of HIV infection

BACKGROUND

Injecting drug users are vulnerable to infection with HIV and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour.

OBJECTIVES

To assess the effect of oral substitution treatment for opioid dependent injecting drug users on rates of HIV infections, and high risk behaviours.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and PsycINFO to March 2007. We also searched reference lists of articles, reviews and conference abstracts

SELECTION CRITERIA

Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered. Two reviewers independently assessed studies for inclusion.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data from included studies, assessed quality and confirmed decisions by consulting with all other reviewers.

MAIN RESULTS

Thirty-three studies, involving 10,400 participants, were included. The majority were not randomised controlled studies and there were problems of confounding and bias. The studies varied in several aspects limiting the extent of quantitative analysis. Studies consistently show that oral substitution treatment for opioid-dependent injecting drug users is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection.

AUTHORS' CONCLUSIONS

Oral substitution treatment for injecting opioid users reduces drug-related behaviours with a high risk of HIV transmission, but has less effect on sex-related risk behaviours. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review.

HIV voluntary counseling and testing and HIV incidence in male injecting drug users in northern Thailand: evidence of an urgent need for HIV prevention

HIV voluntary counseling and testing (VCT), an important strategy for HIV prevention and care, has been available in all government hospitals in Thailand since 1992. We assessed factors associated with HIV testing, its uptake, and estimates of HIV incidence after HIV testing among male northern Thai injecting drug users (IDUs) admitted for inpatient drug treatment. Participants were interviewed about risk behaviors and HIV testing history before VCT was provided as part of the study. Of 825 IDUs who participated, 36% reported a prior HIV test. Factors associated with prior HIV testing in multiple logistic regression analysis included higher education and having >1 lifetime sex partner. Needle sharing was not associated with prior HIV testing. Of the 298 men with a prior test, 80% reported a negative result on their last prior HIV test, of whom 28% tested positive in our study, leading to an estimated incidence rate of 10.2 per 100 person-years. Fifty-nine percent of the IDUs who reported a prior HIV test stated that they did not receive pre- and/or posttest counseling. HIV incidence among IDUs remains high despite having VCT. Extending HIV prevention and harm reduction programs is urgently needed for IDUs in the region.

Behavioral interventions for HIV-positive and HCV-positive drug users

The nature, context and frequency of use of various licit and illicit non-injection drugs associated with an elevated risk of HIV infection. Beyond HIV, a high proportion of HIV-infected IDUs are co-infected with HCV (hepatitis C virus). In this review, we provide a brief review of the epidemiology of these problems, discuss behavioral interventions that can reduce ongoing high risk behaviors among HIV-seropositive IDUs and MSM-DUs, and review the literature which has evaluated their effectiveness. The majority of these interventions have focused on HIV-seronegative heterosexuals and therefore need to be considered in this larger context; however, where possible we discuss the potential impact of these interventions among HIV-seropositive persons. In addition, we briefly discuss interventions which have the potential to simultaneously reduce ongoing transmission of both HIV and HCV. Finally, given the dearth of information on the effectiveness of behavioral interventions in reducing the burden of the HIV and HCV epidemics among persons already infected with either or both viruses, we describe some newer, promising interventions and offer suggestions for future studies.

Substitution treatment of injecting opioid users for prevention of HIV infection

BACKGROUND

Injecting drug users are vulnerable to infection with HIV and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour.

OBJECTIVES

To assess the effect of oral substitution treatment for opioid dependent injecting drug users on rates of HIV infections, and high risk behaviours.

SEARCH STRATEGY

Multiple electronic databases were searched. Reference lists of retrieved studies, reviews and conference abstracts were handsearched.

SELECTION CRITERIA

Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered.

DATA COLLECTION AND ANALYSIS

Each potentially relevant study was independently assessed by two reviewers. For studies that met the inclusion criteria, key information was extracted by one reviewer and confirmed by consultation between all four reviewers.

MAIN RESULTS

Twenty-eight studies, involving 7900 participants, were included. The majority were not randomised controlled studies. Issues of confounding and bias are discussed. The studies varied in several aspects limiting the extent of quantitative analysis.

REVIEWERS' CONCLUSIONS

Oral substitution treatment for opioid-dependent injecting drug users is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review. However, these findings add to the stronger evidence of effectiveness of substitution treatment on drug use, and treatment retention outcomes shown by other systematic reviews. On this basis, the provision of substitution treatment for opioid dependence in countries with emerging HIV and injecting drug use problems as well as in countries with established populations of injecting drug users should be supported.

Overdose deaths attributed to methadone and heroin in New York City, 1990-1998

AIMS

Methadone treatment has been shown to be an effective intervention that can lower the risk of heroin-induced overdose death. Recent reports have suggested increases in methadone-induced overdose deaths in several locations in the USA and in Europe. This study investigated the role of methadone and opiates in accidental overdose deaths in New York City.

DESIGN

We analysed data from the Office of the Chief Medical Examiner to examine all accidental drug overdose deaths in New York City between 1990 and 1998.

FINDINGS

Of 7451 total overdose deaths during this period, there were 1024 methadone-induced overdose deaths, 4627 heroin-induced overdose deaths and 408 overdose deaths attributed to both methadone and heroin. Fewer than a third as many accidental overdose deaths were attributed to methadone than were attributed to heroin during this period. The proportion of accidental overdose deaths attributed to methadone did not change appreciably (12.6-15.8% of total overdose mortality), while the proportion of overdose deaths attributed to heroin increased significantly (53.5-64.2%) during the period of study.

CONCLUSIONS

There was no appreciable increase in methadone-induced overdose mortality in New York City during the 1990s. Both heroin-induced overdose mortality and prescriptions of methadone increased during the same interval.

Readiness for cessation of drug use among recent attenders and nonattenders of a needle exchange program

Needle exchange programs (NEPs) represent a bridge to drug abuse treatment. NEP attenders tend to have more severe drug problems, however, and may be less ready to reduce their drug use than other drug users. This study investigated the relationship between NEP attendance and readiness for cessation of drug use. Since the period from 1988 through 1989, a community-based sample of injection drug users (IDUs) in Baltimore has undergone semiannual interview-administered questionnaires and HIV testing. A total of 288 IDUs completed a questionnaire on readiness for cessation of drug use. Readiness for drug use cessation was assessed from a 28-item validated scale of problem drug use and intention to quit, based on the "stages of change" model. Logistic regression was used to determine factors associated with readiness for cessation of drug use, including sociodemographics, drug use behaviors, and NEP attendance. Thirty percent of respondents attended the NEP in the past month. Stage of change in readiness for cessation of drug use did not differ between NEP attenders and nonattenders (OR = 0.9; 95% CI: 0.5-1.6). Similar proportions of persons recently attending and not attending the NEP were classified as ready to stop drug use (about 30%). In multivariate analysis, readiness for cessation of drug use was associated with speedball injection and previous enrollment in drug treatment but not with NEP attendance. NEP attenders, although exhibiting characteristics consistent with more severe drug dependence, were as motivated for cessation of drug use as were nonattenders. These findings suggest that formal collaboration between NEPs and drug treatment programs could increase the proportion of IDUs in treatment.

Optimal investment in a portfolio of HIV prevention programs

OBJECTIVES

In this article, the authors determine the optimal allocation of HIV prevention funds and investigate the impact of different allocation methods on health outcomes.

METHODS

The authors present a resource allocation model that can be used to determine the allocation of HIV prevention funds that maximizes quality-adjusted life years (or life years) gained or HIV infections averted in a population over a specified time horizon. They apply the model to determine the allocation of a limited budget among 3 types of HIV prevention programs in a population of injection drug users and nonusers: needle exchange programs, methadone maintenance treatment, and condom availability programs. For each prevention program, the authors estimate a production function that relates the amount invested to the associated change in risky behavior.

RESULTS

The authors determine the optimal allocation of funds for both objective functions for a high-prevalence population and a low-prevalence population. They also consider the allocation of funds under several common rules of thumb that are used to allocate HIV prevention resources. It is shown that simpler allocation methods (e.g., allocation based on HIV incidence or notions of equity among population groups) may lead to alloctions that do not yield the maximum health benefit.

CONCLUSIONS

The optimal allocation of HIV prevention funds in a population depends on HIV prevalence and incidence, the objective function, the production functions for the prevention programs, and other factors. Consideration of cost, equity, and social and political norms may be important when allocating HIV prevention funds. The model presented in this article can help decision makers determine the health consequences of different allocations of funds.

Resource allocation for epidemic control over short time horizons

We present a model for allocation of epidemic control resources among a set of interventions. We assume that the epidemic is modeled by a general compartmental epidemic model, and that interventions change one or more of the parameters that describe the epidemic. Associated with each intervention is a 'production function' that relates the amount invested in the intervention to values of parameters in the epidemic model. The goal is to maximize quality-adjusted life years gained or the number of new infections averted over a fixed time horizon, subject to a budget constraint. Unlike previous models, our model allows for interacting populations and non-linear interacting production functions and does not require a long time horizon. We show that an analytical solution to the model may be difficult or impossible to derive, even for simple cases. Therefore, we derive a method of approximating the objective functions. We use the approximations to gain insight into the optimal resource allocation for three problem instances. We also develop heuristics for solving the general resource allocation problem. We present results of numerical studies using our approximations and heuristics. Finally, we discuss implications and applications of this work.

Incidence of HIV among injection drug users entering drug treatment programs in four US cities

We estimated seroincidence of human immunodeficiency virus (HIV) and prevalence of risk behaviors among injection drug users (IDUs) who accepted voluntary HIV testing on entry to drug treatment. Record-based incidence studies were conducted in 12 drug treatment programs in New York City (n = 890); Newark, New Jersey (n = 521); Seattle, Washington (n = 1,256); and Los Angeles, California (n = 733). Records of confidential HIV tests were abstracted for information on demographics, drug use, and HIV test results. More detailed data on risk behaviors were obtained by a standardized questionnaire. Although overall incidence rates were relatively low in this population (<1/100 person-years), there was a high prevalence of risk behaviors. Needle sharing was reported by more than one-third of the participants in each of the cities. HIV seroincidence rates were up to three-fold higher among younger ID Us. We found that HIV continued to be transmitted among ID Us who had received both drug treatment and HIV counseling and testing. HIV/AIDS (acquired immunodeficiency syndrome) prevention education should continue to be an important component of drug treatment.

Methadone treatment and HIV and hepatitis B and C risk reduction among injectors in the Seattle area

Drug treatment has the potential to reduce incidence of blood-borne infections by helping injection drug users (IDUs) achieve abstinence or by decreasing the frequency of injection and sharing practices. We studied the associations between retention in methadone treatment and drug use behaviors and incidence of hepatitis B and C in a cohort of IDUs in the Seattle, Washington, area. Data on IDUs entering methadone treatment at four centers in King County, Washington, were collected through face-to-face interviews using a standardized questionnaire at baseline and 12-month follow-up between October 1994 and January 1998. Blood specimens were obtained and tested for human immunodeficiency virus (HIV) and hepatitis B and C. Drug treatment status at follow-up was analyzed in relation to study enrollment characteristics and potential treatment outcomes, including injection risk behaviors, cessation or reduced frequency of injection, and incidence of hepatitis B and C. Of 716 IDUs, 292 (41%) left treatment, 198 (28%) disrupted (left and returned) treatment, and 226 (32%) continued treatment throughout the 1-year follow-up period. Compared to those who left treatment, subjects who disrupted or continued were less likely to inject at follow-up (odds ratio [OR] = 0.5, 95% CI 0.3-0.7; and OR = 0.1, 95% CI 0.1-0.2, respectively). Among the 468 (65%) subjects who continued injecting, those who continued treatment injected less frequently, were less likely to pool money to buy drugs (OR = 0.5, 95% CI 0.3-0.8) and inject with used needles (OR = 0.5, 95% CI 0.2-0.8) compared to those who left treatment. Cooker or cotton sharing was not associated with retention in treatment, but hepatitis B incidence was lowest among those who continued treatment. The results of this study suggest drug use risk reduction is more likely to be achieved by those who remain in drug treatment and by those who stop injecting, but that those who drop out and return and those who continue to inject while in treatment may also benefit. This supports the role of consistent drug treatment in an overall harm-reduction strategy.

HIV transmission and the cost-effectiveness of methadone maintenance

OBJECTIVES

This study determined the cost-effectiveness of expanding methadone maintenance treatment for heroin addiction, particularly its effect on the HIV epidemic.

METHODS

We developed a dynamic epidemic model to study the effects of increased methadone maintenance capacity on health care costs and survival, measured as quality-adjusted life-years (QALYs). We considered communities with HIV prevalence among injection drug users of 5% and 40%.

RESULTS

Additional methadone maintenance capacity costs $8200 per QALY gained in the high-prevalence community and $10,900 per QALY gained in the low-prevalence community. More than half of the benefits are gained by individuals who do not inject drugs. Even if the benefits realized by treated and untreated injection drug users are ignored, methadone maintenance expansion costs between $14,100 and $15,200 per QALY gained. Additional capacity remains cost-effective even if it is twice as expensive and half as effective as current methadone maintenance slots.

CONCLUSIONS

Expansion of methadone maintenance is cost-effective on the basis of commonly accepted criteria for medical interventions. Barriers to methadone maintenance deny injection drug users access to a cost-effective intervention that generates significant health benefits for the general population.

Personal, cognitive, behavioral, and demographic predictors of HIV testing and STDs in homeless women

Using a multiracial sample of 621 homeless women, we tested a latent variable causal model of personal, cognitive, behavioral, and demographic predictors of two coping mediators and the outcome variables of HIV testing and return for test results and a recent STD infection. HIV testing and return were predicted by more social support, greater AIDS knowledge, greater perceived risk for AIDS, and more problem-focused coping strategies. Recent STDs were predicted by more AIDS knowledge, emotion-focused coping strategies, and risky sexual behavior and one measured variable, crack cocaine use. Emotion-focused coping strategies were predicted by drug use, less self-esteem, more social support, and greater perceived risk for AIDS. Hispanics reported less emotion-focused coping strategies than African-Americans. Predictors of problem-focused coping strategies included less drug use, more self-esteem, more social support, more AIDS knowledge, and less risky sexual behavior. African-Americans reported less problem-focused coping strategies than Latinas. Indirect effects on the outcomes mediated through coping styles are also reported. Theoretical and practical implications of results for community outreach are discussed.

Understanding condom use among heroin addicts in methadone maintenance using the information-motivation-behavioral skills model

The current study represents the application of a health behavior model to account for unsafe sexual behavior (as opposed to unsafe needle use) among heroin addicts in methadone treatment. The Information-Motivation-Behavioral Skills (IMB) model of HIV preventive behavior asserts that HIV prevention information, motivation, and behavioral skills are fundamental determinants of HIV preventive behavior. Participants (N = 156 heroin-addicted individuals in methadone treatment) completed assessments of their levels of HIV prevention information, motivation, behavioral skills, and safer sexual behavior. Overall measures of fit generated via structural equation modeling indicate that the IMB model adequately fits the data obtained. The constructs of the model accounted for a substantial proportion of the variance in safer sexual behavior, and tests of parameter estimates indicate that while information and motivation had direct and reliable associations with safer sexual behavior in this population, behavioral skills did not. Discussion focuses on the primary roles of HIV prevention information and motivation as determinants of safer sexual behavior in this population, on the lack of a significant contribution of HIV prevention behavioral skills, and on the implications for intervention of this pattern of findings.

Methadone, methadone treatment and non-fatal overdose

This paper provides a mainly qualitative investigation of the role of methadone and methadone treatment in non-fatal illicit drug overdose. During 1997 and 1998, semi-structured interviews were conducted with 33 individuals in six hospital accident and emergency departments in two Scottish cities. The research identified four overdose situations related to methadone/methadone treatment. These were: (1) topping up a legitimate methadone prescription; (2) abusing another's methadone prescription; (3) preferring illegal drugs to prescribed methadone; and (4) failing to obtain prescribed methadone. The implications of these findings for methadone treatment policy and practice are discussed.

Linking clients from HIV antibody counseling and testing to prevention services

The effectiveness of HIV antibody counseling and testing as a prevention intervention is limited: persons testing seronegative do not usually change their risk behaviors, some actually increase their risk behaviors, and decreases in risk behaviors are usually short-lived. Referrals to additional prevention and other needed services are therefore recommended, although the extent and determinants of referral provision for persons testing seronegative are unknown. We assessed the prevalence of referrals and the association between risk behaviors and prevention referrals among seronegatives. We reviewed HIV testing and referral data on all persons receiving confidential seronegative test results in San Francisco (SF) in the first 10 months of 1995 (n = 5,595), and gathered more detailed referral information at the municipal STD clinic from November 1995 through May 1996 (n = 747). The overall prevalence of referrals was low: a referral was given to 19.1% of the SF sample and 10.6% of the STD clinic sample; 15.4% of the SF sample and 5.9% of the STD clinic sample received a prevention referral. Injection drug users (IDUs) were the most likely to receive a prevention referral (48.5% of SF IDUs, 36.4% of STD clinic IDUs); men having sex with men and women with high-risk partners were also more likely to get a prevention referral than others. For SF IDUs, unsafe sex and needle sharing were not associated with an increased likelihood of receiving a prevention referral. Opportunities to link high-risk clients from counseling and testing to HIV prevention services are being missed. The referral component of HIV counseling and testing should be improved.

Health-related service utilization and HIV risk behaviors among HIV infected injection drug users and crack smokers

This study was designed to assess utilization of health-related services and HIV risk related behaviors by HIV infected drug users one year prior to and two years following the availability of Ryan White Title I funding. Using a cross-sectional design, a total of 777 drug injectors and crack smokers from five US cities were surveyed, over three waves of data collection, about their use of drug treatment, medical services, housing, mental health, and case management and about their sex and drug-related risk behaviors. For all service categories and in each wave, including the year prior to Title I funding, HIV risk behaviors were lower among those who used health-related services, with the exception of housing. Use of services did not increase significantly following the disbursement of Title I funds except for housing and case management. These findings suggest that it may be necessary to increase the attractiveness of health-related services, not just funding for services, for HIV infected substance abusers.

Targeted prevention for people with HIV/AIDS: feasible and desirable?

People with HIV/AIDS are rarely chosen as a target group for prevention activities. In this paper we look at empirical and theoretical evidence for the feasibility and desirability of directing preventive interventions at HIV-positives. Research data on the behaviour and motivation of HIV-positives suggests that the differences between HIV-positives and HIV-negatives and those who are unaware of their HIV-status are not large. However, specific determinants of behaviour, such as responsibility for others or the risk of superinfection, have seldom been measured. Effective interventions targeting at HIV-positives and focussing on prevention are lacking. Fear of increased stigmatization has been used as an argument against focussing prevention activities at HIV-positives. Theoretically that argument is probably not correct: positive coping with HIV may invite positive reactions. The conclusion is that HIV-positives should be chosen as a special target group for additional planned preventive interventions. Because people need to be aware of their HIV status, testing and treatment sites are adequate settings. Effective interventions should be developed on the basis of theory and evidence about the specific determinants of risk behaviour of HIV-positives: protecting oneself for superinfection and protecting one's partner.

Consistency in maintaining contact with HIV-related service providers: an analysis of the AIDS Cost and Services Utilization Study (ACSUS)

Patients (n = 1949) infected with HIV were recruited for the AIDS Cost & Service Utilization Survey (ACSUS) from ten U.S. cities and administered face to face interviews at three month intervals over an 18 month period from March 1, 1991 to August 31, 1992. The interview was designed to obtain information at each wave of data collection on the use of the following services: ambulatory care, hospitalization, emergency room use, support groups/counseling, drug and alcohol treatment, and dental care. Patients were found to be highly consistent in their patterns of utilization across time, regardless of the service in question. Of the patients who reported using an emergency room (ER) at Time 1, 52% also reported using an ER during the next three months later at Time 2. Of those who reported having been hospitalized during the Time 1 reporting period, almost 58% reported a hospitalization again at Time 2. Next, use of a service at Time 6 (n = 1404, 72.2%) was regressed onto whether the person received the service at Time 2 and the personal, financial, and medical variables. Except for dental services, utilization of a service one year in the past (Time 2) was the strongest predictor of Time 6 use. The findings indicated that the one factor consistently related to service use within this sample is a factor (as opposed to education, race, or even insurance) that is amenable to intervention: previous use of that service. The individuals studied established patterns of service utilization that are of reasonably long duration once they began use of a service. This continuity of care becomes more critical as the initiation of treatments begins with the diagnosis of HIV rather than AIDS. Findings suggest that HIV outreach efforts be targeted to increasing early use of medical and behavioral services in ambulatory care settings.