Drug use patterns over time among HIV-seropositive and HIV-seronegative women: the HER study experience

Predictors of active injection drug use in a cohort of patients infected with hepatitis C virus

OBJECTIVES

We investigated potential risk factors for active injection drug use (IDU) in an inner-city cohort of patients infected with hepatitis C virus (HCV).

METHODS

We used log-binomial regression to identify factors independently associated with active IDU during the first 3 years of follow-up for the 289 participants who reported ever having injected drugs at baseline.

RESULTS

Overall, 142 (49.1%) of the 289 participants reported active IDU at some point during the follow-up period. In a multivariate model, being unemployed (prevalence ratio [PR] = 1.93; 95% confidence interval [CI] = 1.24, 3.03) and hazardous alcohol drinking (PR = 1.67; 95% CI = 1.34, 2.08) were associated with active IDU. Smoking was associated with IDU but this association was not statistically significant. Patients with all 3 of those factors were 3 times as likely to report IDU during follow-up as those with 0 or 1 factor (PR = 3.3; 95% CI = 2.2, 4.9). Neither HIV coinfection nor history of psychiatric disease was independently associated with active IDU.

CONCLUSIONS

Optimal treatment of persons with HCV infection will require attention to unemployment, alcohol use, and smoking in conjunction with IDU treatment and prevention.

Changes in transmission risk behaviors across stages of HIV disease among people living with HIV

Advances in treatments for HIV infection and related opportunistic illnesses have significantly extended the life expectancy of people living with HIV. A review of the literature on HIV transmission risks among HIV-infected individuals shows patterns of risk behavior that vary according to HIV disease stage. Studies confirm that the period immediately preceding HIV infection is characterized by high rates of risk behaviors, indicating the potential for rapid spread of HIV during acute infection. Reductions in risk behavior are often seen immediately following an HIV diagnosis. However, these behavioral changes are not universal, and an individual's state of health is an important factor relating to transmission risks. Chronic periods of asymptomatic HIV infection are generally associated with some degree of reverting to risky behaviors. CD4 cell counts below 200 cells/mm(3), resulting in a formal diagnosis of AIDS, are associated with decreased sexual and drug-related risk behaviors. HIV risk reduction interventions for HIV-infected persons, therefore, require tailoring to address the health and psychological challenges individuals face as they progress through stages of HIV disease. Additional research on both risk behaviors of long-term HIV-infected persons and longitudinal data on risk behaviors is needed.

"I thought there was no hope for me": a behavioral intervention for urban mothers with problem drinking

In this article, the authors evaluate the effects of a behavioral intervention for mothers with problem drinking who were infected with, or at risk for, HIV. They randomly selected 25 mothers from a larger longitudinal randomized controlled intervention trial for a qualitative interview. The authors found that mothers' participation in the program was facilitated by the development of a strong therapeutic alliance with the intervention facilitator and the use of a harm reduction approach toward alcohol and/or drug abuse. Mothers also reported that training in coping skills and the emphasis on parent-adolescent relationships were beneficial for program engagement and behavior change. The authors conclude from these results that treatment approaches that take into account the complexity of urban mothers' lives and substance use patterns can successfully engage and treat these women at high risk for adverse outcomes.

Psychiatric barriers to readiness for treatment for hepatitis C Virus (HCV) infection among injection drug users: clinical experience of an addiction psychiatrist in the HIV-HCV coinfection clinic of a public health hospital

Among injection drug users, psychological and psychiatric barriers to readiness for treatment for hepatitis C virus (HCV) infection include mood and anxiety disorders, cognitive deficits, temperament disorders, and personality vulnerabilities, as well as ongoing drug use. Many aspects of these barriers can be overcome with direct treatment or social support. To establish effective treatment for HCV infection in this population of patients, it is essential that the patient and providers develop a rapport that allows for active communication. It is also important that the patient make an effort to adhere to the treatment requirements and that the patient receive the appropriate evaluation and management of treatable barriers.

Gender differences in illicit substance use among middle-aged drug users with or at risk for HIV infection

OBJECTIVE

The objective of the present study was to examine gender differences and other factors associated with current heroin and cocaine use among middle-aged drug users.

METHODS

Baseline data were merged from 2 studies of men and of women with or at risk for HIV infection. Analysis was restricted to study participants who had ever used heroin or cocaine and who were 49-60 years of age at the time that they were interviewed. HIV-antibody status, drug-use history, and psychosocial and sociodemographic data were examined. Logistic regression models were used to assess factors independently associated with current heroin and cocaine use.

RESULTS

Of 627 persons who ever used heroin and/or cocaine, 250 (39.9%) reported using these drugs within 6 months of the study interview conducted at baseline. Men were more likely to be using drugs currently, compared with women (42.3% vs. 28.2%; P = .007). In multivariate analysis, men, unemployed persons, and HIV-seronegative persons were more likely to be using heroin or cocaine at the time of the interview. In addition, current marijuana users, persons drinking alcohol on a daily basis, and persons who had been homeless in the 6 months before the interview were also more likely to be using these drugs.

CONCLUSION

A relatively high proportion of middle-aged substance users with or at risk for HIV infection, especially men, may continue to use illicit drugs into the sixth decade of life. The differences noted between men and women who have used heroin and/or cocaine at some point in their lives suggest that special attention be given to aging and gender issues in framing HIV-prevention and drug-treatment programs.

Bacterial pneumonia, HIV therapy, and disease progression among HIV-infected women in the HIV epidemiologic research (HER) study

BACKGROUND

To determine the rate and predictors of community-acquired bacterial pneumonia and its effect on human immunodeficiency virus (HIV) disease progression in HIV-infected women, we performed a multiple-site, prospective study of HIV-infected women in 4 cities in the United States.

METHODS

During the period of 1993-2000, we observed 885 HIV-infected and 425 HIV-uninfected women with a history of injection drug use or high-risk sexual behavior. Participants underwent semiannual interviews, and CD4+ lymphocyte count and viral load were assessed in HIV-infected subjects. Data regarding episodes of bacterial pneumonia were ascertained from medical record reviews.

RESULTS

The rate of bacterial pneumonia among 885 HIV-infected women was 8.5 cases per 100 person-years, compared with 0.7 cases per 100 person-years in 425 HIV-uninfected women (P < .001). In analyses limited to follow-up after 1 January 1996, highly active antiretroviral therapy (HAART) and trimethoprim-sulfamethoxazole (TMP-SMX) use were associated with a decreased risk of bacterial pneumonia. Among women who had used TMP-SMX for 12 months, each month of HAART decreased bacterial pneumonia risk by 8% (adjusted hazard ratio [HR(adj)], 0.92; 95% confidence interval [CI], 0.89-0.95). Increments of 50 CD4+ cells/mm3 decreased the risk (HR(adj), 0.88; 95% CI, 0.84-0.93), and smoking doubled the risk (HR(adj), 2.12; 95% CI, 1.26-3.55). Bacterial pneumonia increased mortality risk (HR(adj), 5.02; 95% CI, 2.12-11.87), with adjustment for CD4+ lymphocyte count and duration of HAART and TMP-SMX use.

CONCLUSIONS

High rates of bacterial pneumonia persist among HIV-infected women. Although HAART and TMP-SMX treatment decreased the risk, bacterial pneumonia was associated with an accelerated progression to death. Interventions that improve HAART utilization and promote smoking cessation among HIV-infected women are warranted.