The types of drugs used by HIV-infected injection drug users in a multistate surveillance project: implications for intervention

Frontline Science: Buprenorphine decreases CCL2-mediated migration of CD14+ CD16+ monocytes

HIV infection of the CNS causes neuroinflammation and damage that contributes to the development of HIV-associated neurocognitive disorders (HAND) in greater than 50% of HIV-infected individuals, despite antiretroviral therapy (ART). Opioid abuse is a major risk factor for HIV infection. It has been shown that opioids can contribute to increased HIV CNS pathogenesis, in part, by modulating the function of immune cells. HIV enters the CNS within two weeks after peripheral infection by transmigration of infected monocytes across the blood brain barrier (BBB). CD14⁺ CD16⁺ monocytes are a mature subpopulation that is increased in number in the peripheral blood of HIV-infected people. Mature monocytes can be productively infected with HIV, and they transmigrate preferentially across the BBB in response to CCL2, a chemokine elevated in the CNS and CSF of HIV-infected people even with ART. Buprenorphine, an opioid derivate, is an opioid replacement therapy for heroin addiction. It is a partial agonist of μ-opioid receptor and full antagonist of κ-opioid receptor. The effects of buprenorphine on CCL2-mediated CD14⁺ CD16⁺ monocytes transmigration across the BBB, a critical mechanism that promotes neuroinflammation and HAND, have not been characterized. We showed for the first time that buprenorphine decreases several steps of CCL2-mediated human mature monocyte transmigration. We propose that buprenorphine treatment in the context of HIV infection could serve a dual purpose, to treat opioid addiction and also to reduce neuroinflammation. Additionally, buprenorphine may be used as a treatment for HAND not only in the context of opioid abuse.

Opioids and Opioid Maintenance Therapies: Their Impact on Monocyte-Mediated HIV Neuropathogenesis

BACKGROUND

HIV-1 enters the CNS within two weeks after peripheral infection and results in chronic neuroinflammation that leads to HIV associated neurocognitive disorders (HAND) in more than 50% of infected people. HIV enters the CNS by transmigration of infected monocytes across the blood brain barrier. Intravenous drug abuse is a major risk factor for HIV-1 infection, and opioids have been shown to alter the progression and severity of HAND. Methadone and buprenorphine are opioid derivates that are used as opioid maintenance therapies. They are commonly used to treat opioid dependency in HIV infected substance abusers, but their effects on monocyte migration relevant to the development of cognitive impairment are not well characterized.

CONCLUSION

Here, we will discuss the effects of opioids and opioid maintenance therapies on the inflammatory functions of monocytes and macrophages that are related to the development of neuroinflammation in the context of HIV infection.

Type of opioids injected: does it matter? A multicentric cross-sectional study of people who inject drugs

INTRODUCTION AND AIMS

Injecting pharmaceutical opioids for non-medical purposes is a major concern globally. Though pharmaceutical opioids injection is reported in India, the exact proportion of people who inject drugs (PWID) using pharmaceutical opioids is unknown. The objectives of this study were to describe the various types of drugs that are injected by people in India and to analyse the differences between the commonly injected drugs.

DESIGN AND METHODS

A cross-sectional, multicentric study covering 22 harm-reduction sites from different regions of the country was conducted. First 50 subjects, chosen randomly from a list of PWIDs accessing services from each site and fulfilling study criteria, were interviewed using a structured questionnaire. Data from 902 male subjects are presented here.

RESULTS

Pharmaceutical opioid injectors (POI) accounted for 65% of PWIDs (buprenorphine: 30.8%, pentazocine: 21.8% and dextropropoxyphene: 11.9%). Heroin, injected by 34.3%, was prevalent in most states surveyed. Buprenorphine and pentazocine were not injected in the north-east region, whereas dextropropoxyphene was injected in the north-east alone. Univariate and multivariate logistic regression showed that, compared with heroin injectors, the POI group was more likely to consume alcohol and pharmaceutical opioids orally, inject frequently, share needle/syringes and develop injection-site complications. Among individual POIs, buprenorphine injectors had significantly higher proportion of subjects injecting frequently, sharing needle/syringes and developing local complications. Irrespective of the opioid type, majority of subjects were opioid dependent.

DISCUSSION AND CONCLUSIONS

Pharmaceutical opioids are the most common drugs injected in India currently and have greater injection-related risks and complications. Significant differences exist between different pharmaceutical opioids, which would be important considerations for interventions.

Impact of HIV and a history of marijuana dependence on procedural learning among individuals with a history of substance dependence

Marijuana (MJ) use and HIV infection are both associated with neurocognitive deficits, yet there is little research to date examining their interactions, specifically how they pertain to procedural learning (PL). We examined a sample of 86 individuals with a history of dependence for multiple substances who underwent a comprehensive evaluation including measures of mental health, substance use history, and three measures of PL: the photoelectric Rotary Pursuit Task (RPT), the Star Mirror Tracing Task (SMT), and the Weather Prediction Task (WPT). We found that a positive HIV serostatus and a history of marijuana dependence were both independently associated with overall poorer performance on the SMT and RPT in this sample of individuals with a history of dependence for multiple substances. Rate of improvement across trial blocks did not differ as a function of HIV serostatus or history of marijuana dependence. Although we found no significant HIV × MJ interaction for any of the PL tasks, we did observe evidence of additive negative effects from HIV and a history of marijuana dependence on overall performance on the SMT and RPT, but not the WPT. The findings suggest that complex motor skills are adversely affected among abstinent polysubstance users with a history of marijuana dependence and that such deficits are compounded by HIV.

Correlates of illicit methadone use in New York City: a cross-sectional study

BACKGROUND

Despite growing concern about illicit methadone use in the US and other countries, there is little data about the prevalence and correlates of methadone use in large urban areas. We assessed the prevalence and examined correlates of lifetime and recent illicit methadone use in New York City (NYC).

METHODS

1,415 heroin, crack, and cocaine users aged 15-40 years were recruited in NYC between 2000 and 2004 to complete interviewer-administered questionnaires.

RESULTS

In multivariable logistic regression, non-injection drug users who used illicit methadone were more likely to be heroin dependent, less than daily methamphetamine users and to have a heroin using sex partner in the last two months. Injection drug users who used illicit methadone were more likely to use heroin daily, share injection paraphernalia and less likely to have been in a detoxification program and to have not used marijuana in the last six months.

CONCLUSION

The results overall suggest that illicit (or street) methadone use is likely not a primary drug of choice, but is instead more common in concert with other illicit drug use.

Rethinking Approaches to Risk Reduction for Injection Drug Users

OBJECTIVE

To identify and compare the drug-injecting network characteristics of cocaine and heroin injectors associated with a risk of HIV and hepatitis C virus (HCV).

METHODS

Active injectors were recruited from syringe exchange and methadone programs. Characteristics of all participants and their social networks were elicited. Regression analysis using generalized estimating equations examined the network characteristics of injection drug users (IDUs) relative to cocaine or heroin use in the past 6 months.

RESULTS

Of 282 IDUs, 228 (81%) used cocaine and 54 (19%) used heroin as their primary injected drug. In analyses adjusted for age and gender, cocaine injectors compared with heroin injectors were more likely to live in unstable housing (odds ratio [OR] = 3.55, 95% confidence interval [CI]: 1.49 to 8.40), self-report HCV infection (OR = 4.69, 95% CI: 2.14 to 10.31), and have a greater number of IDUs in their social network (OR = 1.61, 95% CI: 1.14 to 2.28) and were less likely to be polydrug users (OR = 0.06, 95% CI: 0.02 to 0.16) and to have social support (OR = 0.97, 95% CI: 0.95 to 0.99). The injecting networks of cocaine users were more likely to have members who were older (OR = 1.08, 95% CI: 1.04 to 1.12), had a history of shooting gallery use (OR = 2.27, 95% CI: 1.08 to 4.76), and had shorter relationships with the subject (OR = 0.91, 95% CI: 0.85 to 0.97).

CONCLUSIONS

Beyond personal behaviors, HIV and HCV infection risk seems to be linked to social network traits that are determined by drug type. Prevention efforts to control the spread of bloodborne viruses among IDUs could benefit from tailoring interventions according to the type of drug used.

Predictors of HIV sero-status among drug injectors at three Ukraine sites

OBJECTIVE

To assess the HIV serostatus of injection drug users (IDU) in Ukraine, as well as associations between serostatus and selected demographic and risk factors.

DESIGN AND METHODS

IDU were recruited from the streets in Kiev, Odessa and Makeevka/Donesk. Participants were interviewed using an HIV risk behavior assessment and tested for HIV with a finger-stick rapid test. Multiple logistic regression was used to identify determinants of HIV infection.

RESULTS

Of the 891 IDUs surveyed, one-third came from each site and 22% were female. Their mean age was 29 years and on average they had been injecting for slightly more than 10 years. Seven hundred and seventy-eight of the total sample did not know their HIV status when first interviewed; they are the participants in this investigation. Overall, 33% tested positive for HIV, including 34% in Kiev, 51% in Odessa and 17% in Makeevka/Donesk. Independent predictors of HIV included injecting a sedative/opiate mixture, female sex, having sex with a person who was HIV positive or whose HIV status was unknown and injecting daily. HIV-negative IDU were significantly younger than those infected, they were more likely to be from Makeevka/Donesk and they were more likely to have been sexually active.

CONCLUSIONS

Rates of HIV infection among IDU vary considerably across Ukraine, although even in the site with the lowest rate nearly one in five was infected. The extent of drug and sex-related risk behaviors calls for interventions to reduce the spread of HIV and other infectious diseases.

A web-based therapeutic workplace for the treatment of drug addiction and chronic unemployment

This article describes a Web-based therapeutic workplace intervention designed to promote heroin and cocaine abstinence and train and employ participants as data entry operators. Patients are paid to participate in training and then to perform data entry jobs in a therapeutic workplace business. Salary is linked to abstinence by requiring patients to provide drug-free urine samples to gain access to the workplace. Prior data show that a prototype of the intervention could promote drug abstinence. Preliminary data on the Web-based intervention suggest that it should be able to teach adults with histories of chronic unemployment and drug addiction to become skilled data entry operators in about 3 to 6 months. Early experience in the business provides preliminary evidence that it might become financially successful. The therapeutic workplace intervention may serve as an effective and practical long-term treatment for chronic unemployment and heroin and cocaine addiction.

Heroin attenuates the negative consequences of cocaine in a runway model of self-administration

It has been presumed that the combination of cocaine (COC)+heroin (HER) is more reinforcing than either of the two drugs alone, thus leading to their coadministration ("speedballing"). An alternative hypothesis is that HER serves to attenuate the undesired negative effects of COC. To test this notion, male Sprague-Dawley rats (n=31) were trained to run a straight alley for a daily intravenous (IV) injection of COC (1.0 mg/kg/injection) for 14 trials. Studies in our laboratory have shown that such animals begin to exhibit approach-avoidance behaviors ("retreats") stemming from concurrent positive and negative associations with the goal box (which, in turn, are the result of COC's immediate rewarding and subsequent dysphoric actions). Thus, retreats can be used as a reliable index of COC's anxiogenic side effects. Following 14 COC-reinforced trials, animals were split into three groups matched on mean retreat frequency. One group (n=11) received IV COC (1.0 mg/kg/injection) for seven additional trials; the remaining two groups (n=10 each) received an IV injection of COC mixed in a single solution with either a low dose (0.025 mg/kg/injection) or a high dose (0.1 mg/kg/injection) of HER. It was hypothesized that adding HER would attenuate the negative consequences of COC administration and thereby produce a reliable decrease in the occurrence of retreats. The resulting data were consistent with this hypothesis, suggesting that "speedballing" in human addicts may be motivated by a desire to reduce the negative impact of COC use.

Injection drug use among stimulant users in a national sample

OBJECTIVE

This study examined the correlates of injection drug use (IDU) in a community sample of psychostimulant users. Factors related to the cessation of illicit drug use and substance abuse service utilization were also determined among a subsample of stimulant users who reported IDU.

METHOD

The study sample consisted of 3408 lifetime psychostimulant users from the National Household Survey on Drug Abuse. Logistic regression procedures were used to estimate independent associations of correlates of IDU.

RESULTS

Approximately one in seven lifetime stimulant users reported IDU in their lifetime. Stimulant users with a lifetime history of IDU were more likely than those who did not inject to be African-American, not have received a high school diploma, have a history of multiple drug use, and report an onset of stimulant use before age 18. Among recent stimulant users, being aged 26 or older, using stimulants at least weekly, and getting drunk in the past year were associated with increased odds of recent IDU. Only one-half of all injection drug users reported having ever used substance abuse services. Cessation of illicit drug use among injectors with a history of stimulant use is common (44%).

CONCLUSIONS

Further studies should clarify the natural history of IDU among stimulant users, including the cessation of drug use without participating in substance abuse treatment services.

Heroin and cocaine co-use in a group of injection drug users in Montréal

OBJECTIVE

To describe the pattern of co-use of heroin and cocaine in individuals who were not receiving methadone maintenance treatment.

DESIGN

Structured interviews.

SETTING

Community hospital.

PARTICIPANTS

Individuals (n = 1111) selected from a cohort of out-of-treatment injection drug users in Montréal, Que.

OUTCOME MEASURE

Frequency (injections per day) and quantity (number of days of use) of heroin, cocaine and speedball (the simultaneous administration of heroin and cocaine) use reported in the month preceding the interview.

RESULTS

About 50% of the sample reported using only cocaine intravenously (C group), about 8% reported using only heroin (H group) intravenously and about 15% reported using both heroin and cocaine (HC group) intravenously. Reported cocaine consumption was similar in the HC and C groups. Heroin was used on fewer days by the HC than by the H group, but the number of injections per day was similar. Speedball use, which was quantified independently from heroin and cocaine use, was reported almost exclusively by the HC group, and speedball was used less often than either heroin or cocaine alone. Finally, a similar proportion of individuals in the C and the HC groups consumed alcohol in the 24 hours preceding the interview, but a larger proportion of individuals in the HC group reported the use of marijuana.

CONCLUSION

In a cohort of injection drug users in Montréal, cocaine was the most prevalent illicit drug. Furthermore, about 70% of the heroin users also injected cocaine, but not in the form of speedball. Thus, the sequential co-use of heroin and cocaine is highly prevalent in Montréal and deserves particular clinical attention.

Effects of cocaine in rats exposed to heroin

We investigated whether chronic exposure to heroin alters responses to cocaine in ways that might explain the use of cocaine by opioid addicts. To this end, the effects of cocaine (5 and 20 mg/kg) were assessed on locomotor activity of rats chronically exposed to heroin (0.0, 3.5, 7.0, and 14.0 mg/kg/day, over 14 days, via osmotic mini-pumps), or withdrawn from heroin (1 day, acute withdrawal, and 14 days, protracted withdrawal). Chronic heroin exposure, in itself, dose dependently increased locomotion and acute cocaine administration further elevated locomotor activity in a dose-dependent and additive manner. During acute withdrawal, there was a dose-dependent decrease in locomotion that was reversed by cocaine in a dose-dependent manner. During protracted withdrawal, spontaneous locomotion normalized, but rats previously exposed to heroin displayed cross-sensitization to cocaine as indicated by small, but significant, enhanced locomotor response to 5 mg/kg of cocaine, and enhanced intravenous self-administration of low doses of cocaine (0.13 mg/kg/infusion). In a separate study, we measured extracellular dopamine (DA) in the nucleus accumbens (Acb) using in vivo microdialysis before and after acute withdrawal from heroin. During chronic exposure to heroin, basal extracellular DA was elevated dose dependently, whereas in acute withdrawal, levels were not different from those in vehicle-treated rats. In response to cocaine, however, DA activity in the Acb was significantly lower in rats withdrawn from the highest dose of heroin.

Routes of drug administration, differential affiliation, and lifestyle stability among cocaine and opiate users: implications to HIV prevention

Types of drugs used and routes of administration were assessed, and correlations to social affiliation, HIV status, and lifestyle stability were explored among 672 street-recruited drug users in Baltimore. Participants reported 63 patterns of drug use, which were categorized into five groups: (1) only sniff heroin; (2) smoke crack and may snort cocaine; (3) sniff heroin and smoke crack; (4) inject heroin and cocaine; and (5) inject heroin and cocaine, smoke crack, and may snort heroin. Social network analysis revealed that heroin sniffers and crack smokers both tended to associate with those with similar drug use patterns. High symptoms of drug dependence were observed among heroin users irrespective of mode of administration. Injectors reported higher rates of hospitalization compared to noninjectors even after adjusting for HIV status. Implications to HIV prevention and drug use transitions are discussed.

Large decline in injecting drug use in Amsterdam, 1986-1998: explanatory mechanisms and determinants of injecting transitions

OBJECTIVES

To study community wide trends in injecting prevalence and trends in injecting transitions, and determinants.

DESIGN

Open cohort study with follow up every four months (Amsterdam Cohort Study). Generalised estimating equations were used for statistical analysis.

SETTING

Amsterdam has adopted a harm reduction approach as drug policy.

PARTICIPANTS

996 drug users who were recruited from 1986 to 1998, mainly at methadone programmes, who paid 13620 cohort visits.

MAIN RESULTS

The prevalence of injecting decreased exponentially (66% to 36% in four to six monthly periods). Selective mortality and migration could maximally explain 33% of this decline. Instead, injecting initiation linearly decreased (4.1% to 0.7% per visit), cessation exponentially increased (10.0% to 17.1%), and relapse linearly decreased (21.3% to 11.8%). Non-injecting cocaine use (mainly pre-cooked, comparable to crack) and heroin use strongly increased. Trends were not attributable to changes in the study sample.

CONCLUSIONS

Harm reduction, including large scale needle exchange programmes, does not lead to an increase in injecting drug use. The injecting decline seems mainly attributable to ecological factors (for example, drug culture and market). Prevention of injecting is possible and peer-based interventions may be effective. The consequences of the recent upsurge in crack use requires further study.

Psychiatric considerations in the diagnosis, treatment, and prevention of HIV/AIDS

HIV/AIDS has the unfortunate distinction of being one of the most devastating epidemics of the twentieth century. By the end of June, 1999, 420,201 deaths in persons with AIDS had been reported in the United States. While HIV/AIDS patients are currently living longer as a result of more effective and complex treatments, no vaccination or cure has yet been discovered. Over the years, the HIV/AIDS epidemic has become multifactorial and currently affects several different special population groups. Individuals who are at high risk for becoming infected with HIV or who already suffer from HIV/AIDS can benefit greatly from the interventions of psychiatrists or other mental health professionals. It is important that psychiatrists collaborate very closely with infectious disease specialists in the management of HIV/AIDS and its psychological sequelae. The authors describe the psychiatric conditions that most often occur in association with HIV/AIDS: mood disorders, anxiety disorders, substance-related disorders, psychotic disorders, insomnia and sleep disorders, delirium, dementia, and pain syndromes. We present guidelines for diagnosis and psychopharmacological and psychotherapeutic treatment of these disorders in patients with HIV/AIDS. The article concludes with a discussion of prevention strategies that can be used in a mental health treatment setting and special issues related to treating HIV/AIDS in certain special population groups.

Substance abuse and HIV: considerations with regard to methamphetamines and other recreational drugs for nursing practice and research

Substance use continues to be closely associated with both HIV infection and treatment considerations in all at-risk populations. Among those groups heretofore not well characterized epidemiologically or clinically are those dual-risk men who have sex with other men (MSM) and use and/or inject drugs. Of particular current concern with regard to drug-using MSM is the growth in popularity of a group of recreational or so-called party drugs associated with specific social and sexual environments and networks. Chief among these drugs are hallucinogens, such as MDMA, ketamine, and GHB, and stimulants, such as cocaine, amphetamines, and methamphetamine. Increased methamphetamine use by MSM is particularly alarming because of its reported associations with high-risk injecting and sexual behaviors. Preliminary data are reported from an ethnographic exploration of MSM methamphetamine users in the Pacific Northwest of the United States. Case studies drawn from the data illustrate the complex and variable patterns of methamphetamine use among MSM. Finally, implications for nursing are discussed, and "upstream nursing" is suggested as a means of patient advocacy for HIV nurses working with substance-using populations.

Use of protease inhibitors among persons with AIDS in Los Angeles County

We evaluated the access to, and the factors associated with, protease inhibitor use among persons with AIDS in Los Angeles County. A population-based sample of adult persons with AIDS is routinely interviewed in Los Angeles County and includes a 30% random sample of men who have sex with men and all other persons reported with AIDS. Since May of 1996, all participants were asked if their physician had ever prescribed a protease inhibitor for their use. The possible association between protease inhibitor use and sociodemographic, temporal and health care factors was assessed for the 12-month period May 1996 through April 1997. Logistic regression was employed for multivariate analysis. Over the 12-month study period, 61.7% (209/339) persons interviewed reported that their physician had prescribed a protease inhibitor as part of their therapy. In bivariate analysis, treatment with protease inhibitor use was more common for whites (71.4%) and US-born Latinos (68.2%) than blacks (53.4%) and foreign-born Latinos (56.6%), among person of higher income (71.2%) than lower (< $10,000) income (50.3%), in those who reported having insurance (66.7%) than those uninsured (47%) and among persons receiving care at private clinics (86.4%) than at HMOs (63.4%) or public clinics (55.2%). An increasing trend of protease inhibitor use with higher educational level and declining CD4+ count was observed. A temporal increase was noted and this trend was most pronounced for persons receiving care at public clinics. In multivariate analysis, persons receiving care at private facilities (adjusted OR = 2.9, 95% CI 1.0, 8.2) and those with higher incomes (adjusted OR = 2.5, 95% CI 1.5, 4.3), were more likely to report that their physician had prescribed a protease inhibitor. The effect of facility type was modified by time. During the first six months of the study period (May 1996-October 1996) persons with AIDS receiving care at public facilities and HMO sites were substantially less likely to report having been offered a protease inhibitor (adjusted OR = 0.13, 95% CI 0.03, 0.58 and adjusted OR = 0.23, 95% CI 0.05, 1.2, respectively). However, no significant facility-specific differences were observed over the last six-month period (November 1997-April 1997) evaluated. Our findings suggest that substantial differences exist in the prescribing and use of protease inhibitors among persons with AIDS in Los Angeles County. Several factors, including facility of HIV care, calendar time, income, education level and level of immunosuppression were independently associated with protease inhibitor use and suggest the existence of important barriers to access. Efforts should be made to identify and remove barriers that will ensure the widest possible access to protease inhibitors for patients with a clinical indication for their use.

HIV/AIDS and drug abuse: epidemiology and prevention

In the United States, the AIDS epidemic is a dynamic process with increasing rates of AIDS reported among women, minority populations, heterosexual men, and users of drugs by routes other than injection. The 1993 CDC AIDS definition change has created some difficulties in interpreting trends in the United States. Drug use continues to represent a significant problem among HIV-infected persons. Several strategies have been advanced to decrease transmission of HIV among drug users, their sexual partners and children. However, more effective and comprehensive prevention and treatment strategies are needed.

Temporal trends in HIV risk behaviors of out-of-treatment injection drug users and injection drug users who smoke crack

This study compared the baseline sociodemographic characteristics and HIV risk behaviors of two groups of out-of-treatment injection drug users (IDUs): 366 who concurrently smoked crack (smoking IDUs) and 212 who did not smoke crack (IDUs) in the past 30 days. Temporal trends in recent risk behaviors were also assessed for each drug user group over an 18-month period, January 1992 through June 1994. Baseline data were collected in South Philadelphia before the implementation of a multisite HIV intervention research project funded by the National Institute on Drug Abuse. For the temporal trend analysis, the sample was grouped into four intake periods based on the date of the baseline interview. The results indicated that although both groups were economically disadvantaged and at high risk of HIV infection and transmission, smoking injectors had fewer economic resources and were at a moderately greater risk because of higher levels of sexual risk behaviors. Analysis of temporal trends revealed few reductions in drug risk behaviors and none in sexual risk behaviors. This study points to the need for examining differences between types of drug users, developing appropriate multidrug treatment programs and assessing the characteristics of communities so that theory-based interventions can be tailored for maximum effectiveness.

Methadone treatment protects against HIV infection: two decades of experience in the Bronx, New York City

OBJECTIVE

We undertook a study of the role of methadone maintenance in protecting injecting drug users (IDUs) from human immunodeficiency virus (HIV) infection from the earliest days of the HIV epidemic in New York City to the present. The historical context of the epidemic in the Bronx is discussed.

METHODS

For close to two decades, we have been tracking changes in injecting drug use and HIV infection levels in a Bronx cohort study of IDUs. An initial sample of 622 IDUs was recruited from a methadone treatment program in 1985, with historical data going back to 1978. Behavioral interviews and HIV testing were performed and methadone treatment program records (urine toxicology and methadone dose history) were reviewed. We examined both prevalent and incident HIV infections. The sample included African Americans (24.3%), Latinos (50.3%), and white non-Latinos (24.4%). The average methadone dose was 64 milligrams (mg) per day with an average time in treatment of five and a half years.

RESULTS

We found a very low rate of incident infection of 1.7 per 100 person-years observation since 1986. Because of this low rate of infection, we were unable to determine the association between methadone treatment factors and HIV seroincidence. We found that our prevalence data on the 622 IDUs enrolled from 1985 to 1988 yielded strong findings on the role of methadone maintenance in a period when most infections occurred in this population. HIV seroprevalence was 42.9%. Logistic regression analysis revealed associations of methadone dose > or = 80 mg (adjusted odds ratio = 3.07/yr, 95% confidence interval (CI): 1.23-7.68) and last year entered methadone treatment (adjusted odds ratio = 1.22/yr, 95% CI: 1.06-1.41) to HIV infection, independent of year of last cocaine injection, needle sharing in shooting galleries, number of IDU sex partners, low income, and African American of Latino ethnicity.

CONCLUSIONS

Properly dosed, long-term methadone treatment was found to be a central protective factor in preventing HIV infection from the earliest days of the epidemic in New York City. It is crucial to have high quality drug treatment programs in place before an epidemic draws our attention to the inadequacies through excess and unnecessary morbidity and mortality.

Opiates and infection

This review on the effects of opiate use on infectious diseases discusses the complete spectrum of infections in the opiate user, including those of the lung, the GI tract, the skin, the skeletal system, and the CNS. There is both increased prevalence and increased severity of bacterial and viral infections in injection drug users with the outcome of increased morbidity and mortality. The experimental administration of opiates has lead to a greater understanding of the effects on susceptibility to and progression of infectious diseases. Animal models of opiate dependence and infection are reviewed with specific attention to cases in which the opiate-mediated effects are harmful and in which cases they are beneficial.

Self detoxication by amphetamine dependent patients: a pilot study

Fifty current or past amphetamine dependent clients attending a Community Drug and Alcohol Team service took part in structured interviews about their previous attempts to stop using amphetamine. Thirty three had made a total of 47 attempts at self detoxication; 15 had undergone enforced withdrawal and ten had previously sought medical treatment. A total of 86% of subjects described significant withdrawal symptoms on stopping use of amphetamines. Increased use of other drugs was commonly reported as a means of coping with withdrawal, psycho-social techniques being used less systematically. The implications for the provision of attractive, effective treatments are discussed.

Speed, sex, gay men, and HIV: ecological and community perspectives

Fifteen years into the HIV/AIDS epidemic, a great deal is now known about the different populations impacted by the disease, including those affected directly or indirectly by drug use. Anthropology has played a critical role in assisting with this task by identifying hidden populations, developing new methodological approaches, and targeting outreach efforts. In spite of this considerable body of ethnographic knowledge, men who have sex with other men (i.e., MSM, or gay and bisexual men) who use drugs have not received the same research attention as other drug users, despite the fact that they represent nearly one-fifth of AIDS cases in the U.S. with injection drug histories. In response to the alarming increase in HIV seroprevalence among this population, this ethnographic project provides preliminary data about those who are at dual risk for HIV through both homosexual behavior and injection drug use.

Meeting the service needs of HIV-infected persons: is the Ryan White CARE Act succeeding?

To evaluate the success of the Ryan White CARE Act in meeting HIV-related service needs, we surveyed HIV-infected clients (n = 1,056) at San Francisco CARE-funded agencies. Most CARE clients were male (85.1%), 51.7% were nonwhite, 84.9% were uninsured or underinsured, and 43.9% had a most recent CD4+ count < 200 cells. The most common HIV risk groups were gay/ bisexual male noninjection drug user (IDU) (53.3%) and gay/bisexual male IDU (22.1%). Health care needs were high for medical (85.5%), dental (70.2%), and mental health care (69.7%); need for basic necessities was great for food (57.2%) and living expenses (55.5%). Unmet health care needs were common for dental care (41.0%), home health care (39.9%), and alternative therapies (38.6%); unmet needs for basic necessities were frequent for childcare (59.5%), household help (52.3%), and transportation (47.9%). Unmet needs for medical care (5.8%) and food (14.7%) were low. Poor persons, those with dependents, and gay/bisexual male IDUs had greater unmet needs. Women and racial/ethnic minorities did not consistently have greater unmet needs. The CARE Act is serving those it intended to reach, is successfully meeting two important service needs, and has equalized access to services for women and racial/ethnic minorities. Remaining unmet needs require continued funding and strategies to increase access to care.

The supplement to HIV-AIDS Surveillance project: an approach for monitoring HIV risk behaviors

A variety of surveillance methods are used to characterize the epidemic of HIV infection and AIDS. Such surveillance includes AIDS case reporting, reporting of diagnosed HIV infections, and HIV seroprevalence surveys among targeted sentinel populations. The need for additional surveillance systems to monitor HIV-related risk behaviors has been increasingly evident. One approach to behavioral surveillance, the CDC's Supplement to HIV-AIDS Surveillance project, uses the infrastructure of HIV infection and AIDS case reporting to collect additional information on risk behaviors among HIV-infected persons, who by definition represent those at highest risk.