Interpersonal Attacks on the Dignity of Members of HIV Key Populations: A Descriptive and Exploratory Study.

Attacks on peoples' dignity help to produce and maintain stigmatization and interpersonal hostility. As part of an effort to develop innovative measures of possible pathways between structural interventions or socially-disruptive Big Events and HIV outbreaks, we developed items to measure dignity denial. These measures were administered to 300 people who inject drugs (PWID), 260 high-risk heterosexuals who do not inject drugs, and 191 men who have sex with men who do not inject drugs (MSM). All of the PWID and many of the high risk heterosexuals and MSM were referred to our study in 2012-2015 by a large New York city study that used respondent-driven sampling; the others were recruited by chain-referral. Members of all three key populations experienced attacks on their dignity fairly often and also reported frequently seeing others' dignity being attacked. Relatives are major sources of dignity attacks. MSM were significantly more likely to report having their dignity attacked by police officers than were the other groups. 40 % or more of each key population reported that dignity attacks are followed "sometimes" or more often both by using more drugs and also by using more alcohol. Dignity attacks and their health effects require more research and creative interventions, some of which might take untraditional forms like social movements.

Drug Use and Sexual HIV Transmission Risk Among Men Who have Sex with Men and Women (MSMW), Men Who have Sex with Men only (MSMO), and Men Who have Sex with Women Only (MSWO) and the Female Partners of MSMW and MSWO: A Network Perspective.

We described drug use, sex risk, and STI/HIV among men who have sex with men and women (MSMW) and their female partners. We used the Network, Norms and HIV/STI Risk among Youth (NNAHRAY) study to evaluate drug use, sex risk, and biologically-confirmed STI/HIV in (1) MSMW and men who had sex with men only (MSMO) versus men who had sex with women only (MSWO) and (2) female partners of MSMW versus female partners of MSWO (N = 182 men, 152 women). MSMW versus MSWO had 30 to 60% increased odds of substance use, over twice the odds of multiple partnerships, and almost five times the odds of sex trade and HIV infection. Female partners of MSMW versus female partners of MSWO had approximately twice the odds of substance use and 1.5-2 times the odds of multiple partnerships and sex trade. Interventions should address STI/HIV risk among MSMW and their female partners.

Developing Measures of Pathways that May Link Macro Social/Structural Changes with HIV Epidemiology.

Macro-social/structural events ("big events") such as wars, disasters, and large-scale changes in policies can affect HIV transmission by making risk behaviors more or less likely or by changing risk contexts. The purpose of this study was to develop new measures to investigate hypothesized pathways between macro-social changes and HIV transmission. We developed novel scales and indexes focused on topics including norms about sex and drug injecting under different conditions, involvement with social groups, helping others, and experiencing denial of dignity. We collected data from 300 people who inject drugs in New York City during 2012-2013. Most investigational measures showed evidence of validity (Pearson correlations with criterion variables range = 0.12-0.71) and reliability (Cronbach's alpha range = 0.62-0.91). Research is needed in different contexts to evaluate whether these measures can be used to better understand HIV outbreaks and help improve social/structural HIV prevention intervention programs.

Taking care of themselves: how long-term injection drug users remain HIV and Hepatitis C free.

Though prevalence of HIV and especially Hepatitis C is high among people who inject drugs (PWID) in New York, about a third of those who have injected for 8-15 years have avoided infection by either virus despite their long-term drug use. Based on life history interviews with 35 long-term PWID in New York, this article seeks to show how successful integration and performance of various drug using and non-drug using roles may have contributed to some of these PWID's staying uninfected with either virus. We argue that analysis of non-risk related aspects of the lives of the risk-takers (PWID) is very important in understanding their risk-taking behaviour and its outcomes (infection statuses). Drawing on work-related, social and institutional resources, our double-negative informants underwent both periods of stability and turmoil without getting infected.

Immediate Impact of Hurricane Sandy on People Who Inject Drugs in New York City.

Over the eight months following Hurricane Sandy, of October 2012, we interviewed 300 people who inject drugs in New York City. During the week after the storm, 28% rescued others or volunteered with aid groups; 60% experienced withdrawal; 27% shared drug injection or preparation equipment, or injected with people they normally would not inject with; 70% of those on opioid maintenance therapy could not obtain sufficient doses; and 43% of HIV-positive participants missed HIV medication doses. Although relatively brief, a hurricane can be viewed as a Big Event that can alter drug environments and behaviors, and may have lasting impact. The study's limitations are noted and future needed research is suggested.

Theory, measurement and hard times: some issues for HIV/AIDS research.

Economic and political instability and related "big events" are widespread throughout the globe. Although they sometimes lead to epidemic HIV outbreaks, sometimes they do not-and we do not understand why. Current behavioural theories do not adequately address these processes, and thus cannot provide optimal guidance for effective intervention. Based in part on a critique of our prior "pathways" model of big events, we suggest that cultural-historical activity theory (CHAT) may provide a useful framework for HIV research in this area. Using CHAT concepts, we also suggest a number of areas in which new measures should be developed to make such research possible.

Correlates of staying safe behaviors among long-term injection drug users: psychometric evaluation of the staying safe questionnaire.

We report on psychometric properties of a new questionnaire to study long-term strategies, practices and tactics that may help injection drug users (IDUs) avoid infection with HIV and hepatitis C. Sixty-two long-term IDUs were interviewed in New York City in 2009. Five scales based on a total of 47 items were formed covering the following domains: stigma avoidance, withdrawal prevention, homeless safety, embedding safety within a network of users, and access to resources/social support. All scales (α ≥ .79) except one (α = .61) were highly internally consistent. Seven single-item measures related to drug use reduction and injection practices were also analyzed. All variables were classified as either belonging to a group of symbiotic processes that are not directly focused upon disease prevention but nonetheless lead to risk reduction indirectly or as variables describing prevention tactics in risky situations. Symbiotic processes can be conceived of as unintentional facilitators of safe behaviors. Associations among variables offer suggestions for potential interventions. These Staying Safe variables can be used as predictors of risk behaviors and/or biological outcomes.

Resilience among IDUs: planning strategies to help injection drug users to protect themselves and others from HIV/HCV infections.

Many long-term injection drug users (IDUs) engage in planning strategies. In this pilot study, we examine the relation of one planning strategy to IDUs' engaging in safer injection practices. Sixty-eight IDUs were recruited in 2010 from a New York City (NYC) needle exchange program and referrals to participate in an innovative Staying Safe Intervention that teaches strategies to stay HIV/HCV uninfected. Responses to a baseline 185-item survey were analyzed using correlations and odds ratios. Planning ahead to have steady access to clean equipment was correlated with both individually based and networks-based safety behaviors including storing clean needles; avoiding sharing needles, cookers, and filters with other injectors; and providing clean needles to sex partners. Implications related to resilience in IDUs are discussed and the study's limitations have been noted.

Incarceration, sex with an STI- or HIV-infected partner, and infection with an STI or HIV in Bushwick, Brooklyn, NY: a social network perspective.

OBJECTIVES: We examined the link between incarceration and sexually transmitted infection (STI), including HIV, from a social network perspective. METHODS: We used data collected during a social network study conducted in Brooklyn, NY (n = 343), to measure associations between incarceration and infection with herpes simplex virus-2, chlamydia, gonorrhea, and syphilis or HIV and sex with an infected partner, adjusting for characteristics of respondents and their sex partners. RESULTS: Infection with an STI or HIV was associated with incarceration of less than 1 year (adjusted prevalence ratio [PR] = 1.33; 95% confidence interval [CI] = 1.01, 1.76) and 1 year or longer (adjusted PR = 1.37; 95% CI = 1.08, 1.74). Sex in the past 3 months with an infected partner was associated with sex in the past 3 months with 1 partner (adjusted PR = 1.42; 95% CI = 1.12, 1.79) and with 2 or more partners (adjusted PR = 1.85; 95% CI = 1.43, 2.38) who had ever been incarcerated. CONCLUSIONS: The results highlight the need for STI and HIV treatment and prevention for current and former prisoners and provide preliminary evidence to suggest that incarceration may influence STI and HIV, possibly because incarceration increases the risk of sex with infected partners.

Changes in time-use and drug use by young adults in poor neighbourhoods of Greater Buenos Aires, Argentina, after the political transitions of 2001-2002: Results of a survey.

BACKGROUND: In some countries, "Big Events" like crises and transitions have been followed by large increases in drug use, drug injection and HIV/AIDS. Argentina experienced an economic crisis and political transition in 2001/2002 that affected how people use their time. This paper studies how time use changes between years 2001 and 2004, subsequent to these events, were associated with drug consumption in poor neighbourhoods of Greater Buenos Aires. METHODS: In 2003-2004, 68 current injecting drug users (IDUs) and 235 young non-IDUs, aged 21-35, who lived in impoverished drug-impacted neighbourhoods in Greater Buenos Aires, were asked about time use then and in 2001. Data on weekly hours spent working or looking for work, doing housework/childcare, consuming drugs, being with friends, and hanging out in the neighbourhood, were studied in relation to time spent using drugs. Field observations and focus groups were also conducted. RESULTS: After 2001, among both IDUs and non-IDUs, mean weekly time spent working declined significantly (especially among IDUs); time spent looking for work increased, and time spent with friends and hanging out in the neighbourhood decreased.We found no increase in injecting or non-injecting drug consumption after 2001. Subjects most affected by the way the crises led to decreased work time and/or to increased time looking for work--and by the associated increase in time spent in one's neighbourhood--were most likely to increase their time using drugs. CONCLUSIONS: Time use methods are useful to study changes in drug use and their relationships to every day life activities. In these previously-drug-impacted neighbourhoods, the Argentinean crisis did not lead to an increase in drug use, which somewhat contradicts our initial expectations. Nevertheless, those for whom the crises led to decreased work time, increased time looking for work, and increased time spent in indoor or outdoor neighbourhood environments, were likely to spend more time using drugs. These data suggest that young adults in traditionally less-impoverished neighbourhoods may be more vulnerable to Big Events than those in previously drug-impacted impoverished neighbourhoods. Since Big Events will continue to occur, research on the pathways that determine their sequelae is needed.

Symbiotic goals and the prevention of blood-borne viruses among injection drug users.

A positive-deviance control-case life history study of injection drug users (IDUs) in New York City who had injected drugs for 8-15 years compared 21 IDUs who were antibody negative for both HIV and hepatitis C with 3 infected with both viruses and 11 infected with hepatitis C virus but not HIV. Eligible subjects were referred from other research studies and from community organizations that conduct testing for HIV and hepatitis C virus. Data were collected during 2005-2008 and were analyzed using life history and grounded theory approaches. They support grounded hypotheses that IDUs who are able to attain symbiotic goals like avoiding withdrawal and maintaining social support are assisted thereby in remaining uninfected with HIV or hepatitis C. These hypotheses should be tested using cohort studies and prevention trials to see if helping IDUs attain symbiotic goals reduces infection risk. The study's limitations are noted.

Positive deviance control-case life history: a method to develop grounded hypotheses about successful long-term avoidance of infection.

BACKGROUND: Prevalence rates for long-term injection drug users in some localities surpass 60% for HIV and 80% for HCV. We describe methods for developing grounded hypotheses about how some injectors avoid infection with either virus. SUBJECTS: 25 drug injectors who have injected drugs 8 - 15 years in New York City. 17 remain without antibody to either HIV or HCV; 3 are double-positives; and 5 are positive for HCV but not HIV. "Staying Safe" methodology compares serostatus groups using detailed biographical timelines and narratives; and information about how subjects maintain access to physical resources and social support; their strategies and tactics to remain safe; how they handle problems of addiction and demands by drug dealers and other drug users; and how their behaviors and strategies do or do not become socially-embedded practices. Grounded theory and life-history analysis techniques compare and contrast doubly-uninfected with those infected with both viruses or only with HCV. RESULTS: Themes and initial hypotheses emerging from analyses included two master hypotheses that, if confirmed, should help shape preventive interventions: 1) Staying uninfected is not simply a question of social structure or social position. It involves agency by drug injectors, including sustained hard work and adaptation to changing circumstances. 2) Multiple intentionalities contribute to remaining uninfected. These conscious goals include balancing one's need for drugs and one's income; developing ways to avoid drug withdrawal sickness; avoiding situations where other drug users importune you to share drugs; and avoiding HIV (and perhaps HCV) infection. Thus, focusing on a single goal in prevention might be sub-optimal. Other hypotheses specify mechanisms of enacting these intentionalities. One example is finding ways to avoid extreme social ostracism. CONCLUSION: We have identified strategies and tactics that some doubly-uninfected IDUs have developed to stay safe. Staying Safe methodology develops grounded hypotheses. These can be tested through cohort studies of incidence and prevention trials of hypothesis-based programs to help drug injectors make their injection and sexual careers safer for themselves and others. This positive deviance control-case life history method might be used to study avoiding other infections like genital herpes among sex workers.

Social capital or networks, negotiations, and norms? A neighborhood case study.

"Social capital" has been critiqued as distracting attention from inequalities and policies that produce ill health. We support this critique insofar as social capital refers to the degree of trust and consensus in a locality, but find value in another dimension often included in the concept of social capital--social network ties and their associated communication patterns. We present a case study of Bushwick, a community of 100,000 people in Brooklyn NY, to suggest that the network aspect of "social capital" is useful to understand the active, on-the-ground processes by which residents of some neighborhoods beset by poverty, racial/ethnic subordination, and internal divisions (that themselves arise from inequalities and state policies) work out ways to defend their own and others' safety and health. We use a combination of population-representative survey data for young adults; sexual network survey data; and ethnography to show that Bushwick residents (including drug users and dealers) have used social network ties, communication, and normative pressures to reduce the extent to which they are put at risk by the drug trade and by drug-use-related HIV/AIDS in spite of conflicting interests, disparate values, and widespread distrust both of other community members and of dominant social institutions. This was done by "intravention" health communications, development of protective norms, informal negotiations, and other forms of adjustments within and among various groups--but it occurred in the absence of trust or consensus in this community. We conclude both (1) that social network interpretations of "social capital" might be better conceptualized in dialectic terms as collective action to survive in a harsh social order, and (2) that the social capital theory emphasis on trust and consensus as important causal factors for lowering drug-related risks at the community level may be a romanticized and erroneous perspective.

Formal and informal organizational activities of people who inject drugs in New York City: description and correlates.

Little is known about group memberships of people who inject drugs (PWID). Three hundred PWID were interviewed about formal and informal group participation and risk behaviors. Many took part in groups related to problems and resources associated with injecting drugs, religion, sports or gender. Harm reduction group and support group participation was associated with less risk behavior; sports groups participation with more risk behavior. Group involvement by PWID may be important to their lives and/or affect prevention or infectious disease transmission. More research is needed about determinants and consequences of their and other drug users' group memberships.

Measuring Altruistic and Solidaristic Orientations Toward Others Among People Who Inject Drugs.

The altruism and/or solidarity of people who inject drugs helps protect sex and drug partners from HIV. Research has been hindered by lack of measures. We developed and administered scales to assess them to 300 people who inject drugs. Altruism and Solidarity Scales were both internally consistent. Each correlated significantly with measures of helping others. These measures appear reliable and valid. They can be used to study how big events or structural interventions affect altruism and solidarity, and how altruism and solidarity are associated with changes in HIV or other risks, among people who inject drugs.

Drug use patterns and infection with sexually transmissible agents among young adults in a high-risk neighbourhood in New York City.

AIMS: To determine relationships between drug use "hardness" (defined in increasing order of hardness as no drug use, marijuana use, non-injected heroin or cocaine use, crack smoking and injection drug use) and prevalences of several sexually transmissible infections among young adults in a high-risk neighbourhood. Drug users, particularly injection drug users and crack smokers, may be a core group for some sexually transmitted infections. DESIGN: Cross-sectional survey and assays of young adults from (a) a household probability sample and (b) a targeted sample of youth who have used injected drugs, crack, other cocaine or heroin. SETTING: Bushwick, an impoverished New York City minority neighbourhood with major drug markets. PARTICIPANTS: A total of 363 18-24-year-olds from a household probability sample; 165 Bushwick 18-24-year-olds who have used injected drugs, crack, other cocaine or heroin. MEASUREMENTS: Drug use by self-report; serum- and urine-based assays for HIV, hepatitis B and C, syphilis, gonorrhoea, chlamydia and herpes simplex (type 2). FINDINGS: Household-sample prevalences: HIV, hepatitis C and syphilis, 1%; gonorrhoea 3%; chlamydia 5%; past or present hepatitis B infection 8%; herpes simplex (type 2) 18%. In combined household and targeted samples, hepatitis C and HIV were concentrated among drug injectors. Herpes simplex (type 2), syphilis and hepatitis B increased among women with "hardest drug ever used". CONCLUSIONS: Using "harder" drugs is associated with some but not all of these infections. Prevention efforts should help youth avoid unsafe sex and higher-risk drugs.

Urging others to be healthy: "intravention" by injection drug users as a community prevention goal.

"Intravention," prevention activities that are conducted by and sustained through ongoing actions of members of communities-at-risk, is an appropriate goal for HIV intervention activities. Data from 120 injection drug users in a Brooklyn, New York, neighborhood that has seen decreases in HIV prevalence among IDUs and little HIV diffusion to young adults indicate that most of them have recently (3 months) urged other people to engage in one or more self-protective actions. These data suggest that the common image of IDUs as simply being sources of social and medical problems is inaccurate. Research is needed into how to create and diffuse "communities of intravention; " and we suggest that behavioral interventions be evaluated for their success or failure at creating outward-focused health communication by participants as well as for their impact on individual risk behaviors.

The staying safe intervention: training people who inject drugs in strategies to avoid injection-related HCV and HIV infection.

This pilot study explores the feasibility and preliminary efficacy of the Staying Safe Intervention, an innovative, strengths-based program to facilitate prevention of infection with the human immunodeficiency virus and with the hepatitis C virus among people who inject drugs (PWID). The authors explored changes in the intervention's two primary endpoints: (a) frequency and amount of drug intake, and (b) frequency of risky injection practices. We also explored changes in hypothesized mediators of intervention efficacy: planning skills, motivation/self-efficacy to inject safely, skills to avoid PWID-associated stigma, social support, drug-related withdrawal symptoms, and injection network size and risk norms. A 1-week, five-session intervention (10 hours total) was evaluated using a pre- versus 3-month posttest design. Fifty-one participants completed pre- and posttest assessments. Participants reported significant reductions in drug intake and injection-related risk behavior. Participants also reported significant increases in planning skills, motivation/self-efficacy, and stigma management strategies, while reducing their exposure to drug withdrawal episodes and risky injection networks.

Group sex events amongst non-gay drug users: an understudied risk environment.

This article discusses relevant literature on group sex events--defined as events at which some people have sex with more than one partner--as risk environments, with a particular focus on group sex events where people who take drugs by non-injection routes of administration participate and where the event is not primarily LGBT-identified, at a "classic" crack house, nor in a brothel. It also briefly presents some findings from a small ethnography of such events. Group sex participation by people who take drugs by non-injection routes of administration seems to be widespread. It involves both behavioural and network risk for HIV and STI infection, including documented high-risk behaviour and sexual mixing of STI- and HIV-infected people with those who are uninfected. Indeed several HIV and STI outbreaks have been documented as based on such group sex events. Further, group sex events often serve as potential bridge environments that may allow infections to pass from members of one high-risk-behavioural category to another, and to branch out through these people's sexual and/or injection networks to other members of the local community. The ethnographic data presented here suggest a serious possibility of "third party transmission" of infectious agents between people who do not have sex with each other. This can occur even when condoms are consistently used since condoms and sex toys are sometimes used with different people without being removed or cleaned, and since fingers and mouths come into contact with mucosal surfaces of other members of the same or opposite sex. In addition to being risk environments, many of these group sex events are venues where risk-reducing norms, activities and roles are present--which lays the basis for harm reduction interventions. Research in more geographical locations is needed so we can better understand risks associated with group sex events in which drug users participate--and, in particular, how both participants and others can intervene effectively to reduce the risks posed to participants and non-participants by these group sex events. Such interventions are needed and should be developed.