Individual and poly-substance use and condomless sex among HIV-uninfected adults reporting heterosexual sex in a multi-site cohort.

BACKGROUND: We analyzed the association between substance use (SU) and condomless sex (CS) among HIV-negative adults reporting heterosexual sex in the Seek, Test, Treat, and Retain (STTR) consortium. We describe the impact of SU as well as person/partner and context-related factors on CS, identifying combinations of factors that indicate the highest likelihood of CS. METHODS: We analyzed data from four US-based STTR studies to examine the effect of SU on CS using two SU exposures: 1) recent SU (within 3 months) and 2) SU before/during sex. Behavioral data were collected via 1:1 or self-administered computerized interviews. Adjusted individual-study, multivariable relative risk regression was used to examine the relationship between CS and SU. We also examined interactions with type of sex and partner HIV status. Pooled effect estimates were calculated using traditional fixed-effects meta-analysis. We analyzed data for recent SU (n = 6781; 82% men, median age = 33 years) and SU before/during sex (n = 2915; 69% men, median age = 40 years). RESULTS: For both exposure classifications, any SU other than cannabis increased the likelihood of CS relative to non-SU (8-16%, p-values< 0.001). In the recent SU group, however, polysubstance use did not increase the likelihood of CS compared to single-substance use. Cannabis use did not increase the likelihood of CS, regardless of frequency of use. Type of sex was associated with CS; those reporting vaginal and anal sex had a higher likelihood of CS compared to vaginal sex only for both exposure classifications (18-21%, p < 0.001). Recent SU increased likelihood of CS among those reporting vaginal sex only (9-10%, p < 0.001); results were similar for those reporting vaginal and anal sex (5-8%, p < 0.01). SU before/during sex increased the likelihood of CS among those reporting vaginal sex only (20%; p < 0.001) and among those reporting vaginal and anal sex (7%; p = 0.002). Single- and poly-SU before/during sex increased the likelihood of CS for those with exclusively HIV-negative partners (7-8%, p ≤ 0.02), and for those reporting HIV-negative and HIV-status unknown partners (9-13%, p ≤ 0.03). CONCLUSION: Except for cannabis, any SU increased the likelihood of CS. CS was associated with having perceived HIV-negative partners and with having had both anal/vaginal sex.

The onset of drug injection among sex partners of injection drug users.

HIV prevention interventions targeting noninjecting sex partners of drug injectors usually focus on sexual behaviors. This strategy may underestimate the likelihood that sex partners will begin injecting drug and thereby greatly increase their exposure to HIV. This 4-year prospective study assesses the incidence of drug injection among 62 street-recruited, heterosexual, HIV negative, baseline noninjection sex partners, 97% of whom were reinterviewed at least once. Sixteen (26%) of the sex partners reported injecting after baseline. Thirty-nine percent of those with no history of illicit drug use beyond marijuana began injecting, compared with 19% of those who had used drugs but had never injected and 11% of those with injection histories. There were two HIV seroconversions, both of which took place soon after the onset of injection and appear attributable to parenteral transmission. These results suggest that interventions targeting sex partners should include strategies for preventing injection and risky injection practices.

From bag brides to skeezers: a historical perspective on sex-for-drugs behavior.

There are many ways that women support their use of crack cocaine, including sex-for-crack bartering and other forms of prostitution. Empirical studies conducted in the mid-1970s and in the mid-1980s in New York City, and in Chicago in the late 1980s to early 1990s are compared, analyzing similarities and differences between the contemporary crack-prostitution scene and previous prostitution scenes. Findings suggest that the arrival of crack cocaine has directly and indirectly affected the drugs-prostitution nexus by lowering the price of sex for street prostitutes, altering the social status of cocaine, and increasing the level of social disorganization in illicit street activities, including prostitution. Barterers are shown to be the heaviest drug users, using the greatest variety of drugs, using larger amounts of drugs, and using more frequently.

Team research methods for studying intranasal heroin use and its HIV risks.

Nineteen years ago Douglas (1976), a sociologist, vigorously recommended team field research. As Douglas noted, most ethnography is carried out using the "Lone Ranger" approach, which--while producing a number of excellent studies--generally limits the researcher to small groups or parts of large groups. In the few cases where field research teams were assembled (e.g., Becker et al. 1961), they tended to be homogeneous and to simply divide the group being studied between them and then essentially perform identical investigations (Douglas 1976). Douglas had a different vision. He saw the optimal field research group as heterogeneous, able to take on large projects, and able to take multiple perspectives. Such a team would have a variety of talents, experiences, and inclinations to call upon and would be more able to connect with the people being studied (e.g., by including indigenous members noted for their sociability). Douglas argued for giving greater consideration in designing research to society's conflictory nature and the desire and need for people to misinform, evade, construct false fronts, lie, and deceive themselves. According to Douglas, field research teams were an excellent means of coping with these problems. With various members using their array of talents to study a problem from multiple perspectives and through numerous webs of social cliques and networks, research teams would be particularly able to get behind people's facades and produce valid data. Though Douglas presented a compelling argument, there is little evidence of an increase in team field research, with one exception: research groups studying HIV/AIDS. The NADR program, funded by NIDA, created a number of field research teams across the United States that combined ethnographers with indigenous staff who, whatever their principal duties, could be used to assist in the research. These field research teams were also part of a survey research effort, and, in this fashion, quantitative and qualitative methods were combined to a degree uncommon in social science research. While many of these research groups have since disbanded, COIP was fortunate enough to remain in operation. The authors have described how they assembled a field research team composed of COIP members that combined ethnographers with selected indigenous staff to address a particular problem--new heroin use and its implications for HIV/AIDS. The goals the researchers set for the study would have been impossible for a single ethnographer or for a survey research team acting alone: to discern potential trends in new heroin use (though researchers were limited to studying mostly poor people); to develop fairly deep understandings regarding the study's central concerns (e.g., factors likely to influence the decision to inject heroin); and to quickly and economically collect data that were useful and valid. The authors note that all members of the research team had a host of other responsibilities; thus, this study was conducted as a sort of side job, that is, researchers had to fit it in when time and circumstances allowed. Altogether, the team field research method as applied to new heroin use in Chicago has enabled the research team to quickly and economically generate data that can be used to inform public policy on this issue (Ouellet et al. 1993; Ouellet et al., submitted). The authors believe that they can make a reasonably strong case for the following: New heroin use deserves greater study--the prevalence and incidence of use are probably sufficient to form a new cohort of potentially longtime users. New users are most likely to be found where major heroin street drug markets operate. Among youth there is a need for education about heroin--current users often report being surprised by heroin's addictiveness. Intranasal use is the predominant form of heroin administration among young, new users, and there is strong peer pressure against injection. Experimentation with injection, how

Injection-related risk behaviors in young urban and suburban injection drug users in Chicago (1997-1999).

We compared injection-related risk practices between urban and suburban injection drug users (IDUs) in a large cross-sectional sample of young IDUs. From 1997 to 1999, we recruited 700 active IDUs aged 18 to 30 years in Chicago and its suburbs. A suburban residence was reported by 38% of participants. Participants were interviewed at four urban locations and screened for HIV and hepatitis C virus antibodies. Receptive sharing of syringes and other paraphernalia by urban and suburban IDUs in the preceding 6 months was compared using univariable and multivariable models. Sharing injection paraphernalia in the total sample was high, with 50% of participants reporting receptive syringe sharing and 70% reporting sharing cotton, cookers, and/or rinse water. After adjusting for demographic characteristics, injection settings, frequency, and duration of injection as well as ease of acquiring new syringes, suburban IDUs were significantly more likely than urban IDUs to share syringes (adjusted odds ratio = 1.7; 95% confidence interval: 1.1-2.5); however, the likelihood of sharing cotton, cookers, or rinse water was roughly equal. Despite overall higher risk profiles among suburban IDUs, HIV and hepatitis C prevalence levels were significantly lower than among urban participants. Current high levels of injection risk behaviors in suburban groups represent a potential for rapid dissemination of infection.

Hepatitis C virus infection: prevalence, risk factors, and prevention opportunities among young injection drug users in Chicago, 1997-1999.

The prevalence, risk factors, and prevention opportunities of hepatitis C virus (HCV) infection were studied in a large sample of 698 young adult injection drug users (IDUs) in Chicago, 18-30 years old. Participants were recruited between 1997 and 1999 by using street outreach, targeted advertising, and chain-referral methods. HCV infection prevalence was 27% and was strongly associated with both age and duration of injecting (P<.001). In multivariable analysis, sexual behaviors were unrelated to seropositivity. Independent drug-related risk factors included frequent injection, heavy crack smoking, injecting in a shooting gallery, and syringe-mediated sharing. Urban residents were more likely than suburban residents to be infected. Most research on hepatitis C has shown rapid spread of infection among IDUs, but these findings underscore that opportunities to identify IDUs uninfected with HCV may be greater than assumed and emphasize the need to target younger, newer IDUs.

Prevalence and incidence of HIV among out-of-treatment injecting drug users, Chicago 1994-1996.

OBJECTIVES: To assess HIV prevalence, incidence, and associated risk factors among IDUs in Chicago. METHODS: Seven hundred ninety-four street-recruited IDUs ranging in age from 18 to 50 years, who were not in drug treatment at study enrollment, were interviewed and tested for HIV at baseline and at two follow-ups scheduled 6 and 12 months after baseline. Questionnaires assessed respondents' demographic characteristics, medical and drug treatment histories, drug use, and sexual practices. RESULTS: HIV seroprevalence at baseline was 18%. Logistic regression identified the following determinants of prevalent HIV infection: Puerto Rican ethnicity, homosexual or bisexual self-identification, injecting for 4 or more years, and having smoked crack cocaine in the past 6 months. Follow-up data were collected from 584 (73.6%) participants. Mean duration of follow-up was 16.5 months, indicating that most subjects had follow-up intervals longer than the scheduled 6 and 12 months. Seven HIV seroconversions were observed in 632 person years of risk, yielding an incidence rate of 1.1 per 100 person years of risk. Injection for 3 or less years was positively associated with HIV seroconversion. CONCLUSIONS: The findings provide evidence of a decline in HIV incidence among IDUs, though newer injectors remain at elevated risk for infection.

Prevention of HIV infection in street-recruited injection drug users. The Collaborative Injection Drug User Study (CIDUS).

BACKGROUND: Injection drug users (IDUs) and their sex partners account for an increasing proportion of new AIDS and HIV cases in the United States, but public debate and policy regarding the effectiveness of various HIV prevention programs for them must cite data from other countries, from non-street-recruited IDUs already in treatment, or other programs, and from infection rates for pathogens other than HIV. METHODS: Participants were recruited from the street at six sites (Baltimore [Maryland], New York [two sites], Chicago [Illinois], San Jose [California], Los Angeles [California], and at a state women's correctional facility [Connecticut]), interviewed with a standard questionnaire, and located and reinterviewed at one or more follow-up visits (mean, 7.8 months later). HIV serostatus and participation in various programs and behaviors that could reduce HIV infection risk were determined at each visit. RESULTS: In all, 3773 participants were recruited from the street, and 2306 (61%) were located and interviewed subsequently. Of 3562 initial serum specimens, 520 (14.6%) were HIV-seropositive; at subsequent assessment, 19 people, all from the East Coast and Chicago, had acquired HIV. Not using previously used needles was substantially protective against HIV acquisition (relative risk [RR], 0.29; 95% confidence interval [CI], 0.11-0.80 ) and, in a multivariate model, was significantly associated with use of needle and syringe exchange programs (adjusted odds ratio [ORadj], 2.08; 95% CI, 1.15-3.85). Similarly, reduction of injection frequency was very protective against seroconversion (RR, 0.33; 95% CI, 0.14-0.80), and this behavior was strongly associated with participation in drug treatment programs (ORadj, 3.54; 95% CI, 2.50-5.00). In a separate analysis, only 37.5% of study-participants had sufficient new needles to meet their monthly demand. CONCLUSIONS: In this large multicity study of IDUs in the United States, several HIV prevention strategies appeared to be individually and partially effective; these results indicate the continued need for, and substantial gaps in, effective approaches to preventing HIV infection in drug users.