Discrepancies between self-report and objective measures for stimulant drug use in HIV: cognitive, medication adherence and psychological correlates.

While it has long been recognized that self-reported drug use may be at variance with objectively obtained evidence such as urine toxicology assays, few studies have explored the behavioral correlates of such discrepancies. Here we compared self-reported and objective measures of stimulant drug use for 162 HIV infected individuals and identified a sub-group with discrepancies between data obtained via the two methods. Results showed poorer neurocognitive performance (attention, learning/memory) and lower medication adherence rates for the discrepant group as compared to those who either acknowledged their drug use or accurately denied recent stimulant use. Using the Millon Clinical Multiaxial Inventory-III, it was also found that those in the discrepant group were more hesitant to reveal psychopathology. Comparisons of self-reported and objectively measured medication adherence data are also discussed.

Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States.

BACKGROUND: There have been no previous nationally representative estimates of the prevalence of mental disorders and drug use among adults receiving care for human immunodeficiency virus (HIV) disease in the United States. It is also not known which clinical and sociodemographic factors are associated with these disorders. SUBJECTS AND METHODS: We enrolled a nationally representative probability sample of 2864 adults receiving care for HIV in the United States in 1996. Participants were administered a brief structured psychiatric instrument that screened for psychiatric disorders (major depression, dysthymia, generalized anxiety disorders, and panic attacks) and drug use during the previous 12 months. Sociodemographic and clinical factors associated with screening positive for any psychiatric disorder and drug dependence were examined in multivariate logistic regression analyses. RESULTS: Nearly half of the sample screened positive for a psychiatric disorder, nearly 40% reported using an illicit drug other than marijuana, and more than 12% screened positive for drug dependence during the previous 12 months. Factors independently associated with screening positive for a psychiatric disorder included number of HIV-related symptoms, illicit drug use, drug dependence, heavy alcohol use, and being unemployed or disabled. Factors independently associated with screening positive for drug dependence included having many HIV-related symptoms, being younger, being heterosexual, having frequent heavy alcohol use, and screening positive for a psychiatric disorder. CONCLUSIONS: Many people infected with HIV may also have psychiatric and/or drug dependence disorders. Clinicians may need to actively identify those at risk and work with policymakers to ensure the availability of appropriate care for these treatable disorders.

Impact of psychiatric conditions on health-related quality of life in persons with HIV infection.

OBJECTIVE: Little is known about the impact of comorbid psychiatric symptoms in persons with HIV. This study estimates the burden on health-related quality of life associated with comorbid psychiatric conditions in a nationally representative sample of persons with HIV. METHOD: The authors conducted a multistage sampling of urban and rural areas to produce a national probability sample of persons with HIV receiving medical care in the contiguous United States (N=2,864). Subjects were screened for psychiatric conditions with the short form of the Composite International Diagnostic Interview. Heavy drinking was assessed on the basis of quantity and frequency of drinking. Health-related quality of life was rated with a 28-item instrument adapted from similar measures used in the Medical Outcomes Study. RESULTS: HIV subjects with a probable mood disorder diagnosis had significantly lower scores on health-related quality of life measures than did those without such symptoms. Diminished health-related quality of life was not associated with heavy drinking, and in drug users it was accounted for by presence of a comorbid mood disorder. CONCLUSIONS: Optimization of health-related quality of life is particularly important now that HIV is a chronic disease with the prospect of long-term survival. Comorbid psychiatric conditions may serve as markers for impaired functioning and well-being in persons with HIV. Inclusion of sufficient numbers of appropriately trained mental health professionals to identify and treat such conditions may reduce unnecessary utilization of other health services and improve health-related quality of life in persons with HIV infection.

Trends in self-reported HIV risk behavior: injection drug users in Los Angeles.

This article reviews trends in HIV risk behaviors across serial samples of Los Angeles injection drug users interviewed between 1987 and 1991. All indicators are based on self-reported behavior during the year before the interview. Findings show persistent drug-related risk behaviors. No decrease has occurred in needle sharing with strangers/acquaintances or at shooting galleries. No increase has occurred in self-reported avoidance of needle sharing for as long as 1 year. The only exception to this pattern is a significant increase in bleach use among injection drug users who share needles. Findings are mixed regarding sex-related risk behaviors. Drug users have not reduced their yearly number of sex partners, but condom use has become more prevalent among nonmonogamous drug users. We conclude that preventive education will need to adopt new strategies for addressing persistent risk behaviors while at the same time reinforcing favorable trends that have already begun.

Ethnic differences in the psychosocial antecedents of needle/syringe disinfection.

This study examined psychosocial antecedents of needle/syringe disinfection by 209 injection drug users in three ethnic groups. Among Whites, high perceived self-efficacy for risk reduction had a positive effect on subsequent disinfection attempts. Among African Americans and Mexican Americans, peer norms favorable to risk reduction had a positive effect on subsequent disinfection attempts, while self-efficacy had no effect. These results suggest that risk-reduction capabilities may be rooted in individualistic perceptions of the self among White drug users, while 'collective self' perceptions are more relevant to these capabilities among African American and Mexican American drug users. HIV risk intervention may have more impact in specific ethnic groups if these distinctions are taken into account. Results also demonstrate the importance of comparing models of behavior change across ethnic groups.

Factors associated with readiness to change drug use among needle-exchange users.

To determine if frequent needle-exchange program (NEP) use is associated with lower readiness to change drug use, NEP clients in Providence, RI were interviewed regarding their drug use, HIV risk, health, and past use of drug treatment services in 1997-1998. Readiness to change drug use was assessed using a nine-step decision ladder. Based on this assessment, 14.3% of the sample were classified as precontemplators (24/168), 29.2% were in the contemplation stage (49/168), and 56.5% were in the determination or ready to change stage (95/168). We found that mean number of NEP visits was 25.5 among precontemplators, 28.7 among contemplators, and 22.5 among those in the determination stage. In multivariate analysis, an inverse relationship between having ever been in alcohol treatment and higher readiness to change drug use was the only significant association. In this exploratory study, we found that more frequent NEP participation did not impact readiness to change drug use among intravenous drug users. Given the high proportion of NEP clients ready to change drug use, improving linkages between NEPs and substance abuse treatment appears warranted.

Psychosocial antecedents of needle/syringe disinfection by drug users: a theory-based prospective analysis.

Working from the AIDS risk reduction model and other theories of behavior change, we tested psychosocial antecedents of needle/syringe disinfection by 136 injection drug users. High perceived self-efficacy for risk reduction exerted a positive effect on needles/syringe disinfection attempts 1 year later. Self-efficacy was, in turn, related to lower perceived infection risk, peer norms more favorable to risk reduction, and greater knowledge of AIDS. Behavioral intention had no significant effect on subsequent disinfection attempts. These results suggest that disinfecting needles/syringes is partly non-volitional; that high perceived infection risk may be counterproductive to injection risk reduction; and that perceive self-efficacy, but not intention to change behavior, may be a useful leverage point for AIDS preventive intervention.

Needle exchange program attendance and injection risk in Providence, Rhode Island.

Needle sharing has long been recognized as a primary route of HIV infection. However, recent research has shown that HIV antibody is also detectable in injection supplies other than needles. In this study we tested frequency of attendance at a Providence, Rhode Island, needle exchange program (NEP) as a correlate of injection risk indicators including not just sharing needles but also sharing cookers, sharing cotton filters, cleaning the skin before injecting, and using bleach as a needle disinfectant. Results showed that drug users who attended the NEP less frequently were more likely to report needle sharing, less likely to report always cleaning their skin, and more likely to report sharing cookers. The Providence NEP is one at which alcohol swabs and cookers are distributed along with clean needles. Our results suggest that NEPs represent a valuable and underexploited opportunity to promote risk reduction efforts beyond the avoidance of needle sharing. NEPs should be distributing risk reduction supplies in addition to clean needles and should adopt strategies (e.g., outreach and more days/hours of operation) to encourage frequent attendance.

AIDS knowledge and attitudes among injection drug users: the issue of reliability.

Among injection drug users (IDUs), AIDS-related knowledge and attitudes have not consistently predicted AIDS risk behavior. This may be due in part to the limited reliability of indexes used to measure drug users' AIDS knowledge and attitudes. In addition, the substantive interpretation of findings is confounded if index reliability is lower for particular demographic groups (e.g., ethnic populations and women). This report is based on 8 measures of AIDS-related knowledge and attitudes in a sample of 332 injection drug users in Los Angeles. The reliability of knowledge and attitude indexes for the overall sample is generally acceptable for the purpose of group comparison (average alpha = .60). But reliability is consistently lower for respondents who are Hispanic (average alpha = .49) and respondents with less formal education (alpha = .56). The reliability of 2 measures of sex-related attitudes is lower for female respondents. It is therefore important that the reliability of knowledge and attitude indexes be assessed not just for drug-user samples as a whole, but also within demographic groups of substantive interest.

PIP: This study pertains to a survey of 365 injection drug users (IDUs) in Los Angeles County from methadone maintenance/detoxification or residential drug free programs and earlier studies of AIDS risk reduction. The sample was stratified by ethnicity and gender and appeared to represent the local IDU population with treatment experience. There were 129 whites, 118 Hispanics, and 85 blacks; 174 were women and 158 men. 189 had completed high school and 143 had not. The purpose of the study was to investigate the reliability of indexes measuring AIDS-related knowledge and attitudes. Background information is provided on AIDS risk demographics and measurement, AIDS knowledge and attitudes, and summary of prior research. The instrument was newly designed to measure general knowledge about AIDS, perceived susceptibility to HIV infection and to self-efficacy regarding drug, and sex related risk reduction techniques and response efficacy of those techniques, and drug and sex-related risk reduction norms. 45 questions were asked by trained interviewers and answered by respondents in English in a Likert agree/disagree format. The results showed that knowledge, susceptibility, self-efficacy/drugs, self efficacy/sex, and norms/sex had the highest alphas ranging from .64 to .78. The minimum acceptable level is .50. The response norm/drugs is barely acceptable at .56. In the demographic analysis, alphas are the lowest for Hispanics in 7 out of 8 indexes, and with statistically significant differences in 4 indexes: response efficacy/drugs, response efficacy/sex, self-efficacy/sex, and norms/drugs. Response efficacy/sex and norms/drugs reach the acceptable minimum of .50 for blacks and whites only. Self-efficacy/sex for total does not reach a minimum acceptable level, however, it does for white at .58 and almost reaches acceptability for blacks at .43. There are inconsistent patterns by sex. In general, men are less reliable on the susceptibility index and women on the response efficacy/sex and self-efficacy/sex indices. Respondents with a high school education had alphas of .61 compared with .56 for low education respondents. There is lower reliability among lower educated respondents on self-efficacy/drugs and norms/drugs. The implications are that subgroup reliability is related to responses, such that low education and Hispanics score lower. Inconsistency of response may be due to methodological problems, which may be corrected statistically or by asking open-ended questions, and affect the effectiveness of interventions.

Perceived AIDS risk among adult arrestee injection drug users in Los Angeles county.

In this paper we examine the determinants of perceived risk for getting HIV and AIDS among adult Los Angeles arrestees reporting any lifetime injection drug use (N = 958). Our sample, drawn from the Drug Use Forecasting program, is 60% male and 40% female. Higher rates of reported risky drug and sexual behaviors than in the general population make this a particularly relevant sample within which to explore correlates of perceived risk for getting HIV and AIDS. We used multiple logistic regression to assess the relationship between perceived risk and a variety of demographic, behavioral, and psychosocial variables. Arrestees reporting celibacy in the past year, having an injection-drug-using sexual partner, having more than 20 sexual partners, engaging in sex while high, knowing someone with AIDS, and having been tested for HIV antibodies were more likely to perceive themselves at greater risk of getting HIV and AIDS. African American arrestees and arrestees reporting having attempted to reduce their sexual risks were less likely to perceive themselves at greater risk for getting AIDS. Implications for AIDS education and prevention are discussed.

Rethinking perceived risk and health behavior: a critical review of HIV prevention research.

Perceived risk of infection, one factor influencing HIV-related behavior decisions, has been the focus of expanding research efforts. A body of research now exists examining factors related to risk perceptions and the relationship between risk perceptions and behavioral decision making. This article examines 60 quantitative studies of HIV-related risk perceptions, identifies methodological and theoretical limitations or gaps in current knowledge, and suggests ways future research might better assess the role of risk perceptions and facilitate the adoption and maintenance of HIV-related health protective behaviors. The authors argue that mixed findings in the quantitative literature are due to (1) cross-sectional study designs that constrain or confound the interpretation of findings, (2) construct confusion and measurement inconsistencies. (3) insufficient consideration of specific subgroup or behavioral differences, and (4) inattention to situational norms and other contextual factors that influence risk perceptions and behavior.

Drug treatment careers. A conceptual framework and existing research findings.

While outcomes for any single intervention are important to determine, the long term evaluation of multiple, sequential interventions is at least equally important. One strategy for examining this process is that of the treatment career. A treatment careers perspective applies a longitudinal dynamic approach to identify and understand key factors influencing the development of, and transitions in the course of, drug dependence and its treatment. After presenting an overview of the treatment careers perspective, this paper reviews and discusses relevant research issues and findings on treatment seeking, utilization and resistance, entry and reentry, engagement and retention, client treatment matching, and outcomes. Key findings include high resistance to entering treatment by many drug users, late development of treatment careers relative to addiction and criminal careers, short durations of most treatment episodes, cumulative and facilitative effects of treatment experiences, and beneficial effects of matching clients to treatment. The treatment careers perspective provides a useful framework within which findings on drug treatment can be better integrated and critical issues can be identified for further research, leading to a better understanding of drug dependence and its treatment.

Associations between drug abuse treatment and cigarette use: evidence of substance replacement.

The influence of risk-behavior bias, drug use, prior cigarette use, and prior and current participation in drug treatment on cigarette use was analyzed using a 3-wave survey of 346 drug abusers. Participation in drug treatment and a risk-behavior bias were hypothesized to predict greater cigarette use. After controlling for prior levels of cigarette use with a longitudinal path model, it was found that participation in drug treatment at Wave 2 significantly predicted increased cigarette use at Wave 2. There were similar results at Wave 3. Additional analyses indicated that reduced heroin use was especially associated with more smoking. Risk-behavior bias predicted more drug and cigarette use and predicted less participation in drug treatment at Wave 3. These results suggest that drug treatment, reduced heroin use, and a tendency toward risky behavior may lead to increased cigarette use, which may represent a form of substance replacement.

Help-seeking by African American drug users: a prospective analysis.

In this study, help-seeking was significantly more likely for African American drug users with more formal education and those scoring higher on both drug-related problem recognition and ethnic identity. This latter result suggests that ethnic identity, despite having no main effect on help-seeking in this sample, may nonetheless make an important contribution to help-seeking by "potentiating" the influence of drug problem recognition.

Drug problem recognition among African American drug-using arrestees.

We examined demographic factors, drug-use severity indicators, social resources, and personal perceptions as correlates of Drug Problem Recognition among African American drug-using arrestees. In particular, we sought to move beyond the "ethnic gloss" of prior research by including ethnicity-related attitudes, perceptions, and experiences among the factors tested. Multivariate regression analysis suggested that Conventional Moral Beliefs and Neighborhood Drug/Alcohol Problems were key determinants of the perception that one's own drug use is a problem. We cite implications of these findings for help seeking and engagement in treatment among African American drug user.

Desire for help among drug-using Mexican-American arrestees.

In a sample of 88 drug-using Mexican-American arrestees, we examined demographic factors, drug-problem severity indicators, and personal and social resources as correlates of self-reported desire for help with problems related to drug use. Ethnicity-related attitudes, perceptions, and experiences were among the factors tested. Among 35 potential correlates in this dataset, recognition of drug-related interpersonal problems was the sole significant correlate of desire for help in a multivariate regression analysis. This finding was interpreted in comparison to previously identified correlates of Mexican-American drug users' desire for help specifically in the form of drug user treatment. We derive implications regarding drug-use-associated problem recognition and other potential determinants of help-seeking and success in drug user treatment among Mexican-American drug users.