Couple-based HIV counseling and testing: a risk reduction intervention for US drug-involved women and their primary male partners.

To help reduce the elevated risk of acquiring HIV for African-American and Latina women drug users in primary heterosexual relationships, we developed a brief couple-based HIV counseling and testing prevention intervention. The intervention was based on an integrated HIV risk behavior theory that incorporated elements of social exchange theory, the theory of gender and power, the stages-of-change model, and the information-motivation-behavior skills model. In this article, we describe the development, content, and format of the couple-based HIV testing and counseling intervention, and its delivery to 110 couples (220 individuals) in a randomized effectiveness trial, the Harlem River Couples Project, conducted in New York City from 2005 to 2007. Components of the couple-based intervention included a personalized dyadic action plan based on the couple's risk profile and interactive exercises designed to help build interpersonal communication skills, and facilitated discussion of social norms regarding gender roles. The couple-based HIV testing and counseling intervention significantly reduced women's overall HIV risk compared to a standard-of-care individual HIV testing and counseling intervention. Experiences and perceptions of the intervention were positive among both clients and interventionists. The study was the first to demonstrate the effectiveness and feasibility of delivering a brief couple-based HIV counseling and testing intervention to reduce risk among drug-using heterosexual couples in high HIV prevalent urban communities in the USA. The intervention can be expanded to include new HIV prevention strategies, such as pre-exposure prophylaxis. Further research is needed to evaluate cost-effectiveness and implementation of the intervention in clinical settings.

Student perceptions about interprofessional education after an elective course.

A growing body of evidence indicates interprofessional collaborative practice improves patient care. With this in mind, Louisiana State University Health Sciences Center formally committed to expanding interprofessional education (IPE) initiatives. Thirty-eight self-selected students enrolled in an IPE elective course during the fall of 2012. Students completed the Readiness for Interprofessional Learning Scale (RIPLS) pre- and post-course and also completed a post-course survey. Results indicated a significant change in the roles and responsibilities scale of the RIPLS. Analysis of the data from the post-course survey demonstrated students were able to identify key terms of an IPE definition, as related to their learning experience. In addition, themes of communication, learning/increased knowledge, and collaboration/contribution of other health care professionals were noted across all questions in the post-course survey. Based on the results of this study, an elective course is a promising educational opportunity to increase awareness and knowledge of IPE within academic medical centers.

Factors associated with delays to diagnosis and treatment of breast cancer in women in a Louisiana urban safety net hospital.

Only lung cancer surpasses breast cancer as a cause of death from cancer. However, the burden of cancer is not borne equally across racial and ethnic groups. In the United States, African American women have significantly higher mortality rates from breast cancer than white women. Delayed follow-up of breast abnormalities and delays from diagnosis to treatment may contribute to higher mortality. This study examined factors associated with delays to diagnosis and treatment of breast cancer in a group of white and African American women. Identified from tumor registry records were 247 women with pathology-confirmed first primary in situ and invasive breast carcinomas with no known previous cancer diagnosis. Factors associated with delays from provider recognition of abnormality to breast cancer diagnosis (diagnostic delays) and from diagnosis to treatment (treatment delays) were determined using chi-square tests and logistic regression. Factors that were considered included age, race, stage of disease at diagnosis, tumor size, type of abnormality, type of medical service at presentation, and prior mammogram within the past two years. The proportion of women experiencing diagnostic delays was high, with more African American women experiencing delays than white women (34% versus 17%, respectively). African American and white women did not differ in distribution of stage of cancer at diagnosis. Significantly smaller tumor sizes were found in women experiencing diagnostic delays compared to those not experiencing delays. Conversely, women experiencing treatment delays were significantly older and had larger tumor sizes compared to those not experiencing delays. More African American women experienced delays in diagnosis; however these delays did not appear to affect outcomes. Older age as a significant factor in treatment delays suggests that comorbidities as well as other possible barriers to treatment warrant further investigation in older women. The reasons for racial disparities in breast cancer outcomes remain and call for further study.

Intranasal transmission of hepatitis C virus: virological and clinical evidence.

Intranasal transmission of hepatitis C virus (HCV) via contaminated drug-sniffing implements is a potential but unconfirmed source of viral infection. We demonstrate the virological plausibility of intranasal transmission by confirming that blood and HCV RNA are present in the nasal secretions and drug-sniffing implements of HCV-infected intranasal drug users recruited from a community health clinic in New York City.

First injection of ketamine among young injection drug users (IDUs) in three U.S. cities.

Ketamine, a dissociative anesthetic, has emerged as an increasingly common drug among subgroups of young injection drug users (IDUs) in cities across the United States. In-depth qualitative interviews were conducted with 213 young IDUs aged 16-28 years recruited in New York, New Orleans, and Los Angeles between 2004 and 2006. While some initiated injection drug use with ketamine, the drug was more frequently injected by IDUs with extensive polydrug using histories. IDUs initiating with ketamine commonly self-injected via an intramuscular mode of administration. The injection group provided crucial knowledge and material resources that enabled the injection event to occur, including ketamine, syringes, and injection skills. Injection paraphernalia was commonly shared during the first injection of ketamine, particularly vials of pharmaceutically-packaged liquid ketamine. Injection events infrequently occurred in a rave or club and more typically in a private home, which challenges ketamine's designation as a 'club' drug. The first injection of ketamine was a noteworthy event since it introduced a novel drug or new mode of administration to be further explored by some, or exposed others to a drug to be avoided in the future. Risk reduction messages directed towards young IDUs should be expanded to include ketamine.

Syringe disposal among injection drug users in Harlem and the Bronx during the New York State Expanded Syringe Access Demonstration Program.

Effective January 1, 2001, New York State enacted the Expanded Syringe Access Demonstration Program (ESAP), allowing syringes to be sold in pharmacies without a prescription or dispensed through doctors, hospitals, and clinics to adults. A concern in the assessment of ESAP is its effects on syringe disposal practices. Syringe use data regarding the last injection episode were combined from three projects (N = 1,030) recruiting injection drug users. Disposal of syringes by methods known to be safe decreased significantly over time after the implementation of ESAP. Syringes obtained either from syringe exchange programs or ESAP sources were more likely to be disposed of safely than syringes obtained from other sources. Efforts to enlist pharmacists and others involved in ESAP implementation to encourage safe disposal are needed. More detailed information on disposal practices is needed to capture the continuum from least to most safe practices and variation within individuals.

Prevalence and Patterns of Prescription Drug Misuse among Young Ketamine Injectors.

In recent years, epidemiological monitoring data has indicated sharp increases in prescription drug misuse. Despite these increases, little is known about the context or patterns associated with prescription drug misuse, particularly among youth or young injection drug users (IDUs). A three-city study of 213 young IDUs found prescription drug misuse to be pervasive, specifically the use of opioids and benzodiazepines. Particular practices not commonly associated with prescription drugs were reported, such as sniffing, smoking, and injection. Associated health risks included initiation into injection drug use, polydrug use, drug overdose, and drug dependency. A greater awareness of the potential health risks associated with prescription drug misuse should be incorporated into services that target IDUs, including street outreach, syringe exchanges, and drug treatment.

Risk of Intimate Partner Violence and Relationship Conflict Following Couple-Based HIV Prevention Counseling: Results From the Harlem River Couples Project.

Heterosexual transmission of HIV often occurs in the context of intimate sexual partnerships. There is mounting evidence that couple-based HIV prevention interventions may be more effective than individual-based interventions for promoting risk reduction within such relationships. Yet, concerns have been raised about the safety of couple-based prevention approaches, especially with regard to the risk of intimate partner violence against women. Although several international studies have examined the potential for adverse consequences associated with couple-based interventions, with inconsistent results, there is little data from U.S. studies to shed light on this issue. The current study analyzed data from a randomized trial conducted in New York City with 330 heterosexual couples to examine whether participation in couple-based or relationship-focused HIV counseling and testing (HIV-CT) interventions resulted in an increased likelihood of post-intervention breakups, relationship conflicts, or emotional, physical, or sexual abuse, compared with standard individual HIV-CT. Multinomial logistic regression was used to model the odds of experiencing change in partner violence from baseline to follow-up by treatment condition. A high prevalence of partner-perpetrated violence was reported by both male and female partners across treatment conditions, but there was no conclusive evidence of an increase in relationship dissolution or partner violence subsequent to participation in either the couple-based HIV-CT intervention or relationship-focused HIV-CT intervention compared with controls. Qualitative data collected from the same participants support this interpretation. HIV prevention interventions involving persons in primary sexual partnerships should be sensitive to relationship dynamics and the potential for conflict, and take precautions to protect the safety of both male and female participants.

A guide for multilevel modeling of dyadic data with binary outcomes using SAS PROC NLMIXED.

In the social and health sciences, data are often structured hierarchically, with individuals nested within groups. Dyads constitute a special case of hierarchically structured data with variation at both the individual and dyadic level. Analyses of data from dyads pose several challenges due to the interdependence between members within dyads and issues related to small group sizes. Multilevel analytic techniques have been developed and applied to dyadic data in an attempt to resolve these issues. In this article, we describe a set of analyses for modeling individual- and dyad-level influences on binary outcomes using SAS statistical software; and we discuss the benefits and limitations of such an approach. For illustrative purposes, we apply these techniques to estimate individual-dyad-level predictors of viral hepatitis C infection among heterosexual couples in East Harlem, New York City.

Recruitment of heterosexual couples in public health research: a study protocol.

BACKGROUND: Public health research involving social or kin groups (such as sexual partners or family members), rather than samples of unrelated individuals, has become more widespread in response to social ecological approaches to disease treatment and prevention. This approach requires the development of innovative sampling, recruitment and screening methodologies tailored to the study of related individuals. METHODS: In this paper, we describe a set of sampling, recruitment and screening protocols developed to enlist urban, drug-using, heterosexual couples into a public health research study. This population is especially hard to reach because they are engaged in illegal and/or stigmatized behaviors. The protocols were designed to integrate adaptive sampling, street- and referral-based recruitment, and screening procedures to verify study eligibility and relationship status. DISCUSSION: Recruitment of heterosexual couples through one partner, preferably the female, can be an effective enlistment technique. Verification of relationship status is an important component of dyadic research. Comparison of parallel questionnaires administered to each member of a dyad can aid in the assessment of relationship status. However, multiple independent sources of information should be used to verify relationship status when available. Adaptive sampling techniques were effective in reaching drug-using heterosexual couples in an urban setting, and the application of these methods to other groups of related individuals in clinical and public health research may prove to be useful. However, care must be taken to consider potential sources of sampling bias when interpreting and generalizing study results.

A potential hidden source of hepatitis C infection among noninjecting drug users.

Hepatitis C virus (HCV) is a major cause of chronic liver disease in the United States and worldwide. It is primarily transmitted through blood-to-blood contact with an infected individual. HCV is hyperendemic among injection drug users (IDUs), who contract the virus through contaminated syringes and drug preparation equipment shared with other IDUs. The prevalence of HCV is also high, to a lesser degree, among noninjection drug users, many of whom report no identifiable HCV risk exposures. This article reviews the epidemiological and virological evidence bearing on a potential hidden source of HCV infection among noninjection drug users: namely, the oral or intranasal transmission of HCV through the sharing of noninjection drug-use implements such as pipes or straws. While there is some epidemiological evidence supporting both oral and intranasal HCV transmission, most studies are hampered by methodological limitations. Thus, there is a need for prospective studies designed specifically to examine these potential routes of transmission. Current biological evidence does not refute either oral or intranasal transmission as possible sources of HCV infection, although more research is needed in the areas of oronasal HCV pathogenesis and the detection of HCV RNA in the nasal mucosa of intranasal drug users.

Effectiveness of Couple-Based HIV Counseling and Testing for Women Substance Users and Their Primary Male Partners: A Randomized Trial.

A randomized trial was conducted to test the effectiveness of couple-based HIV counseling and testing (CB-HIV-CT) and women-only relationship-focused HIV counseling and testing (WRF-HIV-CT) in reducing HIV risk compared to the National Institute on Drug Abuse HIV-CT standard intervention. Substance using HIV-negative women and their primary heterosexual partner (N = 330 couples) were randomized to 1 of the 3 interventions. Follow-up assessments measuring HIV risk behaviors and other relevant variables were conducted at 3- and 9-months postintervention. Repeated measures generalized linear mixed model analysis was used to assess treatment effects. A significant reduction in HIV risk was observed over the 9-month assessment in the CB-HIV-CT group compared to that of the control group (b = -0.51, t[527] = -3.20, P = 0.002) and compared to that of the WRF-HIV-CT group (b = -0.34, t[527] = -2.07, P = 0.04), but no significant difference was observed between WRF-HIV-CT and controls (b = -0.17, t[527] = -1.09, P = 0.28). A brief couple-based HIV counseling and testing intervention designed to address both drug-related and sexual risk behaviors among substance using women and their primary male partners was shown to be more effective at reducing overall HIV risk compared to a standard HIV-CT intervention in an urban setting.

Individual and couple-level risk factors for hepatitis C infection among heterosexual drug users: a multilevel dyadic analysis.

BACKGROUND: Hepatitis C virus (HCV) is the most common bloodborne pathogen in the United States and is a leading cause of liver-related morbidity and mortality. Although it is known that HCV is most commonly transmitted among injection drug users, the role of sexual transmission in the spread of HCV remains controversial because of inconsistent findings across studies involving heterosexual couples. METHODS: A novel multilevel modeling technique designed to overcome the limitations of previous research was performed to assess multiple risk factors for HCV while partitioning the source of risk at the individual and couple level. The analysis was performed on risk exposure and HCV screening data obtained from 265 drug-using couples in East Harlem, New York City. RESULTS: In multivariable analysis, significant individual risk factors for HCV included a history of injection drug use, tattooing, and older age. At the couple level, HCV infection tended to cluster within couples, and this interdependence was accounted for by couples' drug-injection behavior. Individual and couple-level sexual behavior was not associated with HCV infection. CONCLUSIONS: Our results are consistent with prior research indicating that sexual contact plays little role in HCV transmission. Rather, couples' injection behavior appears to account for the clustering of HCV within heterosexual dyads.

Contextual determinants of condom use among female sex exchangers in East Harlem, NYC: an event analysis.

Recent studies have revealed a variety of contexts involving HIV risk behaviors among women who exchange sex for money or drugs. Event analysis was used to identify the individual, relationship, and contextual factors that contribute to these high-risk sex exchange practices. Analyses were conducted on data obtained from 155 drug-using women who reported details of their most recent sex exchange event with male clients. The majority of sex exchange encounters (78%) involved consistent condom use. In multivariable analysis, protective behavior was associated primarily with situational and relationship variables, such as exchange location, substance use, sexual practices, and respondent/client discussion and control. In order to inform HIV prevention programs targeted to women sex exchangers, further research is needed on the contextual determinants of risk, especially with regard to condom-use negotiation and factors involving substance use that adversely affect women's ability to manage protective behavior in the context of sex exchange.

Recruiting injection drug users: a three-site comparison of results and experiences with respondent-driven and targeted sampling procedures.

Several recent studies have utilized respondent-driven sampling (RDS) methods to survey hidden populations such as commercial sex-workers, men who have sex with men (MSM) and injection drug users (IDU). Few studies, however, have provided a direct comparison between RDS and other more traditional sampling methods such as venue-based, targeted or time/space sampling. The current study sampled injection drug users in three U.S. cities using RDS and targeted sampling (TS) methods and compared their effectiveness in terms of recruitment efficiency, logistics, and sample demographics. Both methods performed satisfactorily. The targeted method required more staff time per-recruited respondent and had a lower proportion of screened respondents who were eligible than RDS, while RDS respondents were offered higher incentives for participation.

Receptive syringe sharing among injection drug users in Harlem and the Bronx during the New York State Expanded Syringe Access Demonstration Program.

BACKGROUND: Effective on January 1, 2001, New York State enacted the Expanded Syringe Access Demonstration Program (ESAP), which allows syringes to be sold in pharmacies without a prescription or dispensed through doctors, hospitals, and clinics to persons 18 years of age or older and permits the possession of those syringes for the purposes of injecting drugs. OBJECTIVE: To assess changes in receptive syringe sharing since the inception of the ESAP. METHODS: Sociodemographic characteristics and syringe use data regarding the last injection episode were combined from 3 projects (n = 1181) recruiting injection drug users in ongoing studies in Harlem and the Bronx in New York City from January 2001 through June 2003. These data were analyzed as serial cross sections by calendar quarter. RESULTS: Receptive sharing decreased significantly over time, from 13.4% in the first quarter to 3.6% in the last quarter. Obtaining the last injection syringe from an ESAP source (mostly pharmacies) increased significantly over time, from 7.5% in the first quarter to 25.0% in the last quarter. In multiple logistic regression analysis, variables that were significantly associated with less receptive sharing were syringe exchange and ESAP syringe source as well as time since ESAP inception. Female gender and white race/ethnicity were significantly associated with greater receptive sharing. CONCLUSIONS: The increase in the use of pharmacies and other ESAP syringe sources in this sample has been accompanied by a decline in receptive sharing.

Women's drug injection practices in East Harlem: an event analysis in a high-risk community.

This study described the most recent injection events of injection-drug-using women, determined the prevalence of HIV, hepatitis B (HBV), and hepatitis C (HCV), and identified significant predictors of injection-related risk behaviors. After validation of drug use, 185 street-recruited women participated in structured interviews and were offered HIV, HBV, and HCV testing and counseling. Interview topics included (1) demographic characteristics, (2) characteristics of injection partners (IPs), and (3) relevant situation-specific factors. Prevalence was 28% for HIV infection, 80% for HBV, and 70% for HCV. Injection events were either solitary (n = 110) or social (n = 75). Most were safe, and 75% of syringes used were obtained from a syringe exchange. Inferential analyses identified two variables that independently predicted unsafe events: (1) respondent had injected previously with her IP, and (2) her IP was her spouse or primary heterosexual partner. Two trends were identified: Injection events in which women felt "very close" to their IP or reported lack of control over injection practices tended to be unsafe. Although most events were safe, safe practices were not adhered to with spouses or primary partners. Syringe exchanges should be supported and may be an ideal setting for interventions targeted to drug-injecting couples.

Sharing of noninjection drug-use implements as a risk factor for hepatitis C.

This study examined sharing noninjection drug implements as a risk factor for hepatitis C (HCV) infection among women drug users (n = 123) with no history of drug injection. Participants were street-recruited from East Harlem, New York City, between October 1997 and June 1999. Participants were administered a survey measuring risk factors for HCV. Prevalence of HCV and HIV infections was 19.5% and 14.6%, respectively. Multiple logistic regression determined significant associations between sharing noninjection drug-use implements and HCV infection. "Ever shared both oral and intranasal noninjection drug implements" was independently associated with HCV infection [Odds ratio (OR) 2.83; Confidence interval (CI) 1.04, 7.72; p = 0.04]; "ever shared noninjected heroin implements with an injector" was a trend (OR 3.06; CI .85, 10.79; p = 0.08). The strongest association between sharing noninjection drug-use implements and HCV infection was found among HIV positive individuals (chi2 = 8.8, 1 d.f., p < 0.01). These findings, if supported by future research, indicate a need to reassess policies regarding HCV infection.