Decreased Odds of Injection Risk Behavior Associated With Direct Versus Indirect Use of Syringe Exchange: Evidence From Two California Cities.

BACKGROUND: While there is substantial evidence that syringe exchange programs (SEPs) are effective in preventing HIV among people who inject drugs (PWID), nearly all the evidence comes from PWID who obtain syringes from an SEP directly. Much less is known about the benefits of secondary exchange to PWID who get syringes indirectly from friends or acquaintances who visit an SEP for them. OBJECTIVES: We evaluated the effectiveness of direct versus indirect syringe exchange in reducing HIV-related high-risk injecting behavior among PWID in two separate studies conducted in Sacramento and San Jose, California, cities with quite different syringe exchange models. METHODS: In both studies associations between direct and indirect syringe exchange and self-reported risk behavior were examined with multivariable logistic regression models. Study 1 assessed effects of a "satellite" home-delivery syringe exchange in Sacramento, while Study 2 evaluated a conventional fixed-site exchange in San Jose. RESULTS: Multivariable analyses revealed 95% and 69% reductions, respectively, in high-risk injection associated with direct use of the SEPs in Sacramento and San Jose, and a 46% reduction associated with indirect use of the SEP in Sacramento. Conclusions/Importance: The very large effect of direct SEP use in Sacramento was likely due in part to home delivery of sterile syringes. While more modest effects were associated with indirect use, such use nevertheless is valuable in reducing the risk of HIV transmission of PWID who are unable or unwilling to visit a syringe exchange.

Change in quality of life among breast cancer survivors after resistance training: is there an effect of age?

To evaluate the effect of age on quality of life (QOL) in breast cancer survivors after resistance training, 20 women were assigned to 1 of 2 groups based on age (YRT 40-59 yr, ORT 60-80 yr). Both groups completed 3 sets of 8 exercises twice a week for 8 wk. Measurements were obtained before and after the training program. QOL was measured using the Body Image and Relationship Scale (BIRS). Both groups improved in chest press (p < .001), leg press (p < .001), arm curls (p < .05), and chair stands (p < .001). For QOL, YRT reported greater improvements compared with ORT in BIRS total score (Group × Time interaction, p = .002) and strength and health subscale score (Group × Time interaction, p = .001), and greater age was related to greater perceived impairment (BIRS total: r = .61, p = .004; strength and health subscale: r = .69, p = .001). Despite significant improvements in strength and function, older women perceived relatively little improvement in QOL compared with younger women, and age had a differential negative influence on improvements in QOL.

Effectiveness of HIV prevention social marketing with injecting drug users.

Social marketing involves applying marketing principles to promote social goods. In the context of health behavior, it has been used successfully to reduce alcohol-related car crashes, smoking among youths, and malaria transmission, among other goals. Features of social marketing, such as audience segmentation and repeated exposure to prevention messages, distinguish it from traditional health promotion programs. A recent review found 8 of 10 rigorously evaluated social marketing interventions responsible for changes in HIV-related behavior or behavioral intentions. We studied 479 injection drug users to evaluate a community-based social marketing campaign to reduce injection risk behavior among drug users in Sacramento, California. Injecting drugs is associated with HIV infection in more than 130 countries worldwide.

Mindset First, Strategy Second: Finding the Savings and Performance in Changing Culture.

Resolving major challenges for health care organizations is a constant challenge. Each military service provides its leaders with superb education and training to lead the constant needs and changes of the mission requirements. The primary trap we leaders may fall into, though, is when we mistake our own expertise and perspectives as the solutions to our organizational challenges. To fully unleash the potential of our people and organizations, we must be deliberate in setting a culture that leverages all the diversity within our organization. At the Carl R. Darnall Army Medical Center, Fort Hood, TX, our leadership team initiated an effort to shift the organizational mindset to create this cultural soil. The seeds of our education, training and strategic initiatives then were able to flourish and address our organizational challenges, but only after we addressed our own leadership mindset gap. By establishing and modeling a foundational outward mindset to ensure our team focused on the impact of our actions, we nurtured a culture that was inquisitive, collaborative, and without blame. In doing so, we eliminated negative financial and safety outcomes that threatened our institution and transformed it into a leading Army Medical Center.

High levels of unprotected sex with men and women among men who have sex with men: a potential bridge of HIV transmission in Beijing, China.

China is experiencing an emerging HIV epidemic among men who have sex with men (MSM). We investigated sexual risk, risk perception, HIV and condom knowledge, and utilization of prevention services in the first large sample of MSM recruited in Beijing. Four hundred eighty-two MSM were sampled from September 2001 to January 2002. Forty-nine percent of participants reported unprotected anal intercourse with men during the previous 6 months. However, only 15% perceived they are at risk for HIV and many had misconceptions about HIV transmission routes and limited knowledge about condoms. Less than one quarter obtained free condoms (24%) and condom lubricants (19%) in the past 2 years. Multiple logistic regression analysis showed that unprotected insertive anal intercourse was associated with not having a Beijing residence card, having six or more male sexual partners, not having sex with women, having a lifetime history of sexually transmitted diseases (STDs), and having never tested for HIV. Unprotected receptive anal intercourse was independently associated with having six or more male sexual partners, not having sex with women, having a lifetime history of STDs, having never tested for HIV, and having less exposure to HIV prevention services. In addition, 28% reported having sex with both men and women during the previous 6 months, and 11% had unprotected intercourse with both men and women. This finding suggests that MSM are a potential bridge of HIV transmission to heterosexual women (or vice versa) and that addressing the HIV prevention needs of MSM may benefit the wider population.

Preliminary evidence of reduced cognitive inhibition in methamphetamine-dependent individuals.

Chronic methamphetamine abuse is associated with disruption of frontostriatal function involving serotonin and dopamine circuitry. Clinically, methamphetamine-dependent (MD) individuals are highly distractible and have difficulty focussing. Here, we used a computerized single-trial version of the Stroop Test to examine selective attention and priming in MD. Subject groups comprised eight MD men (31.7+/-7.2 years of age), who had used methamphetamine for 15.75+/-8.4 years but were currently abstinent for 2-4 months, and 12 controls (35.7+9.7 years of age). Compared with the control group, the MD group exhibited significantly greater interference (P<0.05) despite intact priming. Error rates did not differ between the groups. This preliminary finding of reduced cognitive inhibition in MD individuals is consistent with the distractibility they show clinically. Furthermore, the dissociation between explicit attentional performance and priming effects suggests that some attentional functions are not as affected by long-term methamphetamine use as others.

Low N-acetyl-aspartate and high choline in the anterior cingulum of recently abstinent methamphetamine-dependent subjects: a preliminary proton MRS study. Magnetic resonance spectroscopy.

Studies based on animal models report that methamphetamine (MA) abuse diminishes dopamine (DA) and serotonin innervation in frontal brain regions. In this in vivo human study, we used proton magnetic resonance spectroscopy (MRS), which yields measures of N-acetyl-aspartate (NAA), a marker of living neurons, to examine frontal brain regions possibly affected by methamphetamine dependence (MD). We tested the hypothesis that MD subjects would exhibit abnormally low levels of NAA, referenced to creatine (Cr), in anterior cingulate gray matter. We further hypothesized that the primary visual cortex, which receives relatively less DA innervation than the frontal brain regions, would show normal NAA/Cr ratios in MD subjects. Subjects included nine MD men (mean+/-standard deviation (S.D.)=32.5+/-6.4 years) and nine age-matched control men (mean+/-S.D.=32.7+/-6.8 years). The MD subjects were MA-free for 4-13 weeks. Proton MRS metabolites were expressed as ratios of creatine; the absolute values of which did not distinguish controls and MD subjects. With regard to metabolite ratios, the MD men had significantly lower NAA/Cr in the cingulum (mean+/-standard error (S.E.): control=1.46+/-0.03; MD=1.30+/-0.03; Mann-Whitney P=0.01) but not in the visual cortex (mean+/-S.E.: control=1.64+/-0.06; MD=1.69+/-11; Mann-Whitney P=0.52) relative to controls. These results provide evidence for NAA/Cr deficit that is selective to the anterior cingulum, at least with respect to visual cortex, in MD subjects. The neuronal compromise that these changes reflect may contribute to the attentional deficits and dampened reward system in MD.

Hospitalization of patients with cocaine and amphetamine use disorders from a psychiatric emergency service.

OBJECTIVES: Among the illicit stimulants, cocaine and amphetamines are the most widely abused. Although these drugs have similar psychoactive properties and routes of administration, their duration of action and mechanism of action are different, as are the psychiatric problems that accompany their use. The authors explored whether these differences and results of urine drug testing were associated with differences in use of psychiatric inpatient services. METHODS: The records of 2,357 patients admitted to a large county psychiatric emergency service were examined to determine whether patients admitted for amphetamine-related or cocaine-related disorders differed in rates of transfer to an inpatient psychiatric ward or in length of stay on the ward after transfer. The authors also examined whether positive or negative results of urine drug screens predicted transfer or length of stay. RESULTS: Patients with amphetamine-related disorders were more than a third more likely than patients with cocaine-related disorders to be transferred to the inpatient ward. Patients with negative urine screens were a third more likely than those with positive screens to be transferred and stayed slightly longer on the ward after transfer. Patients with cocaine-related disorders stayed slightly longer on the ward than patients with amphetamine-related disorders. CONCLUSIONS: Patients with amphetamine-related disorders have higher rates of psychiatric hospitalization than patients with cocaine-related disorders. Diagnostic uncertainty and other factors may also influence transfer rates and subsequent length of stay.

Epidemiology and public health Consequences of methamphetamine use in California's Central Valley.

Methamphetamine use is an increasingly serious public health problem in California and other parts of the country. Despite sensationalistic media attention, however, very little is known about users of this clandestinely consumed drug. Employing methods known as Rapid Assessment and Response, the authors describe the epidemiology and public health implications of methamphetamine use in California's Central Valley, with a focus on Sacramento, which many social indicators suggest has been more severely affected by methamphetamine than any city in the nation. Data sources for this report include interviews with drug users, statistical reports, epidemiologic studies, and local informed expert opinion. In their social demography, methamphetamine users in the Central Valley are in marked contrast to those of coastal cities such as Seattle and San Francisco, being largely heterosexual, and of mixed racial/ethnic heritage. Three-quarters or more initiate their use of the drug while still in their teens, with more than a quarter beginning use before the age of 15. Many of these rapidly gravitate to regular use, and continue using well into their thirties. Methamphetamine users are at much higher risk of infection with HIV than opiate users, particularly if they inject. Partly because methamphetamine enhances libido, users of the drug typically also have many more sexual partners. Not surprisingly, data indicate that methamphetamine users are more likely than heroin users to be HIV-infected. Methamphetamine appears to be less of a street drug than heroin, complicating efforts at street outreach. However, because it is typically used in social settings, a social or diffusion approach to HIV prevention might be particularly promising.

Two- to sixfold decreased odds of HIV risk behavior associated with use of syringe exchange.

We report results of a community study of syringe exchange that compared the HIV risk behavior of exchange clients with that of nonclients. A prospective cohort of 259 untreated injecting drug users (IDUs) was followed a mean of 10.7 months after baseline. In assessing whether HIV risk behavior at follow-up was associated with study participants' follow-up use of the exchange, we controlled their baseline risk behavior and exchange use as markers of risk-taking tendency in addition to other potential confounders. We also examined whether there was a differential benefit of exchange use for IDUs with versus those without access to other sources of syringes. Both univariate and multivariate analyses revealed a more than twofold decreased odds of HIV risk behavior associated with use of the exchange. In a second multivariate analysis, which examined the interaction of exchange use with access to other sources of syringes, the odds of HIV risk behavior were decreased more than sixfold for IDUs without other sources. We conclude that use of the exchange had a substantial protective effect against HIV risk behavior and may have been especially critical for IDUs without other sources of syringes.