Characteristics of research-related HIV testing programmes contribute to detection of more HIV infections.

HIV prevalence estimates from bathhouse testing programmes differ widely, ranging from 3% to 11%. The observed difference may be a consequence of whether the programme was part of a research project or a community-based programme. A research-funded testing programme was offered at a bathhouse between May 2001 and December 2002. A local community-based organization began a testing programme in July 2006 at the same bathhouse; the data for this analysis cover the period July 2006 through December 2007. County-wide HIV prevalence estimates were available across the two time periods (i.e. 2001-2002 and 2006-2007). The research-funded testing programme recruited fewer men but identified more positive individuals (10.7% of those testing in the research programme) than were identified among men who tested in the area clinics (3.8% of those men who have sex with men [MSM] testing throughout the county in the same time period). However, the community-based testing programme identified about the same proportion of positive MSM (2.6%) as county clinics (2.7%) in the same time period. In conclusion, results confirmed that even in the same venue, a community-based HIV testing programme identified a similar proportion of positive MSM as the area clinics; however, the research-funded programme identified appreciably more. Incentives may contribute to the difference.

Bringing HIV/STI testing programmes to high-risk men.

The aim of this study was to examine the meaning of significantly higher proportions of positive test results through outreach HIV/sexually transmitted infection testing programmes at gay bathhouses compared with clinic programmes among high-risk men who have sex with men. We conducted a random digit dial survey of men who have sex with men in New York, Los Angeles, Chicago, and San Francisco. Half of the men in the sample did not test in the past year. Among those who did not test, a sizeable minority (17%) reported engaging in high-risk sexual behaviour with a casual or secondary partner. Over half of these non-testing, high-risk men went to bathhouses. These findings strongly support the potential value of locating outreach-testing programmes in bathhouses. Although further studies are necessary, such programmes have the potential to increase testing among the high-risk segment of the population. This is particularly noteworthy given that many men among those who do not test regularly engage in high-risk behaviours.

A novel use of the link-file system for longitudinal studies of HIV infection: a practical solution to an ethical dilemma.

BACKGROUND: Longitudinal studies that collect sensitive data, such as test results for HIV antibodies, present difficult ethical problems for investigators. Personal identifiers are needed for longitudinal follow-up, but current regulations in the United States require that all subjects be informed of their HIV test results when identifiers are retained. Therefore, subjects who do not wish to learn their HIV status must be excluded from prospective research. Because these subjects may be at particularly high risk for HIV infection, this situation may lead to substantial bias. METHODS: We describe a new application of a methodology for blinding such studies, based on the link-file system used for protecting subjects' sensitive research data. This design enables investigators to hold each subject's HIV test result and survey data for multiple ascertainments over time while effectively severing any link between this information and the subject's identity. This objective is achieved by a process of sequential coding, using at least two coders who are not associated with the study. CONCLUSIONS: The method described in this paper permits investigators in the United States to perform important prospective epidemiologic studies while adhering to current regulations for the conduct of such investigations.

Changes in HIV-related risk behaviors following drug abuse treatment.

OBJECTIVES: To measure changes in HIV-related injection drug and sexual risk behaviors following drug treatment in a therapeutic community program. METHODS: We conducted a prospective cohort study of 261 drug users, randomly assigned to day or residential treatment. Participants were interviewed 2 weeks after entering treatment and 6, 12 and 18 months later (follow-up rate: 83%). RESULTS: Greater reductions in injection risk behaviors were associated with more time in treatment and the later waves of measurement. Wave was also associated with a reduction of sexual risk behavior. CONCLUSIONS: Drug abuse treatment was associated with a decrease in HIV-related risk behavior.

Levels of HIV testing and low validity of self-reported test results among alcoholics and drug users.

OBJECTIVES: To evaluate HIV testing behavior, validity of self-reported serostatus, and intention to test among alcoholics and drug users entering treatment. DESIGN: Longitudinal cohort study. METHODS: A total of 952 clients voluntarily entering three outpatient and two inpatient public alcohol treatment centers in San Francisco were enrolled. Seventy-six per cent were men, 50% black, 81% had used both alcohol and drugs during the last year, 43% had injected drugs and 9% of the men were homosexual. Subjects completed an interviewer-administered questionnaire and blindly-linked HIV-antibody test at entry and after 1 year (81% follow-up). RESULTS: Fifty-seven per cent of subjects reported that they had previously sought HIV testing. Factors associated with HIV testing included homosexual contact, injecting drug use, having a partner who had been tested, and using condoms. Hispanics were the least likely of all ethnic groups to report testing. Of 60 subjects with HIV antibodies, 47 (78%) said they had already been tested; however, 19 (40%) inaccurately reported that their serostatus was negative and another four (9%) had no collected their test results. Blacks were much more likely than other groups to misreport or be unaware of their HIV status. Only half of the 68% who said they planned to be tested during the following year did so. Five (42%) out of 12 HIV-positive individuals who were unaware of, or misreported their serostatus at baseline, and who sought another HIV test during the follow-up year continued to report themselves as uninfected. CONCLUSIONS: A large proportion of clients attending public alcohol treatment centers report having been HIV tested, much greater than that observed in other populations. However, misreporting of HIV test results was very common among seropositive subjects. Alcohol and drug treatment programs for this high-risk population should include interventions to optimize use of HIV testing for prevention and treatment, and improve understanding of test results.

Picosecond neodymium:yttrium lithium fluoride laser sclerectomy.

The picosecond neodymium:yttrium lithium fluoride laser, a high-power, short-pulse laser that uses low energy per pulse and has a high repetition rate and a highly coherent energy source of 1,053 nm, was used to perform sclerectomies by an ab externo approach in human cadaver eyes. We evaluated laser settings with regard to full-thickness scleral perforation and thermal damage to surrounding tissue. We studied energy per pulse, depth per burst (a present number of spots), spot and line separation of the pattern (spacing between spots of the laser in length [spot separation] and width [line separation]), and total energy required to perforate the sclera. Efficiency was determined by evaluating which settings required the fewest spots and least total energy to perforate the sclera. We studied histologic sections of the sclerectomy sites to determine thermal damage to the surrounding sclera. The picosecond neodymium:yttrium lithium fluoride laser is effective in performing full-thickness sclerectomy with minimal thermal damage to the surrounding tissue. The anterior chamber could be penetrated with an average total energy of 13.3 +/- 0.4 (SEM) J. The sclerectomy size was 545 +/- 11 microns externally and 163 +/- 4 microns internally. Successful sclerectomies were performed with as little as 3 to 5 microns of thermal damage to the surrounding scleral tissue with 250 microJ per pulse.

Changes in HIV-related behaviors among heterosexual alcoholics following addiction treatment.

In order to measure changes in HIV-related behaviors among heterosexual alcoholics following treatment, we conducted a prospective cohort study of 700 self-identified alcoholics recruited from five public alcohol treatment centers, all of which included HIV risk-reduction counseling. Respondents underwent an HIV antibody test and interviewer-administered questionnaire at entry to alcohol treatment and after a mean of 13 months later. Compared to baseline, at follow-up there was an overall 26% reduction in having sex with an injection-drug-using partner (23% versus 32%, P < .001) and a 58% reduction in the use of injection drugs (15% versus 37%, P < .001), along with smaller improvements in other behaviors. Respondents also showed a 77% improvement in consistent condom use with multiple sexual partners (35% versus 20%, P < .01) and a 23% improvement in partner screening (71% versus 57%, P < .001). Respondents who remained abstinent showed substantially greater improvement than those who continued to drink.

HIV testing in gay sex clubs.

The purpose of this study was to evaluate a programme of human immunodeficiency virus (HIV) antibody testing at gay sex clubs. Conducting secondary analyses with 2 datasets, we evaluated HIV-testing preferences of patrons at 2 sex clubs and compared their risks to testers at a standard testing clinic. Sex club testers had significantly more partners and were significantly older than their clinic peers. Sixteen per cent of sex club testers reported that they would not test if testing were not available at the sex club. Gay sex clubs offer an opportunity to reach men at high risk for HIV, some who otherwise may not test.

Does centralized intake improve drug abuse treatment outcomes?

This study was designed to assess whether centralized intake and assessment in a drug abuse treatment system would lead to improved outcomes. Clients entering treatment through a centralized intake unit (CIU) or through individual programs (non-CIU) were interviewed at admission, and at 1 month and 1 year postadmission. Interviews included measures of treatment access and satisfaction, psychiatric symptoms, social support, and Addiction Severity Index composite scores. At treatment entry, CIU participants had more employment and psychological problems and lower social support, were more often required to be in treatment, and were more often placed on a waiting list. In analyses controlling for baseline differences between groups, there were main effects of time, but no CIU status effects or CIU status by time interactions. The CIU may have improved access to treatment for a more disabled population; however, clients entering treatment through the CIU did not have better outcomes than those entering treatment directly.

Relapse outcomes in a randomized trial of residential and day drug abuse treatment.

Relapse outcomes at 6-, 12-, and 18-month intervals were compared between clients randomly assigned to day (n=114) versus residential (n=147) drug abuse treatment. Day clients were more likely than residential clients to relapse 6 months post-admission (OR=3.06, p<0.001); however, no setting differences at 12 or 18 months were found. Few baseline predictors were prospectively related to relapse at 12 and 18 months. These predictors were usual employment status (part-time OR=17.47, p<0.001; full-time OR=2.54, p<0.001), history of drug injecting (OR=5.39, p<0.01), multiple sex partners (OR=1.16, p<0.01), and not having a gay sexual partner (OR=0.05, p<0.03) during 6 months prior to admission. Still, these baseline predictors, together with the existing literature, could be used by drug treatment professionals to identify individuals who may be at high risk for relapse over time, and to offer specialized treatment and aftercare resources as intervention and prevention measures.

Screening for human immunodeficiency virus antibody in urine.

OBJECTIVE: To determine the diagnostic accuracy of an investigational test for human immunodeficiency virus (HIV) envelope antibodies in urine. DESIGN: Matched blood and urine specimens were tested for HIV by two independent laboratories, both of which were blinded to all results at the other site. Duplicate positive enzyme-linked immunoassay (EIA) results were confirmed by immunofluorescent antibody or western blot. SETTING: Six alcohol treatment centers in the San Francisco metropolitan area. PATIENTS: Five hundred ninety-two recovering alcoholics. MAIN OUTCOME MEASURES: Diagnosis of HIV infection by blood and urine EIA and western blot. RESULTS: The experimental urine EIA, when confirmed by urine western blot, led to a correct diagnosis in all samples. One sample was negative by urine EIA screening, positive by blood EIA, and exhibited an indeterminate blood western blot pattern (p24 band only). CONCLUSIONS: We encountered no false positive or false negative results using an investigational HIV antibody test for urine samples. There are several important advantages to HIV testing of urine versus serum or blood; however, there are also cogent reasons for limiting the use of alternative specimens for HIV testing.

HIV infection and risk behaviors in two cross-sectional surveys of heterosexuals in alcoholism treatment.

OBJECTIVE: To measure the prevalence of human immunodeficiency virus (HIV) infection and high-risk behaviors among heterosexuals in alcoholism treatment, comparing two cross-sectional surveys completed 2 to 3 years apart. METHOD: Two groups of entrants to alcoholism treatment clinics were recruited, between October 1990 and December 1991 (n = 860; 639 men) and between January 1993 and March 1994 (n = 752; 520 men). Participants underwent a structured interview including an assessment of demographics. substance abuse characteristics and sexual behaviors, as well as serotesting for HIV antibodies. Associations were examined between HIV serostatus and several factors, including demographic variables, substance use and high-risk sexual behaviors. RESULTS: The overall HIV seroprevalence in the first and second samples was 5% (95% CI: 3-6%) and 5% (95% CI: 3-7%). When the two samples were compared, there were no significant differences in prevalence of HIV infection by categories of gender, race, income and most other demographic characteristics within either sample: history of injection drug use (IDU) was significantly related to HIV serostatus in both samples. Unsafe sexual practices were common in both samples. When samples were combined, those 30 years of age or older were more likely to be HIV infected, and men and women with no reported history of IDU still had an HIV prevalence of 3% and 2%, respectively. More than half of the respondents had two or more partners in the previous 6 months and reported a history of a sexually transmitted disease. CONCLUSIONS: There was no change in the substantial prevalence of HIV infection and high-risk behavior among heterosexual clients entering alcoholism treatment programs over the 3.5-year study period. The HIV prevalence among non-IDU clients remained several times higher than published estimates from similar community-based heterosexual samples. These data reinforce the concept that heterosexual noninjection drug users are at high risk for HIV and may benefit from intervention programs.

Alcohol-related risk factors associated with HIV infection among patients entering alcoholism treatment: implications for prevention.

OBJECTIVE: Reports suggest that alcoholics may be at risk for HIV infection. In this article we examine several alcohol-related risk factors for HIV infection among patients entering alcoholism treatment in an AIDS epicenter. Our objective was to identify key factors for HIV prevention and screening among populations receiving treatment for alcohol abuse or alcohol dependence. METHOD: Clients (N = 921) entering five alcoholism treatment centers in the San Francisco Bay area underwent an interview and blind serotesting for HIV antibodies (76% were male, 16% men who had sex with men, 50% black, 10% Latinos and 6.5% were HIV seropositive). Logistic regression was used to predict HIV serostatus from five possible alcohol-associated risk factors, controlling for demographics and traditional HIV risk factors. These were alcohol impairment, attitudes about socializing in bars, increased sexual risk expectancies when drinking, enhanced sexual expectancies when drinking and decreased nervousness when drinking. Male and female heterosexuals and men with a history of homosexuality were analyzed separately. RESULTS: Among male and female heterosexuals, HIV infection was positively associated with higher alcohol impairment (OR = 2.69, p = .031) and negatively associated with higher sexual risk expectancies when drinking (OR = 0.24, p = .075). Among men who had sex with men, HIV infection was positively associated with higher bar socializing orientations (OR = 10.06, p = .004). Infection was also negatively associated with higher alcohol impairment (OR = 0.34, p = .052) and higher sexual risk expectancies when drinking (OR = 0.26, p = .024) for these men. CONCLUSIONS: Since these associations were independent of demographics and traditional HIV risk factors, our research suggests it may be important to also focus HIV screening and prevention on alcohol-related risk factors in AIDS epicenters. For heterosexual alcoholics, the focus should be on those with higher alcohol dependence. For male alcoholics who had sex with men, the focus should be on those who primarily socialize in bars. Further research is needed to determine why higher sexual risk perceptions when drinking were associated with lower rates of HIV infection for both groups, since this discovery may have important prevention implications. The negative association between infection and alcohol impairment among homosexual men also warrants further investigation.

Predictors of HIV-related risk behaviors among heterosexuals in alcoholism treatment.

OBJECTIVE: To determine which measures of alcohol and drug use are associated with HIV-related sexual risk and protective behaviors. METHOD: Entrants (N = 743, 72% male) to alcoholism treatment clinics underwent a structured interview including an assessment of demographics, substance abuse characteristics and sexual behaviors. Associations were examined between alcohol- and drug-related behaviors, and demographic variables, with the prevalence of high-risk sexual behaviors. RESULTS: Those more likely to use alcohol or drugs when having sex, and those who expect to have high-risk sex when they drink alcohol, were more likely to engage in high-risk sexual behavior. Measures of severity of alcohol or drug problems alone were not consistently related to high-risk or protective behaviors. Several other concurrently used measures (such as the Addition Severity Index and alcohol expectancies) showed more consistent association with high-risk behaviors. There was no apparent reduction in the likelihood of practicing risk-reducing behaviors among those more severely addicted and those who combined alcohol and/or drugs with sex. CONCLUSIONS: This study suggests that sexual risk and protective behaviors are not consistently associated with severity of addiction problems. Some measures of alcohol and drug use (i.e., the ASI Drug Composite Score and the Enhanced Risk subscale of the alcohol expectancy measure) were more consistently related to the specific risk behaviors measured than were others (e.g., the ASI Alcohol Composite Score), while most measures showed little or no association with protective behaviors.

Drug court effectiveness: a review of California evaluation reports, 1995-1999.

Over the past two decades, drug courts have emerged as a viable alternative for addressing drug cases within the criminal justice system. In California, the Drug Court Partnership Program (DCPP) was created in 1998 and has supported and funded the development of drug courts throughout the State. This article reports on a review of California drug court evaluations through January 2000 conducted as part of an evaluation of the California DCPP. A total of 23 evaluations were collected. Seventeen were reviewed in detail, and six were excluded because they were internal reports rather than evaluations. A standardized review process was initiated which led to a scored rating of the evaluation reports. Results of this review support previous findings that drug court participants may experience reduced rearrest rates by 11% to 14% compared to nonparticipants. The largest reduction in rearrest rates appears among graduates. The graduation rates were between 19% and 54%. Costs and savings associated with drug courts were discussed but no conclusions were possible based on the findings from these evaluations. The evaluation of the effectiveness of drug courts presents unique challenges. This review concludes with a discussion of evaluation methods (e.g. standardizing rate calculations, term definitions) that would strengthen drug court research.

Implementing bathhouse-based voluntary counselling and testing has no adverse effect on bathhouse patronage among men who have sex with men.

Implementing HIV voluntary counselling and testing (VCT) in bathhouses is a proven public health strategy for reaching high-risk men who have sex with men (MSM) and efficiently identifying new HIV cases. However, some bathhouse managers are concerned that VCT programmes could adversely affect business. This study examined whether offering VCT on the premises of a bathhouse changed patterns of patron visits. A collaborating bathhouse provided electronic anonymized patron data from their entire population of attendees. VCT was offered on premises with varying frequencies over the course of three years. Club entrances and exits were modelled as a function of intensity of VCT programming. Club entrances did not differ as a function of how many days per week testing was being offered in a given month. Additionally, club entrances did not decrease, nor did club exits increase, during specific half-hour time periods when testing was offered. Implementing bathhouse-based VCT did not have any demonstrable impact on patronage. Public health officials can leverage these results to help alleviate club managers' concerns about patron reactions to providing testing on site, and to support expanding sexual health programmes for MSM in these venues.

Availability of combination therapy for HIV: effects on sexual risk taking in a sample of high-risk gay and bisexual men.

The objective of this study was to assess the impact of successes in the medical treatment of HIV disease on the perceptions of high-risk gay and bisexual men attending an anonymous testing site towards becoming infected with HIV and on their decisions to have unsafe sex. A cross-sectional survey with a face-to-face interview and self-recorded information was used. A convenience sample of high-risk men seeking anonymous HIV antibody counselling was recruited for an intervention study. To be eligible, men had to have a history of at least one previous negative antibody test and unprotected anal intercourse within the last year. Upon enrollment, subjects were asked about the impact of new treatment developments on their decisions to engage in high-risk sex both in the recent past and in the future. In general, neither the recent successes in treating HIV nor the availability of combination therapy had any impact on the men's decisions about safe sex, although a minority of men reported less concern about becoming HIV-positive. Also, some men reported already having taken more risk. In conclusion, a small number of men in this high-risk population have increased risk behaviour as a result of recent treatment advances. These results merit continued monitoring.

Differential HIV risk in bathhouses and public cruising areas.

OBJECTIVES: This report investigates differences in risk behaviors among men who have sex with men (MSM) who went to gay bathhouses, public cruising areas, or both. METHODS: We used a probability sample of MSM residing in 4 US cities (n = 2,881). RESULTS: Men who used party drugs and had unprotected anal intercourse with nonprimary partners were more likely to go to sex venues than men who did not. Among attendees, MSM who went to public cruising areas only were least likely, and those who went to both public cruising areas and bathhouses were most likely to report risky sex in public settings. CONCLUSIONS: Distinguishing between sex venues previously treated as a single construct revealed a significant association between pattern of venue use and sexual risk. Targeting HIV prevention in the bathhouses would reach the segment of men at greatest risk for HIV transmission.