Male and female rural probationers: HIV risk behaviors and knowledge.

Individuals involved in the criminal justice system are at substantial risk for HIV infection and have elevated rates of AIDS. Offenders under community supervision, such as probationers, have substantially more opportunities to engage in high-risk behaviors than prisoners. Furthermore, probationers in rural areas are at risk because rural areas may be slower to adopt HIV risk-reduction approaches. Consequently, the primary goal of this study is to describe the HIV risk behaviors and level of HIV knowledge of 800 rural felony probationers. Bivariate results indicate that males have substantially greater criminal histories and engage in more substance use risk behaviors than females. Overall, there was minimal and inconsistent use of condoms, but there were no significant differences by gender. Gender differences prevailed in perceived HIV knowledge, with females reporting high levels of perceived HIV knowledge. Multivariate models did not support the hypothesis that perceived knowledge would be a more robust correlate of scores on the HIV Risk Behavior Knowledge Test for males than females. Results suggest that rural residents are not protected from engaging in HIV risk behaviors and future studies should examine gender discrepancies between perceived and actual HIV knowledge among offenders under community supervision.

Tailoring an HIV-prevention intervention for cocaine injectors and crack users in Porto Alegre, Brazil.

Brazil has the second largest number of reported AIDS cases in the world. Porto Alegre, like most other large urban centres in Brazil, has been greatly impacted by an AIDS epidemic driven by high rates of drug use and risky sexual behaviours. While epidemiologic surveillance of HIV/AIDS and treatment initiatives for HIV-infected individuals are well developed in Brazil, comparatively little attention has focused on developing interventions directed toward high-risk populations. Intervention programmes, particularly those tailored for chronic drug users, are lacking. This pilot project successfully adapted and tailored a cognitive behavioural HIV intervention developed in the US to the cultural setting in Porto Alegre. The project established feasibility and acceptability of the approach for targeting risky drug and sexual behaviours among a group of male Brazilian drug users. A sample of 120 male cocaine users was recruited from a public health clinic serving the target population in the city of Porto Alegre. The average age of the participants was 29; they averaged less than 8 years of formal education; and less than half (41%) were married. Lifetime self-reported drug use was high with 93% reporting cocaine use, 87% reporting crack use, and 100% reporting marijuana use. 43% of the sample reported ever injecting drugs. Reports of risky sexual behaviours were similarly elevated. Almost half (45%) tested positive for HIV. Preliminary evidence suggests that intervention acceptability was high among participants. Given the reported high risk sexual and drug use behaviours among these men, HIV interventions must be evaluated and expanded to include this population as well as their sexual partners.

History of head injury among substance users: preliminary findings.

Traumatic brain injury is associated with a variety of problems in cognitive functioning that may be related to substance use and that may influence recovery. This pilot study of 591 inmates in medium and minimum-security prisons examined self-reports of head injury, mental health problems, and health service utilization in three groups: no head injury, one head injury, and two or more head injuries. The group with multiple head injuries reported significantly more emergency room visits, more hospital admission, and number of hospital stays when compared with those with no head injury. This preliminary analysis reflects a need for additional research on brain injury among substance misusers.

Age differences in HIV risk behaviors and drug treatment utilization among drug users in Kentucky.

The purpose of this study was to (1) profile demographic and other characteristics of two age groups, younger aged 30 to 39 (N = 643), and older aged 40 to 49 (N = 395), (2) examine and identify differences in lifetime drug use patterns and age of drug use initiation, (3) examine HIV risk behaviors: drug use and sexual practices, (4) compare drug user treatment utilization between the two age groups, and (5) examine barriers to drug is treatment utilization by gender. The study sample (N = 1038) was drawn from individuals recruited into the NIDA Cooperative Agreement in Kentucky. The median age in the study sample was 38, the majority were male (72%), and African-American (81%). Results indicate that older subjects initiated drug use at a later age than younger subjects. Compared to the younger age group, significantly more subjects in the older group reported having ever used any of the 10 drugs examined. Injection drug use patterns and lifetime sex exchange practices were more prevalent in the older age group. Older subjects also were more likely to utilize drug user treatment, specifically methadone maintenance treatment. When barriers to drug user treatment were examined, significantly more women than men did not qualify for treatment, and they did not have enough money for treatment. Implications for interventions are discussed.

Rural-urban differences in substance use and treatment utilization among prisoners.

Surveys of incarcerated offenders and arrestees consistently report high rates of both alcohol and drug use in this population. This drug-crime connection has highlighted the need to learn more not only about drug treatment effectiveness, but also about drug treatment utilization. While studies have begun to examine drug treatment utilization, most of these studies have been based on urban substance abusers. Little is known about the extent to which urban and rural substance abusers may be different in terms of treatment utilization. This study, therefore, examines differences between urban and rural drug use patterns and treatment utilization among chronic drug abusers to determine whether, and in what ways, rurality may affect substance abuse and treatment seeking. The study examines these issues in a group of chronic drug users who were incarcerated at the time of the study. Findings show significant differences in drug use and treatment utilization of urban and rural offenders. Chronic drug abusers from rural and very rural areas have significantly higher rates of lifetime drug use, as well as higher rates of drug use in the 30 days prior to their current incarceration than chronic drug abusers from urban areas. Nonetheless, being from a very rural area decreased the likelihood of having ever been in treatment after controlling for the number of years using and race. While problem recognition appears to explain much of the effect of very rural residence on treatment utilization for alcohol abuse, the effects of being from a very rural area on seeking treatment for drug abuse remain statistically significant even after controlling for several other variables. The findings point to the importance of providing culturally appropriate education to very rural communities on the benefits of substance abuse treatment and of providing substance abuse treatment within the criminal justice system.

The association of testosterone with nicotine use in young adult females.

This pilot laboratory study examined the relationship of testosterone levels, carbon monoxide (CO) levels, current and adolescent nicotine use, and histories of pubertal onset in 30 young adult female smokers. These females had completed questionnaires regarding nicotine use in the 7th through 10th grades, and again at age 21 as part of a cohort study of drug use. In addition, history of pubertal onset was obtained at age 21, as were testosterone and CO levels. Testosterone levels were positively correlated with cigarette use in the last 30 days (P< or =.01), CO levels (P< or =.05), cigarette use reported in the 7th and 10th grades (P< or =.05), and negatively correlated with age of pubertal onset (P< or =.001). The relationship of testosterone to nicotine will be discussed.

Assessing the differential impact of an hiv prevention intervention: who's putting the message into practice?

Recent data suggest that educational interventions aimed at reducing HIV risk behaviors have shown some success. Nonetheless, HIV risk behaviors are not always reduced by interventions and probably do not reduce risk behavior randomly. That is, the success of interventions may be related to participant characteristics. Identifying participant characteristics related to both intervention completion and reduction in risk behaviors may be useful for further developing explanatory models of health behavior and for targeting and customizing interventions. In this study differences between participants who completed an AIDS educational intervention (N = 741) and those who did not complete the intervention are first examined (N = 652) and then variables related to reducing drug and sexual risk behaviors among those who completed the intervention and follow-up interviews are examined. Results show that the majority of respondents report decreasing five out of six risk behaviors, with the smallest percentage (48.8%) decreasing rates of unprotected sex and the largest percentage (83.4%) decreasing frequency of drug injection. Different variables were found to be related to changes in the various risk behaviors. However, some relatively consistent results emerge. For all risk variables, the frequency of the specific behavior at baseline predicted the amount of change in that behavior, with those having higher levels of risk behaviors reducing their behavior the most. Positive HIV test results significantly decreased three of the four sexual risk behaviors examined, and living in a very rural area was found to be significantly related to three of the six risk behaviors. However, perceived chance of getting AIDS did not significantly reduce any of the risk behaviors. Gender and education level were also not related to changes in any of the risk behaviors. Implications include the importance of developing approaches to retain higher proportions of younger participants, males and homeless in interventions. It is particularly important to develop specific approaches to retain women in interventions. Because very rural participants were more likely to decrease crack use and alcohol or drug use with sex, rural interventions should target these behaviors at the outset of the intervention.

Primary socialization theory and a bio/psycho/social/spiritual practice model for substance use.

This article supports primary socialization theory as a theory for practitioners to use in drug-user treatment and prevention interventions. Primary socialization theory is compatible with the bio/psycho/social/spiritual practice model and targeting the individual within his or her etiological domains/situation to initiate specific interventions. Governmental institutions are posited as an additional secondary socialization factor for primary socialization theory. Gender is stressed as important for primary socialization theory and is emphasized for carrying out interventions. [Translations are provided in the International Abstracts Section of this issue.]

Rural attitudes, opinions, and drug use.

There are two primary purposes of this paper. The first is to summarize the results of a survey conducted in a rural area of Kentucky on attitudes and behaviors regarding substance use. The second purpose is to examine differences in drug attitudes and behaviors for higher and lower density rural areas. Participants for this study were contacted by telephone in March 1996. The sample was generated by random digit dialing for eight county telephone exchanges. The sample included 334 respondents from the eight counties who were grouped into respondents from higher density areas (n = 132) and lower density areas (n = 202). Results indicated that respondents from both higher density and lower density areas were similar on drug use and attitudes. However, lower density areas reported their county as a worse place to live and less safe than respondents from higher density areas. Respondents from lower density areas were also more likely to report there was more alcohol/drug use and more alcohol bootlegging in the past year, and that bootlegging alcohol is a serious problem in their county. Future research could include the examination of heterogeneity of rural areas using different indices.

Drug use in very rural Alaska villages.

The Alaska Native Preschool Project was centered in the Head Start Programs of two typical Alaska native villages near the Bering Sea. Data were collected over 5 years, 1990 to 1995, from preschool parents (N = 342) with surveys, a panel of villagers (N = 25 to 30) using qualitative interviews; villagers using participant observation; and a limited review of public records. The villages typify the changing life of Alaskan villagers who live in the Bering Straits area. Qualitative data indicated that a number of problems were associated with drug and alcohol use in the villages. The level of smokeless tobacco use from surveys in the previous month among preschool parents (41%) was self-reported to be almost 10 times greater than the national level reported in the 1995 National Household Survey. The use of marijuana reported by preschool parents in the previous month was almost 3 times higher than the 1995 National Household Survey estimates (19 vs 6.7%). Tobacco use in the previous month was reported at over 56%, a level that was over 1 1/2 times the level of use at 34.7% estimated from the 1995 National Household Survey. For 26-34 year olds, previous month alcohol use was lower for the village parents than estimated from the 1995 National Household Survey (38 vs 63%). The self-reported levels of other drug use among preschool parents were very low compared with overall United States rates.

Opportunities for AIDS prevention in a rural state in criminal justice and drug treatment settings.

This study examined the likelihood that drug users would receive HIV/ AIDS prevention information and supplies (e.g., condoms and bleach) in the rural state of Kentucky. Despite evidence of high HIV risk among criminal justice and substance-using populations, incarceration and substance-user treatment were only minimally associated with prior HIV prevention exposure or HIV testing. These data strongly support the use of criminal justice and treatment settings to provide AIDS prevention interventions for the high-risk drug-using populations they serve, and to target HIV prevention services in rural as well as urban areas.

Developing a rural therapy with big city approaches.

Both rural communities and urban communities experience problems associated with drug use and drug dependence. However, existing treatment interventions are not tailored for rural settings. This article describes a project which will modify an existing social skills behavioral therapy for rural populations, refine the therapy, develop a manual, train and supervise therapists, and pilot test the structured behavioral outpatient rural therapy to treat rural drug users and drug dependents as Stage I Research for NIDA's Behavioral Therapies Development Program.

Recommendations to bridge rural/urban drug-use(r) research and practice.

This article presents recommendations developed by a group of United States drug-use(r) researchers interested in rural and urban research and practice who met in Lexington, Kentucky, in October 1996. Overall, there was consensus about the importance of better understanding the urban/rural drug and alcohol use/dependency continuum. It was emphasized that drug and alcohol use/dependency are chronic and relapsing disorders. Definitions of rural and urban are most important, and different definitions may be associated with factors that are masked by population density. Specific recommendations are presented in the following areas: Rural Factors, Epidemiology, HIV/AIDS, Treatment and Other Services, Migration, Youth, Protective Factors, Systems Perspective, Measurement, Confidentiality, Criminal Justice, Research, Policy Research, Economic Factors, Service Providers, and Managed Care.

HIV prevention protocols: adaptation to evolving trends in drug use.

Applied research in HIV prevention with out-of-treatment substance abusers takes place in a constantly changing environment. Researchers must be able to identify changes in drug use and sexual risk patterns, develop and evaluate appropriate interventions to respond to those changes, and find ways to make effective use of new technologies as they are developed. An example of this process is the collaborative revision made to NIDA's Standard Intervention for HIV prevention by the final six study sites funded under the NIDA Cooperative Agreements for AIDS Community-Based Outreach and Intervention Research. To illustrate the process of responding to changes in the substance abuse environment, to advances in knowledge about risk, and to newer technologies, this article provides an overview of the history of two federally funded HIV-prevention programs for out-of-treatment substance abusers and reviews recent changes made to the Standard Intervention protocol. The rationale for the changes is discussed, and the substance abuse population in the study is described.

A comparison of HIV risk behaviors among women drug users from two cities in a rural state: recommendations for targeted prevention.

Most HIV prevention programs for women target individual risk behaviors while the influence of larger contextual factors, such as city of residence, are often neglected. This preliminary study compares women drug users from two different cities in the largely rural state of Kentucky on HIV risk behaviors. The women are from Lexington, a medium sized metropolitan area, and from Louisville, a large metropolitan area. Comparisons between the women from the two cities indicate that there are many similarities in their risk behaviors, but also some important differences. The women from Lexington (the smaller city), are more likely to be at risk for becoming infected with HIV due to their drug use, while the women from Louisville (the larger city) are more likely to be at risk because of their sex exchange practices and economic situation. The implications for prevention are discussed.

The needs of women with substance use problems: an expanded vision for treatment.

Although the number of females served in United States treatment programs for substance use has increased over the last decade, women continue to be underrepresented. This suggests that the prevalent treatment models, which tend to be male-oriented, may not provide appropriate strategies to meet women's needs. Substance use problems in women appear to be multideterminded phenomena in which genetics, familial history, psychosocial issues, and other environmental factors play contributing roles. Working from a relational theoretical model of female psychosocial development, a continuum of expanded services addressing the entire context of women's lives is discussed.

Drugs, crime, and HIV.

The use of criminal justice authority is discussed as a possibility for keeping drug users in treatment to decrease drug use, decrease injection, and to reduce the spread of HIV. It is hypothesized that the perception of treatment and control is a central factor in the limited use of criminal justice authority by community drug treatment providers.

Perceptions of rural addictions and related HIV.

Rural addictions and related HIV behaviors, including drug use and sexual behaviors, have received limited attention in United States rural areas when compared with urban areas. However, prevalence rates are similar for alcohol and tobacco in rural and urban United States areas. The perception of policymakers and others is generally that drug use and HIV are urban problems, and resources are more likely to be directed to urban areas than rural areas. A major trend for the future is the continued expectation of limited resources for rural areas.

Drug prevention: The past as the future?

This article presents selected themes which the authors believe have helped shape drug prevention in the United States. These themes include prevention interventions as well as research and evaluation activities focused on preventing drug abuse. Recommendations are also presented for future prevention-activities.