Racial differences in overdose training, naloxone possession, and naloxone administration among clients and nonclients of a syringe services program.

OBJECTIVE: To evaluate racial (Black/White) differences in overdose response training and take-home naloxone (THN) possession and administration among clients and nonclients of the Baltimore syringe service program (SSP). METHODS: The study derived data from a cross-sectional survey of 263 (183 SSP clients, 80 nonclients) people who inject drugs (PWID). The study recruited SSP clients using targeted sampling and recruited nonclients through peer referral from April to November 2016. RESULTS: In our sample, 61% of the participants were Black, 42% were between the ages of 18 and 44, and 70% were males. SSP clients, regardless of race, were more likely to have received overdose response training than Black nonclients (Black clients AOR: 3.85, 95% CI: 1.88, 7.92; White clients AOR: 2.73, 95% CI: 1.29, 5.75). The study found no significant differences in overdose response training between Black and White nonclients. SSP clients and White nonclients were more likely to possess THN than Black nonclients (Black clients: AOR: 4.21, 95% CI: 2.00, 8.87; White clients: AOR: 3.54, 95% CI: 1.56, 8.04; White nonclients AOR: 4.49, 95% CI: 1.50,13.47). CONCLUSION: SSP clients were more likely to receive overdose response training than their nonclient peers who they referred to the study, illustrating the utility of SSPs in reaching PWID at high risk of overdose. We also observed that Black PWID, who did not access services at the SSP, were the least likely to possess THN, suggesting the need to employ outreach targeting Black PWID who do not access this central harm reduction intervention.

The PEARL study: a prospective two-group pilot PrEP promotion intervention for cisgender female sex workers living in Baltimore, MD, U.S.

HIV remains elevated among female sex workers (FSW) globally, with a number of structural (e.g., poverty, access to care) factors driving these persistently high rates. Pre-exposure prophylaxis (PrEP), a user-controlled prevention method, is a promising means of empowering vulnerable populations to protect themselves and enhance agency. Yet there is a dearth of PrEP research and interventions targeting cisgender women in the United States, and even fewer aimed to reach FSW. We developed and implemented a multifaceted PrEP pilot intervention, the Promoting Empowerment And Risk Reduction (PEARL) study, to meet this gap. This paper describes the development process and nature of a community-informed intervention for tenofovir/emticitrabine (TDF/FTC) pre-exposure prophylaxis engagement among street-based cisgender FSW in Baltimore, Maryland, U.S. In the course of the study's implementation, structural, programmatic, and medical barriers have already posed significant barriers to full engagement. PEARL implemented a number of strategies in an effort to counter barriers and facilitate increased success of PrEP uptake and maintenance. The study will provide critical insights into the nature of intervention components that could help FSW to initiate PrEP and reduce PrEP care cascade gaps.

The evaluation of the JEWEL project: an innovative economic enhancement and HIV prevention intervention study targeting drug using women involved in prostitution.

The JEWEL (Jewellery Education for Women Empowering Their Lives) pilot study examined the efficacy of an economic empowerment and HIV prevention intervention targeting illicit drug-using women (n=50) who were involved in prostitution in Baltimore, Maryland. The intervention was comprised of six 2-hour sessions that taught HIV prevention risk reduction and the making, marketing and selling of jewellery. Bivariate comparisons examined behaviour change pre- and 3-months post-intervention. The intervention's effect on the change in the number of sex trade partners from baseline to follow-up was explored with multiple linear regression. Participants were 62.0% African American, 5.0% were currently employed, and the median age was 39 years old (Inter Quartile Range [IQR]: 34-45). Women attended an average of six (IQR: 4.5-6.0) sessions. The women sold over $7,000 worth of jewellery in eleven sales. In comparing self-reported risk behaviours pre and 3-month post intervention participation, we found significant reductions in: receiving drugs or money for sex (100% versus 71.0%, p<0.0005); the median number of sex trade partners per month (9 versus 3, p=0.02); daily drug use (76.0% vs. 55.0%, p=0.003); the amount of money spent on drugs daily (US$52.57 versus US$46.71, p = 0.01); and daily crack use (27.3% versus 13.1.0%, p = 0.014). In the presence of other variables in a multivariate linear model, income from the jewelry sale was associated with a reduction in the number of sex trade partners at follow-up. The pilot indicated effectiveness of a novel, HIV prevention, economic enhancement intervention upon HIV sexual risk behaviours and drug utilization patterns.

Herpes simplex virus 2 and syphilis among young drug users in Baltimore, Maryland.

OBJECTIVES: To examine the sex specific seroprevalence and correlates of herpes simplex virus 2 (HSV-2) and syphilis among a cohort of young drug users. METHODS: Drug users aged 15-30 years old who used heroin, cocaine, or crack were recruited between October 1999 and August 2002. Baseline interviews gathered information on sociodemographics, drug use and sexual behaviours. Serum was tested at baseline for HSV-2 and syphilis seroreactivity. For each sexually transmitted infection (STI), infected and non-infected participants were stratified by sex and compared using chi2, Mann-Whitney tests, and logistic regression. RESULTS: Of the 543 participants recruited, 42.4% were female and 39.3% were African-American. The seroprevalence of STIs among females and males, respectively, were HSV-2: 58.7% and 22.0%; syphilis: 4.3% and 0.3%. In multivariate models, older age, African-American race, having over 30 lifetime sex partners, current HIV infection and previous incarceration were independently associated with HSV-2 infection among males. For females, older age, African-American race, sex trade, and daily heroin use were independently associated with HSV-2. For females, only a self reported previous syphilis diagnosis was associated with current syphilis seroreactivity in multivariate analyses. CONCLUSIONS: Examination of this cohort revealed a particularly high seroprevalence of HSV-2 and syphilis, especially among female drug users. Few infected participants had been previously diagnosed with these infections.

Individual and environmental factors related to quitting heroin injection.

This study examines the relationship between individual-level and the certain neighborhood characteristics with drug use cessation among a sample of long-term inner-city heroin injectors in Baltimore, Maryland. The data were derived from baseline and first follow-up visits of SHIELD, a larger HIV prevention intervention study targeting members of the drug-using community. The survey instrument was interviewer-administered and ascertained sociodemographics, drug use history, and sexual and drug risk behaviors. The data were collected between August 1997 and March 1999. The current study was limited to participants with a median age of 41 years old. 27.5% (n=53) reported quitting drug use at follow-up. Compared with those who quit, participants who continued (n=147) were close to five times as likely to buy drugs in the neighborhoods in which they lived, 80% less likely to have used drugs in a shooting gallery in the past 6 months, and close to five times more likely to have used drugs in outside places. Controlling for other factors, enrollment in drug user treatment programs or attending self-help groups were not significantly associated with drug use cessation. This study points to the importance of examining specific environmental factors in relation to quitting drug use. Research is needed to further articulate the types and characteristics of physical environments that are related to and could be intervened in promoting sustainable drug cessation.

The reliability and validity of the Modified Condom Outcome Expectancy Scale (MCOES) among an international sample of HIV-negative partners of people living with HIV/AIDS.

Safer sexual behaviour is vital in curbing the HlV epidemic in many developing countries where the epidemic is primarily transmitted through heterosexual sex. Reliable and valid assessment of factors related to HIV risk behaviours are important in testing behavioural theories as well as informing effective AIDS prevention programmes. The current study tests the reliability and validity of a modified version of the Condom Outcome Expectancy Scale (COES) among a sample of HI'-negative sexual partners (n = 100) of HIV-infected individuals in Pune, India, Chang Mai,Thailand and Kampala, Uganda. Internal consistency reliability was measured using Cronbach's alpha coefficient, which had a value of 0.80 for the entire sample, with site-specific values of. 0.78 for India; 0.75 for Thailand; and 0.79 for Uganda. Test-retest reliability was conducted to test the scale's stability over time with 60% of the sample, resulting in a Cronbach's alpha coefficient of 0.70. The scale's structure was explored by analyzing response scores on the items using principal components analysis, which yielded a two-factor solution. The study indicates the utility of a modified version of the widely tested COES across international settings. Such research is necessary in understanding intervention targets across international settings.

Intimate relationship characteristics associated with condom use among drug users and their sex partners: a multilevel analysis.

Few studies have examined sexual risk behaviors among drug users in the context of their primary sexual relationships. The aim of this study is to examine characteristics of sexual partners associated with inconsistent condom use among a sample of 703 cocaine and opiate users from Baltimore, MD who participated in a network oriented intervention study of human immunodeficiency syndrome (HIV) risk behaviors among drug users. The current study examines relationship characteristics between drug users and their sexual partners (n=1003). Some of the study participants had more than one sexual partner, accounting for the greater number of sexual pairs than study participants. Study participants reported using multiple drugs (56% injected, 48% sniffed heroin, and 48% smoked crack) and that 70% of their sexual partners also used heroin and/or cocaine. Forty percent reported consistent condom use in the past 3 months. In multiple logistic regression, characteristics associated with consistent condom use were, the drug user being HIV infected; not living with their sexual partners; and not being financially interdependent. Previous research has demonstrated lower rates of condom use with main compared with casual and exchange partners. Primary sexual partners provide a sense of stability and introducing condoms may not be desirable or realistic. HIV prevention programs that target drug users should focus on the benefits, such as trust and a sense of security, and risks of not using condoms in primary relationships. Programs should also focus on enhancing communication and negotiation skills through targeting individuals as well as couples.

Point Defiance: a case study of the United States' first public needle exchange in Tacoma, Washington.

The first publicly funded needle exchange program in the United States began in Tacoma, Washington, in August 1988. The exchange's history is characterized by a series of firsts: the first American publicly funded exchange; the first pharmacy exchange; the first American needle delivery program; and the first state Supreme Court ruling not only supporting the existence of a needle exchange program but superseding existing drug paraphernalia laws. It is also unique because it began outside of the public health system and was not compromised by political feasibility. This article documents the events and personalities which led to the exchange's establishment and its expansion over time; the program's local, state and legal challenges and advocates; its portrayal in the local and national media; the research that documented its successes; and its important contribution to the fight for drug users' unencumbered access to sterile needles.

Social factors related to syringe sharing among injecting partners: a focus on gender.

The study of social networks has become an increasingly utilized method of examining the relationship between injection drug users' social environment and risk of HIV. This study examined relational aspects of two injection drug users (IDUs) within a single social network as they relate to sharing syringes. Data presented in this study were derived from baseline interviews of 508 IDUs from Baltimore, MD. Analyses were performed separately for male and female participants in an effort to understand gender differences in social aspects of syringe sharing. Among this sample, women shared syringes with a significantly higher percentage of injecting partners compared to men. In separate multilevel logistic regression models, significant variables associated with males' and females' syringe sharing were: sharing drugs daily with female injecting partners, injecting partners' provision of drugs when indexes' were withdrawing, being sexual partners, and injecting partners' injecting speedballs. Factors associated with male injecting dyads sharing of syringes were: being kin, injecting partners' injection of heroin and daily drug use, and drinking alcohol together. Results from this study demonstrate the usefulness of examining relationship characteristics of injecting dyads related to syringe sharing as they differ between men and women.

"What the 'caine was tellin' me to do." Crack users' risk of HIV: an exploratory study of female inmates.

This study describes factors that place crack-addicted female jail inmates at risk for HIV infection. The study provides a portrait of the spheres of influences that directly and indirectly promote HIV risk-taking behaviors, women's efforts toward protecting themselves, and reported sexual behaviors. The study documents the far-reaching effects of crack addiction. One-and-a-half-hour interviews were conducted with 14 inmates recovering from crack addiction. The women were aged 19 to 39, and 13 were African American. The results of this study suggest that women's addictions are greatly shaped by their family and intimate relationships. Addictive behavior often precluded safer sex behaviors and increased a woman's likelihood of engagement in HIV-risky behaviors. Many women were victims of childhood and adulthood sexual and physical victimization. Women sought to protect themselves through sexual self-protection strategies, although these measures were often not effective HIV risk-reduction strategies.