Mandrax use, sexual risk, and opportunities for pre-exposure prophylaxis among out-of-school adolescent girls and young women in Cape Town, South Africa.

BACKGROUND: In South Africa (SA), adolescent girls and young women (AGYW) aged 15 - 24 years account for nearly 25% of all new HIV infections in the country. The intersection of substance use and sexual risk continues to drive the HIV epidemic among AGYW. For example, methaqualone, also known as Mandrax, has sedative effects that may affect women's ability to negotiate condom use during sex, refuse sex without a condom, or consent to sex, thereby increasing their risk for HIV. Consequently, it is critical to understand how Mandrax use affects HIV risk among AGYW and to assess awareness of and willingness to use biomedical HIV prevention methods, such as pre-exposure prophylaxis (PrEP), among AGYW who use Mandrax. OBJECTIVES: To examine the role of Mandrax use in sexual behaviours and investigate the extent to which AGYW who use Mandrax are aware of and willing to initiate PrEP. METHODS: Data for this report were derived from baseline and 6-month follow-up data provided by 500 AGYW participating in a cluster-randomised trial assessing the efficacy of a young woman-focused intervention to reduce substance use and HIV risk. AGYW who self-identified as black African or coloured, reported using substances, reported condomless sex in the past 3 months, and had discontinued school early were recruited from 24 community clusters across Cape Town, SA. Following consent/assent, participants provided biological specimens to test for recent drug use (including Mandrax) and completed the self-report questionnaire. RESULTS: Logistic regression analysis revealed that the AGYW who had a positive test result for Mandrax use were less likely to use a condom with their main partner (p=0.01), and almost three times more likely to use alcohol and/or other drugs before or during their last act of sexual intercourse (p<0.001), compared with the AGYW who had a negative Mandrax test result. Mandrax use was not significantly related to PrEP awareness (p>0.10) or willingness to use PrEP (p>0.10), but 70% of AGYW who used Mandrax were willing to initiate PrEP. CONCLUSION: The study findings highlight how Mandrax use may contribute to HIV risk among SA AGYW. Key decision-makers should consider incorporating substance use prevention efforts into existing HIV reduction programmes and equip youth-friendly clinics with the resources to identify AGYW who use Mandrax and offer them PrEP.

Individual and poly-substance use and condomless sex among HIV-uninfected adults reporting heterosexual sex in a multi-site cohort.

BACKGROUND: We analyzed the association between substance use (SU) and condomless sex (CS) among HIV-negative adults reporting heterosexual sex in the Seek, Test, Treat, and Retain (STTR) consortium. We describe the impact of SU as well as person/partner and context-related factors on CS, identifying combinations of factors that indicate the highest likelihood of CS. METHODS: We analyzed data from four US-based STTR studies to examine the effect of SU on CS using two SU exposures: 1) recent SU (within 3 months) and 2) SU before/during sex. Behavioral data were collected via 1:1 or self-administered computerized interviews. Adjusted individual-study, multivariable relative risk regression was used to examine the relationship between CS and SU. We also examined interactions with type of sex and partner HIV status. Pooled effect estimates were calculated using traditional fixed-effects meta-analysis. We analyzed data for recent SU (n = 6781; 82% men, median age = 33 years) and SU before/during sex (n = 2915; 69% men, median age = 40 years). RESULTS: For both exposure classifications, any SU other than cannabis increased the likelihood of CS relative to non-SU (8-16%, p-values< 0.001). In the recent SU group, however, polysubstance use did not increase the likelihood of CS compared to single-substance use. Cannabis use did not increase the likelihood of CS, regardless of frequency of use. Type of sex was associated with CS; those reporting vaginal and anal sex had a higher likelihood of CS compared to vaginal sex only for both exposure classifications (18-21%, p < 0.001). Recent SU increased likelihood of CS among those reporting vaginal sex only (9-10%, p < 0.001); results were similar for those reporting vaginal and anal sex (5-8%, p < 0.01). SU before/during sex increased the likelihood of CS among those reporting vaginal sex only (20%; p < 0.001) and among those reporting vaginal and anal sex (7%; p = 0.002). Single- and poly-SU before/during sex increased the likelihood of CS for those with exclusively HIV-negative partners (7-8%, p ≤ 0.02), and for those reporting HIV-negative and HIV-status unknown partners (9-13%, p ≤ 0.03). CONCLUSION: Except for cannabis, any SU increased the likelihood of CS. CS was associated with having perceived HIV-negative partners and with having had both anal/vaginal sex.

Think Inside the Box: the Heterogeneity of "in Risk" Among "at Risk" Female African American Adolescents in North Carolina.

INTRODUCTION: An abundance of research investigates the health of often referred to as "at risk" or "high risk" youth from underserved communities and usually racial/ethnic minorities. These ubiquitous terms relate to poverty, violence, and unsafe behaviors (e.g., sex without condoms, alcohol, and drug use). METHODS: This analysis distinguished the heterogeneity of risks among African American female adolescents recruited for an intervention study from underserved communities in North Carolina. Eligibility included: ages 16-19, considered or dropped out of school, never completed high school, and during the past 3 months had sex with a male partner and used drugs or alcohol. A variable was created to represent the continuum of risk comprised of history of homelessness, or trading sex, or current heavy alcohol and marijuana use. Participants fell into 0, 1, or 2-3 categories. Ordinal logistic regression estimated the odds of adverse poor outcomes by category. Linear regression estimated reduction in material and emotional support by category. RESULTS: Of the 237 participants, 59.5%, 27.8%, and 12.7% were in 0, 1, or 2-3 categories, respectively. Relative to adolescents in 0 categories, participants in other categories were more likely to report food insecurity (OR = 3.27, 95%CI [1.8, 5.94]); past arrest (OR = 3.56 [2.08, 6.09]); run away (OR = 3.30 [1.79, 6.10]); multiple sex partners (2.97 [1.61, 5.48]); and vaginal/anal sexual abuse (OR = 3.21[1.73, 5.96]). Material and emotional support was significantly lower for participants in 2-3 risk categories. CONCLUSIONS: Vague use of "at risk" fails to recognize the heterogeneity of experiences and needs of underserved African American youth.

Substance use and depressive and anxiety symptoms among out-of-school adolescent girls and young women in Cape Town, South Africa.

BACKGROUND: There is a high prevalence of substance use among youth in South Africa (SA), and adolescent girls and young women (AGYW) experience high rates of depression and anxiety. Substance use behaviours and mental health are associated with other public health problems among AGYW such as HIV and unintended pregnancy. Therefore, understanding the relationship between substance use and mental health is imperative to improve AGYW's health. OBJECTIVES: To examine the association between heavy drinking, marijuana, methamphetamine and methaqualone (Mandrax) use and depressive and anxiety symptoms among AGYW aged 16 - 19 years who have dropped out of school in Cape Town, SA. METHODS: Data for this report come from the baseline data of 500 participants of an ongoing cluster-randomised trial assessing the efficacy of a young woman-focused intervention to reduce substance use and HIV risk. After AGYW consented/assented to participate, they completed a urine drug screen and a baseline questionnaire. RESULTS: Logistic and negative binomial regressions, controlling for clustering at the neighbourhood level, revealed that frequency of depressive symptoms was significantly and positively related to a positive drug screen for Mandrax (ß=0.07; p=0.03). All other associations between the frequency of depressive symptoms and substance use were not statistically significant (ps>0.05). The associations between frequency of anxiety symptoms and substance use were not statistically significant (ps>0.05). CONCLUSIONS: Our findings highlight the need to address substance use, especially Mandrax use and its associated risk, and depression in an integrated, youth-friendly setting.

Methamphetamine use and sexual risk behaviour in Cape Town, South Africa: a review of data from 8 studies conducted between 2004 and 2007.

OBJECTIVE: Community studies and studies of admissions to drug treatment centers indicate a dramatic increase in the prevalence of methamphetamine use in Cape Town since 2003. There has also been a substantial increase over this time period in the prevalence of HIV infection among women attending public antenatal clinics in the Western Cape province. This study aimed to review research conducted in Cape Town on the link between methamphetamine use and sexual risk behaviour. METHOD: A review of published research conducted in Cape Town between 2004 and 2007 was undertaken using PubMed, EBSCOhost and Science Direct. RESULTS: Eight studies were identified, both quantitative and qualitative, and focusing on diverse populations, such as learners in school, out of school youth, adults in the community, men who have sex with men and sex workers. The total sample across the studies was 8153. Across multiple studies methamphetamine was fairly consistently associated with early vaginal sex, condom use during sex, having casual sex and other HIV risk behaviours. For some sub-groups the direction of the relationship was in an unexpected direction. CONCLUSION: The consistency of the findings across studies highlights the increased risk for contracting HIV among methamphetamine users, and reinforces the importance of interventions addressing both methamphetamine use and unsafe sexual behaviour among young people and other sectors of the population. The need for further research is also considered, particularly research that will explain some of the racial differences that were found.

Addiction severity index composite scores as predictors for sexual-risk behaviors and drug-use behaviors in drug-using pregnant patients.

BACKGROUND: HIV sexual-risk and drug-use behavior predictors have been studied in non-pregnant but not pregnant drug-dependent populations. OBJECTIVE: Examine the ability of the ASI composite scores to predict HIV sexual- and drug-risk scores as well as the individual items of a modified version of the Risk Assessment Battery in drug-using pregnant women. METHODS: Pregnant women (N = 76) completing pretreatment ASI and HIV-risk questionnaires. RESULTS: The Legal composite score was the sole significant predictor of the sexual-risk score, with a 1 SD increase in the Legal composite score resulting in a 24% increase in sexual-risk, p < .001. The Medical, Drug, and Legal composite scores were each significant predictors of the drug-risk score, with a 1 SD increase resulting in a 31% decrease, and 121% and 73% increases, respectively, in drug-risk, all ps < .05. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Drug-using pregnant women and their fetuses are vulnerable to the consequences of both sexual-risk behaviors and drug-use. The ASI may help screen such patients for HIV sexual-risk and drug-use behaviors as a first step in tailoring treatment to address these issues.

Violence against substance-abusing South African sex workers: intersection with culture and HIV risk.

The Republic of South Africa has become an epicentre of heterosexual HIV transmission among Black women, and the interface between violence against women, substance abuse, and HIV risk is becoming evident. This paper describes the characteristics of Black South African women who engage in sex work in Pretoria and examines their intersecting experiences of high-risk sexual behaviour, substance abuse, and victimization. Ninety-three women were recruited into the study. Field staff collected biological measures of drug use and administered a structured, self-report interview. Findings indicate that young South African women who engage in sex work and use drugs rely on this activity as their main source of income and are supporting other family members. The majority of sample women reported experiencing some victimization at the hand of men, either clients or boyfriends, with many reporting childhood abuse histories; young women also report great fear of future victimization. Findings also suggest that as a result of their decreased likelihood of using protection, women who reported any sexual or physical victimization are at increased risk for HIV and other STIs. Results support the critical need for targeted, comprehensive interventions that address substance abuse, sexual risk, and violence as interrelated phenomena.

Physicians practicing in methadone treatment programs: who are they and what do they do?

OBJECTIVE: This study examines the characteristics and roles of physicians practicing in methadone maintenance treatment programs (MTPs). METHODS: Physicians and clinic directors at 172 MTPs in the United States completed surveys. MTPs were selected for study participation based on their locations (large urban, urban, or nonurban area) ownership status (for profit and non-profit), and size (patient capacity of 1-100, 101-300, and 300+). Weighted data were analyzed with descriptive and multivariate methods. RESULTS. Physicians were primarily white males aged 45 or older; 44% had 10 or more years of experience working in methadone treatment. Physicians reported spending 26% of their time completing administrative tasks. Most reported that they determine dosing levels on an individual patient basis. Average maintenance dose was 69 mg/day. CONCLUSIONS: Physicians' treatment practices play a major role in overall treatment, treatment retention, and outcomes. Physicians at for-profit and large urban MTPs reported spending the most time in direct patient contact.

The cost and cost-effectiveness of an enhanced intervention for people with substance abuse problems at risk for HIV.

OBJECTIVE: To estimate the costs, effectiveness, and cost-effectiveness of prevention interventions for out-of-treatment substance abusers at risk for HIV. This is the first cost-effectiveness study of an AIDS intervention that focuses on drug use as an outcome. STUDY DESIGN: We examined data from the North Carolina Cooperative Agreement site (NC CoOp). All individuals in the study were given the revised NIDA standard intervention and randomly assigned to either a longer, more personalized enhanced intervention or no additional intervention. We estimated the cost of each intervention and, using simple means analysis and multiple regression models, estimated the incremental effectiveness of the enhanced intervention relative to the standard intervention. Finally, we computed cost-effectiveness ratios for several drug use outcomes and compared them to a "back-of-the-envelope" estimate of the benefit of reducing drug use. PRINCIPAL FINDINGS: The estimated cost of implementing the standard intervention is $187.52, and the additional cost of the enhanced intervention is $124.17. Cost-effectiveness ratios range from $35.68 to $139.52 per reduced day of drug use, which are less than an estimate of the benefit per reduced drug day. CONCLUSIONS: The additional cost of implementing the enhanced intervention is relatively small and compares favorably to a rough estimate of the benefits of reduced days of drug use. Thus, the enhanced intervention should be considered an important additional component of an AIDS prevention strategy for out-of-treatment substance abusers.

Homelessness and gender in out-of-treatment drug users.

This study examines 5225 out-of-treatment crack users and drug injectors drawn from five different geographic areas to examine selected factors associated with homelessness. Of these crack users, 27% considered themselves undomiciled, and 60% had previously entered some type of drug treatment. Logistic regression found that substance abusers who were married, female, and persons of color were less likely to be without a home when other variables were controlled. Trading sex for money and perceived chance of getting acquired immunodeficiency syndrome (AIDS) were associated positively with homelessness, while participating in methadone detoxification and methadone maintenance programs seemed to offer some protection from homelessness.

Patterns of HIV risk and alcohol use among African-American crack abusers.

Although the association between heavy alcohol use and HIV risk has been studied in treatment populations, we know little about patterns of alcohol use and HIV risk among out-of-treatment African-American drug users. This study examines the extent to which alcohol use affects HIV risk in a sample of 495 African-American crack users who did not inject drugs. We present differences between levels of alcohol and crack use with regard to sexual practices (including sex while impaired), number of partners, frequency of sexual activity, and condom use. The findings suggest an intimate relationship between alcohol use, crack use, and sexual risks for HIV infection. Respondents who reported frequent use (15-30 days in the last 30 days) of alcohol, crack, or both displayed significantly greater risk than those who reported less than frequent use.

Reaching and enrolling drug users for HIV prevention: a multi-site analysis.

Since 1994, several sites have participated in a NIDA Cooperative Agreement for AIDS Community-based Outreach/Intervention Research Program to examine rates of HIV risk behaviors and evaluate HIV risk reduction interventions among out-of-treatment drug injection and crack cocaine and heroin smokers. We studied the process and outcome of community outreach for recruitment of drug users in AIDS research and education projects in three metropolitan areas: St. Louis, MO; San Antonio, TX, and Durham and Wake Counties, NC. There were two primary areas of focus: (1) the level of accuracy among community health outreach workers (CHOWs) in identifying potentially eligible persons for HIV prevention, and (2) overall effectiveness in recruiting and enrolling persons in formal assessment and intervention studies. We found cross-site and within-site differences in levels of accuracy and in recruitment and enrollment yields. Drug users who had never been in treatment and drug users who had never been tested for HIV infection were underrepresented at all sites. We discuss the factors which may have contributed to cross-site and within-site differences. The findings suggest a need for continued study, refinement, and evaluation of community outreach strategies in order to enroll a broad spectrum of vulnerable groups in HIV prevention activities.

Effectiveness of HIV risk reduction initiatives among out-of-treatment non-injection drug users.

While attention has been paid recently to the effectiveness of HIV/AIDS interventions among injection drug users, less focus has been given to out-of-treatment noninjecting drug users. This study examines the the NIDA Cooperative Agreement standard intervention versus an enhanced intervention for HIV/AIDS risk among noninjecting drug users. Data come from five sites of the NIDA-funded Cooperative Agreement on HIV risk behaviors. The sample is comprised of those who never injected drugs or reported not injecting in the 12 months prior to the interview; and who completed a three-month follow-up assessment. Three risk behaviors in the prior 30 days were analyzed: frequency of crack/cocaine use, number of sex partners, and frequency of condom use. The levels of both baseline and follow-up risk were analyzed. Individuals remaining at low risk or decreasing risk behaviors were classified as "improved." Those increasing risk behavior or remaining at moderate or high levels were classified as "worsened." Of the 1,434 noninjecting crack/cocaine users, 82% improved crack/cocaine use at the follow-up. The enhanced intervention group showed more improvement in crack/cocaine use than the standard intervention group. Overall, 76% reported reducing sexual partners, maintaining a one-partner relationship, or abstaining from sex at both time periods. Women in the enhanced intervention group improved more than women in the standard intervention (81% versus 75%). In terms of condom use, more respondents worsened than improved (55% versus 45%). This study confirms that HIV/AIDS interventions can reduce crack/cocaine use; however, high-risk sexual behaviors are more difficult to change. Reasons for this lack of improvement and suggestions for future interventions are discussed.

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.

Cluster analysis of HIV intervention outcomes among substance-abusing women.

The study described here presents an innovative approach to analyzing intervention outcomes among women substance abusers participating in a national HIV prevention research study funded by the National Institute on Drug Abuse. We used cluster analysis to divide the women in our sample (N=557) into four distinct subgroups predominantly characterized by differences in drug use, injecting risk, sexual behaviors, and drug and sexual risk combined. The four subgroups resulting from this process were primary crack-using women, primary needle-using women, high-frequency needle-using women, and women with multiple drug and sex risk behaviors. Our analysis focuses on changes in self-reported risk behaviors from baseline to 6-month follow-up. In general, the results clearly indicate that the women are heterogeneous; that is, the subgroups exhibit varying patterns of drug use, injecting risk, sexual behavior, and HIV seropositivity. Significant outcomes were found in many areas, indicating positive changes in risk behaviors. The two smaller subgroups of women--high-frequency needle users and those in the multiple-risk behavior subgroup--reported the highest rate of high-risk behaviors and seropositivity but also showed the greatest change at follow-up. A particularly important finding resulting from our analytical approach is that well over half the women in our sample were primary crack users (n=313). This finding is even more significant in light of the fact that the Cooperative Agreement specifically tried to include 70% or more participants who were injectors. Although the rate of HIV seropositivity is not as high for this crack-using subgroup as for the two smaller needle-using subgroups, a greater number of "women who are HIV positive" are in this primary crack-using subgroup than in all the other subgroups. Most of the crack-using women reported that they were not currently injecting drugs and never shared needles, but 10% were seropositive for HIV, suggesting that their risk comes primarily from sexual behaviors. Behaviors in this larger subgroup of women did not change as dramatically as those of women in the smaller subgroups; however, the women did show improvement in areas related to indirect risk (e.g., alcohol and crack use) and in several areas where change is most needed (e.g., trading sex for drugs and using condoms). The results demonstrate a promising alternative approach to analyzing substance abuse and HIV risk behaviors, and they suggest the need for further research on alternative interventions for women with different patterns of risk behaviors.