HIV risk factors among injecting drug users in five US cities.

OBJECTIVES: To examine factors associated with HIV infection in injecting drug users (IDU), the independent and interactive effects of potential risk factors, and geographic differences in risk factors. METHODS: IDU entering methadone treatment in New York City, Asbury Park and Trenton in New Jersey, Baltimore and Chicago between February 1987 and December 1991 were interviewed using a standard questionnaire and tested for HIV antibodies (n = 4584). Associations of HIV serostatus with race/ethnicity, other demographic characteristics, and injecting and sexual risk behaviors were assessed by logistic regression analyses. RESULTS: African Americans were at increased risk for HIV in four of the five cities, and Puerto Ricans in two cities. Injection in shooting galleries and 'speedball' injection emerged as behavioral variables highly associated with HIV, although interaction of these variables indicates that each variable contributes to HIV risk only in the absence of the other behavior. CONCLUSIONS: Geographic differences in HIV risk factors and the interaction of 'speedball' and shooting gallery use suggest that multiple HIV risk models are needed that reflect seroprevalence rates, variation in risk behaviors, and the social context of risk behaviors. Increased risk among racial/ethnic minorities independent of risk behaviors, suggests the need to examine further potential social and environmental factors, such as the social networks in which injecting and sexual behaviors occur, HIV seroprevalence within these networks, and the locales in which risk behaviors occur.

Cause-specific mortality associated with HIV and HTLV-II infections among injecting drug users in the USA.

BACKGROUND: Human T-lymphotropic virus type II (HTLV-II) is widespread among injecting drug users (IDU) and may contribute to the risk of leukemia/lymphoma, neurodegenerative disease, and perhaps pneumonia, especially with HIV co-infection. METHODS: In 1987--1991, 6570 IDU were tested for HIV and HTLV-II antibodies. In 1998, they were matched to the National Death Index. Numbers of observed deaths of each cause were compared by standardized mortality ratios with the numbers expected, using sex-, race-, age-, and year-specific rates in the general population. Relative risk (RR) associated with each virus, compared to uninfected drug users, was estimated by Poisson modeling. RESULTS: There were 1351 deaths, including 683 (15%) of 4604 participants who enrolled seronegative for both viruses; 328 (47%) of 701 who had HIV but not HTLV-II infection; 220 (21%) of 1033 who had HTLV-II but not HIV infection; and 120 (52%) of 232 who were infected by both viruses. Compared to the general population, mortality for participants with neither virus was increased 4.3-fold [95% confidence interval (CI), 4.0--4.7] and was significantly elevated for virtually every cause of death. With HIV, mortality from medical causes, but not external causes, was increased 3.7-fold (95% CI, 3.3--4.2), particularly with AIDS and related conditions. With HTLV-II, all-cause mortality was reduced (RR, 0.8; 95% CI, 0.7--0.9), with no statistically significant reduction or elevation for any specific cause. A non-significant excess of tuberculosis deaths (RR, 4.6; 95% CI, 0.8--25.2) was noted with HTLV-II, but there was no excess mortality from leukemia/lymphoma, other malignancies, or neurodegenerative disease. CONCLUSIONS: Without HIV or HTLV-II, IDU had profoundly increased mortality from medical and external causes. HIV was specifically associated with death due to AIDS and related conditions. HTLV-II infection was not significantly associated with mortality from any cause, suggesting that it is not a significant human pathogen, even when present with HIV infection.

HIV infection and AIDS risk behaviors among intravenous drug users entering methadone treatment in selected U.S. cities.

To assess trends in HIV infection and AIDS risk behaviors among intravenous drug users (IVDUs), a series of nonblinded point-prevalence surveys was conducted with admissions to methadone treatment in seven areas, including New York City; Trenton and Asbury Park, New Jersey; Baltimore; Chicago; San Antonio, Texas; and Los Angeles County between February and December 1987 (n = 713), January and June 1988 (n = 1,089), July and December 1988 (n = 932), and January and June 1989 (n = 1,110). Over the 2-year period, significant changes in HIV seropositivity levels were found in only one of the seven cities (Chicago, with levels increasing from 8.4 to 14.7%). High levels of AIDS risk behaviors (frequency of injection, needle sharing, needle cleaning, and use of shooting galleries) were found in all cities. Comparisons of trends in recent risk behaviors (past year) within cities suggest that relatively little reduction in AIDS risk behaviors had occurred during the study.

Introduction of HIV infection among intravenous drug abusers in low prevalence areas.

To explore the introduction of human immunodeficiency virus (HIV) infection into intravenous drug abusing populations, risk behaviors of 1,154 intravenous drug abusers (IVDAs) in four U.S. cities with low prevalence of IVDA/HIV infection (0.9-13.0%) were examined. Seropositive subjects (N = 54) were compared with demographically matched seronegative controls regarding drug use practices, homosexual contact, blood transfusions, risk behaviors while traveling or living in high prevalence areas, and acquaintance with persons with AIDS. With the exception of needle sharing with homosexual/bisexual males, no differences in risk behaviors were found between seropositive subjects and matched seronegatives. Seropositives were substantially more likely than matched seronegatives to report having shared a needle with a homosexual or bisexual male, suggesting that needle sharing between homosexual/bisexual IVDAs and heterosexual IVDAs may be an important means by which HIV is introduced among heterosexual IVDAs in low prevalence areas.

HTLV-I/II seroprevalence and HIV/HTLV coinfection among U.S. intravenous drug users.

Data from a continuing multiyear seroprevalence survey of human T-lymphotropic virus types I or II (HTLV-I/II) among intravenous drug users in seven U.S. locations were analyzed to detect demographic patterns of seropositivity and coinfection with human immunodeficiency virus type 1 (HIV-1). Seropositivity for HTLV-I/II and HIV-1 was detected by whole-virus enzyme immunoassay, with Western blot confirmation. Of 1,800 subjects recruited from methadone maintenance and detoxification clinics, 207 (11.5%) were infected with HTLV-I/II. Seropositivity for HTLV-I/II varied by racial group, age, sex, and geographic location. Blacks had a higher (age- and location-adjusted) infection rate (17.1%) than Hispanics (8.7%) or whites (5.6%), and seropositivity showed a strong gradient with increasing age. Females had a slightly higher rate (14.0%) than males (10.0%), after adjustment for age and location. Among the seven locations, the rate varied from approximately 1% (Miami and Baltimore) to 20% (Los Angeles), although the former rates were based on relatively few subjects (47 and 65, respectively). Overall, the occurrence of coinfection by HIV-1 and HTLV-I/II did not occur more frequently than expected by chance.

Introduction to the special issue: treatment process in DATOS.

Several important findings from the drug abuse treatment outcome studies (DATOS) are presented in this issue of drug and alcohol dependence. These studies focus on the drug abuse treatment process in areas of engagement in treatment and participation in program activities, the effect of the patient's age and treatment history in predicting treatment retention and outcomes, and the impact of prior treatment experience on the level of treatment engagement and subsequent outcomes. A cost-benefit model for drug abuse treatment is developed. Significant contributions are made in the development of a comprehensive model of the treatment process, including the relationship of patient attributes, program factors, and outcomes. Findings on retention from the United Kingdom's national treatment outcome research study (NTORS), a study similar in design to DATOS, also are presented.

Community prevention efforts to reduce the spread of AIDS associated with intravenous drug abuse.

Drug abusers currently represent almost 30% of AIDS cases reported to the Centers for Disease Control. Intravenous drug abusers have been recognized as a major vector for the spread of HIV to the general public. Considering the high levels of AIDS risk behaviors among intravenous drug abusers, prevention efforts to reduce risk are a priority. Since community prevention approaches have been found effective with other target populations, this article considers community prevention as an AIDS reduction strategy. Consensus recommendations developed by a panel of researchers and practitioners who met at the National Institute on Drug Abuse in 1988 are presented. Specific recommendations for community prevention with intravenous drug abusers and their sex partners are introduced along with suggested research initiatives.

Effectiveness of a stand-alone aftercare program for drug-involved offenders.

A study was made of the effectiveness of an aftercare program operating in conjunction with area outpatient drug free treatment programs while organizationally independent of those programs. Parolees and probationers mandated to treatment were assigned to aftercare on the basis of residence in the catchment areas in which aftercare facilities were located (n = 32) and randomly to aftercare (n = 62) and control (n = 51) when not a resident in a catchment area. No outcome differences were found between aftercare groups based on proximity to facility. At 6 months postbaseline the combined aftercare group showed significantly lower levels of criminal activity and frequent drug use as compared to controls. At 12 months postbaseline there was an attenuation of group differences with only tendencies toward significance obtained for lower levels of frequent drug use by the aftercare group. The findings are discussed in terms of the relevance of community variables for programming and for understanding long-term treatment outcomes.

Smoking as an issue in alcohol and drug abuse treatment.

Little attention has been given to the role of tobacco dependence within alcohol and drug abuse treatment. Yet, smoking behavior appears to be interrelated with the use of alcohol and other drugs. This interrelationship is explored, and the role of smoking cessation within alcohol and drug abuse treatment is considered. Areas for future research on this topic are identified. Addictive disorders are generally thought to include alcohol abuse, drug abuse, smoking, overeating, and, sometimes, gambling and caffeine dependence. While some attention has been paid to the common etiological roots of various addictive disorders, relatively little systematic attention has been paid to commonalities in their treatment and especially to the treatment of multiple disorders in the same individuals. The one significant exception is alcohol abuse and drug abuse. Of the other addictive disorders, tobacco dependence has been most closely interrelated with alcohol and drug abuse. Yet, little attention has been given to tobacco dependence within alcohol and drug abuse treatment. This paper will focus on smoking in relationship with alcohol and drug abuse, and will consider the possible role of smoking cessation treatment within the context of alcohol and drug abuse treatment. First, background regarding the interrelationship of alcohol and drug abuse is explored. Then, the relationship of smoking with other substance use is considered, followed by a review of special concerns related to smoking among alcohol and drug abuse clients. Next, the current status of smoking cessation within alcohol and drug abuse treatment is addressed. Finally, implications are considered.

Prevention of adolescent drug abuse.

The prevention of drug abuse has been of public concern since the mid-1960s. Research efforts to document program effectiveness have met with relatively little success. Past research efforts are reviewed. Research on social pressures and social skills training approaches to smoking prevention is reviewed in detail because of the promise these approaches hold for the prevention of drug abuse. Future research needs are identified.

Similarity of clients and treatment outcome in outpatient drug-free programs.

Client peer groups in drug abuse treatment programs can be expected to impact on the treatment of drug abusers. This ex post facto study explored whether similarity in demographic characteristics and drug use history within client peer groups influences treatment outcome. Subjects were 455 clients in outpatient drug-free treatment. Four aspects of similarity were assessed-age, drug use history, race/ethnicity, and sex. Follow-up data on levels of criminality, nonopiate drug use, and opiate drug use during the first year posttreatment were analyzed using multiple regression analysis. Client similarity was found to influence treatment outcome. While the findings do not warrant substantial changes in the delivery of drug abuse treatment, they suggest that peer relationships and the influence of similarity among clients should be considered in the formulation of treatment plans for individual clients.

Symbolic interaction theory: a perspective on drug abuse and its treatment.

Symbolic interaction theory is employed to explain the etiology of drug abuse and addiction. Selected interactionist concepts, which are especially pertinent to an understanding of drug abuse, are considered in relation to current drug abuse theory and the literature on the characteristics of drug abusers. The implications of this theoretical perspective for treatment are considered.

Needle sharing among intravenous drug abusers: future directions.

In summary, the conference focused on one means of HIV transmission among intravenous drug abusers: exposure through the sharing of drug injection equipment. The participants emphasized the urgency of the AIDS epidemic among intravenous drug abusers. A massive effort is needed now to prevent further spread of the disease. The prevention of AIDS requires a multipronged approach to reach intravenous drug abusers, with various motivations for behavior change: Communities across the United States should quickly implement programs to educate addicts regarding their risk for AIDS and how they may reduce their risk. Aggressive outreach is a key educational tool. Drug abuse treatment is an important means of combating the AIDS epidemic among intravenous drug abusers who wish to quit using drugs and are willing to enter treatment. Resources need to be expanded so that drug abuse treatment is readily available. Since a substantial number of intravenous drug abusers will continue to inject drugs, an effective AIDS prevention strategy must encourage these individuals not to share injection equipment and must provide clear and explicit information on how they can clean their injection equipment to decrease the likelihood of HIV transmission if they continue to share. Public policies that restrict the availability of needles and thereby encourage needle sharing should be reexamined. As part of this reexamination, research should be conducted to determine the effectiveness of needle exchange programs that provide intravenous drug abusers with sterile needles in exchange for used needles.

Future directions in drug abuse prevention research.

For most youth, substance use appears to be the result, in large part, of social influences. Thus, teaching youth to resist these influences appears to be a reasonable approach to the prevention of use. However, it is not realistic to assume that all youth use for the same reason or respond to the same prevention approach. Moreover, identification of factors that act to promote or deter the transition from experimental or occasional use to abuse has not been addressed by these studies. While the social inoculation and social skills approaches appear to hold considerable promise for many youth, the research results indicate that a sizeable number of youth initiate and escalate use in spite of these programs. It appears that those youth who are most at risk for compulsive drug use are those who use drugs for reasons other than social influences (Robins and Przybeck 1985). Thus there is a need not to focus on any single prevention approach, but to explore multiple strategies. Identifying effective prevention approaches also requires the ability to target programs--to identify which types of individuals are effectively reached with a specific approach. Alternative programs, such as the cognitive-developmental approach described by Glynn, Leventhal, and Hirschman, warrant additional attention. A host of areas needing further research have been identified above. While the RAUS review participants did not establish priorities among areas, some attempt to do so is necessary since funds available for research are limited.(ABSTRACT TRUNCATED AT 250 WORDS)

Age at first injection and HIV risk among intravenous drug users.

The relationship of age at first injection and HIV risk was explored in a nonblinded HIV seroprevalence study of intravenous drug users (IVDUs) admitted to methadone treatment in seven United States cities between February 1987 and June 1989. Comparisons were made of IVDUs who began injecting as adolescents, young adults, and adults in terms of drug use and sexual HIV risk behaviors and HIV serostatus. Early injectors consistently reported higher levels of drug-using risk behaviors (e.g., frequency of injection, frequency of needle sharing, and use of shooting galleries), and were more likely to be HIV seropositive. Among females, early injectors were also more likely to report sexual risk behaviors (e.g., multiple sex partners, prostitution). The relationship of age at first injection with selected risk behaviors and HIV serostatus was independent of subjects' age at interview, gender, and race/ethnicity. This study suggests that adolescent injectors are an important target group for HIV prevention efforts.

HIV infection and AIDS risk behaviors among injecting drug users entering methadone treatment: an update.

Trends in HIV infection and AIDS risk behaviors among injecting drug users (IDUs) were assessed through a series of nonblinded point-prevalence surveys conducted between 1987 and 1991 with admissions to methadone treatment in eight areas, including New York City; Asbury Park and Trenton, New Jersey; Philadelphia; Baltimore; Chicago; San Antonio, Texas; and Los Angeles County. Over the 5-year period, significant changes in HIV seropositivity were found in two of the eight cities, with seroprevalence decreasing in Asbury Park from 43.1 to 21.2% and increasing from 10.1 to 17.6% in Chicago. Initially high levels of injection-related risk behaviors decreased substantially across cohorts in most cities, except for San Antonio and Los Angeles, where risk levels remained high. Sexual risk behaviors continued at high levels in all cities, suggesting relatively little sexual risk reduction during the course of the study.

Drug abuse treatment entry and engagement: report of a meeting on treatment readiness.

Although the effectiveness of drug abuse treatment has been demonstrated repeatedly, many drug abusers do not enter treatment, many who do enter leave prematurely, and relapse following treatment is common. To further research treatment entry and engagement, the National Institute on Drug Abuse convened scientists representing diverse research traditions in December 1996. This article summarizes meeting presentations and recommendations. Presentations focused on treatment readiness/motivation for change, ethnographic reports of drug abusers' perceptions of and attitudes toward treatment, and reports on alternative treatments for high-risk drug abusers. Recommendations focused on the potential contribution of qualitative research, integration of qualitative and quantitative research approaches, development of flexible treatment approaches that are cognizant of patients' life circumstances, and services research to improve the organization and delivery of drug abuse treatment.

Heterosexual transmission of human immunodeficiency virus among intravenous drug users.

To examine sexual transmission of human immunodeficiency virus (HIV) among heterosexual intravenous drug users (IVDUs), HIV antibody status of IVDUs with intravenous drug-using sexual partners (IVSPs) was compared with that of IVDUs with no IVSPs. Initial bivariate analyses indicated IVDUs with IVSPs were more likely to be HIV antibody-positive than those with no IVSPs. Analyses by gender indicated that this relationship held for men but not women. IVDUs with IVSPs also differed from those without IVSPs demographically, in drug use, and in other sexual behaviors. When effects of other variables were controlled, no statistically significant relationship was found between injection history of sex partners and HIV status for the total sample or separately for men or women.

The acquired immunodeficiency syndrome and intravenous drug abuse.

Intravenous drug abusers constitute 25 per cent of the cases of the acquired immunodeficiency syndrome (AIDS) in adults in the United States of America and 21 per cent of such cases in Europe. The potential for the rapid spread of the human immunodeficiency virus (HIV) among intravenous drug abusers exists because such drug abusers commonly share drug injection equipment. The heterosexual and perinatal spread of AIDS is also largely associated with intravenous drug abusers, and drug abusers have been identified as a major vector for the spread of the AIDS epidemic as it is associated with intravenous drug abuse. As long as intravenous drug abusers are addicted, they will continue to be at risk of contracting AIDS. Thus, the primary AIDS prevention strategy must be to help addicts to stop using drugs. It is suggested that drug abuse treatment resources should be expanded and outreach programmes developed to encourage more intravenous drug abusers to enter treatment. AIDS risk-reduction counseling must also be provided to intravenous drug abusers who continue injecting drugs, and to addicts and their sexual partners to prevent the sexual spread of HIV. Vigorous AIDS prevention initiatives must be undertaken now, using the most promising intervention strategies, while simultaneously evaluating and refining these strategies.

Seroprevalence of human T cell lymphotropic virus type II infection, with or without human immunodeficiency virus type 1 coinfection, among US intravenous drug users.

Seroprevalence of human T lymphotropic virus (HTLV) and human immunodeficiency virus type 1 (HIV-1) was determined among 7841 intravenous drug users (IVDUs) from drug treatment centers in Baltimore, Chicago, Los Angeles, New Jersey (Asbury Park and Trenton), New York City (Brooklyn and Harlem), Philadelphia, and San Antonio, Texas; 20.9% had evidence of HTLV infection, as determined using a p21e EIA for screening and p21e blot for confirmation. With a type-specific EIA and blot used in combination, HTLV-II was identified in 97.6% of HTLV-positive IVDUs whose sera could be subtyped. HIV-1 seroprevalence was 13.2%. HTLV-II without HIV-1 was most common in Los Angeles and San Antonio. HIV-1 without HTLV-II was most common in New York, New Jersey, and Baltimore. Dual infection was most common in New York and New Jersey. Logistic regression analysis revealed that seroprevalence of HTLV-II was significantly greater with HIV-1 infection and increasing age and among women, blacks, and Mexican-Americans. In conclusion, it appears that among US IVDUs, nearly all HTLV infection is attributable to HTLV-II, and HTLV-II infection is associated with HIV-1 and sociodemographic background.