Preliminary laboratory studies of inactivation of HIV-1 in needles and syringes containing infected blood using undiluted household bleach.

To evaluate the effectiveness of bleach disinfection of injection equipment, we tested HIV-1 inactivation by household bleach in needles and syringes. We obtained blood from HIV-1 infected injecting drug users (IDUs), placed small aliquots in needles and syringes. Blood with and without anticoagulant was incubated at room temperature for 3, 6, 18, and 24 h, and some needles and syringes from each condition were exposed to undiluted bleach for 15 and 30 s. The needles and syringes were then rinsed and the rinses were used to inoculate peripheral blood mononuclear cells (PBMNCs). HIV-1 replication was monitored using p24 enzyme linked immunosorbent assay (ELISA). We describe results that HIV-1 is inactivated in clotted and unclotted blood allowed to stand at room temperature for 3, 6, 18, and 24 h in needles and syringes using undiluted household bleach at 30 s of exposure time. These results are consistent with earlier findings that micropellets of HIV-1 were inactivated by bleach under similar conditions of exposure to bleach; 10% bleach was not effective at an exposure time of 30 s and undiluted bleach was not effective at an exposure time of 15 s to inactivate HIV-1 in clotted blood. Bleach concentration and exposure time are critical and HIV disinfection may not occur with inadequate exposure to bleach HIV.

Compliance to bleach disinfection protocols among injecting drug users in Miami.

Bleach cleansing of injection equipment has been recommended to reduce the risk of human immunodeficiency virus (HIV) transmission associated with the reuse of injection equipment by injecting drug users (IDUs). We evaluated the recall and performance of the most commonly recommended bleach cleansing procedure of two complete fillings of the syringe with bleach, followed by two complete fillings with rinse water, and not putting used bleach and water back into source containers. IDUs were taught this procedure on enrollment in an HIV prevention demonstration project in Dade County, Florida. During follow-up session 6-12 months after initial training, the knowledge and ability of IDUs to perform bleach cleansing were assessed by trained observers using a standardized method. In 1988-90, we assessed the knowledge and ability of 450 IDUs to perform the bleach cleansing procedure taught at enrollment. More than 90% of IDUs assessed performed the basic steps. However, only 43.1% completely filled the syringe with bleach and only 35.8% completely filled the syringe with bleach at least twice. Substantial proportions of IDUs did not perform all the steps of the previously taught bleach cleansing procedure. Compliance decreased as the number of steps required was increased. This limited compliance may make bleach cleansing less effective and suggests that some IDUs may fail to adequately disinfect injection equipment and therefore sterile needles and syringes are safer than bleach-cleansed ones. Compliance testing can help assess the effectiveness of HIV prevention programs.

Cocaine abuse and HIV-1 infection: epidemiology and neuropathogenesis.

The epidemiology of cocaine abuse and potential relationships of cocaine withdrawal to human immunodeficiency virus type 1 (HIV-1)-associated dementia (HAD) are discussed. Neuroendocrinological changes in HIV-1 infection of the central nervous system (CNS) are discussed with the relevant impact of cocaine abuse. HIV-1 load in the brain tissue of infected substance users is described along with possible associations with neuropathology and HAD. Finally, the molecular epidemiology and sequence heterogeneity of HIV-1 and their implications for neuropathogenesis are summarized. The complex context of addressing cocaine abuse in the setting of HIV-1 infection appears more tractable when decomposed into its components.

Urban rape survivors: characteristics and prevalence of human immunodeficiency virus and other sexually transmitted infections. Multicenter Crack Cocaine and HIV Infection Study Team.

OBJECTIVE: To determine the prevalence of recent rape, the characteristics or recent rape survivors, and the seroprevalence of human immunodeficiency virus (HIV), syphilis, and genital herpes (HSV-2) among recent rape survivors. METHODS: We surveyed women 18-29 years old who were recruited from places unassociated with medical or drug treatment or the criminal justice system in three urban communities where illicit drug use is common. We compared characteristics and HIV, syphilis, and HSV-2 seroprevalence of women who reported recent rape with those of women who denied recent rape. RESULTS: One hundred fifty-one of 1104 (13.7%) women reported having been raped in the year before our interview. Rape survivors were more likely than women who denied recent rape to smoke crack cocaine (86.8 versus 56.7%; odds ratio [OR] 5.0, 95% confidence interval [CI] 3.2-7.8), to be homeless (17.2 versus 6.1%; OR 3.2, CI 2.0-5.2), to report a recent sexually transmitted disease (38.7 versus 18.7%; OR 2.7, CI 1.9-3.9), and to be infected with syphilis (42.4 versus 28.4%; OR 1.9, CI 1.3-2.6) and HSV-2 (71.9 versus 57.5%; OR 1.9, CI 1.3-2.8). Survivors were more likely to acknowledge any HIV risk behavior (including sex work) (85.4 versus 49.5%; OR 5.9, CI 3.9-9.0) and to be HIV-infected (23.3 versus 13.4%; OR 1.9, CI 1.3-2.9). Rape was not independently associated with HIV (OR 0.8, 95% CI 0.4-1.3), syphilis (OR 0.9, 95% CI 0.6-1.3), or HSV-2 (OR 1.3, 95% CI 0.9-2.0) infections after adjustment for confounding factors. CONCLUSION: One in seven women reported being raped recently. Rape was most common among sex workers, crack smokers, and the homeless. Most survivors reported HIV risk behaviors, and many were HIV-infected. Programs to prevent repeated rape, voluntary HIV counseling and testing, and other medical and social services may benefit survivors in these and similar communities.

HIV-1 RNA load in needles/syringes from shooting galleries in Miami: a preliminary laboratory report.

We quantified HIV-1 RNA load in rinses from needles/syringes (N/S) obtained at shooting galleries in Miami and also analyzed the rinses for antibodies for viral proteins. In rinses from 36 N/S that contained visible blood, 14 (39%) had detectable amounts of HIV-1 RNA. Numbers of copies of HIV-1 RNA ranged from the detection limit (400 copies/ml) to 268,000 copies/ml. We also detected antibodies to HIV-1 polypeptides in 34/36 (94%) of rinses from visibly contaminated N/S using Western blots specific for the HIV-1 proteins. No antibodies were detected in laboratory rinses from six visibly clean needles. The presence of HIV-1 RNA in N/S is an important indication of the risk created by N/S sharing as well as by shared paraphernalia and wash waters by injecting drug users.

HIV-1 prevention: interdisciplinary studies on the efficacy of bleach and development of prevention protocols.

In the United States, a major federally-funded approach to HIV-1 prevention for injecting drug users (IDUs) includes teaching them to always rinse their needles/syringes with household bleach and water before use. This report describes interdisciplinary studies of the extent to which HIV-1 can be found in injection equipment and the efficacy of bleach as a disinfectant, under simulated field conditions. Bloody needle/syringe units collected from Miami, Florida, shooting galleries or from community outreach prevention participants were selected for these studies. Groups of needle/syringe units were cleansed with bleach using a standard technique taught to IDUs in community outreach programs. Cleansed and uncleansed groups of needles/syringe units were then tested for the presence of HIV-1. The data demonstrate the efficacy of bleach rinses in reducing the risks of HIV-1 infection from needle/syringe units and indicate that the teaching of a bleach cleansing method to IDUs should be part of a total AIDS prevention protocol.

Chronic illicit drug use, health services utilization and the cost of medical care.

Few studies have examined the relationships between drug use, health services utilization and the cost of medical care for a community-based sample of drug users. The purpose of this study was to analyze recently collected data on chronic drug users (CDUs), CDUs who were also injecting drug users (IDUs) and non-drug users (NDUs) to determine whether these groups exhibited differences in health services utilization and cost. In addition to descriptive analyses, these relationships were estimated with multivariate regression models. Data were collected in 1996 and 1997 through a standardized self-reported questionnaire administered to individuals who were recruited through community outreach activities in the USA. Annual differences in health services utilization between CDUs, IDUs and NDUs were estimated for three measures: number of times admitted to a hospital, number of outpatient visits and number of emergency room episodes. Results of this study indicate that CDUs and IDUs consumed significantly more inpatient and emergency care, but less outpatient services relative to NDUs. Analyses of total health care costs showed that CDUs and IDUs each generated about $1000 in excess services utilization per individual relative to NDUs. This research is the first study to compare differences in health services utilization and cost among out-of-treatment drug users relative to a matched group of non-users in a community-based setting. The findings suggest that health care providers and managed care organizations should consider policies that promote more ambulatory care and discourage emergency room and inpatient care among drug users. Innovative and culturally acceptable approaches may be necessary to provide incentives without posing unusual financial hardship.

Moving substance-abusing women from welfare to work.

Substance abuse and welfare reform are among the nation's highest priorities, and research that examines linkages between the two is of extreme importance to both government policy and the community. Welfare reform will have serious implications for substance abusers as well as for the various professionals who treat them and work to move their clients into functional recovery and self-sufficiency. Within the context of welfare reform and the special needs of substance-abusing populations, the present study examines current welfare status, work status, and barriers and facilitators to gaining and maintaining employment among 100 low income women who participated in a long-term residential substance-abuse treatment program in Miami, Florida. Participants completed a face-to-face interview to assess a detailed employment history and current sources of income as well as the Addiction Severity Index. Results indicate that completers of the treatment program were more likely to be working post-discharge than non-completers. Similarly, the longer the length of stay in the program, the more likely the client was to be working post-discharge. Multivariate analysis indicates a high-school education, participation in the treatment center's aftercare program, and treatment duration of more than one year were independently related to work status. These data suggest that as welfare reform becomes a reality, continuing support of various types, particularly drug treatment, is needed to assist substance-abusing women in gaining and maintaining employment.

Effects of migration on cancer incidence and resources for prevention and treatment in Florida.

Migration adds a complex dimension to the task of those who plan and allocate resources for health care. The authors offer a methodology for estimating the contribution of migration to the incidence of cancer, allow for age- and sex-specific cancer risks, and estimate, by country, the impact of recent migration on the annual incidence of cancer in Florida. Cancer and migration data were used to develop estimates of the number of cancer cases for Florida counties that were attributable to recent migrants. A net gain and loss ratio was calculated for new cancer cases in 1980 resulting from the 1975-80 migration pattern. Florida data was used because that State has one of the highest crude cancer incidence rates in the nation, is one of the most populous States, and has a population growth from migration rather than from natural increase. Preliminary findings on the relationship between cancer health services resources and net cancer rates from migration are discussed. County cancer health services resources had a strong positive relationship to population size, but the impact of migration on cancer incidence was in a curvilinear relationship to population size.

HIV-1 heterogeneity and cytokines. Neuropathogenesis.

Mild manifestations (HIV-1 associated minor cognitive/motor disorder), severe manifestations (HIV-1 associated dementia complex and HIV-1 associated myelopathy), and sensory neuropathy are consequences of HIV-1 infection. Our goal is to elucidate the role of HIV-1 in the complications of AIDS including cytokine immunopathology and HIV-1 DNA sequence variants. We have examined the brain and sensory ganglia from 60 AIDS patients and 20 seronegative controls using PCR, DNA sequencing of the HIV-1 envelope protein (env), in situ hybridization (ISH), and immunohistochemistry (IHC). Using our combined ISH-IHC technique, we could identify different types of cells and HIV-1 simultaneously in cryostat and paraffin sections. We found HIV-1 predominantly in macrophage/microglia in brain. In dorsal root ganglia (DRG) we found rare macrophages infected with HIV-1 and neurons and interstitial cells (including macrophages) which were apoptotic. Cytokines were detected in mononuclear and endothelial cells near neurons. We achieved single copy sensitivity detecting HIV-1 in nervous tissue using nested PCR. We sequenced HIV-1, DNA from 3 intravenous drug users (IDUs): from brain, CSF, and blood. PCR amplification was followed by cloning and then sequencing the HIV-1 insert: V1-V5 regions of the envelope (env) gene. We found that the env genes had increased sequence variation compared to the literature, cDNA sequences derived from RNA were less heterogeneous than clones derived from DNA from the same specimens, clones derived from brain are more closely related (show restricted heterogeneity) compared to clones from blood and CSF from the same patients. Patient 149 clones we examined to date did not correspond to any of the designated subtypes (A-F) of HIV-1 based on the DNA sequences of the C2-V3 regions. Finally, the HIV-1 RNA produced in these tissues is derived from a minority of DNA clones. Although HIV-1 infected macrophages are not entirely responsible for pathology in the brain and less so in sensory ganglia, some of the products of infection, cytokines, are more widespread in these tissues. Furthermore, HIV-1 strains infecting the brain appear to exhibit restricted heterogeneity compared to autologous CSF and blood and these strains may be associated with cytokines and pathology. HIV-1 strains that infect nervous tissue and cytokines produced in this tissue may effect neuropathogenesis, in vivo, in spite of low levels of local HIV-1 infection. We attempt to delineate, here, common sequence variations in HIV-1 isolates in the hope of developing future therapeutic strategies.

The association between cigarette smoking and drug abuse in the United States.

Cigarette smoking has been identified as an independent risk factor for many human diseases. However, the association between cigarette smoking and illegal drug use has not been thoroughly investigated. We have analyzed the 1994 National Household Survey on Drug Abuse to clarify whether cigarette smoking has any effect on the initiation of illegal drug use. Data from 17,809 respondents completing the 1994 "new" (1994-B) questionnaire were analyzed. Logistic regression analyses were performed with the use of statistical package SUDAAN, taking into consideration the multistage sampling design. The results show that those who had smoked cigarettes were far more likely to use cocaine (OR = 7.5; 95% CI: 5.7-9.9), heroin (OR = 16.0; 95% CI: 6.8-37.9), crack (OR = 13.9; 95% CI: 7.9-24.5) and marijuana (OR = 7.3; 95% CI: 6.2-8.7). The associations are consistent across age-strata and remain after adjusting for race and gender. This study suggests that cigarette smoking may be a gateway drug to illegal drug use.

Injection drug users' practices and attitudes toward intervention and potential for reducing the transmission of HIV.

Miami is one of the major centers of illegal drug activity and has a significant proportion of AIDS cases among injection drug users (IDUs). Since Needle Exchange Programs (NEP) are illegal and therefore do not exist in the state of Florida, other strategies must play a large role in reducing the transmission of HIV among IDUs. In order to effectively communicate with IDUs about needle safety, it is necessary to understand the practices and culture of IDUs, including where and how the needle/syringes are obtained and used. Data from recent studies conducted in Miami and other local sites indicate that IDUs inject frequently, averaging more than 1,000 per year, per person. While the vast majority of IDUs feel it is very important to clean needles and to use a needle only one time, these sentiments are not always practiced. Furthermore, data indicate that the context where shooting takes place must be considered in the planning of HIV risk reduction interventions. These findings suggest the importance of understanding patterns of drug use, attitudes toward intervention, and the cultural context where risky behaviors occur. Although Needle Exchange Programs are illegal in Florida, intervention programs must still stress the importance of using only new needles, but since new needles cannot always be obtained, IDUs should be taught and motivated not to use contaminated drug paraphernalia.

Problem drinking, health services utilization, and the cost of medical care.

The purpose of this study was to examine the relationships between problem drinking, health services utilization, and the cost of medical care in a community-based setting. In addition to descriptive analyses, these relationships were estimated with multivariate regression models. Data were collected in 1996 and 1997 through a standardized self-administered questionnaire designed to obtain important information on demographics, health status, morbidity, health care utilization, drug and alcohol use, and related lifestyle behaviors. The survey instrument also included the 10-item Michigan Alcoholism Screening Test (MAST-10), which was used to identify problematic alcohol users (PAUs). The empirical findings indicated that PAUs had a significantly higher number of outpatient visits, more emergency room episodes, and more admissions to a hospital than a combined group of nondrinkers and nonproblematic alcohol users (NPAUs). Analyses of total health care cost showed that the estimated differential in total cost for PAUs during the past year, including the interaction effect with problematic drug use, was $367. The total cost (full effect) for PAUs was composed of a main effect ($984) and an interaction effect (-$617). These findings have implications for substance abuse interventions and health care policy.

Crack use and correlates of use in a national population of street heroin users. The National AIDS Research Consortium.

Traditionally, researchers and clinicians have viewed street heroin users as representing an end point in a drug-using career. It is toward this population that major national treatment efforts have been directed. Concomitant with the historical national concern about heroin use has been concern about the increase in crack cocaine use. There has been speculation that crack use may have become a substitute for the higher risk of heroin injection. This article examines the impact of crack use in a national population of heroin users. It was consistently found that there was a correlation between the frequency of crack use and the frequency of speedballing as well as the use of other forms of cocaine, amphetamines, and marijuana. There was also a positive relationship between frequency of crack use and such HIV risk behaviors as renting needles and having a large number of sex partners. The data suggest that in this population of heroin users, crack is not a substitute for heroin but rather is a part of a drug-use pattern that includes an increased use of other drugs and increased high-risk behaviors for contracting HIV.

Crack cocaine use and sexual activity in Miami, Florida.

Data are analyzed from the Multicenter Study of Crack Cocaine and HIV Infection in Miami, Florida, examining interrelationships among use of crack cocaine, use of other drugs, sexual activity, and exchange of sex for money and drugs. This study was designed to recruit two groups of approximately equal size: persons who reported current use of crack cocaine three or more times per week, and those who had never used crack. Participants (N = 641) were recruited in Miami. Participants' median age for first use of crack cocaine was higher than for use of alcohol, marijuana or powdered cocaine. It was also higher than participants' ages at first sexual activity, and somewhat higher than the median age for reporting initiation of trading sex for money or drugs. The median age of first crack use was lower among younger participants, suggesting that crack use in older participants followed quickly upon availability of the drug. Crack users reported reduced desire for sex and diminished ability to have sex after smoking crack. However, crack use was associated with increased sexual activity, trading sex for money or drugs, and sex with multiple partners. Participants who traded sex for money or drugs (traders) reported higher rates of condom use than nontraders; however, neither traders nor nontraders reported rates of condom use sufficient to substantially reduce the transmission of sexually transmitted diseases and HIV infection.

Implementation of a family-centered treatment program for substance-abusing women and their children: barriers and resolutions.

Recent federal health financing and health care delivery programs have increased access to alcohol and other drug abuse treatment programs for low-income women, and have provided intervention and prevention services for their children and families. The Village South Families in Transition (FIT) in Miami, Florida, implemented a residential treatment program for women and their children that aims to decrease alcohol and other drug use, reduce reliance on social and health welfare systems, improve functioning in specific life-skill and vocational areas, improve parenting techniques and maternal/child relations, and provide intervention and prevention services for the clients' children in a safe and supportive environment. Program implementation required resolutions to numerous barriers, including securing a facility for women and children; recruiting, hiring and training of staff; establishing and maintaining community linkages; treatment considerations; balancing treatment versus evaluation/research; and critical decisions faced by treatment staff as they modify client-centered programs to incorporate gender-specific and family-centered programs.

HIV-related risk behaviors and seropositivity among homeless drug-abusing women in Miami, Florida.

This article examines the multifaceted interactions among homelessness, HIV, substance abuse, and gender. Data were collected on 1,366 chronic drug users using a nationally standardized validated instrument within the Miami CARES project of a multisite federally funded program. HIV testing accompanied by pretest and posttest counseling was conducted on-site by certified phlebotomists and counselors. In addition to descriptive analyses and corresponding tests of significance, logistic regression analyses were used to clarify the complex associations between the outcome variables of homelessness and HIV, recognizing difficulties of determining temporal sequence. HIV infection was found to be 2.35 times more prevalent among homeless women than homeless men and significantly higher for homeless women. The findings indicate that among women, homelessness and HIV have a highly interactive effect increasing the vulnerability of this population and thus rendering them an extremely important priority population on which to focus public health efforts and programs.

Adoption of injection practices in heroin users in Guangxi Province, China.

This preliminary study collected data from 326 heroin users in Guangxi Province, China, in 1997. Logistic regression analysis was performed to identify the risk factors for injection. Survival analysis identified factors independently associated with time from initiation of heroin use to adoption of injection. Four factors were independently associated with injection: number of friends who used heroin in the last year, duration of heroin use, dose of heroin consumed, and total number of times detoxified in drug treatment and rehabilitation centers. Only gender and duration of heroin use were independently associated with time to first injection. Median time to first injection was 11 months for males and 22 months for females. Median time to first injection varied by age. Median time to injection for those who used heroin for more than one year was 8.1 months; it was 19.1 months for on to five years of use, and 40.5 months for more than five years of use. This study's preliminary findings suggest that younger, more recent heroin users, and males are at increased risk of becoming injectors, a major risk behavior for HIV acquisition.

High-risk sex behavior among young street-recruited crack cocaine smokers in three American cities: an interim report. The Multicenter Crack Cocaine and HIV Infection Study Team.

Since crack cocaine appeared in urban areas in the United States in the mid-1980s, reports have suggested that crack smokers may be at increased risk of sexually transmitted diseases (STDs), including infection with HIV, because they have multiple sex partners, trade sex for money or drugs, and rarely use condoms. A cross-sectional survey is being conducted in urban neighborhoods in Miami, New York and San Francisco--where crack use is common--to explore these issues. Indigenous street outreach workers are recruiting men and women who are either current regular crack smokers or who have never smoked crack; each group is further stratified according to whether participants had ever injected drugs. Participants were interviewed about their sexual and drug-use practices. Overall, crack smokers, whether injectors or not, engaged in higher-risk sexual behaviors than nonsmokers, reported greater numbers of sex partners than nonsmokers, and were more likely than nonsmokers to have exchanged sex for money or drugs or to have had an STD. Differences between crack smokers and nonsmokers were generally greater among non-injectors than among injectors, and generally greater among women than among men. Condom use, although somewhat more common with paying than nonpaying partners, was infrequent overall. Most of the subjects had not been in substance abuse treatment in the preceding 12 months, and a majority had never been in substance abuse treatment. Education and prevention programs specifically targeted at crack smokers not currently in substance abuse treatment are needed to reach these high-risk persons.

Sex, drugs, and the spread of HIV/AIDS in Belle Glade, Florida.

Belle Glade, Florida, an agricultural community in the heart of the state's vegetable and sugar cane production areas, has the highest cumulative per capita incidence of AIDS in the United States. A risk reduction intervention program was introduced to lessen unsafe AIDS-related behaviors and to generate data on the epidemiology of HIV infection. Initial attention focused on individuals who were believed to be at the core of the transmission pattern, injection drug users and their sexual partners. We found, however, that injection drug use was much less widespread than anticipated. Results suggested that the primary mode of HIV transmission is heterosexual intercourse-mediated by drug taking (particularly crack smoking) and a flourishing sex industry-a finding that is corroborated by the increased and disproportionate rate of heterosexual AIDS in Belle Glade. The prevalence and types of risk behaviors engaged in would not have been completely explained without the use of ethnographic methods including observation of, and lengthy interviews with, the populations at risk.