Alex H. Kral

Sexual transmission of HIV-1 among injection drug users in San Francisco, USA: risk-factor analysis

BACKGROUND Many new HIV-1 infections in the USA occur in injection drug users (IDUs). HIV-1seroconversion of IDUs is mainly associated with injection-related risk factors. Harm- reduction programmes concentrate on injection-risk behaviour. We aimed to establish whether injection or sexual risk factors, or both, were associated with HIV-1antibody seroconversion of street-recruited IDUs in San Francisco, from 1986 to 1998. METHODS IDUs were enrolled every 6 months from four community sites. We did a nested case-control study comparing 58 respondents who seroconverted between visits with 1134 controls who remained seronegative. Controls were matched with cases by sex and date. Adjusted odds ratios and 95% CI were calculated for men and women by use of conditional logistic regression. FINDINGS Men who had sex with men were 8.8 times as likely to seroconvert (95% CI 3.7-20.5) as heterosexual men. Women who reported having traded sex for money in the past year were 5.1 times as likely as others to seroconvert (95% CI 1.9-13.7). Women younger than 40 years were more likely to seroconvert than those 40 years or older (2.8 [1.05-7.6]), and women who reported having a steady sex-partner who injected drugs were less likely to seroconvert than other women (0.32 [0.11-0.92]). INTERPRETATION HIV-1 seroconversion of street-recruited IDUs in San Francisco is strongly associated with sexual behaviour. HIV-1risk might be reduced by incorporation of innovative sexual-risk-reduction strategies into harm-reduction programmes.

High Prevalence of Abscesses and Cellulitis Among Community-Recruited Injection Drug Users in San Francisco

The prevalence of and risk factors for abscesses and cellulitis were investigated among a community sample of injection drug users (IDUs). Participants were interviewed, and those with symptoms were examined. Of 169 IDUs, 54 (32%) had abscesses (n=35), cellulitis (n=5), or both (n=14); 27% had lanced their own abscesses; and 16% had self-treated with antibiotics they purchased on the street. IDUs who skin-popped (injected subcutaneously or intramuscularly) were more likely to have an abscess or cellulitis than those who had injected only intravenously (odds ratio, 4.9; 95% confidence interval, 2.2-11). The likelihood of abscesses and cellulitis increased with frequency of skin-popping and decreased with increasing duration of injection drug use. Abscesses are extremely prevalent among IDUs in San Francisco. Skin-popping is a major risk factor, and self-treatment is common.

The Effect of Syringe Exchange Use on High-Risk Injection Drug Users: A Cohort Study

Objective:To determine whether syringe exchange program use is associated with cessation of syringe sharing among high-risk injection drug users. Design and methods:Between 1992 and 1996, street-recruited injection drug users were interviewed and received HIV testing and counseling semi-annually, as part of a dynamic cohort study. We examined a cohort of 340 high-risk injection drug users for whom two observations, 6-months apart, were available and who reported syringe sharing at the first interview. Multivariate logistic regression analysis was performed to determine the relationship between syringe exchange program use and cessation of syringe sharing, while controlling for confounding factors. Results:At follow-up interview, 60% (204 of 340) reported quitting syringe sharing. High-risk injection drug users who began using the syringe exchange program were more likely to quit sharing syringes [adjusted odds ratio (AOR), 2.68; 95% confidence interval (CI), 1.35–5.33], as were those who continued using the syringe exchange program (AOR,1.98; 95% CI, 1.05–3.75) in comparison with non-syringe exchange program users, while controlling for confounding factors. Conclusions:The initiation and continuation of syringe exchange program use among high-risk injection drug users is independently associated with cessation of syringe sharing. Syringe exchange program use can be an important component in reducing the spread of blood-borne infectious diseases among high-risk injection drug users.

Predictors and Prevention of Nonfatal Overdose Among Street-Recruited Injection Heroin Users in the San Francisco Bay Area, 1998–1999

OBJECTIVES This study sought to determine prevalence of and risk factors for nonfatal recent overdose among street-recruited injection heroin users. METHODS From August 1998 through July 1999, 1427 heroin injectors were recruited from 6 inner-city neighborhoods in the San Francisco Bay Area, Calif, and interviewed. Factors hypothesized to be associated with recent overdose were analyzed with logistic regression. RESULTS Of the 1427 participants, 684 (48%) had had an overdose, 466 (33%) had experienced 2 or more overdose events, and 182 (13%) had had a recent overdose. In multiple logistic regression, being younger (adjusted odds ratio [OR] for each year of increasing age = 0.95; 95% confidence interval [CI] = 0.94, 0.97), having been arrested 3 or more times in the past year (adjusted OR = 2.50; 95% CI = 1.61, 3.87), drinking 4 or more alcoholic drinks per day (adjusted OR = 2.05; 95% CI = 1.37, 3.05), and having participated in methadone detoxification during the past year (adjusted OR = 1.47; 95% CI = 1.03, 2.09) were independently associated with recent overdose. Being homeless; identifying as gay, lesbian, bisexual, or transgender; having spent 5 or more years in prison or jail; and having engaged in sex work also were associated with recent overdose. CONCLUSIONS Targeted interventions that decrease risk for overdose are urgently needed.

Suicidal behavior and sexual/physical abuse among street youth

OBJECTIVE To examine the relationship between home life risk factors and suicide attempts among homeless and runaway street youth recruited from both shelters and street locations in Denver, CO; New York City; and San Francisco, CA. METHOD Street youth 12-19 years old (N = 775) were recruited by street outreach staff in Denver, New York City and San Francisco in 1992 and 1993 and interviewed. Cross-sectional, retrospective data were analyzed to examine the relationship between suicide attempts and antecedent home life variables. Logistic regression was used to identify factors predicting suicide attempts. RESULTS Forty-eight percent of the females and 27% of the males had attempted suicide. The mean number of suicide attempts was 6.2 (SD = 12.9) for females and 5.1 for males (SD = 7.6). Among females, 70% reported sexual abuse and 35% reported physical abuse. Among males, 24% reported sexual abuse and 35% reported physical abuse. Sexual and physical abuse before leaving home were independent predictors of suicide attempts for females and males. Other home life factors hypothesized to be risk factors for suicide attempts were not significant. Interaction terms were not significant. Among street youth who were sexually or physically abused in this sample, the odds of attempting suicide were 1.9 to 4.3 times the odds of attempting suicide among those not sexually or physically abused. CONCLUSIONS Interventions attempting to reduce risky behaviors in this population must include assessments of suicidal behaviors as well as components for assisting youth in dealing with the behavioral and emotional sequelae of physical and sexual abuse.

Naloxone Distribution and Cardiopulmonary Resuscitation Training for Injection Drug Users to Prevent Heroin Overdose Death: A Pilot Intervention Study

Fatal heroin overdose has become a leading cause of death among injection drug users (IDUs). Several recent feasibility studies have concluded that naloxone distribution programs for heroin injectors should be implemented to decrease heroin overdose deaths, but there have been no prospective trials of such programs in North America. This pilot study was undertaken to investigate the safety and feasibility of training injection drug using partners to perform cardiopulmonary resuscitation (CPR) and administer naloxone in the event of heroin overdose. During May and June 2001, 24 IDUs (12 pairs of injection partners) were recruited from street settings in San Francisco. Participants took part in 8-hour training in heroin overdose prevention, CPR, and the use of naloxone. Following the intervention, participants were prospectively followed for 6 months to determine the number and outcomes of witnessed heroin overdoses, outcomes of participant interventions, and changes in participants’ knowledge of overdose and drug use behavior. Study participants witnessed 20 heroin overdose events during 6 months follow-up. They performed CPR in 16 (80%) events, administered naloxone in 15 (75%) and did one or the other in 19 (95%). All overdose victims survived. Knowledge about heroin overdose management increased, whereas heroin use decreased. IDUs can be trained to respond to heroin overdose emergencies by performing CPR and administering naloxone. Future research is needed to evaluate the effectiveness of this peer intervention to prevent fatal heroin overdose.

HIV seroprevalence among street-recruited injection drug and crack cocaine users in 16 US municipalities.

OBJECTIVES This study deter- mined human immunodeficiency virus (HIV) seroprevalence and factors associated with HIV infection among street-recruited injection drug users and crack cocaine smokers. METHODS An analysis was performed on HIV serologies and risk behaviors of 6402 injection drug users and 3383 crack smokers in 16 US municipalities in 1992 and 1993. RESULTS HIV seroprevalence was 12.7% among injection drug users and 7.5% among crack smokers. Most high-seroprevalence municipalities (>25%) were located along the eastern seaboard of the United States. In high-seroprevalence municipalities, but not in others, HIV seroprevalence was higher for injection drug users than for crack smokers. Among injection drug users, cocaine injection, use of speedballs (cocaine or amphetamines with heroin), and sexual risk behaviors were independently associated with HIV infection. Among crack smokers, sexual risk behaviors were associated with HIV infection. CONCLUSIONS Injection drug users and crack smokers are at high risk for HIV infection.

Impact of law enforcement on syringe exchange programs: A look at Oakland and San Francisco

Drug paraphernalia and prescription laws make syringe exchange programs (SEPs) illegal in most states in the U.S. Nonetheless, SEPs have been started in 25 states and the District of Columbia as of September 1995. In some states like California and New Jersey, SEPs have operated despite police arrest of volunteers and clients. We examine the impact of police action and threat on SEPs by comparing an underground syringe exchange site (SES) in West Oakland to a tolerated SES in the Fillmore neighborhood of San Francisco. The following data sources are utilized: demographic and service utilization data from Alameda County Exchange (ACE) in West Oakland and Prevention Point Needle and Syringe Exchange (PPNSE) in the Fillmore, San Francisco; demographic and syringe exchange utilization information collected from street-recruited samples of injection drug users (IDUs) in West Oakland and the Fillmore; and participant observation of SES in these two communities. We found that police action and the threat of police action in West Oakland decreased utilization of SEP by IDUs, limited the number and diversity of volunteers at SES, and inhibited the operation and expansion of SEP.

Fatal Heroin-Related Overdose in San Francisco, 1997-2000: a Case for Targeted Intervention

Heroin-related overdose is the single largest cause of accidental death in San Francisco. We examined demographic, location, nontoxicological, and toxicological characteristics of opiate overdose deaths in San Francisco, California. Medical examiner’s case files for every opioid-positive death from July 1, 1997, to June 30, 2000, were reviewed and classified as overdose deaths or other. Demographic variables were compared to two street-based studies of heroin users and to census data. From 1997 to 2000, of all heroin-related overdoses in San Francisco 47% occurred in low-income residential hotels; 36% occurred in one small central area of the city. In 68% of deaths, the victim was reportedly alone. When others were present between last ingestion of heroin and death, appropriate responses were rare. In three cases, police arrested the person who called emergency services or others present on the scene. We recommend the development of overdose response training targeted at heroin users and those close to them, including the staff of residential hotels.

Overdose Prevention and Naloxone Prescription for Opioid Users in San Francisco

Opiate overdose is a significant cause of mortality among injection drug users (IDUs) in the United States (US). Opiate overdose can be reversed by administering naloxone, an opiate antagonist. Among IDUs, prevalence of witnessing overdose events is high, and the provision of take-home naloxone to IDUs can be an important intervention to reduce the number of overdose fatalities. The Drug Overdose Prevention and Education (DOPE) Project was the first naloxone prescription program (NPP) established in partnership with a county health department (San Francisco Department of Public Health), and is one of the longest running NPPs in the USA. From September 2003 to December 2009, 1,942 individuals were trained and prescribed naloxone through the DOPE Project, of whom 24% returned to receive a naloxone refill, and 11% reported using naloxone during an overdose event. Of 399 overdose events where naloxone was used, participants reported that 89% were reversed. In addition, 83% of participants who reported overdose reversal attributed the reversal to their administration of naloxone, and fewer than 1% reported serious adverse effects. Findings from the DOPE Project add to a growing body of research that suggests that IDUs at high risk of witnessing overdose events are willing to be trained on overdose response strategies and use take-home naloxone during overdose events to prevent deaths.