Benjamin P. Bowser

High-Risk Sex Behavior Among Young Street-Recruited Crack Cocaine Smokers in Three American Cities: An Interim Report

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.

Crack cocaine smokers who turn to drug injection: characteristics, factors associated with injection, and implications for HIV transmission

A survey of 1220 street-recruited crack cocaine smokers revealed that crack smokers may turn to drug injection to ease crack withdrawal. Crack smokers who later injected tended to smoke crack more heavily and for longer periods than those who did not inject. The initiation of injection was significantly associated with ever snorting heroin (prevalence ratio [PR] = 3.4, 95% confidence interval [CI] = 2.0-5.9) or snorting heroin specifically while smoking crack (PR = 2.3, 95% CI = 1.3-4.0), suggesting that snorted heroin use may mediate the transition to injection among crack smokers. Programs to prevent and treat crack dependence may prevent later injection and injection-related infections including HIV.

Prevention of HIV Infection in Street-Recruited Injection Drug Users

Background: Injection drug users (IDUs) and their sex partners account for an increasing proportion of new AIDS and HIV cases in the United States, but public debate and policy regarding the effectiveness of various HIV prevention programs for them must cite data from other countries, from non‐street‐recruited IDUs already in treatment, or other programs, and from infection rates for pathogens other than HIV. Methods: Participants were recruited from the street at six sites (Baltimore [Maryland], New York [two sites], Chicago [Illinois], San Jose [California], Los Angeles [California], and at a state womens correctional facility [Connecticut]), interviewed with a standard questionnaire, and located and reinterviewed at one or more follow‐up visits (mean, 7.8 months later). HIV serostatus and participation in various programs and behaviors that could reduce HIV infection risk were determined at each visit. Results: In all, 3773 participants were recruited from the street, and 2306 (61%) were located and interviewed subsequently. Of 3562 initial serum specimens, 520 (14.6%) were HIV‐seropositive; at subsequent assessment, 19 people, all from the East Coast and Chicago, had acquired HIV. Not using previously used needles was substantially protective against HIV acquisition (relative risk [RR], 0.29; 95% confidence interval [CI], 0.11‐0.80 ) and, in a multivariate model, was significantly associated with use of needle and syringe exchange programs (adjusted odds ratio [ORadj], 2.08; 95% CI, 1.15‐3.85). Similarly, reduction of injection frequency was very protective against seroconversion (RR, 0.33; 95% CI, 0.14‐0.80), and this behavior was strongly associated with participation in drug treatment programs (ORadj, 3.54; 95% CI, 2.50‐5.00). In a separate analysis, only 37.5% of study‐participants had sufficient new needles to meet their monthly demand. Conclusions: In this large multicity study of IDUs in the United States, several HIV prevention strategies appeared to be individually and partially effective; these results indicate the continued need for, and substantial gaps in, effective approaches to preventing HIV infection in drug users.

Background to Crack Cocaine Addiction and HIV High-Risk Behavior: The Next Epidemic

BACKGROUND Increasing rates of sexually transmitted diseases among users of noninjection drugs prompt speculation that crack cocaine users who do not inject are at particularly high risk of HIV (human immunodeficiency virus) infection. METHODS A street recruitment technique was employed to enroll 331 primarily African-American men aged 18-29 in an area of San Francisco where crack cocaine is sold openly. One-half were regular crack users and the other half had never used the drug. Few reported injection drug use or male-to-male sex. In a face-to-face interview, participants reported on their drug use, knowledge of HIV, sexual practice, condom use, and demographic characteristics. Following counseling, each was tested for HIV and syphilis. RESULTS Comparisons showed that demographically similar, crack users reported more sexual partners in the last 12 months, more sexually transmitted diseases (STDs) in their lifetime, and greater frequencies of paying for sex, exchanging sex for drugs, and having sex with injection drug users. Users reported greater current depression, anxiety, and social isolation. They reported earlier initiation into alcohol use and less positive parenting experiences during their adolescence. CONCLUSION These results are consistent with findings that report the comorbidity of drug abuse and mental illness. Implications are drawn for reducing HIV infection among this high-risk population for early adolescent, community mental health, and substance abuse treatment programs.

Drug Treatment Effectiveness: African-American Culture in Recovery

Abstract African-Americans are overrepresented among drug abusers in the United States when compared to European-Americans, and have lower rates of recovery from drug addiction after treatment. There has been no comprehensive research to date to specifically explain either this overrepresentation or lower rates of recovery among African-Americans. In this anicle, it is suggested that one reason for this lack of attention is due to the failure of drug abuse treatment providers and researchers to see race as a cultural rather than physical phenomenon. The point is made that cultural factors are intrinsic to successful effons to address drug abuse among African-Americans. Several historic African-American coping strategies are outlined and shown to be powerful factors in client addictive behavior and barriers to recovery. Through case studies of clients who were successful in their effon to recover, the necessity to address cultural as well as personal issues is shown to be vital to successful recovery among African-Americans.

The social dimensions of the AIDS epidemic: a sociology of the AIDS epidemic

Concentrates on HIV/AIDS prevention practitioners and how the AIDS epidemic can be recognized in such a way as to influence individuals to assist in prevention. Highlights how the gay community, in particular, have managed to reduce deaths and infection but that the newer members of the community seem to be falling by the wayside now. Discusses social and psychological theories involved in the fight in AIDS prevention. States that in the USA the effective interventions being discontinued are the poorly funded or not at all. Concludes the fight against AIDS through publicity and knowledge must go on.

External Influences on Drug Treatment Interventions: East Palo Altoʼs Free-at-Last

External influences on community-based drug treatment program outcomes have not been adequately accounted by either treatment providers or evaluators. In 2001–2003, a cohort of 197 African American and Latino crack cocaine and heroin users was interviewed at intake into the Free-at-Lasts treatment program in East Palo Alto, California. Objective:The goal of this research was to identify, and then measure, the impact of a series of theory-based, hypothesized external influences on 3 client treatment outcomes: (1) program completers, (2) dropouts, and (3) referrals to more intensive inpatient treatment. Methods:All program clients were interviewed using the Government Performance and Results Act and the California Alcohol and Drug Data System questionnaires. Supplemental questions hypothesized the external influences and were based on prior research and staff focus groups. Results:There were statistically significant differences in treatment outcomes based on employment status, homelessness, living situation, and jail time. Regression analyses indicated that the strongest outcome predictors were treatment intensity, followed by prior crack use, homelessness, income, and number of illegal drugs used. Path analysis showed that former crack use and time in jail formed a particularly strong cluster of external influences on treatment outcomes. This cluster was the result of court-mandated treatment of arrested crack users who chose treatment over incarceration. If users failed treatment, they went back to jail. In a community such as East Palo Alto, court-mandated referrals had a powerful external influence on treatment and, therefore, need to be considered when evaluating a treatment program.

Harm Reduction for Drug Abusing Ex-Offenders: Outcome of the California Prevention and Education Project MORE Project

MORE was a mobile outreach drug abuse prevention and HIV harm reduction program primarily for ex-offenders who are active drug users. Through case management, clients were provided substance abuse education, counseling, and referral. Long term goals of these services were to reduce their drug use and re-incarceration for drug related crimes. From January 2002 to May 2006, 487 unduplicated clients were recruited in year long cohorts and offered services. The program evaluation tool was the Federal Office of Budget and Management Government Performance and Results Act questionnaire. Government Performance and Results Act interviews were conducted at in-take into the program, approximately six months later and again approximately 12 months after their initial in-take. By the six and 12 month follow-up interviews, active drug using clients reported significant reductions in their use of alcohol, cocaine/crack, heroin, and fewer sex partners and crimes. Program completers reported significantly reduced cocaine/crack and heroin use as well as fewer days in jail and crimes than non-completers (p < .01 to .001). Six program components account for these reductions: case management, day-treatment, outpatient services, outreach, HIV/AIDS, and substance abuse education. The differences in program service intensity, income, and employment for program completers and non-completers were analyzed using logistic regression. The intensity of case management and all services received along with having higher income by month six were the most significant predictors of program completion.

Drug Treatment Clients and Their Community Peers: How They Differ

Free-at-Last is a drug treatment program in East Palo Alto, California, a low-income predominantly African American community in Silicon Valley. In this research, a cohort of treatment clients was compared to a random sample of community residents. Both groups used drugs. Two-way analysis of variance was used to identify factors that predicted the number of drugs used, controlling for client or community sample status. Significant predictors turned out to be perception of race discrimination, ever selling drugs, contact with the police, the number of relatives who died suddenly as a juvenile, ever having thoughts of suicide, and marital status. Path analysis was used to show the relationship between predictors of the number of drugs used for treatment clients; a second path was done for community clients. By comparing each path analysis, we were able to show how treatment clients arrived at significantly higher drug use than peers in the community.

Fighting drug and alcohol abuse in communities and improving race relations: Theoretical lessons learned

In 1989 the Robert Wood Johnson (RWJ) Foundation began a