Benny Jose

HIV incidence among injecting drug users in New York City syringe-exchange programmes

BACKGROUND There have been no studies showing that participation in programmes which provide legal access to drug-injection equipment leads to individual-level protection against incident HIV infection. We have compared HIV incidence among injecting drug users participating in syringe-exchange programmes in New York City with that among non-participants. METHODS We used meta-analytic techniques to combine HIV incidence data from injecting drug users in three studies: the Syringe Exchange Evaluation (n = 280), in which multiple interviews and saliva samples were collected from participants at exchange sites; the Vaccine Preparedness initiative cohort (n = 133 continuing exchanges and 188 non-exchangers, in which participants were interviewed and tested for HIV every 3 months; and very-high-seroprevalence cities in the National AIDS Demonstration Research (NADR) programme (n = 1029), in which street-recruited individuals were interviewed and tested for HIV every 6 months. In practice, participants in the NADR study had not used syringe exchanges. FINDINGS HIV incidence among continuing exchange-users in the Syringe Exchange Evaluation was 1.58 per 100 person-years at risk (95% CI 0.54, 4.65) and among continuing exchange-users in the Vaccine Preparedness Initiative it was 1.38 per 100 person-years at risk (0.23, 4.57). Incidence among non-users of the exchange in the Vaccine Preparedness Initiative was 5.26 per 100 person-years at risk (2.41, 11.49), and in the NADR cities, 6.23 per 100 person-years at risk (4.4, 8.6). In a pooled-data, multivariate proportional-hazards analysis, not using the exchanges was associated with a hazard ratio of 3.35 (95% CI 1.29, 8.65) for incident HIV infection compared with using the exchanges. INTERPRETATION We observed an individual-level protective effect against HIV infection associated with participation in a syringe-exchange programme. Sterile injection equipment should be legally provided to reduce the risk of HIV infection in persons who inject illicit drugs.

Sociometric risk networks and risk for HIV infection.

OBJECTIVES This study examined whether networks of drug-injecting and sexual relationships among drug injectors are associated with individual human immunodeficiency virus (HIV) serostatus and with behavioral likelihood of future infection. METHODS A cross-sectional survey of 767 drug injectors in New York City was performed with chain-referral and linking procedures to measure large-scale (sociometric) risk networks. Graph-theoretic algebraic techniques were used to detect 92 connected components (drug injectors linked to each other directly or through others) and a 105-member 2-core within a large connected component of 230 members. RESULTS Drug injectors in the 2-core of the large component were more likely than others to be infected with HIV. Seronegative 2-core members engaged in a wide range of high-risk behaviors, including engaging in risk behaviors with infected drug injectors. CONCLUSIONS Sociometric risk networks seem to be pathways along which HIV travels in drug-injecting peer groups. The cores of large components can be centers of high-risk behaviors and can become pockets of HIV infection. Preventing HIV from reaching the cores of large components may be crucial in preventing widespread HIV epidemics.

High-risk personal networks and syringe sharing as risk factors for HIV infection among new drug injectors.

In a cross-sectional study of 174 new injecting drug users (IDUs) in New York City who had injected for < or = 6 years, we examined whether those who both share syringes and have personal risk networks that include high-risk injectors are particularly likely to be infected with HIV. Subjects were street recruited between July 1991 and January 1993, were interviewed about their risk behaviors in the prior 2 years and their personal risk networks with other IDUs in the prior 30 days, and were tested for HIV; 20% were HIV seropositive. Among those who both shared syringes and had a personal risk network member who injected more than once a day, 40% were HIV seropositive (versus 14% for others, p < 0.001). In simultaneous multiple logistic regression, the interaction of both sharing syringes and having a personal risk network member who injected more than once a day remained independently and significantly associated with being HIV seropositive (OR, 3.57; 95% CI, 1.22, 10.43; p < 0.020), along with Latino race/ethnicity and exchanging sex for money or drugs. These findings suggest that the combination of sharing syringes with having a high-risk personal network is a risk factor for HIV infection among new IDUs. Studies of risk factors for HIV infection among new IDUs and interventions to reduce the spread of HIV among them should focus on their risk networks as well as their risk behaviors.

Syringe-mediated drug-sharing (backloading) : a new risk factor for HIV among injecting drug users

Background:In syringe-mediated drug-sharing (backloading), injecting drug users (IDU) use their syringes to mix drugs and to give measured shares to other IDU by squirting drug solution into the syringes of other IDU. Backloading has been discussed as a potential HIV risk factor, but its role as an HIV transmission route has not been established empirically. Methods:Six hundred and sixty IDU who had injected drugs in the previous 2 years were street-recruited from Bushwick, New York City through chain referral, tested for HIV antibody and interviewed about sexual and drug-risk behaviors. Results:Receiving drugs via backloading in the previous 2 years was reported by 24.5% of the subjects. These subjects had significantly higher HIV seroprevalence than those who did not receive drugs by backloading (odds ratio, 2.2; 95% confidence interval, 1.5–3.1). Backloading remained positively and significantly associated with HIV seropositivity in stepwise logistic regression, and in a series of simultaneous logistic models controlling for sociodemographic variables and for sexual and drug risk variables. Conclusions:Backloading can be a route of HIV transmission among IDU and should be incorporated into risk-factor studies and HIV transmission modeling. Many IDU who avoid other high-risk drug-injection practices may overlook the risk of backloading. HIV prevention programs should warn IDU against syringe-mediated drug-sharing and work together to develop ways to avoid it. AIDS 1993, 7:1653–1660

Syringe-mediated drug sharing among injecting drug users: Patterns, social context and implications for transmission of blood-borne pathogens

Drug injectors are at risk for infection with human immunodeficiency virus (HIV) and other blood-borne pathogens through the exchange of (infected) blood resulting from unhygienic injecting practices. Research attention and public discussion have focused primarily on the sharing of syringes and needles. While the focus on syringe sharing has sparked important interventions (bleach distribution, syringe exchange) it may have obscured the social relationship in which injecting equipment is used. Drug sharing plays a crucial role in the social organization of the drug using subculture. In this paper, various drug sharing practices and other distinguishable aspects of the injecting process-collectively termed Syringe-Mediated Drug Sharing (SMDS)-are described. All of these behaviors may put injecting drug users (IDUs) at risk for infection. The purpose of this paper is to stimulate scientific inquiry into SMDS behaviors and the social contexts which shape them. Descriptions are based primarily on field studies in Rotterdam and New York City. Recommendations for safer injecting training and education are proposed, as are directions for future research.

Street-level drug markets: Network structure and HIV risk

Abstract Ethnographic and formal social network methods are used to define and situate three categories of injecting drug users - a core, an inner periphery and an outer periphery - in a street-level drug market scene. Different locations in these network structures are shown to be associated with different levels of AIDS risk behaviors and of HIV infection rates. A network perspective helps to understand HIV risks and to devise appropriate interventions.

Sex, drugs, and infections among youth: Parenterally and sexually transmitted diseases in a high-risk neighborhood

Background and Objectives: To determine the extent to which youth who reside in households in a neighborhood with large numbers of drug injectors 1) are infected with parenterally or sexually transmitted agents, and 2) engage in high‐risk behaviors. Study Design: A multistage probability household sample survey was conducted in Bushwick, Brooklyn from 1994 to 1995. All households in 12 randomly selected primary sampling units were screened for age‐eligible youth. One hundred eleven English‐speaking 18‐ to 21‐year‐olds were interviewed. One hundred three sera were tested for human immunodeficiency virus type 1 (HIV‐1), hepatitis B virus, hepatitus C virus (HCV), human T‐cell lymphotrophic virus types I and II (HTLV‐I/II), herpes simplex virus type 2 (HSV‐2), or syphilis. Urines were tested for chlamydial infection, and for opiate and cocaine metabolites. Results: Eighty‐nine percent had sex in the past year, 45% with two or more partners. Only 19% of the sexually active always used condoms. Two (of 95) had had sex with a crack smoker. Thirty percent of women reported being coerced the first time they had sex, and 23% of women and 3% of men reported having been sexually abused. Only 3% reported ever using heroin, and 9% cocaine. Only one reported ever having injected drugs or smoked crack. Some underreporting of stigmatized behaviors occurred: two “nonreporters” had opiatepositive urines and two had cocaine‐positive urines. Marijuana use was common, with 48% using it in the past year. No subjects tested positive for HIV‐1, HTLV‐II, or syphilis; 2% tested positive for HTLV‐I and 3% for hepatitis C; 3% had hepatitis B markers, 12% had chlamydial infection, and 50% serologic HSV‐2 markers. Conclusions: Population‐representative samples of high‐risk communities can provide important knowledge. Although heroin and cocaine use, drug injection, and rates of infection with parenterally transmitted infectious agents appear to be lower among these youth, sexual risk behaviors and chlamydial and HSV‐2 infection are widespread. Sexually transmitted disease screening and outreach strategies are needed both to prevent sexually transmitted disease sequelae (including potential increased susceptibility to HIV infection) and to prevent transmission to partners.

Networks, Norms and Solidaristic/Altruistic Action against Aids among the Demonized

Abstract Drug injectors have simultaneously faced a devastating HIV/AIDS epidemic and an intense program of government repression and media demonization known as the “War on Drugs.” We address patterns of association (networks) among drug injectors; how these networks shape their norms toward condom use and safer sex; the extent to which drug injectors take it upon themselves to promulgate safer sex norms to others; and, on a different level of analysis, the extent to which drug injectors have created organizations to reduce HIV transmission and to deal with other problems. Data from 767 street-recruited Brooklyn drug injectors indicate that about half of their drug injector network ties, and of their sexual network ties, have lasted for at least five years; perceived peer norms supportive of condom use are widespread; almost half had told others (in the last month) that they should use condoms, and this was particularly likely among those in an ethnographically defined core group; consistent condom use w...

Operational issues in syringe exchanges: the New York City tagging alternative study.

It is estimated that 50% of the approximate 200,000 intravenous drug users (IDUs) in New York City (NYC) are infected with HIV. Syringe exchange, a common method of HIV prevention in many countries was legalized in NYC in 1992. As syringe exchange has gained public support and the number of functioning exchanges has grown in the country, more attention has been given to the study of operational characteristics of syringe exchanges.Syringe exchanges may be considered health service delivery organizations, and the specific methods of service delivery may greatly influence their effectiveness in reducing HIV risk behavior among injecting drug users. Improving operational characteristics of syringe exchanges requires both careful data collection, in order to reduce ambiguity in interpretation, and methods for cumulating knowledge, so that previous learning experiences need not be repeated with each new exchange. We report here on the practice of marking (“tagging”) syringes distributed by exchanges in NYC during the period from 1990 through 1994. During this period the NYC exchanges operated illegally as underground exchanges, and then received legal status and expanded greatly.Developing regulations that reflect the reality of the program operations while allowing for monitoring and oversight is a complicated process, especially when implemented in states that maintain paraphernalia and prescription laws and where “unauthorized” possession of injection equipment remains a criminal activity under existing legal statutes. The particular situation in NYC which required the revision of existing regulations during a period of rapid program expansion and implementation of a large system of syringe exchange further illustrates the multiple pressures which accompany such a process. In order to implement meaningful regulations which maximize the public health benefits of syringe exchange programs on an individual and community level, recommendations are made.

Using Retrospective Behavioral Data to Determine HIV Risk Factors among Street-Recruited Drug Injectors

This paper investigates whether the time period during which retrospective behavioral data are collected affects the results of studies of HIV risk factors. In particular, we address the concern that questionnaires probing behaviors in the recent past may not isolate the risk behaviors involved at the time of actual HIV infection. During 1987 and 1988, 278 street-recruited injecting drug users (IDUs) in New York City were interviewed about their sexual behaviors, medical history, drug-injection behaviors in the prior ten years, and specific needle-use behaviors during 1985–86 and thereafter. Among the 278 subjects, 52% were HIV-seropositive. In univariate analysis, serostatus was significantly related to: a) total drug-injection frequency during 1983–84 and 1985–86; b) mean monthly total drug-injection frequency during 1977 to 1987; c) cocaine injection frequencies during 1983–84 and 1985–86, and during the last thirty days; and d) injecting in shooting galleries and using previously used cookers during 1985–86. Significant predictors of seroprevalence in stepwise logistic regression were total drug and cocaine injection frequencies during 1983–84, years of injection, residence in the Bronx, not being Hispanic and history of any sexually transmitted disease. The data confirm previous reports on behavioral risk factors for HIV serostatus. Re-analysis using drug-injection frequency data for different time periods indicates that in the context of an “older” HIV epidemic like that in New York City, analysis of risk factors may be less sensitive to time periods than had previously been feared, although it may be true that data for behaviors in “the last thirty days” cover a sufficiently atypical period as to produce misleading results.