Crystal M. Fuller

High-risk behaviors associated with transition from illicit non-injection to injection drug use among adolescent and young adult drug users: a case-control study

OBJECTIVE The goal of our study was to elucidate characteristics of persons likely to transition into injection drug use so that an identifiable group with high-risk for blood-borne infection may be targeted for interventions. METHODS An age-matched case-control analysis was performed from a cohort study in Baltimore, 1997-1999, of street-recruited non-injection and injection drug users (IDUs), aged 15-30. Cases were IDUs injecting < or = 2 years and controls were age-matched persons who used non-injection heroin, cocaine or crack. At baseline, all were interviewed about prior year-by-year behaviors; analysis using conditional logistic regression was based on information for the year prior to injection onset for the case and the same calendar time for the controls as well as recent behaviors for both groups. RESULTS Of 270 participants, most were African American (78%), female (61%), and HIV seroprevalence was 7% at baseline. IDUs were significantly more likely than controls to be non-African American (adjusted odds ratio (AOR)=0.09) and report high school dropout (AOR=2.32), early sex-trading (AOR=2.72), and recent violence victimization (AOR=9.28). CONCLUSION Given that new injectors are at high-risk for HIV and hepatitis yet difficult to reach for prevention efforts, our data suggest some categories to use to target non-injectors who are likely to transition into injection use.

Childhood sexual abuse and age at initiation of injection drug use

OBJECTIVES We examined the relation between childhood sexual abuse and injection drug use initiation among young adult injection drug users. METHODS We used mixed effect linear models to compare age at first injection among 2143 young injection drug users by first sexual abuse age categories. RESULTS The participants were predominantly male (63.3%) and White (52.8%). Mean age and age at first injection were 23.7 and 19.6 years, respectively; 307 participants (14.3%) reported childhood sexual abuse. After adjustment for gender, race/ethnicity, noninjection drug use before first injection drug use, and recruitment site, childhood sexual abuse was independently associated with younger age at first injection. CONCLUSIONS Childhood sexual abuse was associated with earlier initiation of injection drug use. These data emphasize the need to integrate substance abuse prevention with postvictimization services for children and adolescents.

Factors associated with adolescent initiation of injection drug use

Objective. The purpose of this study was to evaluate the extent to which demographic, sexual, and non-injection drug use practices predict adolescent initiation of injection drug use. Methods. Street recruited injection drug users 15–30 years of age in Baltimore, Maryland, who initiated injection within five years of study enrollment, completed a questionnaire that included a year-by-year history regarding the five years prior to initiation of injection. Factors associated with initiation during adolescence (≤21 years of age) versus young adult-hood (>21) were determined using logistic regression. Results. Of 226 participants, most were female (61%) and African American (64%). Median age of participants was 25; median age at initiation of injection was 23. Factors significantly associated with adolescent initiation in multivariate analysis included race other than African American, and practices prior to initiating injection including condom use, lack of cocaine use, exclusive crack smoking just prior to initiation, and smoking marijuana. Adolescent initiates also had shorter durations of illicit drug use prior to initiating injection. Conclusion. Short-term non-injection drug use, particularly exclusive crack smoking, was associated with adolescent initiation of injection drug use. Early prevention efforts targeting this high-risk group of younger drug users are warranted in order to delay or prevent onset of injection drug use.

Effects of Race, Neighborhood, and Social Network on Age at Initiation of Injection Drug Use

OBJECTIVES We investigated individual- and neighborhood-level factors associated with adolescent initiation of injection drug use. METHODS Injection drug users (IDUs) who had been injecting 2 to 5 years underwent HIV testing and completed a sociobehavioral risk survey. Modeling techniques accounting for intraneighborhood correlations were used in data analyses. RESULTS Adolescent-initiating IDUs were less likely than adult-initiating IDUs to report high-risk sex and injection behaviors and more likely to report high-risk networks. African American IDUs from neighborhoods with large percentages of minority residents and low adult educational levels were more likely to initiate injection during adolescence than White IDUs from neighborhoods with low percentages of minority residents and high adult education levels. CONCLUSIONS Racial segregation and neighborhood-level educational attainment must be considered when drawing inferences about age at initiation of injection drug use and related high-risk behaviors.

Social circumstances of initiation of injection drug use and early shooting gallery attendance: implications for HIV intervention among adolescent and young adult injection drug users.

To determine correlates of early shooting gallery (SG) attendance and HIV prevalence and incidence among new injection drug users (IDUs), baseline data from a prospective cohort study of street-recruited IDUs aged 15 to 30 years and injecting ≤5 years were used to identify early high-risk practices and salient social circumstances associated with early SG attendance to help in the design of innovative intervention strategies. Of 226 IDUs, 10.6% were HIV-seropositive, and HIV incidence was 6.6 per 100 person-years (95% CI: 2.2–13.3). Median age was 25 years, and most participants were African American (64%) and female (61%). Using multiple logistic regression, early SG attendees were three times as likely to be HIV-seropositive and twice as likely to be initiated by an older IDU. Early SG attendees were also five times more likely to share injection equipment and over three times more likely to report a high-risk injecting network soon after initiating injection. These data suggest that young new IDUs who attend SGs early tend to be initiated by older high-risk IDUs and to share and inject within a high-risk social setting early on as well. Hence, older IDUs may serve as a bridge group to SGs, transmitting HIV from older to younger IDUs.

Multilevel community-based intervention to increase access to sterile syringes among injection drug users through pharmacy sales in New York city

OBJECTIVES Research has indicated that there is minimal use of pharmacies among injection drug users (IDUs) in specific neighborhoods and among Black and Hispanic IDUs. We developed a community-based participatory research partnership to determine whether a multilevel intervention would increase sterile syringe access through a new policy allowing nonprescription syringe sales in pharmacies. METHODS We targeted Harlem, NY (using the South Bronx for comparison), and disseminated informational material at community forums, pharmacist training programs, and counseling or outreach programs for IDUs. We compared cross-sectional samples in 3 target populations (pre- and postintervention): community members (attitudes and opinions), pharmacists (opinions and practices), and IDUs (risk behaviors). RESULTS Among community members (N = 1496) and pharmacists (N = 131), negative opinions of IDU syringe sales decreased in Harlem whereas there was either no change or an increase in negative opinions in the comparison community. Although pharmacy use by IDUs (N=728) increased in both communities, pharmacy use increased significantly among Black IDUs in Harlem, but not in the comparison community; syringe reuse significantly decreased in Harlem, but not in the comparison community. CONCLUSIONS Targeting the individual and the social environment through a multilevel community-based intervention reduced high-risk behavior, particularly among Black IDUs.

Income distribution and risk of fatal drug overdose in New York City neighborhoods

Accidental drug overdose is a substantial cause of mortality for drug users. Neighborhood-level factors, such as income distribution, may be important determinants of overdose death independent of individual-level factors. We used data from the Office of the Chief Medical Examiner to identify all cases of accidental deaths in New York City (NYC) in 1996 and individual-level covariates. We used 1990 US Census data to calculate the neighborhood-level income distribution. This multi-level case-control study included 725 accidental overdose deaths (cases) and 453 accidental deaths due to other causes (controls) in 59 neighborhoods in NYC. Overdose deaths were more likely in neighborhoods with higher levels of drug use and with more unequal income distribution. In multi-level models, income maldistribution was significantly associated with risk of overdose independent of individual-level variables (age, race, and sex) and neighborhood-level variables (income, drug use, and racial composition). The odds of death due to drug overdose were 1.63-1.88 in neighborhoods in the least equitable decile compared with neighborhoods in the most equitable decile. Disinvestment in social and economic resources in unequal neighborhoods may explain this association. Public health interventions related to overdose risk should pay particular attention to highly unequal neighborhoods.

Updating the Infection Risk Reduction Hierarchy: Preventing Transition into Injection

Current approaches to prevention of blood-borne infections in injection drug users include referral to drug abuse treatment, access to sterile syringes, bleach disinfection of injection equipment, and education about not sharing equipment. However, rates of some blood-borne infections (e.g., hepatitis C virus) remain elevated among injection drug users, especially early after initiation into injection drug use. With lower infection rates in noninjectors and transition into injection drug use occurring most commonly among these noninjectors, prevention of transition into injection drug use as an additional step to reduce risk for acquisition and transmission of blood-borne infections merits closer attention.

Receptive syringe sharing among injection drug users in Harlem and the Bronx during the New York State Expanded Syringe Access Demonstration Program.

Background:Effective on January 1, 2001, New York State enacted the Expanded Syringe Access Demonstration Program (ESAP), which allows syringes to be sold in pharmacies without a prescription or dispensed through doctors, hospitals, and clinics to persons 18 years of age or older and permits the possession of those syringes for the purposes of injecting drugs. Objective:To assess changes in receptive syringe sharing since the inception of the ESAP. Methods:Sociodemographic characteristics and syringe use data regarding the last injection episode were combined from 3 projects (n = 1181) recruiting injection drug users in ongoing studies in Harlem and the Bronx in New York City from January 2001 through June 2003. These data were analyzed as serial cross sections by calendar quarter. Results:Receptive sharing decreased significantly over time, from 13.4% in the first quarter to 3.6% in the last quarter. Obtaining the last injection syringe from an ESAP source (mostly pharmacies) increased significantly over time, from 7.5% in the first quarter to 25.0% in the last quarter. In multiple logistic regression analysis, variables that were significantly associated with less receptive sharing were syringe exchange and ESAP syringe source as well as time since ESAP inception. Female gender and white race/ethnicity were significantly associated with greater receptive sharing. Conclusions:The increase in the use of pharmacies and other ESAP syringe sources in this sample has been accompanied by a decline in receptive sharing.

Lack of Behavior Change after Disclosure of Hepatitis C Virus Infection among Young Injection Drug Users in Baltimore, Maryland

We evaluated behavior change after disclosure of a positive hepatitis C virus (HCV) antibody test result among a cohort of young injection drug users (IDUs). Participants underwent semiannual interviews, human immunodeficiency virus (HIV) and HCV antibody testing, and pretest and posttest counseling. We used chi(2) statistics to study changes in the frequencies of high-risk behaviors from baseline to a 6-month follow-up visit among 46 IDUs who had a positive HCV test result and among 60 IDUs who did not have a positive HCV test result or who were unaware of their test result. No significant differences were detected between the 2 groups. Both groups continued to share syringes, needles, and other injection paraphernalia. These findings suggest that young IDUs may not be aware of the risk of HCV infection and highlight the urgent need for post-HCV test guidelines and behavioral interventions to reduce ongoing high-risk behavior that perpetuates the risk of HCV transmission.