Dale D. Chitwood

Methodological problems in AIDS behavioral research: influences on measurement error and participation bias in studies of sexual behavior.

An unprecedented number of human sexuality studies have been initiated in response to the acquired immune deficiency syndrome (AIDS) epidemic. Unfortunately, methodological developments in the field of sex research have been slow in meeting the demands of AIDS investigations focusing on the diverse populations at risk for infection with the human immunodeficiency virus (e.g., adolescents, gay men, intravenous-drug users, ethnic minorities, elderly transfusees). In this article, we review and integrate current literature on measurement error and participation bias in sex research, with an emphasis on collecting sexual information in the context of AIDS. The relevance of these findings for AIDS-related sex research is discussed, and recommendations are made to guide future investigations.

Validity of self-reported drug use among injection drug users and crack cocaine users recruited through street outreach

This paper examines the validity of self-reported drug use as a measure of behavior change for the evaluation of drug use prevention and HIV risk reduction programs. The results of urinalysis are used to evaluate responses from 154 subjects from 4 cities to questions about drug use in the past 48 hours in the National Institute on Drug Abuses (NIDA) Risk Behavior Assessment (RBA). This instrument is currently being used in 21 studies throughout the United States. Unlike criminal justice or employment settings where there is a tendency to underreport drug use, participants in this research study acted more like a treatment seeking population and were slightly more likely to report drug use than to be tested positive. Urinalysis and self-reports agreed for 86.3% of the subjects who reported use of some form of cocaine (Kappa = .658) and 84.9% of the heroin users (Kappa = .631). The percentage of subjects reporting drug use and testing negative was somewhat higher than the percentage reporting no use and testing positive for both cocaine (7.8% vs. 5.8%) and heroin (9.7% vs. 5.2%). The results suggest that self-reported drug use in not-in-treatment, noninstitutionalized populations is accurate enough for measuring changes in risk behavior practices. Urinalysis may not be necessary if respondents are asked about their drug use in a nonthreatening manner, and if they are assured of the confidentiality of their results.

HIV risk-related sex behaviors among injection drug users, crack smokers, and injection drug users who smoke crack.

OBJECTIVES This study was designed to assess and compare sex risk behaviors for human immunodeficiency virus (HIV) transmission of three drug user groups: injectors who do not smoke crack, crack smokers who do not inject, and injectors who also smoke crack. METHODS Sexual risk behaviors for HIV were assessed among 246 drug users from Denver, Miami, and San Francisco. Respondents were classified into the three drug groups based on self-report and verified through urinalysis and physical inspection. RESULTS An increased risk for HIV through sexual transmission was associated with crack cocaine use, particularly among those who also injected. Crack smoking injectors were more likely to report sex with an injector, exchanging sex for drugs and/or money, drug use before or during sex, and unprotected sexual intercourse. They also injected more than injectors only, smoked crack as often as smokers only, and reported higher overall frequencies of drug use. CONCLUSIONS These findings, together with the higher rates of gonorrhea and syphilis reported by smokers and injectors/smokers, are indicators of the risk crack poses for the heterosexual transmission of HIV.

Sex related HIV risk behaviors: differential risks among injection drug users, crack smokers, and injection drug users who smoke crack

This study was designed to assess differences in sex-related risk behaviors between drug injectors who did not smoke crack cocaine, crack smokers who did not inject drugs, and drug users who both injected drugs and smoked crack. Current drug users (i.e. used within the past 30 days) from 22 cities were recruited and assessed. The sample (n = 26,982) included 28% who injected only, 42% who smoked crack only, and 30% who both injected and smoked crack. Results showed that active drug users were at risk of HIV infection through sexual transmission: in the 30 day period prior to their interview, 28% reported sex with two or more individuals, 23% had an IDU sex partner, and 24% had exchanged sex for drugs or money. In addition, more than 80% did not use a condom during sex. Crack only smokers and crack smoking injectors were more likely than injectors only to report multiple sex partners and exchanging sex. Because of these high risk behaviors, condom use was of particular importance. The number of days of alcohol use and having an IDU sex partner were independently associated with not using a condom. Crack smoking injectors reported the highest average number of days of alcohol consumption and were the most likely to have had an IDU sex partner.

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

Health Care Need and Utilization: A Preliminary Comparison of Injection Drug Users, Other Illicit Drug Users, and Nonusers

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.

The consistency of self-reported HIV risk behavior among injection drug users.

This paper investigates the relationship between chronic drug use and the health care system. Data from 536 African-American, Hispanic, and non-Hispanic White men and women were analyzed to determine independent risk factors for three outcome variables: 1) Need for health care treatment, 2) Utilization of health care treatment, and 3) Failure to receive needed treatment. Nine independent demographic, health, and drug-use history variables were assessed in logistic regression models. Chronic drug users were more likely in the past year to need health care treatment, were as likely to receive some health care treatment, and were more likely not to receive needed treatment than were nonusers.

A Systematic Review of Recent Literature on Religiosity and Substance Use

OBJECTIVES Most studies of risk factors for human immunodeficiency virus (HIV) rely heavily on retrospective self-reports. The degree to which these reports provide reliable information has received little research attention. The purpose of this study was to assess the extent to which the reliability of retrospective self-report data is affected over time. METHODS Data were examined from a longitudinal study of risk behaviors among injection drug users. Structured interviews were administered to 366 injection drug users who were asked to recall behaviors that they had reported 6, 12, or 18 months earlier. RESULTS Kappa coefficients showed moderate initial memory loss for injection and sexual risk behaviors. After 6 months, time had little effect on the ability of injection drug users to recall injection and sexual risk behaviors. For ordinal measures of risk, subjects who gave different reports over time were most likely to disagree by one response category. CONCLUSIONS These findings support the use of retrospective self-reports in assessing HIV risk behaviors among injection drug users. Retrospective inquiry is likely to remain an important method for collecting data over time.

Drug use and barriers to use of health care services.

This paper contains a systematic review of articles about the relationship between religiosity/spirituality and alcohol and drug use that were published between 1997 and 2006. Summaries of methodological characteristics (e.g., study design, sample size and composition, specific dimensions of religiosity, and substances investigated) and general findings of 105 studies provide an overview of the field. The association between religiosity/spirituality and reduced risk of substance use is well established, but a well defined body of knowledge on this relationship has been slow to emerge. The development of more sophisticated instrumentation to measure religiosity and spirituality, the investigation of samples that include users of major drugs of abuse, and the integration of the study of religion and drug use into the broader literature on religion and health can help the field build upon the considerable work that has been published.

HTLV-I/II seropositivity and death from AIDS among HIV-1 seropositive intravenous drug users

This paper examines barriers to health care utilization and the correlates associated with these barriers. As part of a larger study of health services utilization, the study sample of 1085 including injection drug users, other chronic users of heroin or cocaine, and a demographically similar group who had used neither heroin nor cocaine, was selected based on the criterion of not having received health care for at least one health problem within the previous 12 months. Both categories of chronic drug users were more likely than non-users not to want health care treatment and to put off seeking needed health care. [Translations are provided in the International Abstracts Section of this issue.]