Denise Paone

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.

Social network characteristics as mediators in the relationship between sexual abuse and HIV risk

Recent research suggests that sexual abuse may be a potent risk factor for engaging in HIV risk behaviors for women. This relationship is likely mediated by the long term sequelae of sexual abuse. One plausible causal pathway posits that specific social network characteristics increase HIV risk exposure opportunities. This is premised on the belief that previous sexual abuse predisposes some women to become members of risk networks characterized by deviant behaviors and that HIV risk occurs in the context of these networks. One hundred and thirty women opiate users were systematically recruited from methadone maintenance and syringe exchange programs in New York City. The women participated in a one hour interview and provided information on drug use and frequency, HIV drug and sex risk behaviors, social network characteristics, and sexual abuse histories. Univariate and logistic regression techniques were used to test the relationship between sexual abuse and increased HIV risk as mediated by social network characteristics. Previous sexual abuse was strongly related to all social network characteristics examined. Moreover, these network characteristics appeared to affect patterns of drug use in identifiable ways. Social isolation was the only network characteristic associated with both HIV drug and sex risk behaviors. However, although a history of sexual abuse was significantly associated with five of the seven specific HIV risk behaviors examined, the relationship between sexual abuse and HIV risk behaviors remained unchanged when social network characteristics were included in the statistical model. Overall, the results suggest that a sexual abuse experience or its aftermath influence behavior far into the future. However, the results of this study did not show social network characteristics mediating the relationship between sexual abuse and HIV risk. Rather, previous sexual abuse and social network characteristics appear to be independent contributors to HIV risk behaviors for women.

Psychiatric histories of drug using mothers: Treatment implications

One hundred forty six crack/cocaine using mothers in New York City were interviewed in a cross sectional study about life histories and drug related behaviors. Forty one (28%) reported histories of previous psychiatric medication or hospitalization. These women were significantly more likely than the rest of the sample to currently be in drug treatment; to have sexual abuse histories; and to be currently involved with men who urged them to use crack during pregnancy. Within this group, two subgroups were distinguishable: one, who had been sexually abused and initiated drug use early, and the other whose psychiatric and drug use histories were not associated with sexual abuse. The implications of these findings for screening, treatment planning, and future research are discussed.

Modulators of "activated motivation": event-specific condom use by drug injectors who have used condoms to prevent HIV / AIDS.

Since sexual transmission of HIV among and from drug injectors is a frequent source of infection, condom use by them is important for prevention. This paper focuses on predictors of condom use at last sex by drug injectors with “activated motivation,” that is, by those who already are trying to use condoms to reduce HIV risk. Principal subjects are 1,240 drug injectors who report activated motivation to use condoms to prevent HIV and who had had sex within 6 months before the interview. Many used condoms at last sexual event with primary partners (65%) and with casual partners (80%). Condom use with primary partners increased over time, and was higher among those who knew they were HIV-positive or who talked about AIDS with sexual partners, but was lower among those who knew they were HIV-negative, who were Black, Hispanic, women, younger, or high school graduates, or who used crack with their partners at the sexual event. Condom use with casual partners was lower among women, older drug injectors, and those who were high on alcohol along with their partners, and tended to be more likely among those who know they are infected. Condom use with both primary and casual partners was greater with partners who did not themselves inject drugs. Programs should urge drug injectors who are trying to use condoms to avoid HIV transmission that having sex while using psychoactive substances may be a barrier to their doing so even if they want to use condoms and have done so in the past. Finally, research should be conducted to determine if persons with activated motivation should receive HIV prevention assistance that is different from that offered those who lack risk-reduction motivation or those who want to reduce their risk behaviors, but have been unable to implement the desired changes.

Organizational Issues in Conducting Tuberculosis Screening at a Syringe Exchange Program

There has been a rise in tuberculosis (TB) cases in the United States and there is a potent link between human immunodeficiency virus (HIV) and tuberculosis. In New City it is estimated that 40% of the 200,000 injecting drug users are infected with HIV. In addition, the tuberculosis case rate is approximately four times the national average, and one third of these cases occurred in those persons infected with HIV. Drug users have a high prevalence of latent tuberculous infection and are at high risk for progression to active tuberculosis. Drug users are at high risk for both HIV and TB. Although studies have shown the value of incorporating TB services into drug treatment programs, the majority of drug users in the United States are not in drug treatment. We have been evaluating the feasibility of conducting TB screening and directly observed TB preventive therapy for active injecting drug users at a syringe exchange program in New York City. This paper describes issues relating to the implementation of the TB screening program and discusses general and operational issues relevant to integrating medical and public health programs into existing programs serving drug using individuals.