Erin P. Ricketts

HIV prevalence and correlates of receptive needle sharing among injection drug users in the Mexican-U.S. border city of Tijuana

Abstract Injection drug use is a growing but understudied problem in Tijuana, a city situated on the northwestern Mexico-U.S border. The authors studied factors associated with receptive needle sharing in an effort to inform prevention activities. In 2003, street-recruited injection drug users (IDUs) in Tijuana underwent interviews on injection risk behaviors and rapid HIV antibody tests. Logistic regression was used to identify correlates of receptive needle sharing at the last injection episode. Of 402 IDUs, 87.6% were male; the median age was 34. HIV prevalence was 4.01% (95%CI: 2.29–6.51). One third reported receptive needle sharing at last injection. Factors independently associated with receptive needle sharing were years living in Tijuana (Adjusted Odds Ratio [AdjOR]= 0.97 per year, 95% CI: 0.96–0.99), being bisexual/homosexual (AdjOR=2.12; 95% CI: 1.30 – 3.44), unemployed (AdjOR=2.5; 95% CI: 1.52–4.10), never having an HIV test (AOR: 4.02; 95% CI: 2.44–6.60), having friends who placed importance on avoiding HIV (AdjOR: 0.36; 95% CI: 0.19–0.68) and last injecting in a shooting gallery (AdjOR=l.98; 95% CI: 1.21–3.24). These results underscore the need to increase access to voluntary HIV testing and counseling to IDUs and migrants in Tijuana, as well as expand access to sterile syringes in an effort to avert widespread HIV transmission.

Physical activity in a cohort of HIV-positive and HIV-negative injection drug users

Abstract Physical activity is beneficial for persons with HIV infection but little is known about the relationships between physical activity, HIV treatment and injection drug use (IDU). This study compared physical activity levels between HIV-negative and HIV-positive injection drug users (IDUs) and between HIV-positive participants not on any treatment and participants on highly active antiretroviral therapy (HAART). Anthropometric measurements were obtained and an interviewer-administered modified Paffenbarger physical activity questionnaire was administered to 324 participants in a sub-study of the AIDS Linked to Intravenous Experiences (ALIVE) cohort, an ongoing study of HIV-negative and HIV-positive IDUs. Generalized linear models were used to obtain univariate means and to adjust for confounding (age, gender, employment and recent IDU). Vigorous activity was lower among HAART participants than HIV-positive participants not on treatment (p=0.0025) and somewhat lower than HIV-negative participants (p=0.11). Injection drug use and viral load were not associated with vigorous activity. Energy expenditure in vigorous activity was also lower among HAART participants than both HIV-negative and HIV-positive participants not on treatment. Thus, HIV-positive participants on HAART spend less time on vigorous activity independent of recent IDU. More research is needed into the reasons and mechanism for the lack of vigorous activities, including behavioral, psychological and physiological reasons.

Social contextual factors associated with entry into opiate agonist treatment among injection drug users

We tested hypotheses that social living arrangement and drug use in ones network are independently associated with entry into opiate agonist treatment modalities. Injection drug users (IDUs) attending the Baltimore Needle Exchange Program who received a referral for drug abuse treatment were studied. Baseline interviews, HIV testing, and the Addiction Severity Index (ASI) were administered. Agency records were used to confirm entry into a treatment program offering opiate agonist maintenance therapy within 30 days of the baseline interview. Logistic regression was used to identify predictors of treatment entry. To date, of 245 IDUs, 39% entered such a program. Multivariate logistic regression models controlling for age and intervention status revealed that compared to individuals who lived alone, in a controlled, or nonstable environment (e.g., streets, abandoned house, transitional housing program, or boarding house), individuals who lived with a sexual partner were 3 times more likely to enter treatment (adjusted Odds Ratio [aOR] = 3.04; p = 0.013) and those who lived with family or friends were almost 3 times more likely to enter treatment (aOR = 2.72; p = 0.016). In the bivariate analyses, a marginal association was observed between being responsible for children or others and entry into treatment (p = 0.066); however, this association was not significant in the multivariate model. Findings from this study suggest that supportive living environments may facilitate entry into treatment and may be helpful in devising appropriate and targeted interventions to encourage drug treatment entry.

Effect of micronutrients and iron supplementation on hemoglobin, iron status, and plasma hepatitis C and HIV RNA levels in female injection drug users: a controlled clinical trial.

Background:Iron deficiency is common among female injection drug users, but it is unclear whether iron supplementation can reduce anemia and improve iron status without increasing plasma hepatitis C virus (HCV) or HIV RNA levels. Methods:We conducted a phase 3, double-blind, randomized, controlled clinical trial of daily micronutrients with 18 mg of iron (iron group) versus micronutrients without iron (control group) for 12 months among hepatitis C-positive female injection drug users in Baltimore, Maryland. The main outcome measures were hemoglobin, markers of iron status, plasma HCV RNA, plasma HIV RNA, and liver enzymes at 6 and 12 months of follow-up. Results:Four hundred fifty-eight women (320 HIV-negative and 138 HIV-positive) enrolled in the trial. There were no significant differences in the proportion of women with anemia, ferritin <30 ng/mL, log10 plasma HCV RNA, or log10 plasma HIV RNA between treatment groups at enrollment. The proportion with anemia in the iron and control groups, respectively, was 20.7% versus 31.3% (P = 0.026) at 6 months and 26.2% versus 30.4% (P = 0.5) at 12 months; with ferritin <30 ng/mL, the proportion was 29.2% versus 55.5% (P < 0.0001) at 6 months and 26.2% versus 46.9% (P = 0.0018) at 12 months. In the iron and control groups, respectively, mean log10 plasma HCV RNA (IU/mL) was 5.2 versus 5.2 (P = 0.86) at 6 months and 5.4 versus 5.3 (P = 0.6) at 12 months. Among HIV-positive subjects, mean log10 plasma RNA (copies/mL) in the iron and placebo groups, respectively, was 3.8 versus 3.7 (P = 0.75) at 6 months and 3.7 versus 4.1 (P = 0.19) at 12 months. There were no significant differences in liver enzyme levels between the treatment groups at enrollment, 6 months, and 12 months. Conclusions:A daily micronutrient supplement with iron can reduce anemia and improve iron status in female injection drug users without increasing plasma HCV or HIV RNA levels or altering liver enzymes.

Quality Control and Reproducibility in M-Mode, Two-Dimensional, and Speckle Tracking Echocardiography Acquisition and Analysis: The CARDIA Study, Year 25 Examination Experience

Few large studies describe quality control procedures and reproducibility findings in cardiovascular ultrasound, particularly in novel techniques such as speckle tracking echocardiography (STE). We evaluate the echocardiography assessment performance in the Coronary Artery Risk Development in Young Adults (CARDIA) study Year 25 (Y25) examination (2010–2011) and report findings from a quality control and reproducibility program conducted to assess Field Center image acquisition and reading center (RC) accuracy.

Cross sectional analysis of respiratory symptoms in an injection drug user cohort: the impact of obstructive lung disease and HIV

BackgroundInjection drug use is associated with an increased risk of human immunodeficiency virus (HIV) infection and with obstructive lung diseases (OLD). Understanding how HIV and OLD may impact respiratory symptoms among injection drug users (IDUs) is important to adequately care for this high-risk population. We characterized the independent and joint effects of HIV and OLD on respiratory symptoms of a cohort of inner-city IDUs.MethodsDemographics, risk behavior and spirometric measurements were collected from a cross-sectional analysis of the Acquired Immunodeficiency Syndrome Link to the IntraVenous Experience study, an observational cohort of IDUs followed in Baltimore, MD since 1988. Participants completed a modified American Thoracic Society respiratory questionnaire and the Medical Research Council (MRC) dyspnea score to assess respiratory symptoms of cough, phlegm, wheezing and dyspnea.ResultsOf 974 participants, 835 (86%) were current smokers and 288 (29.6%) were HIV-infected. The prevalence of OLD (FEV1/FVC ≤ 0.70) was 15.5%, and did not differ by HIV status. OLD, but not HIV, was associated with increased frequency of reported respiratory symptoms. There was a combined effect of OLD and HIV on worsening of MRC scores. OLD and HIV were independently associated with an increased odds of reporting an MRC ≥ 2 (OR 1.83 [95%CI 1.23-2.73] and 1.50 [95%CI 1.08-2.09], respectively). COPD, but not HIV, was independently associated with reporting an MRC ≥ 3 (OR 2.25 [95%CI 1.43-3.54] and 1.29 [95%CI 0.87-1.91], respectively).ConclusionsWhile HIV does not worsen cough, phlegm or wheezing, HIV significantly increases moderate but not severe dyspnea in individuals of similar OLD status. Incorporating the MRC score into routine evaluation of IDUs at risk for OLD and HIV provides better assessment than cough, phlegm and wheezing alone.

Cortisol levels and depression in men and women using heroin and cocaine

Abnormalities in the hypothalamic-pituitary-adrenal (HPA) axis are well documented in men using illicit drugs and/or infected with HIV; however, less is known about HPA function, or the health consequence of HPA dysfunction, in their female counterparts. People with depression exhibit hypercortisolemia, and depression is common in people with HIV or substance use problems. The current study investigated cortisol secretion in 209 demographically matched men and women, stratified by their HIV and drug use status. Self-reported depressive symptoms were evaluated using a standardized, validated questionnaire (CES-D). Women reported more depressive symptoms than men (p=.01). Male and female drug users exhibited higher cortisol concentrations (p=.03), and were more likely to report depressive symptoms (p=.04), than non-users. Depression was related to elevated cortisol concentrations for the study population (p=.03), and women with elevated cortisol concentrations were significantly more depressed than all other participants (p=.05). While it is unknown whether high cortisol concentrations precede depressive symptoms or vice versa, these data indicate that higher cortisol concentrations are associated with depressive symptoms in heroin and cocaine users, and that this association is more pronounced in women than men. HIV status did not act in an additive or synergistic way with drug use for either cortisol or CES-D measures in the current study. Unique therapies to treat the endocrine and mental health consequences of illicit drug use in men and women deserve consideration as depressive symptoms, and high cortisol concentrations associated with depressive symptoms, differ by gender.

The Relationship Between Lifetime Abuse and Suicidal Ideation in a Sample of Injection Drug Users

Abstract This study examined the relationship between lifetime abuse and suicidal ideation in a sample of 245 injection drug users (IDUs) who attended the Baltimore Needle Exchange Program and received a referral for opiate agonist therapy. Data were obtained from baseline interviews and HIV antibody tests. The sample mean age was 42.2 (SD = 8.1); 77% were African American; 69% were male. Overall, 27% reported thoughts of suicide in the last six months, and lifetime emotional, physical and sexual abuse was reported by 17%, 12% and 10%, respectively. In bivariate analyses, recent suicidal ideation was associated with emotional (odds ratio [OR] = 3.2; p = 0.001), physical (OR = 2.5; p = 0.026), and sexual abuse (OR = 5.0; p < 0.001). In multiple logistic regression models controlling for HIV status and Center for Epidemiological Studies Depression (CES-D) score, individuals who experienced emotional abuse were more than twice as likely to report recent suicidal ideation (adjusted odds ratio [AOR] = 2.6; p = 0.011); those who experienced sexual abuse were four times more likely to report suicidal ideation (AOR = 4.0; p = 0.004). These findings suggest that emotional and sexual abuse might be risk factors for suicidality among IDUs and also might suggest that suicide prevention should be an integral part of drug treatment for treatment-seeking IDUs.

Predictors of opiate agonist treatment retention among injection drug users referred from a needle exchange program.

AIMS The aim of this study was to examine the effect of a case management intervention on retention in opiate agonist therapy among injection drug users (IDUs) referred from a needle exchange program (NEP). DESIGN, INTERVENTION, PARTICIPANTS, AND SETTING: A randomized trial of a strengths-based case management intervention versus passive referral (control) was conducted among NEP attendees requesting and receiving referrals to subsidized, publicly funded opiate agonist treatment programs in Baltimore, MD. MEASUREMENTS Multivariable Cox regression models were used to identify predictors of treatment retention using an ecological model approach, taking into account factors at the individual, social, and environmental level. FINDINGS Of 245 IDUs, 127 (51.8%) entered opiate agonist treatment, for whom median retention was 7.9 months. The intervention was not associated with longer retention (p = .91). Individual-level factors predictive of shorter retention included being employed and greater levels of psychiatric distress. Participants who had prior treatment experience and multiple treatment requests were retained significantly longer. Social factors adversely affecting treatment retention included unstable housing and buying drugs for others. Living further away from the treatment site was an environmental barrier that negatively affected treatment retention. CONCLUSIONS Multilevel interventions that address individual, social, and environmental factors are necessary to improve substance abuse treatment retention and treatment outcomes among IDUs referred from NEP.

Hypothalamic-pituitary-gonadal function in men and women using heroin and cocaine, stratified by HIV status.

BACKGROUND Most studies of hypothalamic-pituitary-gonadal (HPG) function in illicit drug users either focus on men or do not consider the impact of HIV. OBJECTIVE This study investigated the relationships between cocaine and/or opiate use, HIV status, and HPG function in both men and women. METHODS Men and women between 18 and 50 years of age were stratified by sex, drug use, and HIV status. Information on demographics, HIV disease and treatment, and illicit drug use patterns was collected. To determine potential effects on HPG function, free testosterone (free T), estradiol, and gonadotropin concentrations were measured. RESULTS In a total of 197 men and women, free T concentrations were lower in men who used cocaine and/or opiates and in women infected with HIV Gonadotropin concentrations were elevated in seropositive men only. In women who received highly active antiretroviral therapy, HIV infection and illicit drug use had an additive or synergistic impact on free T concentrations. CONCLUSIONS Our data reveal the importance of considering the independent effects of illicit drug use and HIV status for both men and women, so that risks may be identified and potential treatments designed for HPG dysfunction in these groups.