H. Virginia McCoy

Crack cocaine smokers who turn to drug injection: characteristics, factors associated with injection, and implications for HIV transmission

A survey of 1220 street-recruited crack cocaine smokers revealed that crack smokers may turn to drug injection to ease crack withdrawal. Crack smokers who later injected tended to smoke crack more heavily and for longer periods than those who did not inject. The initiation of injection was significantly associated with ever snorting heroin (prevalence ratio [PR] = 3.4, 95% confidence interval [CI] = 2.0-5.9) or snorting heroin specifically while smoking crack (PR = 2.3, 95% CI = 1.3-4.0), suggesting that snorted heroin use may mediate the transition to injection among crack smokers. Programs to prevent and treat crack dependence may prevent later injection and injection-related infections including HIV.

Immigration and HIV among Migrant Workers in Rural Southern Florida

We studied HIV seropositivity among a targeted sample of migrant workers who used drugs, primarily crack cocaine, and their sexual partners in rural southern Florida from 1993 to 1995. We enrolled men and women who were born in the United States (n = 369) or in other countries (n = 174). Overall, 11.2% of the sample were HIV positive, including 18% of Blacks from the United States, and about 8% of non-Hispanic whites from the United States, Blacks from the Caribbean, and persons from Central or South America. No Hispanics from the United States or the Caribbean, but 3.4% of Hispanics from Mexico, were HIV positive. In logistic regression analyses, race/ethnicity, gender, and age were most highly associated with HIV seropositivity. Immigration status, current drug use, and current sexual activity were not related to HIV seropositivity. HIV prevention programs must help reduce heterosexual transmission of HIV associated with drug use both locally and where migrants travel and work.

Behavior changes among crack-using rural and urban women.

This study compared rural and urban crack-using women and examined their responses to two interventions. A prospective cohort study design was employed to assess the effectiveness of standard and innovative HIV prevention interventions on 541 urban and 268 rural women in Florida. Generalized estimating equation analysis, accounting for repeated measures, found that for combined urban and rural samples, the innovative intervention was more effective than the standard for a number of drug and sexual risk behaviors. However, the analysis indicated no significant differences in intervention efficacy between rural and urban women. The results imply that there is a need for similar HIV prevention services in both areas.

HIV seroprevalence across the rural/urban continuum

While the first decade of the AIDS epidemic was characterized by high prevalence rates of AIDS infection in urban areas, there is increasing recognition of the spread of HIV into rural communities in the United States. Data from the Miami CARES cohort collected on 3,555 chronic drug users from 1988 to 1994 provide a unique opportunity to assess sociodemographic characteristics, drug-using behaviors and HIV risk behaviors related to HIV seropositivity in three communities across the rural-urban continuum: Miami, Florida; Belle Glade, Florida and Immokalee, Florida. The three very different communities studied demonstrate that HIV is no respecter of ecological site. The spread of HIV between areas and within areas is specifically correlated with the risk factors including injection drug use, use of crack cocaine, exchange of sex for money, and the rates for sexually transmitted diseases. All of these factors are shown to increase the risk of HIV so that the constellation of these practices helps determine the differential rates and spread of HIV in the three different areas.

An Evaluation of a Brief HIV Risk Reduction Intervention Using Empirically Derived Drug Use and Sexual Risk Indices

This paper presents the results of an evaluation of a brief, educational HIV risk reduction intervention implemented in a community setting. Participants were 7,733 not-in-treatment drug users. Multi-item needle and sex risk measures were developed to assess the efficacy of the intervention. Behavior change was assessed within 6 empirically derived homogeneous risk groups. Drug users in all 6 groups reduced their needle use and sexual risks after participating in the brief educational intervention. Sexual risks were reduced to a greater extent than were risks associated with needle use, both in relative terms and when measured as a percentage of risk exhibited at intake. Brief educational interventions may be more effective in reducing sexual risk behaviors than it was previously believed. Needle risk, on the other hand, appears to be more robust, especially among high frequency cocaine injectors. Theses findings suggest that HIV prevention strategies may be more effective and more efficient if drug users are triaged into an intervention appropriate to their level of needle risk.

Health services for chronic drug users in an era of managed care

This chapter reports findings on two studies that culminated in the development of a multilevel intervention to improve access to health care among chronic drug users. The first two studies began with an investigation of the health care delivery system serving chronic drug users in Miami-Dade County, Florida from the perspectives of both consumers and providers. These studies documented the health care needs and use patterns of chronic drug users as well as the practices and perspectives of the providers who served them. Findings indicated that (1) chronic drug users demonstrated greater health care needs than nondrug users; (2) chronic drug users were less likely to receive appropriate health care services; and (3) the gap between services needed and services actually provided can be ameliorated. By participating in our multilevel intervention, both health care providers and health care consumers changed attitudes and behaviors resulting in the provision of appropriate, accessible, and acceptable health care.

The effect of migration patterns on exposure to HIV prevention in a migrant community

This study examined the effects of migratory stream patterns on the amount of exposure to HIV prevention. It was hypothesized that fewer number of moves, a homebase in Collier County, Florida, greater number of years lived in Collier County, and having field-related jobs increase the potential for exposure to HIV prevention. Rural drug users and their sex partners were recruited from migrant camps in Collier County. Each camp was randomly assigned to either a Standard group or an Enhanced group. Descriptive analyses and multiple regression analyses were conducted to examine the effects of migration patterns on exposure (measured by the total number of contacts subjects had with study personnel) while controlling for demographic characteristics. A separate model was analyzed for the Standard group and the Enhanced group. The analysis revealed that being female, having lived in Collier County for a longer period of time, having a field-related job, and moving fewer times during the previous three years were significantly related to greater exposure to the HIV prevention intervention. The current study identifies a subgroup of migrants who are at high risk for deprivation of HIV-related information. Intervention efforts need to be targeted toward migrants who are male, have lived in Collier County for a short period of time, move frequently during agricultural seasons, or who are unemployed, prostitutes, or have other non-field-related jobs.

Predictors of Stages of Change for Condom Use in Crack Cocaine Users

This paper addresses the question of whether sexual activity and partner characteristics differentiate people in different stages of change. Factors expected to distinguish people in different stages of change were partner type, drug use during sex, and HIV status. Three discriminant functions emerged. The loading matrix demonstrates that partner type was the strongest predictor that distinguished people in the precontemplation stage from those in the preparation, action, and maintenance stages (first function) (.962). The loadings on the second discriminant function suggest that when controlling for partner type, HIV status (.935) was the best predictor for distinguishing between the people in the maintenance stage and those in the other stages. The loadings on the third function were not significant. The overall classification results indicate that individuals using crack cocaine and engaging in high risk sexual behaviors can be classified into the stages of change for condom use based on these variables.