Holly Hagan

Regional Patterns and Correlates of Substance Use Among Young Men Who Have Sex With Men in 7 US Urban Areas

OBJECTIVESnWe sought to characterize substance use patterns in young men who have sex with men (MSM) in 7 US urban areas and sociodemographic characteristics and history associated with such use.nnnMETHODSnWe examined data collected from 1994 through 1998 in a venue-based, cross-sectional survey.nnnRESULTSnAmong the 3492 participants, 66% reported use of illicit drugs; 28%, use of 3 or more drugs; 29%, frequent drug use (once a week or more); and 4%, injection drug use. These practices were more common among participants who were White, self-identified as bisexual or heterosexual, had run away, or had experienced forced sex.nnnCONCLUSIONSnEffective drug prevention and treatment programs addressing local drug-use patterns and associated factors are urgently needed for young MSM, a population with a high rate of illicit drug use.

Self-Reported Hepatitis C Virus Antibody Status and Risk Behavior in Young Injectors

Objective. This study was conducted to assess the accuracy of self-reported hepatitis C virus (HCV) antibody (anti-HCV) serostatus in injection drug users (IDUs), and examine whether self-reported anti-HCV serostatus was associated with recent injection risk behavior. Methods. In five U.S. cities (Baltimore, Chicago, Los Angeles, New York, and Seattle), 3,004 IDUs from 15 to 30 years old were recruited for a baseline interview to determine eligibility for a randomized controlled trial of a behavioral intervention. HIV and HCV antibody testing were performed, and subject data (e.g., demographics, drug and sexual risk behavior, and history of HIV and HCV testing) were collected via audio computer-administered self-interview. Risk behavior during the previous three months was compared to self-reported anti-HCV serostatus. Results. Anti-HCV prevalence in this sample of young IDUs was 34.1%. Seventy-two percent of anti-HCV-positive and 46% of anti-HCV-negative IDUs in this sample were not aware of their HCV serostatus. Drug treatment or needle exchange use was associated with increased awareness of HCV serostatus. Anti-HCV-negative IDUs who knew their serostatus were less likely than those unaware of their status to inject with a syringe used by another IDU or to share cottons to filter drug solutions. Knowledge of ones positive anti-HCV status was not associated with safer injection practices. Conclusions. Few anti-HCV-positive IDUs in this study were aware of their serostatus. Expanded availability of HCV screening with high quality counseling is clearly needed for this population to promote the health of chronically HCV-infected IDUs and to decrease risk among injectors susceptible to acquiring or transmitting HCV.

A peer-education intervention to reduce injection risk behaviors for Hiv and hepatitis C virus infection in young injection drug users

Objectives:To evaluate whether a behavioral intervention, which taught peer education skills, could reduce injection and sexual risk behaviors associated with primary HIV and hepatitis C virus infection (HCV) among young injection drug users (IDU). Design:We conducted a randomized controlled trial involving HIV and HCV antibody-negative IDU, aged 15–30 years, recruited in five United States cities. A six-session, small-group, cognitive behavioral, skills-building intervention in which participants were taught peer education skills (n = 431) was compared with a time-equivalent attention control (n = 423). Baseline visits included interviews for sociodemographic, psychosocial, and behavioral factors during the previous 3 months; HIV and HCV antibody testing; and pre/posttest counselling. Procedures were repeated 3 and 6 months postintervention. Results:The intervention produced a 29% greater decline in overall injection risk 6 months postintervention relative to the control [proportional odds ratio 0.71; 95% confidence limit (CL) 0.52, 0.97], and a 76% decrease compared with baseline. Decreases were also observed for sexual risk behaviors, but they did not differ by trial arm. Overall HCV infection incidence (18.4/100 person-years) did not differ significantly across trial arms (relative risk 1.15; 95% CL 0.72, 1.82). No HIV seroconversions were observed. Conclusion:Interventions providing information, enhancing risk-reduction skills, and motivating behavior change through peer education training can reduce injection risk behaviors, although risk elimination might be necessary to prevent HCV transmission.

Factors Associated with Interest in Initiating Treatment for Hepatitis C Virus (HCV) Infection among Young HCV-Infected Injection Drug Users

OBJECTIVEnWe sought to identify factors associated with interest in receiving therapy for hepatitis C virus (HCV) infection among HCV-infected injection drug users (IDUs) in 3 United States cities.nnnMETHODSnIDUs aged 18-35 years who were HCV-infected and seronegative for human immunodeficiency virus underwent surveys on behaviors, experience, and interest in treatment for HCV infection and readiness to quit drug use.nnnRESULTSnAmong treatment-naive IDUs (n=216), 81.5% were interested in treatment for HCV infection, but only 27.3% had seen a health-care provider since receiving a diagnosis of HCV infection. Interest in treatment for HCV infection was greater among IDUs with a high perceived threat of progressive liver disease, those with a usual source of care, those without evidence of alcohol dependence, and those with higher readiness scores for quitting drug use. Interest in treatment for HCV infection was 7-fold higher among IDUs who were told by their health-care provider that they were at risk for cirrhosis or liver cancer.nnnCONCLUSIONSnImproving provider-patient communication and integrating treatments for substance abuse and HCV may increase the proportion of IDUs who initiate treatment for HCV infection.

Screening for depressive symptoms among HCV-infected injection drug users: Examination of the utility of the CES-D and the Beck Depression Inventory

The prevalence of depression is high among injection drug users (IDUs) and among those infected with the hepatitis C virus (HCV). Moreover, one of the drugs used in the standard treatment for HCV infection (interferon) has been known to exacerbate, underlying psychiatric disorders such as depression and has been associated with the development of major, depressive disorder among HCV-infected patients. For these reasons, the most recent National Institutes of Health consensus statement on the management of HCV infection recommends the identification and treatment of depression prior to the start of HCV treatment. This study aimed to examine the extent of current moderate/severe depressive symptoms in a cohort of HCV-infected IDUs as measured by two screening tools, the Center for Epidemiologic Studies Depression Scale (CES-D) and the Beck Depression Inventory (BDI). Subjects were participants in a multisite behavioral intervention trial among HCV-seropositive, human immunodeficiency virus-negative IDUs aged 18–35 years; the trial was designed to prevent secondary transmission of HCV and to enhance uptake of HCV treatment. Baseline data on demographics, risk behaviors, depression, alcohol use, and health care utilization were measured via audio computer-assisted self-interview. A factor analysis was conducted on each scale to examine the clustering of items used in each to measure depressive symptoms. Baseline depressive symptoms, as measured via the CES-D and the BDI, were also compared using Pearson’s correlation coefficient. Of 193 HCV-infected individuals enrolled to date, 75,6% were male, and 65.3% were white. Median age was 25.8 years. Factor analyses revealed that these scales measured depression differently; a distinct somatic component was present in the BDI, but not the CES-D. Using cutoff scores of 23 for the CES-D and 19 for the BDI, 44.0% and 41.5% of the participants were identified as having moderate/severe depressive symptoms, respectively. Over half (56.0%) were identified as having depressive symptoms

Young adult injection drug users in the United States continue to practice HIV risk behaviors

BACKGROUNDnInjection drug users (IDUs) are at risk of acquiring HIV through injection and sexual practices.nnnMETHODSnWe analyzed data collected in five U.S. cities between 2002 and 2004 to identify correlates of HIV infection among 3285 IDUs ages 15-30 years.nnnRESULTSnOverall, HIV prevalence was 2.8% (95% CI 2.3-3.4), ranging from 0.8% in Chicago to 6.3% in Los Angeles. Mean age was 24 years, 70% were male, 64% non-Hispanic (NH) white, 7% NH black, 17% Hispanic, and 12% were other/mixed race. HIV infection was independently associated with: race/ethnicity (NH black [AOR 4.1, 95% CI 1.9-9.1], Hispanic [AOR 3.6, 95% CI 1.5-8.4], or other/mixed [AOR 2.3, 95% CI 1.1-5.2] vs. NH white); males who only had sex with males compared to males who only had sex with females (AOR 15.3, 95% CI 6.8-34.5); injecting methamphetamine alone or with heroin compared to heroin only (AOR 4.0, 95% CI 1.7-9.7); reporting inconsistent means of obtaining income compared to regular jobs (AOR 2.3, 95% CI 1.1-4.8); and having a history of exchanging sex for money/drugs (AOR 2.8, 95% CI 1.5-5.2).nnnCONCLUSIONSnMore than two decades after injection and sexual practices were identified as risk factors for HIV infection, these behaviors remain common among young IDUs. While racial/ethnic disparities persist, methamphetamine may be replacing cocaine as the drug most associated with HIV seropositivity. HIV prevention interventions targeting young IDUs and address both sexual and injection practices are needed.

Positive deviance control-case life history: a method to develop grounded hypotheses about successful long-term avoidance of infection.

BackgroundPrevalence rates for long-term injection drug users in some localities surpass 60% for HIV and 80% for HCV. We describe methods for developing grounded hypotheses about how some injectors avoid infection with either virus.MethodsSubjects: 25 drug injectors who have injected drugs 8 – 15 years in New York City. 17 remain without antibody to either HIV or HCV; 3 are double-positives; and 5 are positive for HCV but not HIV. Staying Safe methodology compares serostatus groups using detailed biographical timelines and narratives; and information about how subjects maintain access to physical resources and social support; their strategies and tactics to remain safe; how they handle problems of addiction and demands by drug dealers and other drug users; and how their behaviors and strategies do or do not become socially-embedded practices. Grounded theory and life-history analysis techniques compare and contrast doubly-uninfected with those infected with both viruses or only with HCV.ResultsThemes and initial hypotheses emerging from analyses included two master hypotheses that, if confirmed, should help shape preventive interventions: 1) Staying uninfected is not simply a question of social structure or social position. It involves agency by drug injectors, including sustained hard work and adaptation to changing circumstances. 2) Multiple intentionalities contribute to remaining uninfected. These conscious goals include balancing ones need for drugs and ones income; developing ways to avoid drug withdrawal sickness; avoiding situations where other drug users importune you to share drugs; and avoiding HIV (and perhaps HCV) infection. Thus, focusing on a single goal in prevention might be sub-optimal.Other hypotheses specify mechanisms of enacting these intentionalities. One example is finding ways to avoid extreme social ostracism.ConclusionWe have identified strategies and tactics that some doubly-uninfected IDUs have developed to stay safe. Staying Safe methodology develops grounded hypotheses. These can be tested through cohort studies of incidence and prevention trials of hypothesis-based programs to help drug injectors make their injection and sexual careers safer for themselves and others. This positive deviance control-case life history method might be used to study avoiding other infections like genital herpes among sex workers.

A Randomized Intervention Trial to Reduce the Lending of Used Injection Equipment Among Injection Drug Users Infected With Hepatitis C

OBJECTIVESnWe evaluated the efficacy of a peer-mentoring behavioral intervention designed to reduce risky distributive injection practices (e.g., syringe lending, unsafe drug preparation) among injection drug users with hepatitis C virus (HCV) infection.nnnMETHODSnA randomized trial with a time-equivalent attention-control group was conducted among 418 HCV-positive injection drug users aged 18 to 35 years in 3 US cities. Participants reported their injection-related behaviors at baseline and at 3- and 6-month follow-ups.nnnRESULTSnCompared with the control group, intervention-group participants were less likely to report distributive risk behaviors at 3 months (odds ratio [OR]=0.46; 95% confidence interval [CI]=0.27, 0.79) and 6 months (OR=0.51; 95% CI=0.31, 0.83), a 26% relative risk reduction, but were no more likely to cite their HCV-positive status as a reason for refraining from syringe lending. Effects were strongest among intervention-group participants who had known their HCV-positive status for at least 6 months. Peer mentoring and self-efficacy were significantly increased among intervention-group participants, and intervention effects were mediated through improved self-efficacy.nnnCONCLUSIONSnThis behavioral intervention reduced unsafe injection practices that may propagate HCV among injection drug users.

Drug treatment program patients' hepatitis C virus (HCV) education needs and their use of available HCV education services

BackgroundIn spite of the disproportionate prevalence of hepatitis C virus (HCV) infection among drug users, many remain uninformed or misinformed about the virus. Drug treatment programs are important sites of opportunity for providing HCV education to their patients, and many programs do, in fact, offer this education in a variety of formats. Little is known, however, about the level of HCV knowledge among drug treatment program patients, and the extent to which they utilize their programs HCV education services.MethodsUsing data collected from patients (N = 280) in 14 U.S. drug treatment programs, we compared patients who reported that they never injected drugs (NIDUs) with past or current drug injectors (IDUs) concerning their knowledge about HCV, whether they used HCV education opportunities at their programs, and the facilitators and barriers to doing so. All of the programs were participating in a research project that was developing, implementing, and evaluating a staff training to provide HCV support to patients.ResultsAlthough IDUs scored higher on an HCV knowledge assessment than NIDUs, there were many gaps in HCV knowledge among both groups of patients. To address these knowledge gaps, all of the programs offered at least one form of HCV education: all offered 1:1 sessions with staff, 12 of the programs offered HCV education in a group format, and 11 of the programs offered this education through pamphlets/books. Only 60% of all of the participating patients used any of their programs HCV education services, but those who did avail themselves of these HCV education opportunities generally assessed them positively. In all, many patients were unaware that HCV education was offered at their programs through individual sessions with staff, group meetings, and books/pamphlets, (42%, 49%, and 46% of the patients, respectively), and 22% were unaware that any HCV education opportunities existed.ConclusionEfforts especially need to focus on ensuring that all drug treatment program patients are made aware of and encouraged to use HCV education services at their programs.

Using hepatitis C virus and herpes simplex virus-2 to track HIV among injecting drug users in New York City

OBJECTIVEnTo explore the potential utility of hepatitis C virus (HCV) seroprevalence as a biomarker for injection risk, and herpes simplex virus-2 (HSV-2) as a biomarker for sexual risk among injecting drug users (IDUs). We examined the relationships between HCV and HIV and between HSV-2 and HIV among injecting drug users in New York City relative to the large-scale implementation of syringe exchange in the mid-1990s.nnnMETHODSn397 injecting drug users were recruited from a drug detoxification program in New York from 2005 to 2007. Informed consent was obtained, a questionnaire covering demographics, drug use and HIV risk was administered. Blood samples were tested for antibody to HIV, HCV and HSV-2.nnnRESULTSnAmong all subjects, HIV prevalence was 17%, HCV prevalence 72% and HSV-2 prevalence 48%. Among IDUs who began injecting before 1995, HIV was 28%, HCV serostatus was strongly associated with HIV serostatus (AOR=8.96, 95% CI 1.16-69.04) and HSV-2 serostatus was not associated with HIV serostatus (AOR=1.31, 95% CI 0.64-2.67). Among subjects who began injecting in 1995 or later, HIV was 6%, HCV was not associated with HIV (AOR=1.04, 95% CI 0.27-4.08) and HSV-2 serostatus was strongly related to HIV serostatus (AOR=10.71, 95% CI 1.18-97.57).nnnCONCLUSIONSnHCV and HSV-2 HCV and HSV-2 may provide important new tools for monitoring evolving HIV epidemics among IDUs. Reconsideration of the current CDC hierarchical transmission risk classification system may also be warranted.