Karin E. Tobin

Evaluation of the Staying Alive programme: Training injection drug users to properly administer naloxone and save lives

BACKGROUND In response to the high rates of opiate-related overdoses and deaths in the United States, a number of overdose prevention programmes have been implemented that include training drug users to administer naloxone, an opiate antagonist. The purpose of this study was to evaluate the Staying Alive (SA) programme in Baltimore, Maryland, which trained drug users to prevent and respond to opiate overdose using techniques including mouth-to-mouth resuscitation and administration of naloxone. METHODS Participants for the SA programme were recruited from multiple locations by Baltimore City Health Department Needle Exchange programme staff. A 1-h training was conducted by two facilitators. Participants who successfully completed the programme were provided with a kit that contained naloxone. Participants in the evaluation study were enrolled prior to the training session. The present analysis includes 85 participants who completed a pre- and post-test evaluation survey. RESULTS At both time points, 43 participants reported having witnessed an overdose. Post-training, naloxone was administered by 19 with no reported adverse effects. Post-training, a greater proportion of participants reported using resuscitation skills taught in the SA programme along with increased knowledge specifically about naloxone. CONCLUSIONS Results from this study provide additional evidence to support the effectiveness of overdose prevention training programmes that include skills building for drug users to administer naloxone.

Results From a Randomized Controlled Trial of a Peer-Mentoring Intervention to Reduce HIV Transmission and Increase Access to Care and Adherence to HIV Medications Among HIV-Seropositive Injection Drug Users

Background:There is a lack of effective behavioral interventions for HIV-positive injection drug users (IDUs). We sought to evaluate the efficacy of an intervention to reduce sexual and injection transmission risk behaviors and to increase utilization of medical care and adherence to HIV medications among this population. Methods:HIV-positive IDUs (n = 966) recruited in 4 US cities were randomly assigned to a 10-session peer mentoring intervention or to an 8-session video discussion intervention (control condition). Participants completed audio computer-assisted self-interviews and had their blood drawn to measure CD4 cell count and viral load at baseline and at 3-month (no blood), 6-month, and 12-month follow-ups. Results:Overall retention rates for randomized participants were 87%, 83%, and 85% at 3, 6, and 12 months, respectively. Participants in both conditions reported significant reductions from baseline in injection and sexual transmission risk behaviors, but there were no significant differences between conditions. Participants in both conditions reported no change in medical care and adherence, and there were no significant differences between conditions. Conclusions:Both interventions led to decreases in risk behaviors but no changes in medical outcomes. The characteristics of the trial that may have contributed to these results are examined, and directions for future research are identified.

Migration, neighborhoods, and networks: approaches to understanding how urban environmental conditions affect syndemic adverse health outcomes among gay, bisexual and other men who have sex with men.

Adopting socioecological, intersectionality, and lifecourse theoretical frameworks may enhance our understanding of the production of syndemic adverse health outcomes among gay, bisexual and other men who have sex with men (MSM). From this perspective, we present preliminary data from three related studies that suggest ways in which social contexts may influence the health of MSM. The first study, using cross-sectional data, looked at migration of MSM to the gay resort area of South Florida, and found that amount of time lived in the area was associated with risk behaviors and HIV infection. The second study, using qualitative interviews, observed complex interactions between neighborhood-level social environments and individual-level racial and sexual identity among MSM in New York City. The third study, using egocentric network analysis with a sample of African American MSM in Baltimore, found that sexual partners were more likely to be found through face-to-face means than the Internet. They also observed that those who co-resided with a sex partner had larger networks of people to depend on for social and financial support, but had the same size sexual networks as those who did not live with a partner. Overall, these findings suggest the need for further investigation into the role of macro-level social forces on the emotional, behavioral, and physical health of urban MSM.

Social Norms, Social Networks, and HIV Risk Behavior Among Injection Drug Users

Social network structure and norms are linked to HIV risk behavior. However little is known about the gradient of norm of HIV risk that exists among social networks. We examined the association between injection risk network structure and HIV risk norms among 818 injection drug users (IDUs). IDUs were categorized into four distinct groups based on their risk behaviors with their drug networks: no network members with whom they shared cookers or needles, only cooker-sharing member, one needle-sharing member, and multiple needle-sharing members. The riskiest group, networks of multiple needle sharers, was more likely to endorse both risky needle-sharing and sex norms. Networks of only cooker sharers were less likely to endorse high-risk norms, as compared to the networks with no sharing. There were also differences based on gender. Future HIV prevention interventions for IDUs should target both injection and sex risk norms, particularly among IDUs in the multiple needle-sharing networks.

The STEP into Action study: a peer-based, personal risk network-focused HIV prevention intervention with injection drug users in Baltimore, Maryland

AIMS To assess the effectiveness of a peer-based, personal risk network-focused HIV prevention intervention to (i) train injection drug users (IDUs) to reduce injection and sex risk behaviors, (ii) conduct outreach to behaviorally risky individuals in their personal social networks [called risk network members (RNM)], and (iii) reduce RNM HIV risk behaviors. DESIGN Randomized controlled trial with prospective data collection at 6, 12 and 18 months. Intervention condition consisted of five group sessions, one individual session and one session with Index and the RNM. SETTING This study was conducted in Baltimore, Maryland from March 2004 to March 2006. PARTICIPANTS (i) Index participants were aged ≥ 18 years and self-reported injection drug use in the prior 6 months and (ii) their RNM who were aged ≥ 18 years and drug users or sex partners of Index. MEASUREMENTS Outcomes included: (i) injection risk based on sharing needles, cookers and cotton for injection and drug splitting, (ii) sex risk based on number of sex partners, condom use and exchanging sex and (iii) Index HIV outreach behaviors. FINDINGS A total of 227 Index participants recruited 336 RNM. Retention of Index at 18-month follow-up exceeded 85%. Findings suggest that the experimental condition was efficacious at 18 months in reducing Index participant injection risk [odds ratio (OR) = 0.38; 95% confidence interval (CI) = 0.18-0.77), drug-splitting risk (OR = 0.46; 95% CI = 0.25-0.88) and sex risk among Index (OR = 0.53; 95% CI = 0.34-0.86). Significant intervention effect on increased condom use among female RNM was observed (OR = 0.34; 95% CI = 0.18-0.62). CONCLUSIONS Training active IDU to promote HIV prevention with behaviorally risky individuals in their networks is feasible, efficacious and sustainable.

The relationship between depressive symptoms and nonfatal overdose among a sample of drug users in Baltimore, Maryland

Nonfatal drug overdoses are common among heroin users. While several factors that increase risk of overdose have been identified, there is little research on the role of mental health status. The purpose of this study was to examine the association between depressive symptoms and history of overdose. A sample of 729 opiate and cocaine users completed a cross-sectional survey. Of the sample, 65% reported never having overdosed, 31% had overdosed longer than 12 months before the interview, and 4% had overdosed within the past 12 months. Results indicate that a high score on the Center for Epidemiological Studies Depression Scale (CES-D), a measure of depressive symptoms, was associated with having overdosed within the past 12 months (relative risk ratio [RRR]=3.06; 95% confidence interval [CI], 1.33 to 7.05) after adjusting for age, gender, injection frequency, and physical health impairment. These results suggest that drug users with depressive symptoms should be targeted for overdose prevention programs.

Individual and Social Network Factors that Predict Entry to Drug Treatment

Prospective data were analyzed to examine individual and social network characteristics that predict entry into drug treatment among a sample of 557 heroin and cocaine users. Entering treatment was associated with being HIV positive [AOR: 2.25, 95% CI: 1.33-3.81] and a history of drug treatment [AOR: 3.41, 95% CI: 2.19-5.31]. Individuals with a greater number of social network members who were in drug treatment [AOR: 1.29, 95% CI: 1.07-1.56] and fewer network members who smoked crack [AOR: 0.86, 95% CI: 0.75-0.99] were more likely to enter treatment. Social network-based interventions that promote successful outcomes in drug treatment are needed.

Acceptability of A-CASI by HIV-positive IDUs in a multisite, randomized, controlled trial of behavioral intervention (INSPIRE).

Audio computer-assisted self-interviewing (A-CASI) is now widely used to gather information from many types of research participants, including injection drug users (IDUs). The purpose of this study was to describe how HIV-positive IDUs participating in an intervention trial viewed A-CASI and to identify the characteristics of participants who held unfavorable attitudes toward A-CASI. Using a sample of participants who completed 12-month assessments (n = 821), we found that most (>80%) of the sample held favorable or neutral attitudes toward A-CASI. Approximately 18% said that they would prefer an interview with a person to a computer, 12% said that they did not understand the questions they heard on the computer, and 14% said that the computer made it hard to be open and honest about risk behavior. Multivariate analyses found that participants who were more socially marginalized (with unstable housing and lower sense of empowerment) and had greater physical limitations and lower CD4 cell counts were consistently more likely to report various negative A-CASI attitudes; however, some outcome-specific findings were also noted. Our research supports the feasibility and general acceptability of A-CASI with HIV-positive IDUs, and it suggests further research exploring the associations between A-CASI attitudes and characteristics of disadvantaged populations.

Unprotected sex among HIV-positive injection drug-using women and their serodiscordant male partners: role of personal and partnership influences.

Summary: We investigated the characteristics of human immunodeficiency virus (HIV)-positive injection drug-using women who reported unprotected vaginal and/or anal sex with HIV-negative or unknown serostatus (serodiscordant) male partners. Of 426 female study participants, 370 were sexually active. Of these women, 39% (144/370) and 40% (148/370) reported vaginal and/or anal sex with serodiscordant main and casual partners, respectively. Sixty percent of women inconsistently used condoms with their serodiscordant main partners, whereas 53% did so with casual partners. In multivariate analysis, during sex with main partners, inconsistent condom users were less likely to feel confident about achieving safe sex (self-efficacy), personal responsibility for limiting HIV transmission, and that their partner supported safe sex. Inconsistent condom use was also more likely among women who held negative beliefs about condoms and in couplings without mutual disclosure of HIV status. Regarding sex with casual partners, inconsistent condom users were more likely to experience psychologic distress, engage in sex trading, but they were less likely to feel confident about achieving safe sex. These findings suggest that there are widespread opportunities for the sexual transmission of HIV from drug-using women to HIV-uninfected men, and that reasons vary by type of partnership. Multifaceted interventions that address personal, dyadic, and addiction problems are needed for HIV-positive injection drug-using women.

Differences in the Social Networks of African American Men Who Have Sex With Men Only and Those Who Have Sex With Men and Women

OBJECTIVES We compared social network characteristics of African American men who have sex with men only (MSMO) with social network characteristics of African American men who have sex with men and women (MSMW). METHODS Study participants were 234 African American men who have sex with men who completed a baseline social network assessment for a pilot behavioral HIV prevention intervention in Baltimore, Maryland, from 2006 through 2009. We surveyed the men to elicit the characteristics of their social networks, and we used logistic regression models to assess differences in network characteristics. RESULTS MSMO were significantly more likely than were MSMW to be HIV-positive (52% vs 31%). We found no differences between MSMO and MSMW in the size of kin networks or emotional and material support networks. MSMW had denser sexual networks, reported more concurrent and exchange partners, used condoms with more sexual partners, and reported interaction with a larger number of sexual partners at least once a week. CONCLUSIONS Although there were many similarities in the social and sexual network characteristics of MSMO and MSMW, differences did exist. HIV prevention interventions should address the unique needs of African American MSMW.