Michael C. Clatts

Alternatives to the randomized controlled trial

Public health researchers are addressing new research questions (e.g., effects of environmental tobacco smoke, Hurricane Katrina) for which the randomized controlled trial (RCT) may not be a feasible option. Drawing on the potential outcomes framework (Rubin Causal Model) and Campbellian perspectives, we consider alternative research designs that permit relatively strong causal inferences. In randomized encouragement designs, participants are randomly invited to participate in one of the treatment conditions, but are allowed to decide whether to receive treatment. In quantitative assignment designs, treatment is assigned on the basis of a quantitative measure (e.g., need, merit, risk). In observational studies, treatment assignment is unknown and presumed to be nonrandom. Major threats to the validity of each design and statistical strategies for mitigating those threats are presented.

New injectors and the social context of injection initiation.

BACKGROUND Preventing the onset of injecting drug use is an important public health objective yet there is little understanding of the process that leads to injection initiation. This paper draws extensively on narrative data to describe how injection initiation is influenced by social environment. We examine how watching other people inject can habitualise non-injectors to administering drugs with a needle and consider the process by which the stigma of injecting is replaced with curiosity. METHOD In-depth interviews (n=54) were conducted as part of a 2-year longitudinal study examining the behaviours of new injecting drug users. RESULTS Among our sample, injection initiation was the result of a dynamic process during which administering drugs with a needle became acceptable or even appealing. Most often, this occurred as a result of spending time with current injectors in a social context and the majority of this studys participants were given their first shot by a friend or sexual partner. Initiates could be tenacious in their efforts to acquire an injection trainer and findings suggest that once injecting had been introduced to a drug-using network, it was likely to spread throughout the group. CONCLUSION Injection initiation should be viewed as a communicable process. New injectors are unlikely to have experienced the negative effects of injecting and may facilitate the initiation of their drug-using friends. Prevention messages should therefore aim to find innovative ways of targeting beginning injectors and present a realistic appraisal of the long-term consequences of injecting. Interventionists should also work with current injectors to develop strategies to refuse requests from non-injectors for their help to initiate.

Club Drug Use Among Young Men Who Have Sex with Men in NYC: A Preliminary Epidemiological Profile

This paper describes findings from a study of young men who have sex with men (YMSM) in New York City. Using a cross-sectional design and a community-based targeted sampling approach, a total of 569 YMSM were recruited during 2000 and 2001 for a structured survey interview. High rates of lifetime exposure to a variety of club drugs (including methamphetamine, ketamine, and MDMA) are observed in the overall sample. Among those who use club drugs on a chronic basis (N = 145), we found high rates of a prior suicide attempt (including high rates of multiple suicide attempts), high rates of lifetime exposure to multiple types of drugs, high rates of current poly drug use (including multiple types of club drugs), and high rates of current depressive symptoms. Chronic club drug users had a mean CES-D score of 8.5 and nearly two-thirds had a score of 7 or more. Although high rates of condom use are reported in some types of sexual exchanges, data show multiple types of sexual risk among chronic club drug users, including high rates of unprotected anal intercourse (UAI) with most frequent partners and comorbid drug use among both YMSM and their sexual partners.

Intranasal Transmission of Hepatitis C Virus: Virological and Clinical Evidence

Intranasal transmission of hepatitis C virus (HCV) via contaminated drug-sniffing implements is a potential but unconfirmed source of viral infection. We demonstrate the virological plausibility of intranasal transmission by confirming that blood and HCV RNA are present in the nasal secretions and drug-sniffing implements of HCV-infected intranasal drug users recruited from a community health clinic in New York City.

An emerging HIV risk environment: a preliminary epidemiological profile of an MSM POZ Party in New York City

Objective: To develop a preliminary epidemiological description of a men who have sex with men (MSM) “POZ Party,” an emerging sex environment for HIV+ MSM. Methods: As part of a pilot study in New York City in 2003, data were collected using a brief, behavioural intercept survey at entry to POZ Party events. Domains include demographic characteristics, history of HIV infection, motivations for attending POZ parties, lifetime and recent exposure to drugs (including use during POZ Party events), and recent sexual practices (both within both POZ Party venues as well as in non-POZ Party venues). Results: Predominantly white and over the age of 30, subjects in the sample include a broad range of years living with HIV infection. Motivations for using a POZ Party venue for sexual partnering include relief from burdens for serostatus disclosure, an interest in not infecting others, and opportunities for unprotected sexual exchange. High rates of unprotected sex with multiple partners are prevalent in the venue. Although the sample evidences high rates of lifetime exposure to illicit drugs, relatively little drug use was reported in these sexual environments. These reports are consistent with evidence from direct observation at the venues themselves, in which no drug use was apparent. Conclusion: Serosorting among HIV+ MSM may reduce new HIV infections, a stated interest of both POZ Party organisers and participants alike. However, high rates of unprotected anal intercourse within these venues signal continued risk for STIs. Additionally, unprotected sexual contact with HIV partners and status unknown partners outside POZ Party venues heightens concern for diffusion of HIV superinfection.

Patterns of Polydrug Use Among Ketamine Injectors in New York City

Polydrug use is an important public health issue since it has been linked to significant adverse health outcomes. Recently, club drugs, including ketamine and other drugs used in dance/rave scenes, have been identified as key substances in new types of polydrug using patterns. While seemingly a self-explanatory concept, “polydrug” use constitutes multiple drug using practices that may impact upon health risks. Ketamine, a club drug commonly administered intranasally among youth for its disassociative properties, has emerged as a drug increasingly prevalent among a new hidden population of injection drug users (IDUs). Using an ethno-epidemiological methodology, we interviewed 40 young (< 25 years old) ketamine injectors in New York during 2000–2002 to describe the potential health risks associated with ketamine and polydrug use. Findings indicate that ketamine was typically injected or sniffed in the context of a polydrug using event. Marijuana, alcohol, PCP, and speed were among the most commonly used drugs during recent ketamine using events. Polydrug using events were often quite variable regarding the sequencing of drug use, the drug combinations consumed, the forms of the drug utilized, and the modes of administrating the drug combinations. Future research should be directed towards developing a more comprehensive description of the risks associated with combining ketamine with other drugs, such as drug overdoses, the transmission of bloodborne pathogens, such as HIV and HCV, the short- and long-term effects of drug combinations on cognitive functioning, and other unanticipated consequences associated with polydrug use.

HIV-1 transmission in injection paraphernalia: heating drug solutions may inactivate HIV-1.

In response to recent concerns about risk of HIV-1 transmission from drug injection paraphernalia such as cookers, ethnographic methods were used to develop a descriptive typology of the paraphernalia and practices used to prepare and inject illegal drugs. Observational data were then applied in laboratory studies in which a quantitative HIV-1 microculture assay was used to measure the recovery of infectious HIV-1 in cookers. HIV-1 survival inside cookers was a function of the temperature achieved during preparation of drug solutions; HIV-1 was inactivated once temperature exceeded, on average, 65 degrees C. Although different types of cookers, volumes, and heat sources affected survival times, heating cookers 15 seconds or longer reduced viable HIV-1 below detectable levels.

Drug and sexual risk in four men who have sex with men populations: evidence for a sustained HIV epidemic in New York City.

The objective of this article was to examine drug and sexual risk in four salient groups of men who have sex with men (MSM) in New York City (NYC): (1) nonhomeless young MSM (YMSM), (2) homeless YMSM, (3) adult MSM Speed users, and (4) HIV-positive “POZ Party” MSM. Lifetime and current exposure to drugs, drug injection, and selected drug-sex interactions are highlighted in each group. Data derive from recently completed field-based, ethnoepidemiological studies that used venue-oriented/targeted sampling and semistructured interviews. Across all four groups, findings show that both drug and sexual risk remain prevalent in the MSM population in NYC. This is especially troubling given the already high background prevalence of HIV and other sexually transmitted diseases in NYC and the widespread suffering and death already wrought by HIV/AIDS among MSM. These findings suggest that available public health interventions today are, in many respects, failing to reach, engage, and affect critical risk groups within the NYC MSM population.

Reconceptualizing the Interaction of Drug and Sexual Risk Among MSM Speed Users: Notes Toward an Ethno-Epidemiology

The significant numbers of new HIV infections among men who have sex with men (MSM) have brought renewed attention to risk practices related to the use of speed among MSM. However, the primary focus on sexual risk has produced gaps in understanding the role of injection risk. In this critical review, we identify tenacious biases in earlier research and present epidemiological indicators of speed use among MSM. We outline four major areas for future research: (1) transitions into injection, (2) situational injection groups, (3) speed injection practices, and (4) risk reduction interventions. Aiming to inform risk reduction interventions for MSM, we describe how an ethnographic epidemiology might reconceptualize the interaction of sexual and drug risk. Detailing a venue-based research approach, we propose ways to study how MSM use speed to “script” both sexual and injection risk behaviors in the context of social hierarchies and commercial settings.

Women Injection Drug Users Who Have Sex with Women Exhibit Increased HIV Infection and Risk Behaviors

This article is a comprehensive review of published research on HIV seroprevalence and HIV-related risk behaviors among women injection drug users (IDUs) who have sex with women (WSW). At least 14 studies since the late 1980s converge into a consistent pattern: compared to other IDUs, WSW IDUs report higher levels of HIV-related risk behaviors and in many cases exhibit higher rates of HIV seroconversion or seroprevalence. Data from these and additional studies also indicate that large numbers of women IDUs are WSWs. Since information regarding WSW IDUs are widely collected but infrequently analyzed and reported, we suggest promising research and analysis strategies for exploring the meaning behind this pattern of increased vulnerability to HIV. Finally, we assert that enough is currently known to warrant significant investment in targeted prevention and intervention programs to address the critical HIV-related needs of lesbian, bisexual, and other WSW IDUs.