Robert C. Freeman

Early life sexual abuse as a risk factor for crack cocaine use in a sample of community-recruited women at high risk for illicit drug use

Subjects for this study were 1,478 community-recruited women sexual partners of male injection drug users who were participants in the National Institute on Drug Abuse (NIDA)-supported Women Helping to Empower and Enhance Lives (WHEEL) project. This study assessed the association between child/adolescent sexual abuse—including specific type of abuse and perpetrator of abuse—and lifetime crack use in this sample of women. About 64% of sample women had ever used crack; 56% had been sexually abused by age 18. In logistic regression analyses, any sexual abuse in childhood, penetrative sexual abuse in childhood, and sexual abuse by a family member in childhood were significantly associated with lifetime crack use. Sexual abuse in adolescence was indirectly associated with lifetime crack use through running away from home and rape in adulthood. Given that many of these subjects reported drug treatment experience, such programs may provide the best setting for helping women with both substance use and sexual abuse issues.

Drug use, AIDS knowledge, and HIV risk behaviors of Cuban-, Mexican-, and Puerto-Rican-born drug injectors who are recent entrants into the United States

To date, relatively little research attention has been devoted to the HIV-risky behaviors of persons who are newly arrived in the United States and who use drugs. Data gathered from street-recruited injection drug users (IDUs) recruited in 10 United States cities who were born in Mexico, Cuba, and Puerto Rico and who are recent entrants into the United States suggest that, in comparison to US-born IDUs, Mexican-born subjects are at elevated risk for acquiring and transmitting HIV as a result of sharing needles with friends and running partners; sharing drug injection implements such as cookers, cotton, and rinse water; frequent injection in HIV-risky settings; use of unsterilized needles; and relatively frequent trading of sex for drugs or money. Puerto-Rican-born IDUs were found to inject drugs relatively frequently, and to do so relatively often in high-risk settings in which sterile injecting equipment and cleaning materials often are scarce. These data also show generally lower levels of AIDS knowledge among the in-migrant IDUs than among US-born IDUs. Respondents from each nationality group most often cited television as the source of their most useful and reliable AIDS information, but also tended to regard community outreach workers as a significant source of reliable AIDS and needle cleaning information. The high levels of involvement in HIV-risky behaviors, deficits in knowledge concerning the means of HIV transmission, and relative ease of mobility of the at-risk (for HIV) individuals examined here indicate a need for a comprehensive public health prevention initiative to limit the future spread of HIV. At a minimum, such an undertaking would do well to incorporate group-specific, culturally appropriate behavioral interventions as well as an information campaign.

The acceptability of a computer HIV/AIDS risk assessment to not-in-treatment drug users

The purpose of this paper is to report the results of a study assessing the acceptability of a computer HIV risk assessment instrument administered to not-in-treatment drug users. The study asked three questions related to acceptability: (1) are drug users comfortable responding to HIV risk questions using the computer assessment; (2) do drug users feel that they possess the requisite skill to respond to questions using a computer; and (3) do drug users believe that the responses they provide using the computer assessment will remain private and confidential. This study differs from other assessments of the acceptability of computer assisted data collection in that the population of interest has only limited education and interaction with computers. Furthermore, the study was implemented under field conditions. To conduct the study, an existing HIV risk assessment instrument was adapted for use with the computer. Only slight modifications were made to the content of the instrument. To facilitate data collection with this population, audio enhancement and touch screen were used. Three scales measuring comfort, skill and perceived privacy were developed. Results of analysis showed that drug users are comfortable responding to an HIV risk assessment using computer assisted interviewing. Drug users also perceived that they possessed the requisite skill to successfully complete the interview. And, study participants reported that they believed that their responses using the computer interview would remain private and confidential. Only minor differences in scale scores based on sociodemographic characteristics were found among study participants. Implications of the findings are discussed.

Perceived compliance with AZT dosing among a sample of African-American drug users.

The purpose of this report was to present findings from a pilot study conducted to explore the associations between sociodemographic, drug use, and health belief factors and perceived compliance with zidovudine (AZT) among African-American drug users. Data were collected in Washington, DC, USA from individuals who were African-American; were recent or current drug injectors or crack smokers; were HIV-seropositive, and were receiving treatment for HIV infection. Participants were recruited through local organizations that provide services to HIV-infected persons. Participants were interviewed using a questionnaire that solicited sociodemographic, lifetime and current drug use, current sexual behaviours, health status, HIV and drug treatment history, and health belief data. Analyses were limited to individuals currently using an illicit substance and who had received AZT during their medical treatment. Parametric (Pearsons r) and non-parametric (Spearmans rho) statistics were used to assess correlations between perceived compliance with AZT dosing and independent variables. As the study was intended to be both descriptive and exploratory, the level of statistical significance was set at 0.10, rather than the customary 0.05. Antiretroviral medications recognized and recalled by participants are presented. The most commonly recalled medication was AZT. Slightly less than one-third of participants reported being completely compliant with an AZT regimen. Perceived compliance was found to be negatively associated with 5 variables: age, homelessness, number of injections in the previous 30 days, trading sex for drugs, and the perception that AIDS is no longer a serious disease since the development of new antiretroviral medications. Intensity of feelings of joy, fear, and the belief that taking more anti-HIV medications would result in better health were found to be positively correlated. Bivariate associations between perceived compliance and sociodemographic, drug use, sexual behaviour, and health belief variables suggest further avenues of study and potential points for intervention to increase compliance with antiretroviral medications among racial/ethnic minority drug users receiving treatment for HIV infection.

Determinants of condom use among African Americans who smoke crack cocaine

This paper presents findings from an elicitation study that focused on the sexual risks and condom use behaviour of African American crack smokers. Of interest were the attitudes, beliefs, and barriers that affect the adoption and maintenance of condoms as an HIV prophylactic. Thick descriptive data were collected from 64 heterosexual African Americans who smoke crack cocaine. Data were content analysed for descriptions of condom use attitudes, normative beliefs, and barriers or facilitators of condom use. Participants described few positive condom use outcome expectations, while detailing several negative expectations. Normative beliefs were found to be weakly related to condom use with casual partners. However, descriptions of sexual relationships with intimate partners indicated that the normative expectations of the partner strongly influenced condom use. Participants described few contextual barriers to condom use, although situational barriers, including crack addiction, were identified.

Improving Adolescent and Young Adult Health — Training the Next Generation of Physician Scientists in Transdisciplinary Research

To address the critical shortage of physician scientists in the field of adolescent medicine, a conference of academic leaders and representatives from foundations, National Institutes of Health, Maternal and Child Health Bureau, and the American Board of Pediatrics was convened to discuss training in transdisciplinary research, facilitators and barriers of successful career trajectories, models of training, and mentorship. The following eight recommendations were made to improve training and career development: incorporate more teaching and mentoring on adolescent health research in medical schools; explore opportunities and electives to enhance clinical and research training of residents in adolescent health; broaden educational goals for Adolescent Medicine fellowship research training and develop an intensive transdisciplinary research track; redesign the career pathway for the development of faculty physician scientists transitioning from fellowship to faculty positions; expand formal collaborations between Leadership Education in Adolescent Health/other Adolescent Medicine Fellowship Programs and federal, foundation, and institutional programs; develop research forums at national meetings and opportunities for critical feedback and mentoring across programs; educate Institutional Review Boards about special requirements for high quality adolescent health research; and address the trainee and faculty career development issues specific to women and minorities to enhance opportunities for academic success.

Introduction of HIV into drug injector networks outside AIDS epicentres

Injection drug users (IDUs) continue to be at risk for HIV infection despite high levels of knowledge about how human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS) is transmitted. Yet, among notin-treatment injection drug users, the chances of becoming infected with HIV vary substantially. Information regarding the factors that facilitate the introduction of HIV into networks of drug injectors in low HIV seroprevalence cities is urgently needed. This study examines the factors related to HIV seroprevalence in a large ( n =9492), multi-site sample of IDUs recruited in 11 low seroprevalence cities. Univariate and multivariate associations between drug injection and sexual behaviours and travel to an AIDS epicentre were examined. Results show that, next to male-to-male sexual contact, having sex at least twice in an AIDS epicentre was the strongest predictor of HIV infection. Also associated with higher odds of being HIV-positive were racial/ethnic characteristics, daily drug injection, and injecting drugs in an AIDS epicentre. These results confirm that travelling to an AIDS epicentre and having sex or injecting drugs play a large role in the introduction of HIV into drug injector networks in low seroprevalence cities.

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.

A Typology of Violence Against Self and Others and Its Associations With Drinking and Other Drug Use Among High School Students in a U.S. General Population Survey

This study examines associations between binge drinking and other substance use and perpetration of violence against self and others. Data were pooled from the 2003, 2005, and 2007 Youth Risk Behavior Surveys, yielding a sample of 43,172 U.S. high school students. A typology was constructed to reflect four categories of behaviors: other-directed violence only, self-directed violence only, combined other- and self-directed violence, and no violence. Results from multinomial logistic regressions show that the frequency of binge drinking and other substance use were significant risk factors for each of the violence categories relative to no violence. However, the strengths of these associations varied across the violence categories.

Association between child sexual abuse and sexual revictimization in adulthood among women sex partners of injection drug users.

Community-recruited women (n = 1490) were interviewed about their early and adult sexual victimization histories to determine whether there was an association between child sexual abuse and adult revictimization by sex partners and strangers/nonsex partners. Adolescent sexual abuse, lifetime sex-trading, drug treatment, and mental health treatment were examined as mediating variables. One-fourth of the women had been revictimized (i.e., experienced child sexual abuse and at least one instance of adult sexual victimization). Child sexual abuse was associated with both rape and other sexual victimization by a sex partner in adulthood, as well as adult rape by a stranger/nonsex partner. Drug and mental health treatments reduced abused women’s chances of being raped by a sex partner; drug treatment also decreased the likelihood of other sexual victimization by a sex partner. Sex-trading increased abused women’s likelihood of rape by a stranger or nonsex partner. Intervention—including drug treatment—can help women with child sexual abuse histories overcome some of the abuse-related sequelae that make them vulnerable to adult revictimization.