S. R. Friedman

Regulating controversial programs for unpopular people: methadone maintenance and syringe exchange programs.

One third of all cases of the acquired immunodeficiency syndrome (AIDS) in the United States are associated with the injection of illicit drugs. There is mounting evidence for the effectiveness of syringe exchange programs in reducing human immunodeficiency virus (HIV) risk behavior and HIV transmission among injection drug users. Expansion of syringe exchange would require increased public funding and undoubtedly would include government regulation of syringe exchanges. An analogy is drawn with the present system of regulation of methadone maintenance treatment programs and possible regulation of syringe exchange programs. Specific recommendations are offered to reduce the likelihood of repeating the regulatory problems of methadone maintenance treatment in future regulation of syringe exchange programs.

Geographic proximity, policy and utilization of syringe exchange programmes

The objective of the research was to assess the effects of geographic proximity on the utilization of syringe exchange among injection drug users (IDUs) in New York City. Between 1994 and 1996, 805 IDUs were interviewed with a structured questionnaire. Geographic proximity was defined as living within a ten-minute walk. Eighty-one per cent of IDUs who lived close typically used a syringe exchange compared to 59% of those who lived further away. In multiple logistic regression analysis, those who lived close remained (adjusted odds ratio of 2.89; 95% CI 2.06 to 4.06, p = 0.001) more likely to use syringe exchange. Those who lived close were less likely to have engaged in receptive syringe sharing at last injection (adjusted odds ratio = 0.45, 95% CI 0.24 to 0.86, p = 0.015). In conclusion, locating exchange services in areas convenient to large numbers of IDUs may be critical for prevention of HIV infection.

A multicentre study on the causes of death among Italian injecting drug users. AIDS has overtaken overdose as the principal cause of death

The causes of death among injecting drug users. (IDUs) are still being discussed worldwide. We analysed the causes of death among IDUs attending 26 centres for drug users in North-Eastern Italy from 1985 to 1994. The study of a total number of 1,022 deaths reveals the following: (1) AIDS has become the primary cause of death among IDUs since 1991 and is rising even in an area with a moderate HIV seroprevalence; (2) the mean age of death in AIDS patients proved higher than among patients who died of other causes (which may be due to the long incubation period of AIDS); (3) our data do not reveal higher HIV seroprevalence among IDUs who died of overdose and suicide as opposed to IDUs who died of other causes; (4) the mortality rate in IDUs is significantly higher when compared to that of the general population in the same age group.

Breast and Ovarian Cancer Risk and Risk Reduction in Jewish BRCA1/2 Mutation Carriers

PURPOSE Mutations in BRCA1/2 dramatically increase the risk of both breast and ovarian cancers. Three mutations in these genes (185delAG, 5382insC, and 6174delT) occur at high frequency in Ashkenazi Jews. We evaluated how these common Jewish mutations (CJMs) affect cancer risks and risk reduction. METHODS Our cohort comprised 4,649 women with disease-associated BRCA1/2 mutations from 22 centers in the Prevention and Observation of Surgical End Points Consortium. Of these women, 969 were self-identified Jewish women. Cox proportional hazards models were used to estimate breast and ovarian cancer risks, as well as risk reduction from risk-reducing salpingo-oophorectomy (RRSO), by CJM and self-identified Jewish status. RESULTS Ninety-one percent of Jewish BRCA1/2-positive women carried a CJM. Jewish women were significantly more likely to undergo RRSO than non-Jewish women (54% v 41%, respectively; odds ratio, 1.87; 95% CI, 1.44 to 2.42). Relative risks of cancer varied by CJM, with the relative risk of breast cancer being significantly lower in 6174delT mutation carriers than in non-CJM BRCA2 carriers (hazard ratio, 0.35; 95% CI, 0.18 to 0.69). No significant difference was seen in cancer risk reduction after RRSO among subgroups. CONCLUSION Consistent with previous results, risks for breast and ovarian cancer varied by CJM in BRCA1/2 carriers. In particular, 6174delT carriers had a lower risk of breast cancer. This finding requires additional confirmation in larger prospective and population-based cohort studies before being integrated into clinical care.

Consistent condom use among drug-using youth in a high HIV-risk neighbourhood.

Abstract The objectives of this study were to determine predictors of consistent condom use in heterosexual relationships of young adults who use hard drugs in a neigbourhood with widespread drug-use-connected HIV. We interviewed 196 18–24 year olds who injected drugs or used heroin, cocaine or crack in the prior year and lived in the Bushwick neighbourhood of New York City.Interviews covered sociodemographics, substance use and sexual networks. The unit of analysis is the relationship; the dependent variable measures consistent condom use over the prior 30 days in a given relationship. Consistent condom use was reported in 26% of 377 non-commercial relationships and in all of 22 commercial relationships. Using multiple logistic regression, consistent condom use in non-commercial relationships was more likely in relationships that are not ‘very close’; for men (but not women) with peers whose norms are more favourable to condom use; and for subjects who had concurrent sex partners in the last 12 months. In conclusion, we found that: (1) the lack of relationship between the peer norms of drug-using women and their condom use suggests they may have little control over condom use in their relationships—programmes should attempt to empower young women drug users and to develop ways for their peers to influence the men in their lives; (2) epidemiologically, the positive association of concurrency to consistent condom use suggests that condom use may be restricting HIV spread through the community—the presence of consistent condom use in all of the commercial sexual relationships also may restrict HIVspread; (3) prevention efforts should attempt to change peer cultures as a way to develop self-sustaining risk reduction. These changes should include changes in gender roles and power relations.

Implications of the revised surveillance definition: AIDS among New York City drug users.

The Centers for Disease Control (CDC) has proposed revising the AIDS surveillance definition to include any HIV-seropositive person with a CD4 cell count of less than 200 cells per microliter. Based on a study of persons receiving treatment for HIV infection, this new definition would lead to an estimated 50% increase in the number of persons recognized as living with AIDS. Among 440 HIV-seropositive research subjects recruited from drug treatment programs and through street outreach in New York City, 59 met this definition, yet only 25% of those had been reported to the New York City AIDS registry. The new definition, if combined with HIV and T-cell testing at drug treatment and street outreach programs, could thus yield very large increases in the number of injecting drug users meeting the new surveillance definition of AIDS.

HIV‐1 infection among intravenous drug users in Manhattan, New York City, from 1977 through 1987

Intravenous drug users are the second largest group to develop the acquired immunodeficiency syndrome, and they are the primary source for heterosexual and perinatal transmission in the United States and Europe. Understanding long-term trends in the spread of human immunodeficiency virus among intravenous drug users is critical to controlling the acquired immunodeficiency syndrome epidemic. Acquired immunodeficiency syndrome surveillance data and seroprevalence studies of drug treatment program entrants are used to trace seroprevalence trends among intravenous drug users in the borough of Manhattan. The virus entered this drug-using group during the mid-1970s and spread rapidly in 1979 through 1983. From 1984 through 1987, the seroprevalence rate stabilized between 55% and 60%--well below hepatitis B seroprevalence rates. This relatively constant rate is attributed to new infections, new seronegative persons beginning drug injection, seropositive persons leaving drug injection, and increasing conscious risk reduction.