Sylvia Cohn

Correlates of hepatitis C virus infections among injection drug users.

Injection drug users are at high risk for hepatitis C virus (HCV) infection. In Baltimore, Maryland, the prevalence of anti-HCV is greater among injection drug users who are black, human immunodeficiency virus (HIV) infected, have injected longer, have injected more frequently, and have injected cocaine than among other injection drug users. HCV infection occurs quickly after the initiation of injecting illicit drugs, with 78% of study participants anti-HCV positive after 2 years of injecting. The prevalence of anti-HCV among injection drug users does not appear to be related to socioeconomic factors or sexual practices. Some injection drug users remain free of anti-HCV even after years of injecting and serologic evidence of other bloodborne pathogens. Some of these injection drug users have HCV infection, demonstrated by HCV RNA in their sera. However, the basis for viral persistence in the absence of anti-HCV and for the absence of HCV infection in long-term drug users is not known. Further studies are indicated to determine the mechanism or mechanisms for the absence of anti-HCV in persons exposed to the virus, because the biologic basis for this condition may elucidate the elements missing in the immune response of the majority of HCV-exposed persons who acquire persistent infection. In addition, interventions to prevent HCV infections should be applied in populations at risk for injection drug use early or before drug use begins.

Reductions in high-risk drug use behaviors among participants in the Baltimore Needle Exchange Program

OBJECTIVE To determine whether enrollment in the Baltimore Needle Exchange Program (NEP) was associated with short-term reduction in risky injection practices. METHODS Demographic information was collected on NEP participants upon enrollment. A systematic sample of enrollees was interviewed at program entry, 2 weeks, and 6 months later on recent drug-related behaviors. Comparisons were performed using paired t-tests. RESULTS Among 221 NEP participants who completed baseline, 2-week and 6-month follow-up visits, significant reductions (p < .01) were reported in using a previously used syringe (21.6%, 11.0%, 7.8%, respectively), lending ones used syringe to a friend (26.7%, 18.4%, 12%, respectively), and several indirect sharing activities. Reductions were reported in the mean number of injections per syringe and the mean number of injections per day (p < .001). CONCLUSIONS These results show rapid and mostly large reductions in a variety of risky injection drug use behaviors. Study findings are consistent with earlier reports showing an association between behavioral risk reduction and participation in a needle exchange program.

Risk factors for shooting gallery use and cessation among intravenous drug users.

BACKGROUND Shooting galleries, locations where intravenous drug users (IVDUs) can rent or borrow needles and syringes, are a high-risk environment for HIV-1 transmission. This study investigates risk factors for lifetime attendance at shooting galleries and differentiates characteristics of those who continue to frequent shooting galleries and those who have stopped. METHODS We interviewed 2615 active IVDUs in Baltimore in 1988 and 1989 and determined patterns of IV drug use, sociodemographics, and HIV-1 serostatus as related to persistence vs cessation of shooting gallery use. RESULTS Over half (52%) of active IVDUs reported ever using a shooting gallery, with 33% reporting use within the prior 3 months. In multivariate analysis, lifetime shooting gallery use was associated with male gender, homosexuality/bisexuality, low socioeconomic status, Black race, and heavier drug involvement. Persistent shooting gallery users were more frequently male, homosexual/bisexual, homeless, less educated, and started IV drug use more recently compared with those who ceased going to shooting galleries. CONCLUSIONS Shooting gallery attendance may be pragmatic from a sociological and economic perspective, but it carries with it a heightened risk of acquiring HIV-1 infection.

Self-Report Interview Data for a Study of HIV-1 Infection among Intravenous Drug Users: Description of Methods and Preliminary Evidence on Validity

This article presents a description and preliminary evidence on validity of self-report interview methods being used in a study of HIV-1 infection and AIDS among intravenous drug users (IVDUs). The study population includes 2,616 currently active IVDUs living in or near Baltimore City, Maryland (USA), many of them reporting no prior treatment for drug dependence, and many with no history of criminal arrest or incarceration. These IVDUs were recruited in 1988–89 by extensive community outreach efforts; most learned of the study by word-of-mouth. To study IV drug use and HIV-1 infection in relation to onset of AIDS, the subjects are being interviewed, examined, and tested at baseline (recruitment), and periodically thereafter. This report compares information from the self-report baseline interview with independently collected data on physical stigmata of drug injection, T-lymphocyte cell subsets, and HIV-1 serostatus. The evidence generally supports the validity of these self-report data on IV drug use, including data from a year-by-year history of sharing injection equipment, obtained by retrospection at baseline.

Correlates of needle sharing among injection drug users

OBJECTIVES The sharing of contaminated injection equipment is the primary mode of human immunodeficiency virus (HIV) transmission for injection drug users. This study examined demographic factors, life events, and drug use practices that are potential risk factors for sharing injection equipment. METHODS Between February 1988 and March 1989, 2921 active injection drug users were interviewed and questioned about their backgrounds, life-styles, and patterns of injection drug use. RESULTS Of 2524 participants who reported injecting drugs within the 6 months prior to study enrollment, 70.4% reported recent needle sharing. A multivariate analysis found needle sharing to be more frequent among those with a history of arrest and lower socioeconomic status, even after accounting for other demographic and drug use variables. In addition, recent needle sharing was higher in male homosexual or bisexual men than in their heterosexual counterparts. CONCLUSIONS These data suggest that injection drug users have an economic motive to share needles and that the availability of free and legal needles may reduce levels of needle sharing.

Vitamin A Supplementation and Human Immunodeficiency Virus Load in Injection Drug Users

The use of vitamin A therapy during human immunodeficiency virus (HIV) infection is under clinical investigation, and vitamin A could potentially modulate HIV replication because the virus genome contains a retinoic acid response element. A randomized, double-masked, placebo-controlled clinical trial was conducted to determine the impact of single high-dose vitamin A supplementation, 60-mg retinol equivalent (200,000 IU), on HIV load and CD4 lymphocyte count. HIV-infected injection drug users (120) were randomly allocated to receive vitamin A or placebo. Plasma vitamin A level, CD4 lymphocyte count, and HIV load were measured at baseline and 2 and 4 weeks after treatment. Vitamin A supplementation had no significant impact on HIV load or CD4 lymphocyte count at 2 and 4 weeks after treatment. This study suggests that high-dose vitamin A supplementation does not influence HIV load.

HIV Infection and Cognition in Intravenous Drug Users Long-term Follow-up

A cohort of 185 HIV-infected injection drug users (IDUs) and seronegative controls was followed with semiannual neuropsychological assessments for up to 4.5 years. Changes in cognitive performance over time were evaluated, and results of seronegative controls were used to adjust for level of education and practice effects. The effects of duration of follow-up, decline in CD4+ count, development of clinical symptoms, antiretroviral use, and diagnosis of AIDS on changes in neuropsychological performance over time were assessed with regression models using the generalized estimating equation approach. Improvement in performance over time, consistent with practice effects, was observed for all measures. The only subtest for which the magnitude of the practice effects was mildly attenuated relative to the seronegative controls was Grooved Pegboard, dominant hand. After adjusting for disease progression and antiretroviral therapy use, none of the time trends for the neuropsychological test scores were significant, suggesting no decline in performance of the seropositive patients relative to the seronegative controls. With development of clinical symptoms, there was a trend in the direction of declining performance. For subjects reporting two or more symptoms but not using antiretroviral therapy, the trend was not significant, whereas having two or more symptoms and using antiretroviral therapy was associated with significantly worse performance on tests of psychomotor speed and memory. With development of AIDS, a significant decline in performance was observed on measures of motor and psychomotor speed as well as memory. There is thus no evidence to suggest that HIV infection in the context of chronic drug and alcohol use significantly alters the frequency or rate of progression of cognitive symptoms. These findings suggest that the natural history of cognitive changes secondary to HIV infection is similar among HIV-infected IDUs and other risk groups such as homosexual/bisexual men. NEUROLOGY 1997;48: 223-230

Syphilis Serology in Human Immunodeficiency Virus Infection: Evidence for False-Negative Fluorescent Treponemal Testing

Injection drug users were assessed serologically for human immunodeficiency virus infection and syphilis every 6 months. Treatment histories were reviewed for any high-titer biologic false-positive (BFP) reactors, that is, persons with rapid plasma reagin (RPR) titers > or = 1:4 and negative results for fluorescent treponemal antibody absorption (FTA-ABS) tests. Selected sera were analyzed further by immunoblotting for the presence of antibodies reactive with specific Treponema pallidum antigens. Of 112 BFP reactors, 35 (31%) had at least one RPR test reactive at a dilution >1:8 while the FTA-ABS test remained nonreactive. Five reactors (4.5%) converted from nonreactive to reactive by FTA-ABS test; 4 (3.6%) were reactive by FTA-ABS tests but later became nonreactive. Antibodies to T. pallidum membrane antigens were detected in some samples that were persistently nonreactive by FTA-ABS test. Serologic patterns over time, along with very high-titer BFP reactions and reactivity with T. pallidum-specific antigens, suggest that some BFP reactions may represent FTA-negative syphilis.

Human immunodeficiency virus infection and infective endocarditis among injecting drug users

&NA; Human immunodeficiency virus (HIV) infection and infective endocarditis are serious complications of injection drug use. To determine whether HIV infection may increase the risk of endocarditis beyond that associated with drug injection, we performed a nested case‐control study among injecting drug users taking part in an ongoing cohort. We identified 26 participants with infective endocarditis between cohort enrollment (in 1988‐1989) and June 1992, through reviews of medical records and death certificates. We matched each endocarditis case with up to five controls (N = 120) on enrollment date, race/ethnicity, and follow‐up time. Data were taken from baseline and from one follow‐up visit: the last visit before the endocarditis occurred for cases and the closest visit (±3 months) for controls. We used conditional logistic regression to quantify the association between HIV serostatus at follow‐up and subsequent endocarditis, after adjusting for a history of endocarditis or sepsis before enrollment, injection duration, current injection frequency, and a recent history of abscess at injection sites. Among current injectors at followup, the adjusted odds ratio (OR) of developing endocarditis for HIV‐seropositive subjects with >350 CD4 cells per &mgr;l, compared with HIV‐seronegative subjects, was 2.31 [95% confidence interval (CI) = 0.61‐8.78]; the corresponding OR for HIV‐seropositive subjects with <350 CD4 cells per &mgr;l was 8.31 (95% CI = 1.23‐56.37). These data indicate that HIV‐related immunodeficiency may independently increase the risk of infective endocarditis among injecting drug users.

Hiv Seroconversion And Disinfection Of Injection Equipment Among Intravenous Drug Users, Baltimore, Maryland

To examine the putative protective effect of disinfectant use on HIV seroconversion among intravenous drug users, we conducted a nested case-control study comparing 22 black heterosexual HIV seroconverters with 95 persistent seronegatives matched on gender, use of cocaine, date of study entry, and duration of follow-up. For intravenous drug users who reported using disinfectant all the time, the odds of seroconversion was 0.77 (95% CI: 0.25-2.38) compared with those who reported no use of disinfectants; for those who used disinfectants some of the time, the corresponding odds ratio was 0.91 (95% CI: 0.26-3.31). The odds ratio for use of disinfectant all the time was 0.63 (95% CI: 0.10-3.91) for those injecting at galleries and 1.08 (95% CI: 0.35-3.11) for those not injecting at galleries. These data suggest a limited protective effect of disinfectant use in the field which may be more beneficial to those injecting in shooting galleries.