Prevalence of HIV infection and HIV risk behaviors associated with living place: on-the-street homeless drug users as a special target population for public health intervention

The study described here examined the prevalence of HIV infection as a function of place of residence and high-risk behaviors in six subpopulations of out-of-treatment drug injectors and crack cocaine users who participated in the National Institute on Drug Abuse (NIDA) Cooperative Agreement project. The subpopulations were blacks, Hispanics, and non-Hispanic whites sampled separately by gender. The research asked three questions: (a) Is the HIV infection rate higher among the on-the-street homeless than among those in other places of residence? (b) Do high-risk drug-related behaviors differ by housing status? and (c) What are the joint effects of high-risk drug-related behaviors and housing status on the probability of HIV infection? Overall, on-the-street homeless had a significantly higher HIV+ rate (19.0%) than the study population as a whole (11.2%). Rates differed by gender and race, with exceptionally high HIV+ rates for on-the-street homeless Hispanic males (29%) and females (32%) and for on-the-street homeless black females (38%). Having used drug works previously used by a HIV-infected person was a strong predictor of HIV+ status, as was frequency of drug injections and crack use. Having multiple sex partners was also a significant risk behavior. Findings argue against considering on-the-street homelessness as equivalent to shelter dwelling or aggregated homelessness for purposes of the AIDS epidemic. On-the-street homeless drug users were at strong risk for acquisition and transmission of HIV infection and therefore in need of targeted-racially relevant, ethnically relevant, and gender-relevant-public health interventions to help prevent the spread of AIDS.     

New minimal substrate structural requirements in the enzymatic peroxidation of alkenes with soybean lipoxygenase

A longitudinal study was conducted to investigate the association between human immunodeficiency virus (HIV) infection, history of major depressive disorder (MDD), and persistent or recurrent MDD among intravenous drug users. Psychiatric disorders were assessed in a sample of HIV-positive (HIV+) and HIV-negative (HIV-) intravenous drug users every 6 months for 3 years. Results indicated that HIV status and baseline MDD independently predicted persistent or recurrent episodes of MDD after gender, drug use, ethnicity, income, and the presence other psychiatric disorders were controlled statistically. Among HIV+ intravenous drug users with baseline MDD, 90% experienced at least one subsequent episode of MDD and 47% experienced at least three subsequent episodes of MDD. However, less than 40% of intravenous drug users with current MDD received treatment for emotional problems. These findings indicate that intravenous drug users with HIV infection and a history of MDD are at considerable risk for future episodes of MDD or recurrent MDD, and that increased provision of treatment for intravenous drug users with MDD may be necessary.     

Harm reduction in the hills of northern Thailand

The human immunodeficiency virus (HIV) pandemic has swept through injecting drug user (IDU) communities around the world. Once HIV is present in an IDU community, seroprevalence rates escalate rapidly unless immediate and comprehensive prevention methods are put in place. Such measures often include providing IDUs with sterile injecting equipment and dispensing methadone or other opiate substitution formulas. These measures fall under the rubric of harm reduction-an attempt to reduce the harm to drug users, their families, and communities, including preventing or limiting the transmission of HIV and other blood-borne viruses. In Thailand, HIV-1 spread rapidly among IDUs with seroprevalence rates jumping from 1 to 40% in the space of a year. Current incidence rates are estimated at 11 per 100 person years. This paper describes the establishment and implementation of needle and syringe exchanges among injecting drug users in nine Hilltribe communities in Northern Thailand. The exchanges have been operating for between 1 and 3 years and have been effective in limiting the transmission of HIV within these small communities. The needle and syringe exchanges are run by indigenous staff with the cooperation of the community and provide a good example of the feasibility of establishing locally-run, community-based harm reduction programs.     

Infection with HIV and hepatitis C virus among injecting drug users in a prevention setting: retrospective cohort study

OBJECTIVES: To estimate the incidence of HIV and hepatitis C virus and risk factors for seroconversion among a cohort of injecting drug users. DESIGN: Retrospective cohort study. SETTING: Primary healthcare facility in central Sydney. SUBJECTS: Injecting drug users tested for HIV-1 antibody (n=1179) and antibodies to hepatitis C virus (n=1078) from February 1992 to October 1995. MAIN OUTCOME MEASURES: Incidence of HIV-1 and hepatitis C virus among seronegative subjects who injected drugs and underwent repeat testing. Demographic and behavioural risk factors for hepatitis seroconversion. RESULTS: Incidence of HIV-1 among 426 initially seronegative injecting drug users was 0.17/100 person years (two seroconversions) compared with an incidence of hepatitis C virus of 20.9/100 person years (31 seroconversions) among 152 injecting drug users initially negative for hepatitis C virus. Incidence of hepatitis C virus among injecting drug users aged less than 20 years was 75.6/100 person years. Independent risk factors for hepatitis C virus seroconversion were age less than 20 years and a history of imprisonment. CONCLUSIONS: In a setting where prevention measures have contributed to the maintenance of low prevalence and incidence of HIV-1, transmission of hepatitis C virus continues at extremely high levels, particularly among young injecting drug users.     

Trends in HIV incidence among young adults in the United States

CONTEXT: Behaviors that result in potential exposure to human immunodeficiency virus (HIV) usually begin in adolescence or young adulthood, but trends in HIV incidence in young people remain unclear. OBJECTIVE: To estimate trends in HIV incidence in teenagers and young adults. DESIGN AND SETTING: Back-calculation of past HIV incidence in persons born between 1960 and 1974 using US national acquired immunodeficiency syndrome (AIDS) incidence data and estimates of the distribution of times between HIV infection and AIDS. MAIN OUTCOME MEASURES: Incidence and prevalence of HIV in 1988 and 1993 in persons aged 20 and 25 years, respectively, in each of those years. RESULTS: As of January 1993, about 22000 men and 11000 women aged 18 to 22 years were living with HIV infection in the United States. Homosexual contact was the leading route of infection among young men. Heterosexual contact was the leading route of infection among young women. The HIV incidence attributed to homosexual contact or injection drug use decreased among persons aged 20 and 25 years between 1988 and 1993, but HIV incidence attributed to heterosexual contact was stable or increasing. Notably, in men aged 20 and 25 years, HIV prevalence declined by about 50% in white men but was relatively stable in black and Hispanic men. In contrast, HIV prevalence in women aged 20 and 25 years rose by 36% and 45%, respectively, because of increasing heterosexual transmission. Overall, HIV prevalence in persons aged 20 and 25 years declined by only 14% between 1988 and 1993. CONCLUSIONS: In young persons, HIV incidence in homosexual men and injection drug users was slowing by 1993; this favorable trend was offset by increasing heterosexual transmission, especially in minorities.     

HIV surveillance among sexually transmitted disease clinic attenders in Amsterdam, 1991-1996

OBJECTIVE: To determine trends in HIV prevalence among attenders of a clinic for sexually transmitted diseases (STD), with emphasis on heterosexuals who did not have a history of injecting drug use. METHODS: Anonymous unlinked HIV surveys with individual consent, conducted each half year from 1991 to 1996 (except 1993) among STD clinic attenders who came for evaluation of a possible new STD episode. RESULTS: Of 10,940 eligible attenders 10,046 (92%) accepted HIV testing. Of all tested attenders, 312 (3.1%) were HIV-infected. Overall HIV prevalence decreased significantly from 4.6% in 1991 to 2.8% in 1996. HIV prevalence among heterosexual men and women who were not injecting drug users was less than 1% in all but one survey period. Except for one woman, none of the 48 HIV-infected heterosexuals was aware of their current serostatus. Among HIV-infected heterosexuals, 21 out of 28 males (75%) and 18 out of 20 females (90%) were of non-Dutch origin. HIV prevalence was 16% among all homosexual men, and 12% among young homosexual men aged < 30 years. HIV prevalence among young homosexual men decreased significantly over time. Among HIV-infected homosexual men, 58% of older men and 59% of younger men were not aware of their current HIV infection. Rates of current STD were generally significantly higher among HIV-infected participants compared with non-HIV-infected participants. CONCLUSIONS: Although HIV prevalence among heterosexual clinic attenders is low, there is a clear potential for ongoing sexual HIV transmission. Most heterosexually acquired HIV infections are found in non-Dutch persons. This observation suggests migration of HIV-infected heterosexuals or the separation of Dutch and non-Dutch heterosexual networks. Awareness of serostatus is almost non-existent among HIV-infected heterosexuals, and is low among male homosexual clinic attenders. To increase awareness of current HIV serostatus and possibly decrease risk behaviour, HIV counselling and testing should be offered actively to all clinic attenders.     

Sequences in the ligand-binding domains of the human androgen and progesterone receptors which determine their distinct ligand identities

A cross-sectional survey was undertaken to describe risk-taking behaviors and to assess the knowledge and risk perception of HIV and AIDS among young males aged 18 to 29 years in 82 villages in Longchuan, Yunnan, China, in 1994. Information on demographic, behavioral, and drug-using factors, and knowledge of HIV transmission and prevention, and risk perception was collected using an interviewer-administered anonymous questionnaire. A total of 1,548 individuals were interviewed and 433 drug users, including 52 nonsharing injectors and 140 sharing injectors, were identified. Over half the individuals scored 0 on HIV knowledge, but knowledge was greater among nonsharing drug injectors. Most drug injectors had initiated drug injection after 1990. The reported incidence continues to increase in all three major ethnic groups. Sharing of equipment was common (73%) among injectors. Drug users were four times more likely to have had premarital or extramarital sex, but condoms were used by only 2.5%. Thus, factors promoting spreading of HIV are common in this area. We recommend that a community-based intervention program, targeting both young men and women, be implemented and evaluated in Longchuan as soon as possible.     

AIDS knowledge and risk perception of cocaine and crack users in a national household survey

Awareness of AIDS among cocaine and crack users has never been studied using national data representative of the U.S. household population. Data from the 1991 National Health Interview Survey were analyzed. Respondents who reported cocaine (n = 448) or crack use (n = 100) in the past year were compared with those who reported never using any form of cocaine (n = 17,259). AIDS knowledge, HIV testing, risk behavior, and perceived risk for HIV were outcomes studied. Over 96% of the drug users know the term HIV compared with 89% of the nonusers. A higher proportion of cocaine users reorganized the effectiveness of condoms compared with nonusers (93% vs. 84%). Over 96% of all groups knew the risk of sharing needles. Cocaine and crack users were more likely to have been tested for HIV (27% and 28%) compared with nonusers (19%), yet less than one third of those tested actually received HIV counseling. High-risk behavior was acknowledged by 22% of cocaine users and 33% of crack users. However, only 10% and 14% respectively considered themselves to be at increased risk for having or getting HIV. These data suggest that cocaine and crack users are knowledgeable regarding HIV/AIDS, however they are underestimating their real risk of infection with HIV.     

Russia: sex, drugs, and AIDS and MSF

The first case of HIV infection in Russia was detected in 1987, there have since been 142 million HIV tests in the country, and 196 and 1535 new HIV cases were reported in 1995 and 1996, respectively. By 2000, the Ministry of Health forecasts that there will be 800,000 HIV-positive people in the country. It is culturally accepted in Russia to use drugs intravenously. There has been a rapid rise in the number of IV drug users in Russia, with an estimated 100,000 users in Moscow forming an important core group for HIV transmission, and similar numbers of users in Leningrad, Kalinigrad, and Rostov. Russian IV drug users are mainly aged 15-25 years who lead regular lives, attend school, and socialize freely with non-users, including having sexual relationships. Such behavior among IV drug users facilitates the rapid spread of HIV to the rest of society. Ketamine is popular among schoolchildren, who inject it intramuscularly, while homemade IV drugs also abound. High levels of IV drug use, a health system in a state of collapse, a growing incidence and prevalence of sexually transmitted diseases (STDs), and government inexperience with the HIV epidemic mean that an HIV epidemic in Russia is inevitable. Medecins Sans Frontieres has launched an HIV prevention campaign together with the government.     

Urinary markers of disease activity in multiple sclerosis

This article documents the prevalence of injection-related HIV risk behaviors among a sample of 758 Mexican-American, Puerto Rican, and African-American drug injectors derived from the National Institute on Drug Abuse Cooperative Agreement database. The results show that the two Hispanic subgroups had higher injection-related risks than the African-American group. Further, among Hispanics, Puerto Ricans had higher rates of drug injection than Mexican-Americans, but Mexican-Americans had higher rates of sharing injection paraphernalia than Puerto Ricans. The research suggests that more aggressive HIV/AIDS intervention efforts be targeted to minority injection drug users, especially those that are contextualized by the racial/ethnic group targeted.     

Cystic prostatic disease associated with adrenocortical lesions in the ferret (Mustela putorius furo)

CONTEXT: In British Columbia, human immunodeficiency virus (HIV)-infected persons eligible for antiretroviral therapy may receive it free but the extent to which HIV-infected injection drug users access it is unknown. OBJECTIVE: To identify patient and physician characteristics associated with antiretroviral therapy utilization in HIV-infected injection drug users. DESIGN: Prospective cohort study with record linkage between survey data and data from a provincial HIV/AIDS (acquired immunodeficiency syndrome) drug treatment program. SETTING: British Columbia, where antiretroviral therapies are offered free to all persons with HIV infection with CD4 cell counts less than 0.50 x 10(9)/L (500/microL) and/or HIV-1 RNA levels higher than 5000 copies/mL. SUBJECTS: A total of 177 HIV-infected injection drug users eligible for antiretroviral therapy, recruited through the prospective cohort study since May 1996. MAIN OUTCOME MEASURES: Patient use of antiretroviral drugs through the provincial drug treatment program and physician experience treating HIV infection. RESULTS: After a median of 11 months after first eligibility, only 71 (40%) of 177 patients had received any antiretroviral drugs, primarily double combinations (47/71 [66%]). Both patient and physician characteristics were associated with use of antiretroviral drugs. After adjusting for CD4 cell count and HIV-1 RNA level at eligibility, odds of not receiving antiretrovirals were increased more than 2-fold for females (odds ratio [OR], 2.53; 95% confidence interval [CI], 1.08-5.93) and 3-fold for those not currently enrolled in drug or alcohol treatment programs (OR, 3.49; 95% CI, 1.45-8.40). Younger drug users were less likely to receive therapy (OR, 0.47/10-y increase; 95% CI, 0.28-0.80). Those with physicians having the least experience treating persons with HIV infection were more than 5 times less likely to receive therapy (OR, 5.55; 95% CI, 2.49-12.37). CONCLUSIONS: Despite free antiretroviral therapy, many HIV-infected injection drug users are not receiving it. Public health efforts should target younger and female drug users, and physicians with less experience treating HIV infection.     

Injecting risk behavior among drug users in Amsterdam, 1986 to 1992, and its relationship to AIDS prevention programs

OBJECTIVES: Serial, cross-sectional trends in injecting risk behavior were studied among drug users from 1986 to 1992. METHODS: From a cohort study in Amsterdam, 616 intake visits of drug users who had injected in the 6 months preceding intake were selected. RESULTS: The proportion of drug users who reported borrowing and lending used injection equipment and reusing needles/syringes (in the previous 6 months), continuously declined from 51% to 20%, from 46% to 10% and from 63% to 39%, respectively. In multivariate analysis, it appeared unlikely that a selective recruitment of participants over time was responsible for these trends. Participants, recruited later in time, had been previously tested for human immunodeficiency virus (HIV) more often, had received daily methadone less often, and had obtained a higher proportion of new needles via exchange programs. Indications were found that (1) voluntary HIV testing and counseling leads to less borrowing, lending, and reusing equipment; and (2) obtaining needles via exchange programs leads to less reusing needles/syringes. It appeared that nonattenders of methadone and exchange programs have reduced borrowing and lending to the same extent as attenders. CONCLUSIONS: Methodologically, evaluating specific measures is difficult. However, the combination of various preventive measures in Amsterdam is likely to be responsible for the observed decrease in injecting risk behavior.     

HIV/AIDS and drug abuse: epidemiology and prevention

In the United States, the AIDS epidemic is a dynamic process with increasing rates of AIDS reported among women, minority populations, heterosexual men, and users of drugs by routes other than injection. The 1993 CDC AIDS definition change has created some difficulties in interpreting trends in the United States. Drug use continues to represent a significant problem among HIV-infected persons. Several strategies have been advanced to decrease transmission of HIV among drug users, their sexual partners and children. However, more effective and comprehensive prevention and treatment strategies are needed.     

Bloodborne viral infection in Irish injecting drug users

AIMS: In Dublin, harm reduction strategies have greatly expanded since 1990. We sought to determine the prevalence of, and factors associated with, hepatitis C (HCV), hepatitis B (HBV) and HIV infections among injecting drug users (IDUs) against this background. DESIGN: Cross-sectional survey. SETTING: Addiction treatment clinic. PARTICIPANTS: Seven hundred and thirty-five IDU tested for antibody to HCV (anti-HCV) between September 1992 and September 1997. MEASUREMENTS: Socio-demographic and drug use characteristics. Serology tests for anti-HCV, HBV surface antigen (HBsAg) and HIV. FINDINGS: The vast majority (89%) commenced injecting since 1990. Prevalence of anti-HCV was 61.8% (453/733), of HBsAg was 1.0% (7/729) and of HIV was 1.2% (7/600). Logistic regression analyses indicated that longer history of injecting and increased daily drug expenditure were the only independent variables associated with significantly increased risk of HCV. The only characteristic associated with increased prevalence of HBsAg was a history of injecting prior to 1990 (3.8%, 3/80). HIV prevalence was significantly higher when aged over 24 years (3.7%, 6/162), when injecting commenced prior to 1990 (6.3%, 4/64) and when injecting over 5 years (6.5%, 4/62). CONCLUSIONS: HIV prevalence has sustained a low level in this population. Interventions which aim to halt transmission of HCV are necessary and will need to target IDU very early in their injecting careers and also those at risk of commencing to inject.     

Prevention indicators for evaluating the progress of national AIDS programmes

Major interventions to reduce HIV transmission involve increasing knowledge about preventing HIV transmission for sustained behavioral changes; and enhancing the control of sexually transmitted diseases (STD), which increase the probability of HIV transmission. Activities have also been developed to prevent the transmission of HIV by blood, donor selection, and more rational use of transfusions. Behavioral changes among injecting drug users have also been promoted. Recommendations are made for the evaluation of AIDS programs, focusing on prevention of sexual transmission of HIV, and outlining the approach developed by the Global Program on AIDS (GPA; Geneva, Switzerland) for use by national programs. Based on the feasibility, accuracy, reliability and validity of the quantitative assessment of programs, 10 indicators of progress and outcomes of prevention activities have been developed by GPA. These include indicators of population knowledge regarding preventive practices, reported sexual behavior and use of condoms in the general population, STD service evaluation, and indicators of program impact. The latter are measured through the reported STD incidence in the general male population, and syphilis and HIV prevalence in women. The four methods are proposed for measuring the 10 core prevention indicators (PI). Five PIs are measured during a population survey: reported knowledge of preventive practices (PI-1), condom availability at peripheral level (PI-3), reported frequency of nonregular sexual partners (PI-4), reported condom use during nonregular sexual encounters (PI-5), and reported STD incidence among men (PI-9). Condom availability at central level (PI-2) is assessed through key-informant interviews with major distributors. Structured health facility surveys allow assessment of the appropriateness of STD case management (PI-6 and PI-7). A serosurvey among antenatal clinic attenders aged 15-24 years allows the measurement of HIV and syphilis seroprevalence in that population (PI-8 and PI-10). GPA recommends that such surveys be repeated after a period of 1 to several years.     

A 12-year study (1975-1986) of mortality in methadone-maintenance patients: selected demographic characteristics and drug-use patterns of AIDS and non-AIDS-related deaths

This paper describes changes in demographic characteristics and drug use patterns of persons who died while enrolled in a New York City methadone-maintenance program during the years preceding and subsequent to the AIDS epidemic. Persons dying from AIDS were more likely to be younger, Hispanic, and male than those dying from other causes. Drug use increased during the 12-year study period, and the spread of the HIV infection among drug users may be reflected in an increased use of injectable drugs.     

Tempora mutantur, nos et mutamur in illis!

In March 1992, KAP investigation and HIV blood test were carried out for 860 drug users and 82 spouses in Ruili, Luxi, Longchuan of Yunnan Province, China. The results show that there were 285 IDUs (33.1%) among 860 drug users. Among 282 blood samples of IDUs, the HIV infection rate was 49.0%, highest in Ruili (81.8%, 63/77), then Longchuan (44.6%, 77/166), lowest in Luxi County (5.1%, 2/36). Twelve new HIV+ were found from 75 persons, who had been tested as HIV- in recent two years. Sixty-two blood samples were collected among 82 spouses of IDUs with HIV+, 6 were HIV+ (9.8%), with an increase of 6.7% comparing with results of the investigation two-years ago (3.1%, 2/64).     

Sexual issues and condom use among injecting drug users

Recent surveys of injecting drug users reveal that their injecting behaviours have changed in the light of HIV, but their sexual behaviours have not and, in particular, they remain reluctant to use condoms to reduce the risks of sexual transmission. In an attempt to explore this issue further the present study assessed the behaviours and attitudes of injecting drug users to sexual issues, including condom use. Condom use was low. Obstacles to their use included for some a desire to conceive, for many a belief in their infertility, a perceived invulnerability to HIV infection through their sexual behaviour patterns, a dislike of condoms and difficulty in negotiating condom use with partners. The lifestyle of drug users may also have an influence on condom use. Many drug users funded their habit through illegal activities including prostitution, theft and fraud. The association between these and other factors and condom use are explored.     

Declining seroprevalence in a very large HIV epidemic: injecting drug users in New York City, 1991 to 1996

OBJECTIVES: This study assessed recent trends in HIV seroprevalence among injecting drug users in New York City. METHODS: We analyzed temporal trends in HIV seroprevalence from 1991 through 1996 in 5 studies of injecting drug users recruited from a detoxification program, a methadone maintenance program, research storefronts in the Lower East Side and Harlem areas, and a citywide network of sexually transmitted disease clinics. A total of 11,334 serum samples were tested. RESULTS: From 1991 through 1996, HIV seroprevalence declined substantially among subjects in all 5 studies: from 53% to 36% in the detoxification program, from 45% to 29% in the methadone program, from 44% to 22% at the Lower East Side storefront, from 48% to 21% at the Harlem storefront, and from 30% to 21% in the sexually transmitted disease clinics (all P < .002 by chi 2 tests for trend). CONCLUSIONS: The reductions in HIV seroprevalence seen among injecting drug users in New York City from 1991 through 1996 indicate a new phase in this large HIV epidemic. Potential explanatory factors include the loss of HIV-seropositive individuals through disability and death and lower rates of risk behavior leading to low HIV incidence.     

Glucose- and phorbol ester-induced insulin secretion in human insulinoma cells--association with protein kinase C activation

To investigate the incidence and demographics of gastric hypoacidity among persons infected with human immunodeficiency virus (HIV), 146 asymptomatic subjects were evaluated with use of a radiotelemetry device (Heidelberg capsule). Gastric hypoacidity (minimum gastric pH of > or = 3) occurred in 24 subjects (17%). Demographic characteristics, CD4 cell counts, and Helicobacter pylori serological status were evaluated for an association with gastric pH. Subjects with hypoacidity were more likely to have positive H. pylori serology than were subjects without hypoacidity (15 of 24 vs. 23 of 74, respectively; P = .004). Multivariate analysis indicated that a positive H. pylori serology was the most significant predictor of hypoacidity, accounting for an increase in gastric pH of 39%. A history of injection drug use, heterosexual transmission of HIV, and male gender were also associated with an elevated gastric pH. CD4 cell counts did not contribute to predictions of gastric pH. A history of H. pylori infection is relatively common in HIV-positive black and Hispanic populations and is a predictor of gastric pH.