National Institute on Drug Abuse
Director's Report to the National Advisory Council on Drug
Abuse
May, 1997
Research Findings
AIDS Research
Salmonella Infections, HIV and Opiates
There is a substantial literature identifying Salmonella as an opportunistic
infection in patients with HIV infection, of whom a substantial portion
are drug abusers. A recent review (Angulo, F.J. and D.L. Swerdlow. Bacterial
Enteric Infections in Persons Infected with Human Immunodeficiency Virus.
Clinical Infectious Diseases, 21, Suppl l:S84, 1995) summarized recent findings
on bacterial enteric infection in patients with HIV and concluded that Salmonella
is a leading cause of such infections and that they are likely to be more
severe, recurrent or persistent, and extra-intestinal. The fact that more
extra-intestinal infections occur suggests that Salmonella can move from
their portal of entry, the gastrointestinal tract, to other areas and organs,
a phenomenon described in a publication in press on opioid treatment of
mice. A paper entitled Morphine Induces Sepsis in Mice by Mary E. Hilburger,
Martin W. Adler, Allan L. Truant, Joseph J. Meissler, Jr., Vilas Satishchandran,
Thomas J. Rogers, and Toby K. Eisenstein from Temple University School of
Medicine describes studies which examine the role of morphine in inducing
sepsis. Mice administered morphine by the subcutaneous implantation of a
slow-release pellet developed colonization of the liver, spleen and peritoneal
cavity with Gram-negative and other enteric bacteria. In addition, the mice
became hyper-susceptible to sublethal endotoxin challenge. The effects were
blocked by the simultaneous implantation of a pellet containing the opioid
antagonist naltrexone. These findings show that morphine pellet implantation
in mice results in the escape of Gram-negative organisms from the gastrointestinal
tract, leading to the hypothesis that morphine used post-operatively or
chronically for analgesia or by drug abusers may serve as a co-factor in
the precipitation of sepsis and shock. Additionally, morphine-induced sepsis
may provide a physiologically-relevant model of Gram-negative sepsis and
endotoxic shock.
Virus Load as a Marker of Disease Progression in HIV-Infected Children
Savita Pahwa and colleagues at North Shore University Hospital, Manhasset,
New York, report that HIV-1 proviral DNA load, as determined in peripheral
blood mononuclear cells by the quantitative competitive DNA polymerase chain
reaction assay, is predictive of disease outcome in HIV infected children
at three months of age or before. They also found that a very early dysregulation
of CD95T-cell surface marker expression in such infants may have profound
implications for the progression of HIV/AIDS. Tetali, S., Abrams, E., Bakshi,
S., Paul, M., Oyaizu, N., and Pahwa, S. AIDS Res. Hum. Retroviruses, 12(8),
pp. 669-675, 1996.
Dietary Intake of Community-Based HIV-1 Seropositive and Seronegative
Injecting Drug Users
Research shows that the dietary habits of HIV-1 positive individuals
are subnormal. Smit and colleagues from Johns Hopkins studied a cohort of
104 inner-city African American injecting drug users (67 men and 37 women);
45 were seropositive and 59 were negative for HIV-1. The food frequency
questionnaire and a 24-hour recall were administered to assess dietary intake
of calories, fat, protein, carbohydrates, vitamins and macro- and micronutrients
(e.g., selenium). HIV-1 seropositives reported higher intake of proteins,
fat, B2, B12, pantothenic acid, phosphorous, and selenium as compared to
the seronegatives. The intake of zinc, vitamins A and E were below the daily
recommended allowances among both groups. Additional research is underway
to understand the implication of dietary habits and nutritional status in
the HIV-1 infected and non-infected IDUs. Smit, E., Graham, N.M.H., Tang,
A., Flynn, C., Soloman, L., and Vlahov, D. Nutrition, 12, pp. 496-501, 1996.
High Risk of Mortality in HIV Infections Is Associated with Selenium
Deficiency
Baum and her colleagues at the University of Miami find that selenium
deficiency is an independent predictor of survival in HIV-1 infection. In
a longitudinal study, a cohort of 125 HIV-1 seropositive drug-using men
and women in Miami, Florida were studied over a period of 3.5 years. CD4
T-cell count, anti-retroviral treatment and plasma levels of vitamins A,
E, B6, B12, selenium, and zinc were determined. Immune parameters and nutrients
known to affect immune function were evaluated at 6 month intervals. A total
21 of the HIV-1 participants died from HIV related causes during the study
period. Subclinical malnutrition (deficiency of vitamin A, B12, zinc, and
selenium) over time, but not AZT treatment, was associated with HIV-1 related
mortality independent of CD4 cell counts <200 at baseline, and CD4 over
time. Data suggest that CD4 over time (RR=0.69, p<0.04) and selenium
deficiency (RR=10.8, p<0.002) were significantly associated with mortality.
Baum, M.K., Shor-Posner, G., Lai, S., Zhang, G., Lai, H., Fletcher, M.A.,
Sauberlich, H., and Page, J.B. J. Acquired Imm Def Synd and Hum Retrovir.
In press.
Risk for Human Immunodeficiency Virus (HIV) Infection Among Persons
With Severe Mental Illness
Kate Carey, a NIDA FIRST awardee and her colleagues at Syracuse University
have found that individuals diagnosed with serious mental illness (SMI;
e.g., schizophrenia, schizo affective disorder, bipolar disorder) are at
enhanced risk for infection with HIV. A review of the published literature
shows that 54-74% of adults who report mental illness are sexually active,
and one-third report having two or more partners. Among the sexually active,
condom use was inconsistent. About 4-35% also report a history of injection
drug use. Overall, the data indicate that the severely mentally ill engage
regularly in practices known to involve increased risk for HIV transmission
(Carey, M.P., Carey, K.B., and Kalichman, S.C., Clinical Psychology Review,
In press). Carey and her co-workers further piloted a six-session HIV-risk
reduction intervention for 9 women and 8 men (average age of 39.8 yrs) with
serious mental illness. The intervention and assessment were based on Fisher
& Fisher's Information-Motivation Behavioral Skills model of HIV-preventive
behavior (Psychological Bulletin, 1992). Data were collected pre-and post-intervention,
and at one-month follow-up. Results showed that this brief intervention
resulted in enhanced HIV-related knowledge, and trends toward enhanced skills
at condom use negotiation and condom use self-efficacy. Overall, a modest
decrease in risk behavior among participants was observed suggesting that
HIV-related risk of the serious mental illness can be reduced through traditional
behavioral skills and education methods. According to the authors, further
research employing intensive interventions and baseline screening for high
risk is needed. Weinhardt L.S., Carey, M.P., and Carey, K.B. HIV Risk Reduction
for the Seriously Mentally Ill: A Pilot Investigation and Call for Research.
J. Behav. Ther. and Exp. Psychiat., 22(2), pp. 1 10, 1997.
Factors that Impact Street Risks Through Sexual Income Generation
Drug addicted women whose economic and social base is the urban street
have limited choices for income generation. These limitations often put
such women in danger of predation, assault, arrest, and illness. In this
context, an important source of income will often become the exchange of
sex for drugs or money. Because of the legal, social, interpersonal, and
safety risks associated with these exchanges, drug addicted women may not
always be able to practice safe sex, raising their chances of contracting
or transmitting HIV infection. These complex conditions may pressure women
engaged is sexual exchanges for drugs or money to respond in a variety of
ways. Street-recruited women drug users participating in NIDA's Cooperative
Agreement AIDS research program in Hartford, Connecticut report a range
of protective and risk behaviors when exchanging sex for drugs or money.
This article discusses some of the ethnic, economic, and drug use differences
among women from the street, analyzes how these differences may affect their
drug and sexual risk behaviors, and describes the various approaches and
significant efforts of many of these women to reduce their HIV risks. Weeks,
M. Grier, M., Romero-Daza, N., et al. Streets, Drugs, and the Economy of
Sex in the Age of AIDS. Women and Health, 7, In press.
Social Gatherings Facilitate HIV Risk Reduction among Drug Users
As part of an HIV risk reduction intervention for out-of-treatment drug
injectors and crack smokers, the Center for Behavioral Research and Services
of California State University has instituted regularly scheduled social
gatherings in the Long Beach community as a means to provide social support
for modifications of HIV risk behaviors. These events are one component
of a 4-to-6 month HIV risk reduction intervention that also includes HIV
counseling and testing, individual and group risk reduction sessions, "support
buddies," and follow-up by outreach workers. The monthly HIV focused
social gatherings provide peer support and opportunities for social modeling
by staff and peers, influence perceived social norms, and increase personal
self-efficacy for reducing HIV risks. The socials last about 2 hours and
include lunch. They are structured around risk reduction activities, including
highly effective role model panels, in which outreach workers and staff
with prior drug experience and clients who have successfully reduced their
risk behaviors discuss a variety of topics, such as the role of social support
in modifying risk behaviors, techniques for dealing with relapse and backsliding,
and techniques for quitting drugs and maintaining sobriety. Over a 3-year
period, 345 of the 510 active clients in the intervention program (68%)
attended at least one social event, and 66% attended more than one. At follow-up,
significant differences were found between clients who attended social events
and those who did not: the former were more likely to report that the program
helped them get off drugs, that they had discussed staying safe from AIDS
with friends and family members, that they had asked an outreach worker
for assistance with a personal problem, and that they were acquainted with
other program participants. The popularity of these social events, which
are relatively cost effective and easily implemented, makes this intervention
mechanism especially valuable for maintaining the participation of active
drug users in programs of this type. Wood, M. and Rhodes, F. Using Social
Gatherings to Encourage HIV Risk Reduction among Drug Users. American Journal
of Public Health (Notes from the Field), 86 (12), pp. 1815-1816, 1996.
Factors Related to Safe Sex Among Heterosexual Drug Injectors
Researchers in Dayton, Ohio conducted a study to determine factors which
affect the self-reported use of condoms among heterosexual injection drug
users and crack cocaine smokers. A total of 354 drug users (70% male and
30% female) who were enrolled in the Dayton/Columbus site of NIDA's Cooperative
Agreement for AIDS Outreach/Intervention Research Program also participated
in this study. Most of the study participants were single (90.1%). The largest
group were current injection drug and crack cocaine users (40.1%), followed
by crack users who did not inject drugs (33.1%), and injection drug users
who did not use crack (26.8%). More than 70% of the participants reported
that they frequently used drugs when having sex. Persons who were high when
they had sex were significantly less likely to use condoms than persons
who were not high, but those whose partners got high when having sex were
more likely to report condom use. Individuals said that they were less likely
to use condoms when they had sex with a main partner. Those who believed
it was important to use condoms were more likely to use them, while persons
who believed condoms reduced sexual pleasure were significantly less likely
to use them. A key result of this research is that drug users frequently
use substances before and during sex, which presents a significant impediment
to the employment of safer-sex techniques that rely on condoms. While it
is important to be sensitive to partner characteristics, it is also critical
that sexual risk reduction interventions which target heterosexual users
of injection drugs or crack address the widespread practice of simultaneous
use of psychoactive drugs. Until such dually focused interventions are in
place, access to drug abuse treatment continue to play a critical role in
preventing the spread of HIV and other sexually transmitted diseases in
this population. Falck, R., Wang, J., Carlson, R., and Siegal, H. Factors
Influencing Condom Use Among Heterosexual Users of Injection Drugs and Crack
Cocaine. Sexually Transmitted Diseases, 24(4), pp. 1-7, 1997.
Effects of Attrition on the Evaluation of an HIV Prevention Program
Attrition impacts the effectiveness of prevention interventions as well
as the external validity of efficacy analyses. A recent article examines
the effects of attrition on the evaluation of an HIV prevention program
for out-of-treatment drug users who participated in the Cooperative Agreement
for AIDS Prevention in Philadelphia. Of the 1,115 injecting drug and crack
cocaine users in the program, 967 (87%) completed the 2-session HIV prevention
intervention. Of these, 679 (69%) also completed the 6-month follow-up assessment.
Factors related to completing the 2-session prevention intervention were
different from those related to completing the longer term, 6-month follow-up
assessment. Results from multiple logistic regression identified three predictors
for completing the 2-session intervention, all of which were related to
HIV risk behaviors: testing HIV seronegative, engaging in high risk use
of needles/syringes, and ever having had a sexually transmitted disease.
By contrast, predictors for completing the study (i.e., to the end of the
6 month follow-up assessment) were not related to HIV risk behaviors, but
were representative of a more stable lifestyle. In particular, being a female,
receiving public assistance, and living with a partner were predictive of
study completion. Persons with high HIV risks, including those who were
homeless and those who injected more frequently in the past 30 days, were
significantly more likely to drop out from the research project. The authors
suggest that research attrition analysis such as this is important for improving
the appeal of interventions which target high risk and hard to-reach subgroups,
for developing better procedures to track and stay in touch with clients,
and for enhancing data collection methods. Lauby, J., Kotranski, L., Feighan,
K., et al. Effects of Intervention Attrition and Research Attrition on the
Evaluation of an HIV Prevention Program. Journal of Drug Issues, 26(3),
pp. 663-677, 1996.
Risk Factors for HIV Seropositivity Among Migrant Workers in Southern
Florida
As part of a NIDA Cooperative Agreement, a study was conducted to identify
variables associated with HIV seropositivity among migrant workers in rural
southern Florida. From 1993 to 1995, researchers enrolled 543 male and female
migrant workers into the study, of whom 369 (68%) were born in the U.S.
and 32% were from other countries. All of the migrant workers currently
used drugs, primarily crack cocaine. Overall, 61 (11.2%) of the participants
were HIV positive, including 18% of African Americans born in the U.S. as
well as 8.0% of non-Hispanic Whites born in the U.S., Blacks from the Caribbean,
and persons from Central or South America. Although 3.4% of Hispanic persons
from Mexico were HIV seropositive, none of the U.S. or Caribbean-born Hispanics
were. From logistic regression analysis, the authors identified race/ethnicity,
gender, and age as significantly associated with being HIV positive. Immigration
status, current drug use, and current sexual activity were not related to
HIV seropositivity. These findings indicate that HIV prevention programs
must address risks associated with heterosexual transmission of HIV as well
as drug use both locally and where migrants travel and work. Weatherby,
N., McCoy, V., Bletzer, K. et al. Immigration and HIV Among Migrant Workers
in Rural Southern Florida. Journal of Drug Issues, 27(1), pp. 155-172, 1997.
Preventing AIDS in Communities of Color
Working in predominately Puerto Rican and African American communities
of the inner cities, researchers in Hartford, Connecticut are witness to
a widening divide between the spread of HIV among non-Hispanic whites --
generally white men who have sex with men -- and the spread of HIV in communities
of color. This article describes the dramatic and increasing over-representation
of AIDS cases diagnosed each year in the U.S. among communities of color,
despite the work of public health and community-based educators. The authors
suggest that the increases in HIV/AIDS among persons of color reflect specific
shortcomings in current AIDS prevention work. For example, risk group categories
may have a role in tracking and predicting the course of the epidemic, but
they have little utility when used to lump individuals of differing ethnicities,
cultures, and experiences into the same social category because they share
a common potential route of infection. In addition, the theoretical models
of motivation and behavioral change which predominate in AIDS prevention
tend to focus on the individual level, with little consideration of family,
communities, and the broader society. The researchers propose that the lessons
learned from their work in AIDS prevention serve as guideposts for the development
of new approaches to combat the epidemic in communities of color. Key among
these is the need to refocus AIDS prevention as social prevention, with
decreased attention on individual level prevention models and epidemiologic
risk exposure categories, and much greater emphasis on three emergent contexts
of AIDS risk reduction: networks, neighborhoods, and natural social groups.
Singer, M. and Weeks, M. Preventing AIDS in Communities of Color: Anthropology
and Social Prevention. Human Organization, 55(4), pp. 488-492, 1996.
A Systematic Method to Improve Data Collection from a Large Network
of Drug Injectors
As part of the Multicultural AIDS Prevention Program in Flagstaff, Arizona
-- one of the sites participating in NIDA's Cooperative Agreement for AIDS
Outreach Intervention Program -- researchers have employed psychosocial
and network interventions to provide knowledge, skills, and incentives to
injection drug users to reduce their HIV-related risk behaviors. A major
component of the study involved administration of a 27-item network questionnaire
to each member of a drug network. When the researchers attempted to use
the instrument with a network of more than 40 members, the problems of respondent
burden and complexity of data analysis became apparent (i.e. each member
in the network was asked to fill out a matrix with more than 1080 cells
(27 items x 40 members) -- a condition which produced fatigue and irritation
among respondents and risked a loss of precision in the data). To remedy
the situation, the researchers applied Principle Components Analysis with
VARIMAX rotation to systematically identify co-occurring sets of questions
across eight network factor solutions, and then to identify the questions
in each set which made the strongest contribution to the various factors.
In this way, they were able to determine the best representative questions
to keep in the questionnaire without destroying either the theoretical underpinnings
for the matrix or the factors found in the empirical administration of the
questions. As a result, it was possible to significantly reduce the burden
on respondents from large networks, preserve the richness and complexity
of the network data, and simplify the analytical computations required.
Trotter, R. T., Bowen, A.M., and Hurlbert, H.J. A Method for Systematic
Reduction of the Number of Questions in a Network Matrix Questionnaire.
Journal of Quantitative Anthropology, 6, pp. 35-47, 1996.
Multicultural AIDS Prevention Programs
A recent volume of Drugs and Society is devoted to HIV and drug use prevention
research, beginning with the initial identification of injection drug use
as a key transmission vector for HIV infection, and continuing through today.
Eleven of the 12 articles are by principal investigators and co-investigators
in NIDA's National AIDS Demonstration Research projects (NADR) and Cooperative
Agreement for AIDS Outreach/ Intervention Research Program, including, among
others, John Anderson, Robert Trotter, Sherry Deren, Antonio Estrada, Mike
Stark, Clyde McCoy, Isaac Montoya, Rafaela Robles, and Robert Booth. As
such, the articles provide a direct historical link to "first generation"
research in community-based AIDS prevention, with its successes, failures,
and methodological and practical ambiguities, while also moving the science
of prevention forward, into the "second generation." The presentations
discuss, and in some instances resolve, key issues that will need to be
addressed in the future, as the epidemiology of HIV changes and as treatment
approaches improve. For example, as individuals become saturated with information
about HIV transmission, it is important that they don't "tune out"
and lower their behavioral risk thresholds. Trotter, R.T. (ed.). Multicultural
AIDS Prevention Programs, (published also as a Special Issue of Drugs and
Society, 9 ( ), 1996.
AIDS Prevention Education in a Puerto Rican Community
In a recent article, the Associate Director of the Hispanic Health Council
(HHC), a community-based health research and services organization in Hartford,
Connecticut, provided (1) an update and expansion of an earlier report on
the 12-year evolution of AIDS prevention education work at the HHC; (2)
a further examination of the contribution of applied medical anthropology
to community-based AIDS prevention; and (3) a critique of assertions by
some researchers about the impact of local, State, and Federal government
funding on local AIDS prevention efforts and the surmountability of barriers
to community-based work. The author describes how, through the application
of "action anthropology," it has been possible at the HHC to focus
on the twin goals of science and a specific culturally defined community.
As a result, HHC has been addressing both the underlying structural causes
of ill health in the Hispanic community as well as the more immediate social,
cultural, medical, and environmental causes. Singer, M. The Evolution of
AIDS Work in a Puerto Rican Community Organization. Human Organization,
55(1), pp. 67-75, 1996.
IDUs Understand and Retain Knowledge about Preventing Risk of HIV
A study was conducted from 1988 to 1989 in Dade County, Florida to evaluate
the recall and performance skills for cleaning syringes/needles among a
sample of 393 out-of-treatment IDUs. The study was guided by a question
about the extent of correct cleaning of syringes. A free recall procedure,
combining cognitive and psychomotor testing, provided a means of verifying
knowledge and skills. Results from the study indicate that IDUs learn and
retain the knowledge and skills necessary to prevent risk of HIV infection
from the use of syringes/needles. Tests of knowledge and performance 6 months
after training showed high retention of the material learned. The population
at risk is capable of reducing the spread of HIV. Even with partial compliance
with the correct cleaning procedures, some preventative impact could be
assumed provided exposure time to bleach exceeds 30 seconds. McCoy, V.,
Chitwood, D., Page, B. et al. Skills for HIV Risk Reduction: Evaluation
of Recall and Performance in IDUs. Substance Use and Misuse, 32(3), pp.
229-247, 1997.
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