National Institute on Drug Abuse
Director's Report to the National Advisory Council on Drug Abuse
September, 1996
Research Findings
AIDS Research
Maternal Drug Use and Mother-to-Infant HIV Transmission
Multivariate analyses in a recent report from the Women and Infants Transmission
Study (WITS) indicate an almost three fold increase (Odds Ratio 2.77) in
the risk of mother-to-infant HIV transmission associated with prenatal drug
use (i.e., a measure combining use of cocaine, heroin/opiates, methadone,
and/or injecting drug use), for women with duration of membrane rupture
greater than 4 hours. The increased risk observed in this subsample was
greater than that seen in univariate analysis for the total sample of 530
HIV-infected women and their infants (Odds Ratio 1.89). These results not
only document a prenatal drug use-perinatal transmission relationship, but
also provide a basis for further hypotheses as to the timing (intrapartum,
intrauterine) and mechanisms of transmission. WITS is an ongoing study
of HIV-infected pregnant women and their infants conducted at pediatric
and obstetric settings in Illinois, Massachusetts, New York, Puerto Rico,
and Texas. NIDA collaborates with the National Institute of Allergy and
Infectious Diseases and the National Institute of Child Health and Human
Development in supporting WITS. Rodriguez, E.M., et al., Association of
Maternal Drug Use During Pregnancy with Maternal HIV Culture Positivity
and Perinatal HIV Transmission. AIDS; 10: pp. 273-282, 1996.
Mycobacterial Disease in a Cohort of Active Injection Drug Users
A cohort study of trends and risk factors for mycobacterial disease (M.
tuberculosis, M. avium complex (MAC) and other atypical mycobacteria) and
the effect of expanded access to isoniazid prophylaxis on tuberculosis (TB)
incidence among active injection drug users found that HIV infection is
the strongest risk factor for TB, M. avium complex and other mycobacterial
disease (relative risk 3.8, 17.2, and 6.9 respectively). After institution
of directly observed therapy (DOT), TB incidence fell from a peak of 6 cases/1000
person years in 1991 to one case in 1992 and no cases through 1994. During
this time, the number of PPD positive patients who received DOT tripled,
indicative of the effectiveness of this mode of therapy delivery. During
this same period, however, the incidence of MAC increased significantly,
reflecting the increasing disease burden among HIV-infected IDUs with progressive
immunosuppression. Other atypical mycobacteria were also observed to increase
among HIV-infected IDUs over the same time period. Graham N, Galai N, Nelson
K, et al., Arch Int Med, 156: pp. 889-894, 1996.
Successful Tuberculosis Screening at a Syringe Exchange
A study of tuberculosis (TB) screening at a syringe exchange found a high
success rate of consent and return rates for skin test (PPD) reading and
follow-up. TB screening was conducted during syringe exchange sessions,
at which PPD and anergy testing, TB education, and HIV testing and counseling
were offered. Of 493 exchange participants approached, 96.5% consented to
TB screening. Of these, 91.5% returned for PPD reading and 78% have completed
follow-up TB screening, including chest radiographs if indicated. Of those
who consented to screening, 39% were homeless or unstably housed, 35% had
no health insurance, and 60% were not in drug treatment. Data indicate
that participating IDUs were aware of their TB risk, frequently confused
TB infection with active TB, and were receptive to availability of TB services
at a syringe exchange. More than 60% reported using the syringe exchange
two or more times per week and 52% reported using the exchange for six months
or more, suggesting that the population of IDUS at this syringe exchange
may be sufficiently stable to allow administration of twice weekly directly
observed therapy for those identified with TB infection. Perlman D., Perkins
M.P., Solomon N. et al., American Journal of Public Health, In Press.
Transmission Behaviors and Self-Protective Health Acts Among HIV Youth
The level and consistency of HIV related sexual and substance use risk acts,
health status and medical adherence were examined among 102 HIV+ youths
aged 14 to 23. Current risk behaviors were assessed twice over two 3-month
periods. During these periods almost a third had been sexually abstinent.
Among youths who were currently sexually active, most had multiple sexual
partners (M=4). Almost half used condoms consistently with 72 percent of
encounters being protected by condoms. Use of alcohol (63%), marijuana
(41%), hard drugs (36%) and injecting drugs (12%) was substantial and remained
consistent over 3 months. Youths were relatively healthy. Medical adherence
rates for appointments was 66 percent over the 3 months. The data suggest
the need for more intensive interventions that must be consistently implemented
over time as youths encounter new challenges associated with their disease
status. Rotheram-Borus, J.J., Murphy, D.A., Coleman, C.L., et al. Risk
Acts, Health Care, and Medical Adherence Among HIV+ Youths in Care Over
Time. AIDS and Behavior. In Press.
Reductions in Needle Sharing
In an experimental study of the effects of a risk reduction intervention,
researchers found that HIV-negative participants were significantly less
likely (on the order of three times or more) to report needle sharing 18
months post-intervention than drug users who did not participate in the
intervention. No significant differences were obtained for the HIV positive
drug users. Latkin, C.A., Mandell, W., Vlahov, D., et al. "The Long-Term
Outcome of a Personal Network-Oriented HIV Prevention Intervention for Injection
Drug Users: The SAFE Study." American Journal of Community Psychology,
24,3, pp. 341-364, 1996.
Barriers to Condom Use and Needle Cleaning Among Impoverished Women
Sexual behaviors and drug use factors that inhibit condom use and needle
cleaning were assessed among 378 homeless African-American and Latino women.
The most highly rated barriers to condom use with partners included believing
the partner did not have AIDS (69%), lack of skills in using condoms (52%),
inability to get condoms (52%), lack of skills in negotiating condom use
with partners (49%), personal dislike of condoms (47%) and discomfort in
discussing condoms (46%). African-American women were more likely than
Latino women to report barriers related to lack of skills in using condoms,
inability to get condoms, discomfort and lack of skills in discussing condoms
with partners, not thinking about condoms when high, a belief that their
partner did not have AIDS, and a belief that they could not transmit HIV
to their partners. On the other hand, Latino women, as compared with African
American women, were more likely to report partner's dislike of condoms.
This barrier was found among almost three-quarters of the less acculturated
Latinos. The most pervasive barrier to needle cleaning among women who
shared needles was not having their own needle (62%). This was closely
followed by a need to hide needles (60%), being high and not interested
in cleaning (59%), and not having disinfectant available (57%). Nyamathi,
A., Lewis, C., Leake, B., Haskerud, J., Bennett, C. Barriers to Condom
Use and Needle Cleaning Among Impoverished Minority Female Injection Drug
Users and Partners of Injection Drug Users. Public Health Reports, 110,
pp. 166-172, 1995.
Relationship Characteristics Influence Both Syringe-Sharing and Consistent
Condom Use
In a study of 767 street-recruited drug injectors, this study examined how
social relationships and perceived peer group culture are related to consistent
condom use and receptive syringe sharing. Whether IDUs used condoms consistently
or not was found to be relationship specific rather than an individual characteristic;
i.e., IDUs used condoms consistently with one partner but not necessarily
with another. Independent significant predictors of consistent use of condoms
were relationship characteristics, peer norms, personal and partner characteristics,
and seropositivity of the IDU whose partner is a non-IDU. Receptive syringe
sharing was also found to be relationship-specific, predicted by social
characteristics of the drug use network, peer norms, and individual risk
behaviors (e.g., injecting speedball). Since sexual and injecting events
which pose a risk of HIV transmission occur between two or more people in
a particular context, prevention projects should focus on promoting relationship-specific
norms about safer sexual practices and injecting behaviors rather than on
individual risk characteristics. Friedman, S.R., Neaigus, A. Perlis, T.,
Jose, B., et al. Personal, Relationship-Specific, and Event-Specific Influences
on Risk Behaviors by Drug Injectors. Seisida, 7 (4), pp. 184-186, April
1996.
Syringe Sharing Combined with High-Risk Personal Networks Increases
HIV Infection Risks in New IDUs
This study explored the question of whether "new" IDUs who both
shared syringes and had personal risk networks that included high-risk injectors
were any more likely than other new IDUs to be infected with HIV. A cross-sectional
study of 174 IDUs in NYC who had injected for no more than six years were
recruited and interviewed about their risk behaviors. They were also tested
for HIV serostatus. Compared to new IDUs who did not have these combined
risk factors, those who shared syringes within high-risk personal networks
were significantly more likely to be HIV positive (40% were HIV positive
compared to 14% for others). The interaction of syringe sharing and having
a personal risk network member who injected more than once a day was found
to be independently and significantly associated with being HIV seropositive,
in addition to Latino race/ethnicity and exchanging sex for money or drugs.
These findings suggest that interventions to reduce the spread of HIV among
new IDUs should focus on their risk networks as well as their risk behaviors.
Neaigus, A., Friedman, S.R., Jose, B., Goldstein, M.F., et al. High-Risk
Personal Networks and Syringe Sharing as Risk Factors for HIV Infection
Among New Drug Injectors. Journal of Acquired Immunodeficiency Syndrome,
11, pp. 499-509, 1996.
Four-Year Study Finds Declines in HIV Seroincidence Among IDUs in Chicago
Six waves of survey and serologic data were analyzed for 641 HIV seronegative
not-in-treatment IDUs participating in the Chicago Community Outreach Intervention
Project (COIP). One of the first NIDA-funded National AIDS Demonstration
Research (NADR) projects, the Chicago COIP used a street-based outreach
intervention which was guided by the Indigenous Leader Outreach Model, in
which ex-addicts deliver HIV-prevention services targeting IDU social networks
in community settings. The cumulative percent lost to the study over the
four year period was 32 (208 IDUs); the cumulative percent seroconversion
was 13 (83 IDUs); and the number of IDUs at the end of the study who remained
seronegative was 308. The observed incidence of HIV infection in the sample
decreased from 8.4 to 2.4 per 100 person-years; the prevalence of drug use
risk behaviors decreased from 100 to 14 percent; and sexual risk behaviors
decreased, but less dramatically, from 71 to 45 percent. Seroconversion
was significantly correlated with injection risk behaviors, but not with
sexual risk behaviors. Wiebel, W.W., Jimenez, A., Johnson, W., et al. Risk
Behavior and HIV Seroincidence Among Out-of-Treatment Injection Drug Users:
A Four Year Prospective Study. Journal of Acquired Immune Deficiency Syndromes
and Human Retrovirology, 12, pp. 282-289, 1996.
Sharing of Drug Preparation Paraphernalia is More Common than Sharing
of Needles/Syringes
Researchers undertook observational studies in Miami to catalogue risky
injection practices by IDUs beyond the direct sharing of needles/syringes.
They also examined epidemiologic data from 19 sites participating in NIDA's
Cooperative Agreement for AIDS Community-Based Outreach Intervention Research
Program. Of 12,323 IDUs, 41 percent used needles/syringes previously used
by another, 49 percent shared cookers/cottons/ rinse water, and 32 percent
shared both used syringes and drug preparation paraphernalia in the 30 days
before the interview. Fewer than 30 percent engaged in none of these high
risk behaviors. The authors discuss the implications of these findings
on the potential transmission of HIV and in terms of the challenges they
pose for HIV prevention. McCoy, C.B., Metsch, L.R., Chitwood, A.D., Shapshak,
P., et al. HIV Transmission Potential Through Person-to-Person Blood Transfer
During Drug Preparation and Injection: A New Challenge for HIV Prevention.
Journal of Acquired Immune Deficiency Syndrome and Human Retrovirology,
In Press.
Drug Injecting Behaviors May Facilitate HIV Transmission Even When Syringes
Are Not Shared
Researchers in Denver, Colorado assessed the prevalence of injection-related
behaviors other than direct sharing of syringes among 585 IDUs. The IDUs
were classified into three groups: those who directly and indirectly shared
syringes, those who indirectly shared only (i.e., by sharing water to mix
drugs or rinse syringes, by sharing the cookers and spoons used to dissolve
the drug before filling the syringe, by sharing the drug solution itself,
and by sharing cottons to filter adulterants from the solution at the time
of injection), and those who did not share either directly or indirectly.
The researchers found that IDUs who injected heroin or speedballs were
less safe in their injection behaviors than those who did not. In addition,
while indirect sharing behaviors were twice as prevalent as direct sharing
of syringes, many IDUs do not recognize the potential link of their behaviors
to HIV transmission. Koester, S., Booth, R.E., and Zhang, Y. The Prevalence
of Additional Injection-Related HIV Risk Behaviors among Injection Drug
Users. Journal of Acquired Immunodeficiency Syndromes and Human Retrovirology,
12 (2), pp. 202-207, 1996.
Evaluating the Effect of Needle Exchange on the Spread of HIV and Other
Viral Infections
Needle testing and syringe tracking methods have demonstrated that the New
Haven needle exchange program (NEP) effectively reduces the spread of HIV
by as much as one-third. NIDA grantees in New Haven extended and elaborated
these methods to hepatitis B (HBV) and hepatitis C (HCV). The investigators
used polymerase chain reaction (PCR) to test returned (used) syringes at
the NEP for HBV DNA and HCV RNA, and the EIA method to test for antibodies
to each. Both methods were effective in detecting either hepatitis viruses
or antibodies in used syringes. The researchers conclude that syringe testing
for hepatitis can inform studies of the efficacy of NEPs in reducing the
transmission of syringe-born infections. Because they found a significant
decline in the percentage of used needles containing hepatitis B virus,
they also conclude that, in addition to their effects on the spread of HIV,
NEPs can slow the spread of HBV transmission. Heimer, R., Khoshnood, K.,
Jariwala-Freeman, et al. Hepatitis in Used Syringes: The Limits of Sensitivity
of Techniques to Detect Hepatitis B Virus (HBV) DNA, Hepatitis C Virus (HCV)
RNA, and Antibodies to HBV Core and HCV Antigens. Journal of Infectious
Diseases, 173, pp. 997-1000, 1996.
Drug Use Patterns and Attitudes toward Intervention in Reducing the
Transmission of HIV
In Miami, Florida, where Needle Exchange Programs (NEPs) are illegal, other
strategies are necessary to reduce the spread of HIV among IDUs. Researchers
examined data from studies of IDUs in Miami and other cities and report
that IDUs inject frequently, averaging more than 1,000 injections per year,
per person. While almost all IDUs feel that it is important to clean needles
and to use a needle only one time, many do not take these precautions.
In addition, the authors describe how the context of injection is important
for understanding HIV risks. Drug use patterns, IDU attitudes toward interventions,
and the cultural contexts in which risky behaviors occur each affect the
potential for reducing the transmission of HIV and must be considered in
the planning of HIV risk reduction interventions. McCoy, C.B., Metsch, L.R.,
Page, J.B., McBride, D.C., et al. Injection Drug Users Practices and Attitudes
toward Intervention and Potential for Reducing the Transmission of HIV.
Medical Anthropology, In Press.
Correlates of Emotional Distress Among HIV Youths
The level of emotional distress and the impact of stress and personal resources
on distress were examined among 149 HIV+ youths ages 14-23. These youths
(who were relatively healthy) reported levels of emotional distress and
self-esteem similar to uninfected adolescents. Positive coping styles were
more common than negative coping styles among youths living with HIV. Social
support from parents, friends, and romantic partners was high, but these
support persons often engaged in sexual and substance use risk acts. Controlling
for youths' physical health status, increased emotional distress was associated
with significantly lower self-esteem, higher stress, and negative coping
styles. Social support did not mediate emotional distress among HIV+ youths.
Rotheram-Borus, J.J., Murphy, D., Reid, H., et al., Correlates of Emotional
Distress Among HIV Youths: Health Status, Stress, and Personal Resources.
Annals of Behavioral Medicine, 18(1), pp. 16-23, 1996.
Psychosocial Predictors of AIDS Risk Behavior
Baseline assessments of personal and social resources, threat appraisal
processes, coping styles, and barriers to risk reduction as predictors of
sexual and drug use behaviors were evaluated among a sample of 714 African
American and 691 Latino homeless women. Based on theoretical perspectives
of the Comprehensive Health Seeking and Coping Paradigm and Health Belief
Models, causal modeling was conducted. Findings revealed active coping
was associated with fewer sexual AIDS risk behaviors for African-American
and Latino women and less drug use behavior among African American women.
High threat appraisal and avoidant coping predicted drug use behavior in
both groups. Self-esteem and social resources were inversely associated
with emotional disturbance for both groups. Lower self-esteem predicted
more barriers to condom use among Latinos. Implications of these findings
point to important cultural differences that should guide educational and
outreach efforts of practitioners and social scientists. Nyamathi, A.,
Stein, J., Brecht, M. Psychosocial Predictors of AIDS Risk Behavior and
Drug Use Behavior in Homeless and Drug Addicted Women of Color. Health
Psychology, 14, pp. 265-273, 1995.
Predictors of Maintained High-Risk Behaviors
Demographic, cognitive, psychosocial and behavioral factors associated with
maintained high risk AIDS behaviors were assessed two to four weeks after
completing an AIDS education program in a sample of 942 crack users and
767 women who had multiple partners. Maintainers of multiple sexual partners
more often reported needle sharing and a sex partner who shot drugs. Maintainers
of crack were more likely to be African-American, age 32 or older, and report
having a sex partner who shot drugs. Further, women who maintained risky
drug and sexual behaviors reported the least improvement in concerns, depression,
affective coping, distress, appraisal of threat, self esteem, and social
support. Implications of these findings point to the need for studies investigating
the effectiveness of providing risk education within a comprehensive health
promotion and resource supplementation program addressed to the couple as
a unit. Nyamathi, A., Bennett, C., Leake, B. Predictors of Maintained
High-Risk Behaviors Among Impoverished Women. Public Health Reports, 110,
pp. 600-606, 1995.
Intervening with Adolescent Girls Living with HIV
Young women who are HIV seropositive have special needs for interventions
to reduce the negative consequences of their infection for themselves, for
their children, partners, and families. This chapter reviews the challenges
posed by HIV to these young women and outlines intervention programs designed
to reduce long-term negative social, behavioral, and mental health consequences
of HIV. Rotheram Borus, M.J., Murphy, D.A., Miller, S., et.al. Intervening
with Adolescent Girls Living with HIV. In A. O'Leary and L. S. Jermmott
(Eds.), Women and AIDS: Coping and Care, Plenum Press, pp. 87-108, New York,
1996.
Network Membership Affects Individuals' Sex Risks
In a recent study of peer group influence and the social context of risk
behaviors, researchers discovered that alcohol and crack use by drug network
members was positively associated with reports of multiple sex partners
and alcohol use by the index subjects. Similarly, the degree of crack use
by network members was positively associated with the numbers of casual
sex partners reported by index subjects. Latkin, C.A., Mandell, W., and
Vlahov, D. The Relationship Between Risk Network Patterns of Crack Cocaine
and Alcohol Consumption and HIV-Related Sexual Behaviors among Adult Injection
Drug Users: A Prospective Study. Drug and Alcohol Dependence, In Press.
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