Harm reduction drug policies and practice: international developments and domestic initiatives. Overview of a symposium. March 22, 1995.
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Drug and Narcotic Control↗
Biomedical subjects
E Drucker
Publications and source records attributed to E Drucker.
Transmission of tuberculosis in New York City. An analysis by DNA fingerprinting and conventional epidemiologic methods.
BACKGROUND: The incidence of tuberculosis and drug resistance is increasing in the United States, but it is not clear how much of the increase is due to reactivation of latent infection and how much to recent transmission. METHODS: We performed DNA fingerprinting using restriction-fragment-length polymorphism (RFLP) analysis of at least one isolate from every patient with confirmed tuberculosis at a major hospital in the Bronx, New York, from December 1, 1989, through December 31, 1992. Medical records and census-tract data were reviewed for relevant clinical, social, and demographic data. RESULTS: Of 130 patients with tuberculosis, 104 adults (80 percent) had complete medical records and isolates whose DNA fingerprints could be evaluated. Isolates from 65 patients (62.5 percent) had unique RFLP patterns, whereas isolates from 39 patients (37.5 percent) had RFLP patterns that were identical to those of an isolate from at least 1 other study patient; the isolates in the latter group were classified into 12 clusters. Patients whose isolates were included in one of the clusters were inferred to have recently transmitted disease. Independent risk factors for having a clustered isolate included seropositivity for the human immunodeficiency virus (HIV) (odds ratio for Hispanic patients, 4.31; P = 0.02; for non-Hispanic patients, 3.12; P = 0.07), Hispanic ethnicity combined with HIV seronegativity (odds ratio, 5.13; P = 0.05), infection with drug-resistant tuberculosis (odds ratio, 4.52; P = 0.005), and younger age (odds ratio, 1.59; P = 0.02). Residence in sections of the Bronx with a median household income below $20,000 was also associated with having a clustered isolate (odds ratio, 3.22; P = 0.04). CONCLUSIONS: In the inner-city community we studied, recently transmitted tuberculosis accounts for approximately 40 percent of the incident cases and almost two thirds of drug-resistant cases. Recent transmission of tuberculosis, and not only reactivation of latent disease, contributes substantially to the increase in tuberculosis.
AIDS-Related Opportunistic Infections↗
Childhood tuberculosis in the Bronx, New York.
The resurgence of tuberculosis (TB) in New York City in the period 1978-92 has been closely linked to the AIDS epidemic but the increase of active TB in areas of urban poverty also implies increased community exposure. We have examined the ecological relation between community rates of AIDS and residential crowding and cases of active TB in Bronx children under age 5. Residential crowding was defined as the percent of households with more than 1 person per room. All childhood TB cases reported between 1986 and 1992 for the Bronx (n = 75) were included. Cumulative AIDS mortality rates for adult females through 1990 represented community HIV burden. All data were coded by the 64 health areas of the borough. We examined trends in these data and used Poisson regression to model the effect of HIV burden and residential crowding on TB risk. For the Bronx as a whole the two variables of TB and residential crowding showed a clear temporal correspondence for the period 1970-90. Residential crowding was associated with poverty and greater dependence on public assistance, large household size, Hispanic ethnicity, and a higher proportion of young children. The overall TB case rate increased with the proportion of crowded households, with a rise from 1.47 to over 8 cases per 10,000 children as the proportion of crowded households increased. At both the lowest and highest levels of AIDS mortality in these areas, the childhood TB risk increased as crowding increased. Children living in areas of the Bronx in which over 12 percent of homes are severely overcrowded were 5.6-fold more likely to develop active TB, even after holding constant the presumed HIV burden in each local community. While HIV infection, the newest risk factor for TB, appears to play a critical role in the resurgent epidemic, our findings show that the earliest known TB risk factors, poverty and household crowding, are still potent forces.
Acquired Immunodeficiency Syndrome↗
AIDS, HIV infection, and illicit drug use within inner-city families and social networks.
OBJECTIVES: Drug use is commonly depicted and treated as an individual problem. This study describes the extent of drug use, human immunodeficiency virus (HIV) infection, and acquired immunodeficiency syndrome (AIDS) among drug users' sexual partners and family and household members in order to broaden considerations of risk. METHODS: Social network charts and structured interviews were administered to 126 women (predominantly African American and Latino) enrolled in methadone treatment. The charts elicited the prevalence of drug use and HIV infection among subjects' family and household members. RESULTS: Drug use and HIV/AIDS permeated subjects' sexual, familial, and household relationships. More than half of the women who resided with a sexual partner reported that their partners currently used drugs. Almost one third of the subjects' siblings were drug users. Of the 715 total siblings (all subjects plus their siblings), 69 (9.7%) were known to be HIV positive or to have an AIDS diagnosis. CONCLUSIONS: The sexual, familial, and household expressions of drug use underscore the notion that drug use and attendant risks, including but not limited to HIV infection, might be usefully viewed and treated as an inter- and intracommunity problem rather than as an exclusively individual one.
Acquired Immunodeficiency Syndrome↗
Intrauterine cocaine, lead, and nicotine exposure and fetal growth.
Intrauterine tobacco, lead, and cocaine exposure often co-occur and may affect fetal growth and development, yet studies of gestational cocaine effects have not adequately measured lead or tobacco. In this anonymous survey, blood lead and urine cotinine levels were determined and mothers were queried about tobacco use. Eighteen cocaine-exposed mother-infant dyads had higher lead and cotinine levels than 46 random nonexposed dyads, regardless of reported cigarette smoking. Crude growth decrements in cocaine-exposed newborns were attenuated after control for lead and cotinine. Future studies of gestational cocaine effects should measure other toxic exposures with more precision.
Adult↗
Molecular epidemiology meets the fourth world.
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Bacterial Typing Techniques↗
Opiate dependency among the subscribers of a New York area private insurance plan.
OBJECTIVE: To estimate the prevalence of opiate use among the subscribers of a large private insurance plan, Empire Blue Cross and Blue Shield (EBCBS). DESIGN: Six and a half million hospital inpatient claims for the period January 1, 1982, through June 30, 1992, were reviewed. Thirty-one thousand eight hundred ten different individuals who had a total of 55,143 hospital admissions with a primary diagnosis of opiate dependency (International Classification of Diseases, Ninth Revision, Clinical Modification 304.0 and 304.7) were identified. In the same period, 17,493 EBCBS subscribers (15,191 male and 2302 female) were identified from hospital admissions data as having acquired immunodeficiency syndrome. These data were cross-matched with the opiate dependency data to estimate the "capture" of opiate users in the EBCBS subscribers with acquired immunodeficiency syndrome and to model the size of the opiate using population in EBCBS. RESULTS: It is estimated that between 1982 and 1992 EBCBS insured approximately 141,000 opiate users, 85,000 of whom are currently insured by EBCBS. CONCLUSION: There is a large population of insured opiate users who may be excluded from the estimates of the overall number of opiate users as insured opiate users are less likely to be counted via contact with government agencies. This suggests that current estimates of the number of opiate users and their social characteristics should be reconsidered.
Acquired Immunodeficiency Syndrome↗
Custody of cocaine-exposed newborns: determinants of discharge decisions.
OBJECTIVES: Maternal cocaine use is a leading grounds for newborn foster placement. This study was initiated to investigate the factors that predict custody status of infants born to substance-abusing women. METHODS: A retrospective cohort design was used to study the correlates of discharge custody decisions for 99 consecutive infants testing positive for cocaine in a public hospital. RESULTS: The population was 49% Black, 40% Hispanic, and 11% other or unknown. Custody at discharge was to mothers (38%), other family members (25%), or agency foster care (36%). Placement outside the family was greater when mothers had prior child welfare records, in Blacks vs others, with no prenatal care, and when mothers were younger at their first delivery or older at the index birth. Denial of custody to the mother was higher with prior child welfare involvement, in Blacks, and when the mother did not live in her own home. Both models also controlled for parity, child sex, and birthweight. CONCLUSIONS: Earlier involvement with child welfare authorities, race, and other factors predict continued separation of mothers and children at newborn discharge, suggesting the need to reexamine current policies and practices.
Birth Weight↗
Trends in AIDS mortality among residents of Puerto Rico and among Puerto Rican immigrants and other Hispanic residents of New York City, 1981-1989.
This study contrasts the acquired immunodeficiency syndrome mortality experience of residents of Puerto Rico with that of New York City residents identified as either Puerto Rico-born and non-Puerto Rico-born Hispanics. Portions of the mortality data examined in this investigation update and extend the data previously published describing selected groups in New York City through the end of 1987 but which did not consider residents of Puerto Rico. The nine-year cumulative, age-adjusted acquired immunodeficiency syndrome mortality rate for males was found to be 5 x higher among Puerto Rico-born New York City residents compared with residents of Puerto Rico (702/100,000 v 141/100,000) and 1 1/2 x greater than that of other male Hispanic New York City residents (447/100,000). In New York City, Puerto Rico-born females had higher age-adjusted mortality rates (121/100,000) than female residents of Puerto Rico (25/100,000) and other female Hispanic residents of New York City (70/100,000). Within five of the six age categories considered, acquired immunodeficiency syndrome mortality rates for adult males and females are higher for Puerto-Rico-born, New York City residents. Limitations of acquired immunodeficiency syndrome incidence data, as they pertain to persons of Puerto Rican ancestry, are discussed.
Acquired Immunodeficiency Syndrome↗
Drug use contexts and HIV-consequences: the effect of drug policy on patterns of everyday drug use in Rotterdam and the Bronx.
Epidemiological data on HIV seroprevalence has been essential in assessing the (future) extent of the AIDS epidemic. By coupling these data with quantifiable variables related to injection drug use (frequency of injecting, number of needle sharing partners) specific 'risk behaviors' could be determined, accounting for the rapid spread of the virus in the injecting drug user (IDU) population. Yet, such data give little information on the social mechanisms and setting generating such risk behaviors. In order to understand the transmission of HIV among the IDU population one needs to study the micro settings and social context of drug use. This paper describes and explores certain patterns of drug use, sharing, and natural support systems found amongst IDUs in two very different cities, Rotterdam (The Netherlands) and the Bronx, New York City (USA). By specifying details of the micro-settings of everyday drug use in both locales, it is possible to identify certain common elements and consequences of personal and social behavior driven by drug use per se (e.g. drug preference), and to differentiate these from behaviors and consequences determined by drug policy and the social context in which drug use actually occurs. These policies and the social context they create can in turn be shown to relate to risks for HIV transmission, e.g. the increased likelihood of sharing injection equipment. A more careful ethnographic approach, taking advantage of natural experimental opportunities, comparisons and controls, may be utilized to examine drug-related behaviors in their social context and to better assess their relevance to public health--especially to AIDS.
Cross-Cultural Comparison↗
A prospective comparison of neuropsychologic function in HIV-seropositive and seronegative methadone-maintained patients.
A prospective longitudinal study of neuropsychological and psychosocial functioning in a methadone-maintained population was initiated to test the hypothesis that cognitive impairments may be present early in the course of HIV infection, before the onset of other physical symptoms. A total of 220 methadone-clinic patients without evidence of HIV-related illnesses were given baseline psychological screening tests, as well as serological testing for HIV antibodies. At baseline, 83 (38%) had antibodies to HIV and 137 (62%) did not. On initial testing, controlling for race/ethnicity, age, sex and drug use, the seropositives were more cognitively impaired than the seronegatives. The differences were statistically significant for three subtests on univariate analysis: finger tapping (dominant), digit span (forward) and similarities. Ninety-one patients whose current serological status was known were given follow-up neuropsychological and psychosocial assessments after a mean interval of 7.4 months from baseline testing. At follow-up, seropositives continued to be more cognitively impaired than seronegatives, but there was no deterioration in the performance of the initial seropositives over the time interval.
Adaptation, Psychological↗
Epidemic in the war zone: AIDS and community survival in New York City.
The characteristics and consequences of the AIDS/HIV epidemic in New York City are examined, with special attention to its impact on inner-city communities. The high numbers of AIDS cases are the source of increasing stress on public and community treatment and family and neighborhood networks of support. As the epidemic deepens (8 to 10 thousand new cases per year are expected by 1992) these resources, already weakened by years of underfunding, are becoming overwhelmed and are in danger of collapse. The high rates of HIV infection in these communities (5 to 20 percent of adults aged 25 to 45) and their linkage to widespread drug use prefigure the development of endemic levels in several population subgroups, with substantial risk of heterosexual spread. Simultaneously, there is a steady diffusion of infection to adjacent urban areas and, via migration patterns, to localities quite distant from New York City (e.g., Puerto Rico). Some hope can be found in the advent of more effective methods of early intervention for presymptomatic HIV infection. These offer an opportunity for combining clinical care with public health strategies that may restrict the spread of HIV while providing humane care for large numbers of people with AIDS and support for their families.
Acquired Immunodeficiency Syndrome↗
AIDS mortality among Puerto Ricans and other Hispanics in New York City, 1981-1987.
Analysis of AIDS mortality data for New York City for 1981-1987 reveals that Puerto Ricans represent the racial/ethnic group most severely affected by this city's AIDS epidemic. Cumulative age-adjusted AIDS mortality rates among Puerto Rico-born males are significantly higher (362 per 100,000) than among blacks (267), whites (182), or other Hispanic (217) males, and cumulative age-specific mortality rates for males are highest for the Puerto Rico-born in every adult age group. AIDS proportional mortality analysis indicates that in 1987 the proportion of all deaths due to AIDS was 10% among those Puerto Rican-born, 12% among other Hispanics (which includes at least 50% United States-born Puerto Ricans), 6% among blacks, and 2% among whites.
Acquired Immunodeficiency Syndrome↗
Increasing rate of pneumonia hospitalizations in the Bronx: a sentinel indicator for human immunodeficiency virus.
To describe secular trends in pneumonia hospitalizations in the Bronx, New York City from 1982-1986, we analysed all cases with a discharge diagnosis of pneumonia, excluding Pneumocystis carinii pneumonia (PCP), for Bronx residents by age, sex, neighbourhood, and length of stay (N = 21,822). Hospital deaths from PCP and immune disorders were analysed separately as a non-recurrent indicator of human immunodeficiency virus (HIV) related disease prevalence by age, sex and geographical areas. From 1982 to 1986, pneumonia hospitalizations increased 132% among males and 100% among females aged 25-54, an age group accounting for 90% of adult AIDS cases in the Bronx, as compared to a 21% rise among males and 38% among females in all other age groups (p less than 0.001). Pneumonia rates increased most in those population groups with the highest rates of PCP and immune disorders. An ecological correlation of pneumonia hospitalization with this measure of AIDS prevalence for residents of a small geographical area is evident (r2 = 0.92). The observed increase in pneumonia hospitalizations, believed to be related to underlying prevalence patterns of HIV in this population, accounts for a significant and previously unrecognized burden on the local health care system. From 1983-1986, these 'excess' pneumonias in the Bronx accounted for 14,707 days of hospitalization--equal to 42% of the total days attributed to all hospital admissions for AIDS per se.
Acquired Immunodeficiency Syndrome↗
Estimating population prevalence of human immunodeficiency virus infection in urban areas with high rates of intravenous drug use: a model of the Bronx in 1988.
The Bronx, a borough of New York City with 1.16 million people, has a distinctive pattern of prevalence and distribution of acquired immunodeficiency syndrome (AIDS), i.e., 62.2% of AIDS patients are intravenous drug users, 20.3% are female, 87.3% are black or Hispanic, and 4.5% are children under age 13 years. Local data on reported AIDS cases by risk factors, age, and sex are combined with local indices of the intravenous drug use population to estimate numbers of intravenous drug users. The Bronx is estimated to have 40,400 intravenous drug users (range, 28,080-52,800), 78% of whom fall into the age group 25-44 years. On the basis of local serosurveys, 45-55% are considered to be human immunodeficiency virus (HIV)-positive. With Bronx population census data as the denominator, minimum rates of HIV seroprevalence are calculated for all Bronx males and females aged 25-44 years, a group comprising 76% of the AIDS cases in the Bronx through February 1, 1987. These data produce a population seroprevalence range for those aged 25-44 years of 5.4-12.5% for all Bronx males and 1.4-3.3% for females. For the South Bronx, with 66% of all intravenous drug users and 38% of the population, these age-specific HIV prevalence estimates are 9.4-21.6% for males and 2.4-5.5% for females.
Acquired Immunodeficiency Syndrome↗
Impact of the AIDS epidemic on morbidity and mortality among intravenous drug users in a New York City methadone maintenance program.
To examine the impact of the AIDS epidemic on morbidity and mortality in a defined population of intravenous drug users, we analyzed overall and cause-specific death rates, AIDS incidence, and acute medical hospitalizations among patients in a long-term methadone maintenance program in New York City for the years 1984 through 1987 (midyear population for each year 828 to 891; demographic characteristics did not differ). The number of deaths while in treatment increased from 11 (13.3/1000) in 1984 to 39 (44.2/1000) in 1987. Deaths from AIDS increased from 3.6/1000 to 14.7/1000, deaths due to bacterial pneumonia/sepsis from 3.6/1000 to 13.6/1000; deaths from cirrhosis, drug overdose, trauma, and other causes remained relatively stable. AIDS incidence rose from six cases/1000 in 1984 to 20.4.1000 in 1987. Hospitalizations for AIDS, pneumonia, tuberculosis, and endocarditis/sepsis increased from 84.9/1000 in 1986 to 144.8/1000 in 1987. These data suggest that the AIDS epidemic has had a profound effect on patterns of morbidity and mortality among intravenous drug users in this methadone program population. Drug treatment programs may be important sites for targeting clinical services for drug users with AIDS, although the increasing burden of AIDS-related disease will require expansion of existing funding and treatment resources.
Acquired Immunodeficiency Syndrome↗
Race/ethnic-specific AIDS risk in New York City, 1981-87.
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Acquired Immunodeficiency Syndrome↗
Reliability and construct validity of the needle sharing inventory.
The Needle Sharing Inventory (NSI) is a 59-item test developed to specify and assess behavior patterns associated with drug use and needle sharing. In order to determine its reliability and construct validity, the NSI was administered to 80 intravenous drug users (IVDUs) recruited from a methadone maintenance program in New York City. Patients were included in the study if they reported using intravenous drugs during the previous month. Factor analysis was performed indicating that 31 of the items loaded onto 6 factors similar to those hypothesized: four dealing with the social context of needle sharing - indiscriminate sharing, social sharing, intimate sharing, and use of shooting galleries; and two dealing with the emotional context of intravenous drug use negative affect states and positive affect states. These variables accounted for 71% of the total variance, suggesting internal consistency of these items. Factor scores significantly correlated to subjects' self-reported estimates of time using nonsterile needles and sharing needles. These data suggest that the NSI is both a reliable and a valid measure which may be used in future studies of intravenous drug use and needle sharing behavior patterns. The NSI may prove useful for the purpose of developing and evaluating interventions aimed at preventing or reducing the spread of HIV through needle sharing.
Adult↗