Editor's introduction: the global epidemiology of HIV and AIDS.
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Disease Outbreaks↗
Biomedical subjects
J A Inciardi
Publications and source records attributed to J A Inciardi.
Tailoring an HIV-prevention intervention for cocaine injectors and crack users in Porto Alegre, Brazil.
Brazil has the second largest number of reported AIDS cases in the world. Porto Alegre, like most other large urban centres in Brazil, has been greatly impacted by an AIDS epidemic driven by high rates of drug use and risky sexual behaviours. While epidemiologic surveillance of HIV/AIDS and treatment initiatives for HIV-infected individuals are well developed in Brazil, comparatively little attention has focused on developing interventions directed toward high-risk populations. Intervention programmes, particularly those tailored for chronic drug users, are lacking. This pilot project successfully adapted and tailored a cognitive behavioural HIV intervention developed in the US to the cultural setting in Porto Alegre. The project established feasibility and acceptability of the approach for targeting risky drug and sexual behaviours among a group of male Brazilian drug users. A sample of 120 male cocaine users was recruited from a public health clinic serving the target population in the city of Porto Alegre. The average age of the participants was 29; they averaged less than 8 years of formal education; and less than half (41%) were married. Lifetime self-reported drug use was high with 93% reporting cocaine use, 87% reporting crack use, and 100% reporting marijuana use. 43% of the sample reported ever injecting drugs. Reports of risky sexual behaviours were similarly elevated. Almost half (45%) tested positive for HIV. Preliminary evidence suggests that intervention acceptability was high among participants. Given the reported high risk sexual and drug use behaviours among these men, HIV interventions must be evaluated and expanded to include this population as well as their sexual partners.
Adolescent↗
HIV/AIDS in the Caribbean Basin.
After Sub-Saharan Africa, the Caribbean Basin has the second highest rate of HIV/AIDS in the world. The number of HIV cases in the region is likely to increase significantly over the next decade due to patterns of sexual behaviour, drug use, migration, and the sociocultural practices and legal and religious taboos which serve as barriers to safe sex, as well as stigma, shame, and denial which preclude many issues from being openly discussed and addressed. Studying the HIV epidemic in the Caribbean Basin is difficult, as efforts to synthesize information are often hampered by a lack of uniformity and availability of surveillance data in many parts of the region. In addition, behavioural surveillance is limited, and interventions addressing the cultural context of Caribbean populations are few in number. Overall, the geographic, political, cultural, and linguistic diversity of the Caribbean underscores the complexity of understanding broader regional patterns of HIV infection and developing and implementing targeted and appropriate responses.
Acquired Immunodeficiency Syndrome↗
The effect of serostatus on HIV risk behaviour change among women sex workers in Miami, Florida.
HIV prevention and risk reduction are especially salient and timely issues for women, particularly among those who are drug-involved or who exchange sex for drugs or money. Studies suggest that HIV-prevention measures can be effective with highly vulnerable women, and have the potential to produce significant reductions in risk behaviours among both HIV-negative and HIV-positive women. Within this context, this paper examines risk behaviours and HIV serostatus among 407 drug-involved women sex workers in Miami, Florida, and investigates the effects of participation in HIV testing, counselling, and a risk-reduction intervention on subsequent behavioural change among this population. Overall, at follow-up, the HIV-positive women were 2.4 times more likely than the HIV-negative women to have entered residential treatment for drug abuse, 2.2 times more likely to have decreased the number of their sex partners, 1.9 times more likely to have decreased the frequency of unprotected sex, 1.9 times more likely to have reduced their levels of alcohol use, and 2.3 times more likely to have decreased their crack use. These data support the importance of HIV testing and risk-reduction programmes for drug-involved women sex workers.
AIDS Serodiagnosis↗
Emerging linkages between substance abuse and HIV infection in St. Croix, US Virgin Islands.
In the US Virgin Islands 575 cases of AIDS had been reported to the Centers for Disease Control and Prevention through mid-2003. Although males continue to be most affected by HIV/AIDS, the feminization of the epidemic is evidenced by recent data showing rates of infection increasing rapidly among women. This paper focuses on the role of substance abuse and the socially and culturally based gender issues that influence risk and vulnerability to HIV in this setting. 254 chronically drug- or alcohol-involved men and women were recruited and interviewed using targeted sampling strategies. Crack use was overwhelmingly reported by females when compared to males (84.7% vs. 48.8%). Women also reported a significantly higher number of sexual partners in the past month (5.6 vs. 2.3) and significantly more occasions of unprotected vaginal sexual contact (11.2 vs. 6.5). Rates of self-reported HIV infection were elevated among women as well (8.8% vs. 1.4%). Women's precarious economic position and lack of access to legitimate income-generating activities tended to drive them into 'survival sex' to support their subsistence and drug needs. As such, it would appear that substance abuse has an emerging role in the spread of the epidemic in St. Croix, particularly among women.
Adult↗
HIV risk, seropositivity and predictors of infection among homeless and non-homeless women sex workers in Miami, Florida, USA.
Although homelessness has frequently been associated with substance abuse, and has been established as a predictor of HIV risk among substance abusers, little is known about the impact of homelessness on HIV risk among female sex workers. This analysis investigated the contribution of homelessness to sexual risk taking among a sample of 485 female sex workers recruited into an HIV prevention programme in Miami, Florida, 41.6% of whom considered themselves to be currently homeless. Findings indicated that in comparison to non-homeless sex workers, significantly more homeless sex workers were daily users of alcohol and crack, and their past month sex work reflected significantly more frequent vaginal and oral sex acts, higher levels of unprotected vaginal sex and more numerous sexual activities while 'high' on drugs. At the same time, a significantly greater proportion of homeless sex workers encountered customers that refused to use condoms than did the non-homeless sex workers. There were no significant differences in HIV seropositivity between the homeless and non-homeless women (22.5 and 24.9%, respectively), primarily because the majority of the women in the study cycled in and out of homelessness.
Adolescent↗
Cross-cultural approaches to harm reduction research: some considerations on the Brazil experience.
Harm reduction initiatives for drug users comprise a range of approaches, including drug-user treatment, advocacy for changes in drug policy, needle exchange programs, bleach distribution, and broad-based interventions that focus on both safer drug use and less risky sexual behaviors. In many developing nations, harm reduction is a relatively new strategy, which focuses almost exclusively on the connections between drug use and the spread of HIV infection. In Brazil, harm reduction programs are few, and little has been documented about their scope, experience, and effectiveness. This paper reviews the status of Brazilian harm reduction initiatives in general, with a specific focus on lessons learned from the conduct of cross-national research in Rio de Janeiro. The study demonstrated the feasibility of implementing a community-based prevention program among an at-risk population of cocaine users in Brazil, and in other countries where there is little tradition of research with out-of-treatment drug users. Finally, the paper addresses aspects of the harm reduction movement that tend to hamper its progress in both developed and developing nations.
Adolescent↗
A postmarketing surveillance program to monitor Ultram (tramadol hydrochloride) abuse in the United States.
Tramadol HCl, marketed as Ultram in the USA, was introduced as a non-scheduled drug in April 1995 based on the assumption that the risk of abuse was sufficiently low to warrant a non-scheduled status. However, approval was contingent upon the development of an innovative proactive surveillance program, to be overseen by an independent steering committee, which would detect unexpectedly high levels of abuse. The postmarketing surveillance program consisted of systematic collection and scientific evaluation of reports of suspected abuse in high-risk populations surveyed through an extensive key informant network of drug abuse specialists and all spontaneous reports of abuse received through the FDA MedWatch system. Methods to estimate the number of patients prescribed tramadol were also developed. Monthly rates of abuse were calculated as an index of the risk-benefit ratio (i.e., abuse cases per 100,000 patients prescribed the drug). The data for the 3 years since the drug was introduced show that the reported rate of abuse has been low. Although a period of experimentation seemed to occur in the first 18 months after its introduction--which reached a peak rate of approximately two cases per 100,000 patients exposed--during the 2 year period prior to June 1998, the reported rate of abuse has significantly (P = 0.011) declined, reaching levels of less than one case per 100,000 patients in the last 18 months. The overwhelming majority of abuse cases (97%) have been found to occur among individuals with a history of substance abuse and the abuse has been confined to isolated pockets around the country-notably none of which have significant populations of street drug abusers. Thus, the data support the decision not to schedule tramadol and, furthermore, suggest that a proactive post-marketing surveillance program can be successfully developed to effectively monitor abuse of new medications.
Analgesics, Opioid↗
Drug use and street crime in Miami: an (almost) twenty-year retrospective.
Researchers at the University of Delaware have been conducting field studies of drug use and crime in Miami, Florida, since 1977. This paper reviews this research and its contributions to understanding drugs-crime relationships. Early studies tested mechanisms for accessing street populations of heroin users and assessing the nature and extent of their drug use and criminality. Subsequent studies targeted a variety of crime-involved heroin and cocaine users, including women as well as men, serious delinquents, adolescent and adult crack users, and cocaine users in treatment as well as on the street. Major findings include the low risk of arrest for income-generating crimes committed by heroin users, and the prevalence of HIV-risk behaviors among both serious delinquents and women crack users. Analyses consistently show the critical importance of sample characteristics in research on drug use, including age, cohort, and street-versus-treatment status.
Acquired Immunodeficiency Syndrome↗
Children in the streets of Brazil: drug use, crime, violence, and HIV risks.
The presence of vast numbers of unsupervised and unprotected children is a phenomenon that is common throughout Latin America, and in few places are the street children more visible, and reviled, than in Brazil. Estimates of their numbers in Brazil have ranged from 7 to 17 million, but more informed assessments suggest that between 7 and 8 million children, ages 5 to 18, live and/or work on the streets of urban Brazil. Accounts of drug misuse among street youths in Brazil are commonplace. Numerous scientific studies and media stories have reported the widespread use of inhalants, marijuana and cocaine, and Valium among street children. Also common is the use of coca paste and Rohypnol. Risk of exposure to HIV is rapidly becoming an area of concern because of the large number of street youths engaging in unprotected sexual acts, both renumerated and nonrenumerated. Moreover, Brazil's street children are targets of fear. Because of their drug use, predatory crimes, and general unacceptability on urban thoroughfares, they are frequently the targets of local vigilante groups, drug gangs, and police "death squads." Although there have been many proposals and programs for addressing the problems of Brazilian street youth, it would appear that only minimal headway has been achieved.
Adolescent↗
Rohypnol misuse in the United States.
Rohypnol, a potent sedative-hypnotic drug prescribed extensively throughout the world, is illicit in the United States. Recently, this drug has gained popularity among United States youths as a cheap means of intoxication and subsequently has become the focus of numerous criminal investigations. College men are alleged to slip Rohypnol tablets into unsuspecting women's drinks and then sexually abuse their sedated victims. Although law enforcement agencies and drug policy groups consider Rohypnol to be an "imminent problem," little is actually known about patterns of misuse. Presented here is a brief overview of Rohypnol's contemporary appearance in the United States.
Adolescent↗
Risk behavior and HIV seroprevalence among injecting drug users in Rio de Janeiro, Brazil.
OBJECTIVE: To characterize HIV seroprevalence and risk behavior among injecting drug users (IDUs) in Rio de Janeiro, Brazil, between 1990 and 1996. DESIGN: We report data from three separate cross-sectional samples of IDUs in Rio de Janeiro: the World Health Organization (WHO) sample (n = 479), the Proviva sample (n = 138) and the Brasil sample (n = 110). These data provide the most comprehensive view available, to date, of this understudied population in Rio. METHODS: Demographic characteristics, HIV/AIDS risk behavior and HIV seroprevalence were compared across the three samples and combined analyses were performed to determine the factors associated with injecting risk behavior, sexual risk behavior and HIV seropositivity. RESULTS: The overall HIV seroprevalence among IDUs was 25%. Two encouraging findings of the present analysis were the lower levels of needle-sharing among participants recruited in the latest years (1995-1996) and the lower HIV seroprevalence in the Proviva sample composed mainly of less educated, poorer IDUs living in deprived neighborhoods. No trends toward safer behavior were found for sexual risk, younger age being the principal factor associated with high risk. CONCLUSIONS: Levels of needle-sharing and sexual risk among IDUs in Rio remain high, demonstrating the urgent need to increase the limited preventive measures undertaken so far. Seroprevalence levels for HIV remain significantly lower in the most deprived sample, arguing for the fundamental importance of prompt and effective prevention strategies to keep infection rates from rising among the poorest and largest strata of Rio's IDUs.
Adolescent↗
Sex, drugs, and the spread of HIV/AIDS in Belle Glade, Florida.
Belle Glade, Florida, an agricultural community in the heart of the state's vegetable and sugar cane production areas, has the highest cumulative per capita incidence of AIDS in the United States. A risk reduction intervention program was introduced to lessen unsafe AIDS-related behaviors and to generate data on the epidemiology of HIV infection. Initial attention focused on individuals who were believed to be at the core of the transmission pattern, injection drug users and their sexual partners. We found, however, that injection drug use was much less widespread than anticipated. Results suggested that the primary mode of HIV transmission is heterosexual intercourse-mediated by drug taking (particularly crack smoking) and a flourishing sex industry-a finding that is corroborated by the increased and disproportionate rate of heterosexual AIDS in Belle Glade. The prevalence and types of risk behaviors engaged in would not have been completely explained without the use of ethnographic methods including observation of, and lengthy interviews with, the populations at risk.
Adult↗
Crack, crack house sex, and HIV risk.
Limited attention has been focused on HIV risk behaviors of crack smokers and their sex partners, yet there is evidence that the crack house and the crack-using life-style may be playing significant roles in the transmission of HIV and other sexually transmitted diseases. The purposes of this research were to study the attributes and patterns of "sex for crack" exchanges, particularly those that occurred in crack houses, and to assess their potential impact on the spread of HIV. Structured interviews were conducted with 17 men and 35 women in Miami, Florida, who were regular users of crack and who had exchanged sex for crack (or for money to buy crack) during the past 30 days. In addition, participant observation was conducted in 8 Miami crack houses. Interview and observational data suggest that individuals who exchange sex for crack do so with considerable frequency, and through a variety of sexual activities. Systematic data indicated that almost a third of the men and 89% of the women had had 100 or more sex partners during the 30-day period prior to study recruitment. Not only were sexual activities anonymous, extremely frequent, varied, uninhibited (often undertaken in public areas of crack houses), and with multiple partners but, in addition, condoms were not used during the majority of contacts. Of the 37 subjects who were tested for HIV and received their test results 31% of the men and 21% of the women were HIV seropositive.
Adult↗
Intersecting epidemics--crack cocaine use and HIV infection among inner-city young adults. Multicenter Crack Cocaine and HIV Infection Study Team.
BACKGROUND AND METHODS: The smoking of "crack" cocaine is thought to be associated with high-risk sexual practices that accelerate the spread of infection with the human immunodeficiency virus (HIV). We studied 2323 young adults, 18 to 29 years of age, who smoked crack regularly or who had never smoked crack. The study participants, recruited from the streets of inner-city neighborhoods in New York, Miami, and San Francisco, were interviewed and tested for HIV. This report presents the findings for the 1967 participants (85 percent) who had never injected drugs. RESULTS: Of the 1137 crack smokers, 15.7 percent were positive for HIV antibody, as compared with 5.2 percent of the 830 nonsmokers (prevalence ratio adjusted for the city, 2.4; 99 percent confidence interval, 1.7 to 3.6). The prevalence of HIV was highest among the crack-smoking women in New York (29.6 percent) and Miami (23.0 percent). Of the 283 women who had sex in exchange for money or drugs, 30.4 percent were infected with HIV as compared with 9.1 percent of the 286 other women (prevalence ratio, 3.1; 99 percent confidence interval, 1.9 to 5.1); of the 91 men who had anal sex with other men, 42.9 percent were infected with HIV as compared with 9.3 percent of the 582 men who did not have anal sex with other men (prevalence ratio, 4.7; 99 percent confidence interval, 3.0 to 7.4). In multivariable analyses, these high-risk sexual practices accounted for the higher prevalence of HIV infection among the crack smokers, as compared with those who did not smoke crack. Women who had recently had unprotected sex in exchange for money or drugs were as likely to be infected as men who had had sex with men (40.9 percent vs. 42.9 percent). CONCLUSIONS: In poor, inner-city communities young smokers of crack cocaine, particularly women who have sex in exchange for money or drugs, are at high risk for HIV infection. Crack use promotes the heterosexual transmission of HIV.
Adolescent↗
Appropriateness of assertive case management for drug-involved prison releasees.
Assertive case management models have been used successfully in both social work and mental health settings and, most recently, in the substance abuse field. This article reports on the application of an assertive case management model with drug-involved parolees in Delaware. Because of a variety of factors, the evaluation proved to be less than an ideal test of the effectiveness of the case management approach. Although there were some modest effects on reducing relapse to drug use, it appears that assertive case management is of limited value for clients who are not merely unable to access services, but who are often quite assertive in their unwillingness to make use of these services.
Assertiveness↗
Compliance to bleach disinfection protocols among injecting drug users in Miami.
Bleach cleansing of injection equipment has been recommended to reduce the risk of human immunodeficiency virus (HIV) transmission associated with the reuse of injection equipment by injecting drug users (IDUs). We evaluated the recall and performance of the most commonly recommended bleach cleansing procedure of two complete fillings of the syringe with bleach, followed by two complete fillings with rinse water, and not putting used bleach and water back into source containers. IDUs were taught this procedure on enrollment in an HIV prevention demonstration project in Dade County, Florida. During follow-up session 6-12 months after initial training, the knowledge and ability of IDUs to perform bleach cleansing were assessed by trained observers using a standardized method. In 1988-90, we assessed the knowledge and ability of 450 IDUs to perform the bleach cleansing procedure taught at enrollment. More than 90% of IDUs assessed performed the basic steps. However, only 43.1% completely filled the syringe with bleach and only 35.8% completely filled the syringe with bleach at least twice. Substantial proportions of IDUs did not perform all the steps of the previously taught bleach cleansing procedure. Compliance decreased as the number of steps required was increased. This limited compliance may make bleach cleansing less effective and suggests that some IDUs may fail to adequately disinfect injection equipment and therefore sterile needles and syringes are safer than bleach-cleansed ones. Compliance testing can help assess the effectiveness of HIV prevention programs.
Disinfection↗
HIV/AIDS risks among male, heterosexual noninjecting drug users who exchange crack for sex.
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Acquired Immunodeficiency Syndrome↗