Target Groups for Preventing AIDS Among Intravenous Drug Users

The acquired immune deficiency syndrome (AIDS) has rapidly become the most serious medical consequence of injecting illicit drugs. Its potential impact on intravenous (IV) drug use is enormous. Human immunodeficiency virus (HIV, also known as HTLV-III and LAV), the virus that causes AIDS, appears, usually, to lead to lifelong infection. At present there is no effective treatment, and the treatments under development may require lifelong antiviral therapy. Since most of the antibody produced in response to HIV infection does not neutralize the virus, and since there is substantial genetic variation in the virus, it will be difficult to develop a vaccine. Even after vaccines are developed, testing their safety and efficacy will be formidable problems. Until either effective treatment or vaccines are developed, control of the epidemic among IV drug users must be attempted through behavior change/prevention efforts. In this paper we will review the epidemiology of AIDS among IV drug users and characteristics of the IV drug-use subculture relevant to prevention efforts. We will then identify different target groups for these prevention efforts, present available evidence about behavior change in these groups, and then briefly discuss how to prevent transmission of HIV to heterosexual partners who are not themselves IV drug users and to the children of IV drug users.     

The AIDS Risk Reduction Model: Examining Intentions to Use Condoms Among Injection Drug Users1

This paper uses the AIDS Risk Reduction Model (ARRM) to examine psychosocial factors involved in adopting safer sex practices in a sample of Los Angeles injection drug users (IDUs; n= 161) who reported having more than one sex partner in the year preceding the interview. The ARRM hypothesizes that behavior change is a process occurring in three stages: (a) labeling one's behavior as problematic, (b) making a commitment to behavior change, and (c) taking action to accomplish that change. We test the first two stages of the model using a measure of perceived risk of HIV infection (Stage I), and intentions to use condoms always during vaginal or anal sex in the next year (Stage 2). We examine differences in the predictive value of the ARM between IDUs who reported using condoms in the year prior to the interview and those who reported not using them. We identify leverage points in the model-factors which appear to have a major influence on intentions to use condoms and which may be amenable to change through educational or other types of intervention. For both condom users and non-users, susceptibility to AIDS predicted perceived infection risk (Stage I). For condom users, knowledge about AIDS also predicted perceived risk. For both groups, self efficacy, peer norms concerning condom use, and the perceived pleasure of using condoms predicted intentions to use condoms (Stage 2). Our findings do not support either direct or indirect relationships between the Stage 1 and Stage 2 outcome variables for either group.     

AIDS-related factors predictive of suicidal ideation of low and high intent among gay and bisexual men.

AIDS-related stressors were studied in relationship to suicidal ideation and suicide intent among 778 gay and bisexual men (none with AIDS). Over the previous six months, 27% (n = 212) reported suicidal ideation. Subjects who reported suicidal ideation (compared to those who did not) were more likely to report recent (last 6 months) bereavement of partner, recent ARC diagnosis, and multiple close friends with ARC. Suicide ideators were divided by a median split on a self-report scale of suicide intent into low (n = 105) and high (n = 107) intent suicide ideators. News of HIV seropositivity was specifically related to low intent suicidal ideation. High intent suicidal ideation was associated with having a partner with AIDS or ARC, or multiple close friends with AIDS, or having ARC. Generally speaking, while temporally discrete AIDS-related events were associated the report of suicidal ideation, ongoing stressors which may more greatly challenge adaptational capacities were more associated with high intent suicidal ideation.     

When are AIDS patients to blame for their disease? Effects of patients' sexual orientation and mode of transmission

This study examined three factors affecting college students' attributions of blame for an AIDS patient's disease: sexual orientation of the patient, mode of HIV transmission, and the sex of the subject. 148 subjects read one of six vignettes describing an hypothetical AIDS patient who was described as either an heterosexual or an homosexual man who contracted HIV through one of three avenues: blood transfusion, sexual contact, or IV drug use. The homosexual AIDS patient was considered more to blame for his illness than the heterosexual AIDS patient, but only when mode of transmission was sexual contact. In addition, mode of HIV transmission was a significant factor in attributions of responsibility, as the patient who contracted HIV through a blood transfusion was rated as less responsible than the patient who contracted HIV through sexual behavior or IV drug use. Women consistently rated the AIDS patient as less responsible than did men.     

Design and implementation of a program for AIDS prevention in female prostitutes

The Companeros model of HIV infection prevention in Ciudad Juarez, Mexico, is presented as conceived by the National Institute of Drug Abuse (NIDA). 518 women who were IV drug users, sexual partners of drug addicts, or prostitutes were requested to participate, and 232 consented. Initial and follow-up AIDS assessments were utilized along with an assessment of sociodemographic variables, including knowledge, sexual behavior, use and abuse of drugs, and previous health history. Educative sessions about AIDs and sexually transmitted diseases (STDs) included group discussions and interaction, video watching, personal experiences, and sociodramas. 61% of prostitutes were 29, 12.6% were 13-19 years old, 31.1% were aged 30-39, and 8.9% were 40. 11% had no formal education, 58% had 6 years of primary and part of 3 years of secondary education, only 18.6% completed secondary education; and 13% had higher education. 19% lived in a hotel or shelter. Family disintegration reached 44%; these women did not live with their children. Only 5.2% thought they had excellent health, 51% said they had good health, 31% stated they had average health, and 12% admitted having had health problems. 14.6% had genital ulcers, 1.3% had herpes, 15% had gonorrhea, and 10% had syphilis. Since IV drug use among these women was almost nonexistent sexual relations constituted the principal risk factor. Responses to a questionnaire showed that the most frequent sexual behavior was vaginal penetration followed by fellatio; anal penetration was less common. 34.9% of the women practiced fellatio without protection, 16.3% had anal intercourse without protection. The proportion of AIDS cases in Mexico in women of reproductive age was growing at an exponential rate, possible because of misinformation about AIDS, a history of STDs, and a low rate of condom use.     

Childhood Factors that Precede Drug Injection: Is there a Link?

Examination of childhood risk factors for injection drug use may provide clues as to why people progress to injection drug use and it can promote identification of at-risk youth. We surveyed current injection drug users (IDUs) and individuals who never injected drugs (non-IDUs), recruited through street outreach and snowball sampling in Denver, CO. Between March 2000 and October 2003, 601 subjects (339 IDUs and 262 non-IDUs) participated in structured interviews. We examined self-reported factors in childhood that may have been influential in whether one progressed to drug injection later in life. These indicators included age at drug and alcohol initiation, childhood risk behavior, parental monitoring, family stability, and other family problems. Differences between IDUs and non-IDUs were assessed using unadjusted tests and logistic regression. Results of the data analysis indicated that IDUs were significantly younger when they first used both alcohol and marijuana, they reported higher childhood risk behavior scores, and they had less parental monitoring and less family stability as children than non-IDUs. This research may assist clinicians in defining factors that put youth at risk for problems associated with injection drug use.     

Dissemination of psychoactive substance information by innovative drug users.

Internet-based drug information may be relayed by innovative drug users, a group of individuals who use the web to learn about a new drug, experiment with that substance, and then disseminate their knowledge and experiences to others. We investigated the mechanisms adopted by innovative drug-using adolescents to distribute Internet drug information and experiences to peers, the size and geographic distribution of the receiving group, and the age at which innovative drug users began to disseminate drug information. Method: Cross-sectional survey of adolescents recruited by a respondent-driven sampling method. Of 18 innovative drug users, 17 reported using instant messaging (IM) to disseminate drug information and experiences to peers. The average age at which respondents adopted IM for this purpose was 16 years. Fifteen of 17 described using a distribution list with as many as 200 individuals who received only drug information. Ten respondents instant messaged drug information to online peers greater than 250 miles distant; nine respondents attached links to online drug resources (including www.erowid.org). This study has identified that IM plays an important role in the dissemination of Internet-based drug information by individual innovative drug users into larger social networks. Pediatricians should consider assessing IM use in drug abuse evaluations and recommending that parents of children with drug abuse problems should consider suspending IM services as a means of truncating the delivery of reinforcing drug information.     

The relationship between childhood sexual abuse and sexual health practices of homeless adolescents

This study explored the gender differences in sexual self-concept, personal resources for sexual health, safe sex behaviors, and risky sexual behaviors among homeless adolescents with and without histories of sexual abuse. Data for this secondary analysis were collected in 2003 to 2004 in the first phase of a larger repeated-measures sexual health intervention study; 371 homeless youth between 16 and 23 years of age (M = 19.26, SD = 1.83) were recruited from a street outreach center. The majority (64.6%) of participants were males. Self-report instruments were completed at the outreach center via audio computer-assisted self-interview (A-CASI) format. It was found that female participants were better off than males on numerous measures of sexual health behaviors and attitudes. Sexually abused participants had significantly less future time perspective (p = .05), fewer sexual self-care behaviors (p = .04), and less social support than nonabused participants (p = .01) and almost significantly more sexual risk-taking (p = .08). However, no significant differences were found between abused and nonabused participants on sexual self-concept, self-efficacy or intention to use condoms, safe sex behaviors, AIDS knowledge, assertive communication, or self-efficacy to perform testicular/ breast self-exams. Overall, participants who did not report a history of sexual abuse had significantly more sexual health resources and engaged in fewer sex-risk behaviors than those who reported having been abused. These differences have notable implications for screening adolescents for a history of sexual abuse. Adolescents who report sexual abuse should receive risk counseling and be screened regularly for the development of sexual risk behaviors.     

Profiling work-related signature strengths of “Born Free” South Africans: A gender perspective

This study investigated the importance of signature strengths of South African trainees in the hospitality industry who are the “Born Free” generation, who have only lived in a democracy, and were given equal opportunities. Utilising a cross-sectional research design, we sampled hospitality industry trainees (n = 290) attending a large South African university (females = 70.3%; black = 91%; mean age = 20.59 years, SD = 3.86 years). For the data analysis we rank order scored the hospitality trainees’ key strengths, and differentiating these by gender. Results indicated the participants to rank Honesty, Love, and Fairness as most important; while Love of learning and Self-regulation were ranked least important of the strengths. Both males and females ranked Fairness highly, while the males ranked Hope as most important, and the females viewed Honesty as an important strength. Moreover, the males scored Leadership significantly higher than the females, while the females scored Forgiveness and Kindness significantly higher than the males. Recognising the signature strengths valued by the South African “Born Free” generation may be important for their self-awareness to provide superior service to guests by using their positive skills.     

Brief counseling to reduce AIDS risk in intravenous drug users and their sexual partners: Preliminary results

Intravenous drug users (N = 88) and their sexual partners (N = 45) were randomly assigned to either a brief counseling intervention or an information-brochure only condition (aimed at reducing behavioral risk for HIV infection). At 10 day follow-up, intravenous drug users exposed to brief counseling were more knowledgeable about risk behaviors, and reported higher levels of self-efficacy and communication skill, and more frequent use of condoms and sterilisation of needles. At 90 day follow-up, intravenous drug users were more accepting of guidelines to reduce sex-related risk and reported greater self-efficacy in relation to drugs. Sexual partners who received brief counseling showed a small reduction in unprotected sex (at 90-day follow-up), while those receiving brochures were slightly less likely to use condoms. Methodological problems of the study are discussed.     

Adolescent Males' Knowledge and Attitudes About AIDS in The Context of Their Social World1

This study sought to find out how much total knowledge adolescents had concerning AIDS, what particular areas of knowledge were deficient, and how those areas might be related to attitudes and experiences in their social world. Seventy-eight adolescent males from one suburban and three urban high schools were interviewed. A 101-item questionnaire was used to assess: a) overall knowledge about AIDS; b) attitudes about sexuality, drugs, death, and AIDS and; c) related aspects of their social world, i.e., number of IV drug users known, and sources of information about AIDS. Analyses of variance were performed on overall knowledge of AIDS and on five content areas of knowledge. Race was shown to relate to significant differences in the knowledge scores. The social world associated with the urban samples were discussed as risk factors for minority youth. Different attitudes related to strengths and weaknesses in different areas of knowledge. Attitudes associated with deficiencies in different subareas of knowledge were discussed as additional risk factors and as presenting target areas for AIDS education efforts.     

Stigma, social risk, and health policy: public attitudes toward HIV surveillance policies and the social construction of illness.

Data from a 1999 national telephone survey with a probability sample of English-speaking US adults (N=1,335) were used to assess how support for HIV surveillance policies is related to AIDS stigma and negative attitudes toward groups disproportionately affected by the epidemic. Anonymous reporting of HIV results to the government was supported by a margin of approximately 2-to-l, but name-based reporting was opposed 3-to-l. Compared with other respondents, supporters of name-based surveillance expressed significantly more negative feelings toward people with AIDS, gay men, lesbians, and injecting drug users. More than one third of all respondents reported that concerns about AIDS stigma would affect their own decision to be tested for HIV in the future. Implications for understanding the social construction of illness and for implementing effective HIV surveillance programs are discussed.     

Contributions of the functional analysis of behavior to the problem of AIDS

Epidemiological patterns in the spread of HIV infection and the potential role of psychologists in encouraging behavioral changes intended to reduce risks of infection are examined. The 1st great wave of AIDS cases in the industrialized countries occurred primarily in specific, fairly self-contained subgroups such as male homosexuals, hemophiliacs, and IV drug users. Large proportions in these groups are either infected or have adapted risk reduction behavior. The risk of infection for the general heterosexual population in industrialized countries is very low but likely to increase progressively unless measures are taken to reduce risks. Psychologists, who expend considerable effort researching and attempting to effect behavioral changes, thus have a potentially significant role in slowing the spread of the AIDS epidemic. The means of avoiding HIV infection in sexually active persons and drug users are known, but the means of motivating individuals to change to less risky behaviors are not as well understood. Several factors have been identified that appear to influence the vulnerability of the organism to HIV infection or to development of AIDS once infected. Several are capable of modification through behavioral changes, such as high-risk sexual practices, use of particular contraceptive methods, inadequate hygiene, poor nutrition, and self-administration of drugs. Several aspects of HIV infection and its spread are capable of producing psychological stress, including anxiety over possible infection and testing, reaction to diagnosis, fear of rejection by others, watching friends and relatives sicken and die of AIDS, encountering suspicious symptoms, and perceiving signs of physical deterioration. Psychological support in these situations can help to prolong life and improve its quality. Examples abound of individuals who continue to display a risk behavior despite being well informed of its risks; physicians who smoke are 1 such group. Information is a necessary but not sufficient condition for adapting preventive behaviors. Functional behavioral analysis suggests that immediate pleasure, ephemeral though it may be, outweighs the mere possibility of an unpleasant consequence at some hypothetical future date.     

Preventing HIV infection among injecting drug users: Intuitive and counter-intuitive findings

The disease now called AIDS was first reported among injecting drug users in 1981. This article reviews the last 15 years of research on preventing HIV infection and AIDS among injecting drug users. Many of the findings were surprising in the context of previous understandings of the illicit injection of psychoactive drugs—both with respect to the much-larger-than-expected size of the epidemic and the much-greater-than-expected potential for behavior change among drug injectors (IDU). The research is reviewed within a framework of eight issues: the importance of the problem in the United States, the global diffusion of injecting drug use, the global diffusion of HIV among IDUs, potential rapid spread of HIV among IDUs, risk reduction among IDUs, community-level prevention, syringe exchange programs, and developing a public-health perspective on psychoactive drug use.     

Preventing HIV infection among injecting drug users: Intuitive and counter-intuitive findings

The disease now called AIDS was first reported among injecting drug users in 1981. This article reviews the last 15 years of research on preventing HIV infection and AIDS among injecting drug users. Many of the findings were surprising in the context of previous understandings of the illicit injection of psychoactive drugs—both with respect to the much-larger-than-expected size of the epidemic and the much-greater-than-expected potential for behavior change among drug injectors (IDU). The research is reviewed within a framework of eight issues: the importance of the problem in the United States, the global diffusion of injecting drug use, the global diffusion of HIV among IDUs, potential rapid spread of HIV among IDUs, risk reduction among IDUs, community-level prevention, syringe exchange programs, and developing a public-health perspective on psychoactive drug use.     

Death in the family and HIV risk-taking among intravenous drug users

The objective of this study was to ascertain the relationship among intravenous drug users between high levels of HIV risk-taking and both (a) deaths of significant others experienced before age 15, and (b) unresolved mourning; 592 out-of-treatment intravenous drug users (71.4% male; mean age = 40.5), stratified as to zip code, were recruited in San Jose, CA, as part of a CDC multisite investigation of access to sterile needles and HIV infection. HIV serostatus tests were obtained and an individual, structured interview administered covering demographics, employment, mental health, HIV risk-taking behavior, family contacts/closeness, and family deaths/mourning. Multivariate analyses indicated that the extent of HIV risk-taking in adulthood was highly and positively related to (a) the number of close-family-member deaths participants experienced as youth, (b) the extent to which respondents effectively mourned sudden family losses, (c) the extent to which those lost were emotionally close to the respondent, and (d) whether or not the respondent attended the funerals of lost relatives. Canonical correlations between sets of death/mourning and HIV risk-taking variables were .55 for the total sample (p < .001) and .70 for the subsample who experienced early and sudden family deaths (p < .001). In both analyses, it made little difference if age and gender were partialed out. These findings give credence to the importance of (a) unexpected deaths experienced early in life, and (b) related, inadequate mourning, as factors in progressively higher adult HIV risk-taking. They suggest that treatment for such individuals and their families should involve grief work dealing with unresolved losses within the family of origin. In addition, prevention efforts may have to revise their modus operandi toward both more focused and more family-based methods of outreach and engagement.     

Predictors of HIV-related stigma among young people living with HIV.

Enacted and perceived HIV stigma was examined among substance-using young people living with HIV (YPLH) in Los Angeles, San Francisco, and New York City (N = 147). Almost all YPLH (89%) reported perceived stigma, and 31% reported enacted experiences in the past 3 months; 64% reported experiences during their lifetime. The HIV stigma questions were characterized by factors of avoidance, social rejection, abuse, and shame. In multivariate models, enacted stigma was associated with gay or bisexual identity, symptomatic HIV or AIDS, and bartering sex. Perceived stigma was associated with female gender, symptomatic HIV or AIDS, bartering sex, lower injection drug use, and fewer friends and family knowing serostatus. Gay or bisexual YPLH who were also HIV symptomatic or AIDS diagnosed experienced more HIV stigma than their heterosexual peers.     

Characteristics of Air Force personnel who choose pharmacological aids for smoking cessation following an involuntary tobacco ban and tobacco control program.

OBJECTIVE: The objective of this study was to compare characteristics of smokers who did and did not report use of cessation aids as part of a tobacco control program in a military setting (n = 8994). DESIGN: The study is a longitudinal epidemiological study where the relationship between smoking status at follow-up and use of pharmacologic aids to quit smoking were assessed. MAIN OUTCOME MEASURES: Smoking cessation, post baseline use of cessation aids to quit smoking. RESULTS AND CONCLUSIONS: Individuals remaining abstinent were 70% less likely to have used NRT/pharmacological aids compared to those that relapsed. NRT/pharmacological aid users were more likely to report plans to smoke after military training, to have friends who smoke, and to accept a cigarette from a friend. NRT/pharmacological aid users were more likely to believe that using NRT was safer than smoking and to have engaged in harm reduction strategies. Our findings suggest that selection bias related to such characteristics may explain some of the discrepancies between effect sizes reported in efficacy compared to effectiveness studies of NRT and smoking outcomes currently reported in the literature.     

Understanding treatment effectiveness for aggressive youth: the importance of regulation in mother-child interactions

Reviews summarizing hundreds of studies cite parent management training (PMT) and cognitive-behavior therapy (CBT) as some of the most effective interventions for aggressive youth. However, studies continue to report variability in outcomes, and researchers have yet to understand why certain interventions only produce behavior change in some children. Using a clinical sample of 57 children (53 boys, 4 girls; mean age = 9.33, standard deviation = 1.16) and their mothers enrolled in a combined PMT/CBT program, the current study examined the relation between changes in real-time mother-child interactions, and children's externalizing outcomes from pre- to posttreatment. Results showed that dyads who were regulated in their interactions over time reported greater reductions in externalizing symptoms from pre- to posttreatment as compared with dysregulated dyads. Changes in mean levels of affective content (e.g., negativity) were not associated with externalizing outcomes. Findings suggest that dyadic regulation may be an important process associated with treatment success for aggressive youth.