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.     

Ethical issues in research on preventing HIV infection among injecting drug users

The ethical issues in conducting research on preventing HIV infection are among the most complex of any area of human subjects research. This article is an update of a 1987 article that addressed potential conflicts between research design and ethics with respect to AIDS prevention among injecting drug users. The present article reviews current ethical issues that arise in the design and conduct of HIV/AIDS prevention research focused on injecting drug users. Disclaimer: The content of this publication is solely the responsibility of the authors and does not necessarily represent the views of the Beth Israel Medical Center or Johns Hopkins University.     

Covariates of Multiplicity of Risk Behavior Among Injecting Drug Users in Nepal

Drug abuse, needle sharing, and high-risk sexual behaviour are often compounded to increase the risk of human immunodeficiency virus (HIV) transmission. This paper analyzes covariates of multiplicity of risk behavior among injecting drug users (IDUs). Findings are based on data from 1471 IDUs following modified time-location cluster sampling across Nepal in 2010–2011. Among Nepalese IDUs, average duration of injecting drugs is 4.4 years with two-fifths initiating it before age 20. Alcohol use is common with two-fifths reporting its daily consumption. Needle sharing is quite prevalent especially among younger and alcoholic IDUs. Further, IDUs practicing needle sharing exhibit rampant multi-partner behavior. Condom use with non-commercial partners is almost 80 %, whereas with intimate partner it is 41 %. Coexistence of needle sharing and unprotected sex enhances STI prevalence (7 %), which is further pronounced among alcoholics (9 %). Working towards risk reduction for IDUs must deal with multiplicity of risk. Interventions should deal with covariates of risk, addressing youth, substance abuse and risky sexual behavior.     

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 editorial perspective

This study utilizes in‐depth interviews of female injecting drug users (IDUs) supplemented by analyses of a large national data set to explore the association between the strength of the social bond and participation in a health‐related form of deviance: AIDS risk behaviors. The theoretical framework extends social control theory by examining the effects of further weakening of the social bond in an already deviant population. Risk behaviors are operationalized as a second‐level of deviance among individuals already participating in initial‐level deviant behavior (drug use). Prior research on how aspects of the social bond deter the individual from further deviance during adulthood has focused on males. Careers and marriage have been examined as elements of social control. The subjects of this study are female, however. For women, careers and marriage are often less salient, and relationships with children may be a more relevant measure of the social bond.

In‐depth interviews with eighteen female IDUs and two former IDUs are presented to explore the degree to which relationships with children deter female IDUs from participating in risky behaviors. Analysis of the interview data suggests that the presence, weakening, or rupturing of the bond to children is related to higher levels of second‐level deviance in the form of AIDS‐risk behaviors. However, the interviews also suggest that there are qualitative differences in the deterrence effects of weakened bonds to children, depending on the circumstances as well as the level of ongoing interaction between mother and child. Analyses of the data from the National AIDS Demonstration Research (NADR) Project are then presented, providing additional support to the conclusion that loss of relationships with children is related to higher levels of risk.     

Knowledge of drug-related health problems among injecting drug users: Implications for the transmission of HIV infection

Abstract

In a project that investigated the HIV-related risk behaviour of injecting drug users, respondents were categorized along dimensions of expertness in HIV/AIDS knowledge and knowledge about drug-related health problems. Knowledge about drug-related health problems was found to be significantly associated with sharing. Better informed respondents were less likely to share injecting equipment and to predict they would share in future. They were more likely to adopt consistent injecting hygiene, seek information about AIDS, and perceive themselves as in control of their lives. No significant relationships were observed between sharing and HIV/AIDS knowledge. The data have relevance for AIDS educational strategies, since knowledge about AIDS and HIV transmission appears to be insufficient to induce behavioural change. Greater emphasis on the health problems that afflict most injectors may be a way of encouraging general harm minimization.     

Heterosexual behaviors and risk of exposure to HIV: Current status and prospects for change

Prevalence of HIV among heterosexuals is relatively low as compared to that of gay and bisexual males and intravenous drug users (IDUs). However, many heterosexuals engage in behavior that places them at risk for exposure to HIV. Changes in sexual behavior in response to HIV are reviewed for both high-prevalence groups such as gay and bisexual men and IDUs and lower prevalence heterosexual groups. Psychosocial factors contributing to behavior change are evaluated. The implications for future changes by heterosexuals, especially the adoption of self-protective behaviors such as condom use, are discussed.     

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.     

A randomized clinical trial of a manual-guided risk reduction intervention for HIV-positive injection drug users.

This study randomized 90 HIV-seropositive, methadone-maintained injection drug users (IDUs) to an HIV Harm Reduction Program (HHRP+) or to an active control that included harm reduction components recommended by the National AIDS Demonstration Research Project. The treatment phase lasted 6 months, with follow-ups at 6 and 9 months after treatment entry. Patients in both treatments showed reductions in risk behaviors. However, patients assigned to HHRP+ were less likely to use illicit opiates and were more likely to adhere to antiretroviral medications during treatment; at follow-up, they had lower addiction severity scores and were less likely to have engaged in high risk behavior. Findings suggest that enhancing methadone maintenance with an intervention targeting HIV-seropositive IDUs increases both harm reduction and health promotion behaviors.     

The long-term outcome of a personal network-oriented HIV prevention intervention for injection drug users: The SAFE study

Social influence processes have been found to affect numerous drug and health-related behaviors. We postulated that by using a network-oriented intervention it may be possible to capitalize on social influence processes to reduce human immunodeficiency virus (HIV) risk behaviors. The present study used an experimental study design for delivering a psychoeducational acquired immunodeficiency syndrome (AIDS) preventive intervention to injection drug sharing networks. Participants were recruited from the ALIVE study, an epidemiological study in Baltimore. In the present paper we examine the self-reported behavioral outcomes of 117 injection drug users 18 months after the baseline interview. HIV seronegative experimental participants reported significantly less frequent needle sharing and less injecting of heroin and cocaine than controls. In multiple logistic regression models of HIV seronegative participants, there was a significant negative association between assignment to the experimental group and the HIV-related behaviors of needle sharing and sharing of cookers in the prior 6 months; controls were 2.8 times more likely than experimentals to report needle sharing and were 2.7 times more likely to report sharing cookers. The results of this 18-month follow-up suggest that among injection drug users network-oriented interventions may be a promising approach to HIV prevention.     

Reducing sexual transmission of HIV for injecting drug users: The challenge for counselling

Harm minimization approaches have been recommended to reduce the risks of transmission of HIV for injecting drug users by the elimination of sharing injecting equipment. The risks associated with the sexual behaviours of these individuals have been given less emphasis, and where considered have been in terms of the threat to non-drug partners and potential penetration of HIV infection into the general population. Data are presented from four survey studies conducted between 1985 and 1990 focusing on both drug-taking behaviours and sexual activities. These provide evidence for larger shifts, over this period, in injecting practices than in sexual behaviours. The risks associated with sexual activities for injecting drug users and their sexual partners are considered. It is concluded that counsellors have an important role to play in introducing a second phase of harm minimization that involves interventions to modify sexual behaviours and offers integrated services for injecting drug users and their families.     

exploring drug users' illness representations of hiv,hepatitis b and hepatitis c using repertory grids

Abstract

Hepatitis B and C viruses are more prevalent among injecting drug users than HIV. This study explored drug users' illness representations of hepatitis B and C using repertory grid methodology. Initially, nine drug users were presented with six elements including hepatitis B and C, and HIV. Constructs were elicited via the sequential form variation of the method of triads. Elements were rated on elicited constructs using a five-point scale, and analyzed using “Flexigrid”. In a second quantitative research stage, 52 drug users were presented with six elements and supplied constructs. Results of the first stage indicated participants were able to generate constructs relating to Leventhal et al.'s (1980) features of illness representations. Most constructs, however, were causal in nature. Participants perceived hepatitis B, C and HIV similarly along the causal component. This similarity on the causal component was largely replicated in the second research stage. Participants, however, distinguished HIV from hepatitis B and C along serious, cure and timeline features. Participants did not distinguish hepatitis B from hepatitis C. The implications of these results for health promotion are discussed.     

Specificity of Discrimination: Does It Matter From Whence It Comes?1

The negative effects of discrimination on those who are stigmatized are well documented. What is less clear, however, is whether the source of the discrimination has differential outcomes on the person being discriminated against. Survey results from 685 injecting drug users (IDUs) revealed that IDUs who experienced discrimination from healthcare workers had poorer physical health, whereas physical health was unrelated to experiences of discrimination by those outside the healthcare system (family, friends, and partners). In contrast, IDUs' mental health status was less sensitive to the source of discrimination. Discrimination by healthcare workers and by others outside the healthcare industry were both related to IDUs' mental health. Implications and limitations of this research are discussed.     

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.     

Using the Theory of Planned Behavior to Predict Intention to Use Condoms Among Male and Female Injecting Drug Users

This study tested the utility of the theory of planned behavior (TPB) for understanding and predicting condom use intentions among male and female injecting drug users (IDUs). Interviews were conducted with 405 male and 315 female sexually active IDUs. Participants indicated their intentions to use condoms with main and nonmain sexual partners as well as attitudes, social norms, partner norms, and perceived behavioral control relevant to condom use with each partner type. The TPB accounted for 36 to 48% of the variance in intentions to use condoms. Intentions were related to attitudes, regardless of partner type. Partner norms were related to intentions to use condoms with main partners (men and women) and nonmain partners (men only). Social norms did not predict intentions, regardless of partner type. Perceived behavioral control was related to intentions to use condoms with main partners (men and women) and nonmain partners (women only). The findings are interpreted in light of the roles of cooperation, intimacy, and concern about self-protection.     

My place,your place,and no place: Behavior settings as a risk factor for HIV-related injection practices of drug users in Baltimore,Maryland

Information is sparse on the social context of illicit drug injection behaviors and their relationship to HIV infection. This study examined relationships between injection settings, injecting with others, and HIV risk behaviors of sharing needles and not cleaning contaminated needles in a sample of 630 inner-city injecting drug users in Baltimore, MD. Through open-ended interviews, five primary settings of injection behavior were identified. These settings included one's own, friends' and mother's residence, shooting galleries, and semipublic areas. Most participants reported injecting in their own residence (92%) and friends' residence (86%) in the prior 6 months. In a multiple regression analysis, injecting at friends' residence, in shooting galleries, and in semipublic areas and frequency of injecting with others were significantly associated with frequency of sharing uncleaned needles, “slipping” (i.e., failure to disinfect shared needles), and not always cleaning used needles before injecting. Results suggest that interventions may benefit from targeting settings as well as behaviors to reduce the spread of HIV. This research was supported by grants DA04334, DA05911, DA06313, and DA08985 from the National Institute on Drug Abuse.     

Prediction of Needle Sharing Among Injection Drug Users1

The aim of the present study was to identify the psychosocial factors associated with the intention and behavior of not sharing used needles and syringes among 459 intravenous drug users (IDUs). The intention to not share used needles was positively associated with personal normative beliefs and self‐efficacy; it was negatively related to the proportion of injections with lending used needles and borrowing syringes from sexual partners. Borrowing used needles was negatively associated with intention whereas loaning syringes was positively related to a negative HIV test result. These results suggest that it is only when a direct personal exposure to HIV infection is possible (borrowing) that intention not to borrow is highlighted. Moreover, being HIV positive appears to reduce loaning used syringes.     

Development of the HIV/AIDS Stress Scale

Development of a self-report measure of stress specific to HIV/AIDS is needed to advance our understanding of the role of stress in adaptation to HIV/AIDS; hence, the aim of this study was the development of the HIV/AIDS Stress Scale. A total of 132 homosexual/bisexual men with HIV/AIDS were interviewed and completed the HIV/AIDS Stress Scale and measures of coping strategies, appraisal, social support and adjustment (global distress, depression, social adjustment, number of HIV symptoms, and subjective health status) at three time points. Thirty-nine primary caregivers were interviewed and completed measures of stress and adjustment. Exploratory factor analyses of the HIV/AIDS Stress Scale items revealed three factors: Social, Instrumental and Emotional/Existential Stress. Factors had adequate internal reliabilities and were stable over 12 months. Construct validation data are consistent with recent stress/coping research that links higher levels of stress with more HIV symptoms, reliance on emotion-focused coping, lower social support, poorer levels of adjustment and higher levels of caregiver stress. Results extend this research by revealing new differential relations between various stress dimensions and stress/coping variables. Convergent validation data suggest that the HIV/AIDS Stress Scale shares conceptual similarity with threat appraisal, and differs from controllability and challenge appraisals. The HIV/AIDS Stress Scale shows potential for the elucidation of the role of stress in coping and adaptation to HIV/AIDS and disease progression in both research and clinical applications.     

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.     

AIDS prevention for intravenous drug users in the community: Street-based education and risk behavior

Conducted a study of behavior change associated with a street-based AIDS education project targeted to intravenous (IV) drug users in San Francisco. Two cross-sections were sampled from drug detoxification clinics and street locations in 1986 (n = 438) and 1987 (n = 623). Significant increases were reported in the percentage of IV drug users who used bleach to decontaminate syringes, who did not share needles in past year, and in condom use. A significant reduction in an index of the number of needle-sharing partners was reported. Respondents ranked treatment program as most important source of AIDS information prior to implementation of the program, and ranked outreach workers as most important after implementation. Findings suggest that this community-based outreach program had at least some impact on knowledge about AIDS and may have led to reductions in behaviors known to transmit HIV.