Women injection drug users who have sex with women (WSW IDUs) constitute 20% to 30% of American women IDUs.1 Compared with other women IDUs, WSW IDUs have higher HIV prevalence and incidence rates and a greater likelihood of engaging in high-risk injection and sexual practices with men.1–16 Previous reports suggested that WSW IDUs may be particularly likely to engage in drug injection and sex with men who have sex with men (MSM)1,2,5,6,9,17–19 and to be subordinated and isolated within drug users’ social milieus and more generally.1,20,21 Historical and generational factors may have changed some relationships as a consequence of the HIV epidemic itself, however. Ethnographic data from New York City and Boston, Mass, suggest that many older MSM IDUs and WSW IDUs who injected drugs together may have died earlier in the epidemic, which might reduce the extent to which WSW IDUs currently engage in drug injection and sex with MSM. To further examine HIV risk among WSW IDUs, we compared social situations, injection and sexual networks, and behaviors of young WSW IDUs with those of other young women IDUs.

Background: Sharing of drug paraphernalia to prepare, measure and divide drugs for injection remains an important residual risk factor for hepatitis C and other blood-borne infections among injection drug users (IDUs) especially as sharing of syringes for injection decreases.Methods: We analyzed data from five U.S. cities to determine the prevalence and independent correlates of non-syringe paraphernalia-sharing (NSPS) and syringe-mediated drug-splitting (SMDS) among 15-30-year-old IDUs who reported not injecting with others' used syringes (receptive syringe-sharing, RSS).Results: NSPS was reported by 54% of IDUs who did not practice RSS and was independently associated (p < 0.05) with having 15 injection partners, injecting with sex partners or regular injection partners, injecting in shooting galleries, peers' sharing behaviors, lower self-efficacy for avoiding NSPS, and less knowledge of HIV and HCV transmission. SMDS was reported by 26% of IDUs who did not practice RSS, and was independently associated with having :5 injection partners, injecting in shooting galleries, and inversely associated with unknown HIV status.Conclusions: NSPS and SMDS were common among young adult IDUs. Increased efforts to prevent these risky practices should address social and environmental contexts of injection and incorporate knowledge and skills building, self-efficacy, and peer norms. (C) 2007 Elsevier Ireland Ltd. All rights reserved.

Objectives: This study examined risk factors for receptive syringe sharing (RSS) during illicit drug injection by persons 15-30 years old in five U.S. cities.Methods: Participants were recruited through street outreach and respondent-driven referrals in Baltimore, Chicago, Los Angeles, New York, and Seattle between May 2002 and January 2004. Surveys of drug use, sexual behaviors, and correlates were administered through audio computerassisted self-interviews at baseline and, for the subset of participants who enrolled in ail HIV/HCV prevention intervention trial, at 3-months and 6-months post-baseline. The proportions of injections involving RSS at baseline and at follow-up were used as outcomes in multivariate models that adjusted for intervention effects.Results: At baseline, 54% of 3128 participants reported RSS in the past 3 months. RSS decreased to 21% at 6-months post-baseline for the combined trial arms. Participants were more likely to report RSS if they perceived that their peers were not against RSS and if they injected with sex partners. Lower levels of perceived risk of infection with HIV (baseline, p <.001) or HCV (follow-up, to <.00 1) through RSS were also significant predictors of greater RSS.Conclusions: Perceived risks, peer influences, and type of injection partner were robust predictors of RSS. Perceived risks and peer influences are particularly amenable to intervention efforts that may prevent RSS in this age group. (C) 2007 Elsevier Ireland Ltd. All rights reserved.

Blood-borne pathogens such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV) are transmitted most commonly among injection drug users (IDUs) through the sharing of needles and syringes. Distributive syringe sharing (DSS) (i.e., passing on a used needle/syringe to another IDU) poses the potential risk of transmitting HIV and viral hepatitis to others. We studied the prevalence and correlates of DSS among IDUs enrolled in a randomized behavioral intervention trial designed to reduce behaviors associated with HIV and HCV transmission in five U.S. cities. Among 3129 IDUs ages 15-30 years who completed the baseline visit, 1432 (45.8%) engaged in DSS during the 3 months prior to baseline. Significant correlates of DSS were perception that peer norms condone needle sharing, frequent injection, not obtaining most syringes from needle exchange programs or pharmacies, injecting most frequently in shooting galleries and with sex partners, low perceived risk of HIV from sharing syringes, increased anxiety, low self-esteem, and having unprotected sex. Restricting to only those IDUs who reported not injecting with previously used syringes, similar independent correlates of DSS were found. These findings suggest that interventions to reduce ongoing transmission of blood-borne infections should focus on altering peer norms among networks of young IDUs.

BACKGROUND:New injection drug users (IDUs) are at high risk for blood-borne viral infections. Given U.S. policy to only fund proven-effective HIV prevention interventions, insights into conducting intervention trials among young IDUs are provided here by describing methods and participants' characteristics in the CIDUS III/DUIT study. METHODS:In 2002-2004, 15-30-year-old IDUs in Baltimore, Chicago, Los Angeles, New York, and Seattle were recruited through community outreach, advertising and coupon-based participant referrals. Baseline interviews assessed sociodemographics, injection, and sexual behaviors. Antibody tests for HIV and hepatitis A, B, and C viruses (HAV, HBV, and HCV) were conducted. IDUs who were HIV and HCV antibody negative at baseline were eligible to participate in a randomized controlled HIV/HCV prevention trial. Follow-up assessments were conducted 3 and 6 months post-intervention. Data were analyzed to identify participant differences at baseline by city, trial enrollment, and trial retention. RESULTS:Baseline assessments were completed by 3285 IDUs. Participants were mean age 23.8 years, 69% male, 64% White, 17% Hispanic, and 8% Black. Seroprevalence of HIV, HCV, HBV, and HAV antibodies were 2.9, 34.4, 22.4, and 19.3%, respectively. Of the 2062 (62.7%) baseline participants who were HIV and HCV antibody negative, 859 (41.7%) were randomized. At least one follow-up assessment was completed by 712 (83%) randomized participants. Contextual factors, primarily homelessness, were associated with lower enrollment and retention. CONCLUSIONS:Recruitment and retention of young-adult IDUs for complex intervention trials is complicated, yet feasible. Risk behaviors among participants enrolling in and completing the trial reflected those eligible to enroll.

AIMS:To examine the effect of a needle exchange program (NEP) on incidence of injection cessation and change in injection frequency; to explore predictors for injection cessation and change in injection frequency; and to assess whether injection quitters transitioned to non-injected drug use.DESIGN AND SETTING:Between 1997 and 2002, 901 injection drug users (IDUs) were recruited from an NEP program or an area with no NEP in Chicago, Illinois, interviewed for drug use behaviors, tested for HIV and followed for three annual visits. All participants were exposed to prevention services targeting HIV and drug abuse.MEASUREMENTS:Injection cessation was defined as no injection drug use since the last interview, and changes in the number of injections in a typical month were examined.FINDINGS:Sixteen per cent of study participants reported stopping injection for a median duration of 16 months, and most of them also ceased rather than initiated the use of non-injected drugs. Those who continued injecting reduced their injection frequency by 12% per year, on average. Independent predictors of injection cessation were infrequent injection at baseline, younger age and injecting with others. NEP use was not associated with injection cessation and change in injection frequency.CONCLUSION:These results did not support the hypothesis that NEP use influences the frequency of injection over time. One-sixth of IDUs stopped injection for more than 1 year, providing a substantial window for relapse prevention interventions.

PURPOSE:This study tested event-level associations between substance use and condom use, as well as potential covariates, among adolescents with substance use disorders (SUDs).METHODS:A total of 134 adolescents (age, 15-21 y), 72% with SUDs, participated in telephone diary data collection of sexual events over a 6-week period. Effects on condom use of event-level substance use, partner type, salience of costs associated with unprotected sex, and subject-level SUD and sensation-seeking were tested in random intercept logistic regression models. A total of 637 sexual events were available for analysis.RESULTS:Event-level alcohol and drug use as well as subject-level SUD and sensation-seeking were not associated with condom use in multivariate models. However, all other event-level measures were significant, including an interaction between partner type and salience of preventing acquired immune deficiency syndrome (AIDS). The importance of preventing AIDS was associated only with condom use with regular partners. Prevention of pregnancy was associated with condom use independent of partner type.CONCLUSIONS:As in other event-level studies, substance use was not related to condom use in our study. Novel results in our study showed that the salience of preventing negative outcomes is a significant predictor of condom use even in the context of event-level substance use and partner type. These results suggest that prevention efforts for substance-using youth should not focus on preventing substance use as a way to prevent unsafe sex, but should emphasize the potential costs of unsafe sex even with known partners.

This study examines changes in the multi-person use of drug injection paraphernalia during the mid-1990s, a time of increasing awareness of HIV transmission modes and availability of prevention programs. Beginning in 1994, 794 street-recruited injection drug users in Chicago were interviewed and followed at 6 and 12 months postbaseline. Random-effects, pattern-mixture logistic regression models were used to determine correlates of five injection-equipment sharing practices, while accounting for repeated measurement and study attrition. At baseline, 45.7% of participants reported receptive syringe sharing in the previous 6 months. Syringe-mediated sharing was reported by 28.7% of participants and the sharing of cookers (65.1%), cotton filters (55.7%), and rinse water (46.9%) was common. During follow-up, the proportion of all sharing behaviors decreased significantly, especially receptive syringe sharing. Participation in a syringe exchange program was associated with reductions in receptive syringe sharing and syringe-mediated sharing, but not the sharing of cookers.

Objectives: We examined the relation between childhood sexual abuse and injection drug use initiation among young adult injection drug users. Methods: We used mixed effect linear models to compare age at first injection among 2143 young injection drug users by first sexual abuse age categories. Results: The participants were predominantly male (63.3%) and White (52.8%). Mean age and age at first injection were 23.7 and 19.6 years, respectively; 307 participants (14.3%) reported childhood sexual abuse. After adjustment for gender, race/ethnicity, noninjection drug use before first injection drug use, and recruitment site, childhood sexual abuse was independently associated with younger age at first injection. Conclusions: Childhood sexual abuse was associated with earlier initiation of injection drug use. These data emphasize the need to integrate substance abuse prevention with postvictimization services for children and adolescents.

This study examines HIV risk practices associated with secondary needle exchange, obtaining needles from a needle exchange program (NEP) through others who attend in person. We analyzed data from NEP logs, a survey and HIV testing from 901 drug injectors who (a) always visited NEPs themselves to get needles (primary-only NEP users), (b) obtained at least some NEP needles by having others exchange for them (mixed/secondary NEP users), and (c) obtained no needles from an NEP. About 22% of 40,000 NEP visits involved secondary exchanges, and these accounted for over half of all needles exchanged. In multiple logistic regression analyses, primary-only needle exchange was significantly associated with lower levels of receptive needle sharing, backloading, sharing other injection equipment and lending used needles, and positively associated with obtaining drug treatment. Mixed/secondary needle exchange was associated with less receptive needle sharing and a greater likelihood of drug treatment. Secondary exchange facilitated HIV risk reduction but the salutary effects of NEPs were attenuated in mixed/secondary exchangers.

ObjectivesTo assess associations between needle exchange program (NEP) use and drug injection risk practices. MethodsBetween 1997–2000, injecting drug users (IDUs) in Chicago were recruited from NEPs and an area with no NEP, interviewed about risk practices, and counseled and tested for HIV. The risk practices of “regular NEP users” —those who obtained at least half of their needles from an NEP (n = 558) —were compared with those of IDUs who did not use an NEP (n = 175). ResultsIn multivariate analysis, regular NEP users, compared with NEP nonusers, were less likely to receptively share needles (adjusted odds ratio [AOR], 0.30; 95% CI, 0.19–0.46); lend used needles (AOR, 0.47; 95% CI, 0.31–0.71); share cookers (AOR, 0.39; 95% CI, 0.25–0.61), cottons (AOR, 0.48; 95% CI, 0.32–0.72), or water (AOR, 0.41; 95% CI, 0.27–0.63); or use a needle for >1 injection (0.15; 95% CI, 0.08–0.27). Among those who shared needles, regular NEP users were significantly more likely to do so for a smaller proportion of injections, with fewer partners and persons socially closer, and to have always bleached used needles before injecting. ConclusionsRegular NEP use is associated with less frequent and lower risk HIV injection risk practices.

Purpose of review Antisocial behaviour and mental illness in adulthood place a high social and financial burden on societies. Rapidly developing knowledge base about both, whether the natural history, overlap, or the increasingly promising findings of evidence based results from prevention, early and late intervention programmes, delivered to children and adolescents, in the context of family, community and institutions, can reduce the burden on adult services, and is the focus of this review.Recent findings Established and new longitudinal studies continue to enrich and inform the "What Works" literature, addressing how to target and deliver programmes and to better engage difficult to access children and families. A needs led, holistic approach is assisting in understanding the complex interplay between antisocial behaviour and mental illness in juveniles. Research on the impact of correctional institutionalization on vulnerable young people, impact of trauma on offending patterns and the importance of linking the institutional and community components of treatment programmes can assist practitioners in how best to deliver services. Treatment for young sexual abusers now recognises the differential presentation of abusive behaviour through childhood and adolescence. Substance misuse, its risks to the young person, and its influence on their offending remains a major challenge even with sophisticated treatment options such as multisystemic therapy. The approach to use of medication in childhood aggression is markedly different in the USA and UK and Europe. Recent research on personality development in adolescence and the trajectory into adult antisocial personality disorder, is not teasing out factors and processes that can be used constrictively in practice interventions for violence and aggression in young people. A developmental underpinning is now informing child and adolescent risk assessment tools.Summary The recent evidence base in the field of child and adolescent forensic mental health and juvenile justice is starting to make a real difference to clinical practice, pointing to practice that can offer multiple interventions at multiple points across the childhood years, and on into adult forensic practice.

This Study analyzed factors associated with utilization of needle exchange programs (NEPs) by Young injection drug users (IDUs). Between 1997-1999, 700 IDUs 18-30 years of age were surveyed in Chicago. The majority Of study participants (65%) had not used an NEP in the 6 months preceding baseline. Frequent NEP users were least likely to share needles (odds ratio [OR] = 0.32; 95% CI = 0.19-0.54) or other injection equipment (OR = 0.51; CI - 0.30-0.85), or to reuse their own needles (OR = 0.25, CI - 0.13-0.45), and were most likely to use condoms with steady sex partners (OR - 2.95; CI = 1.56-5.56). This study found that while frequent NEP use was associated with less risk behavior, Young IDUs used NEPs infrequently or not at all.

Designing studies to examine hepatitis C virus (HCV) transmission via the shared use of drug injection paraphernalia other than syringes is difficult because of saturation levels of HCV infection in most samples of injection drug users (IDUs). The authors measured the incidence of HCV infection in a large cohort of young IDUs from Chicago, Illinois, and determined the risk of HCV seroconversion associated with specific forms of sharing injection paraphernalia. From 1997 to 1999, serum samples obtained from 702 IDUs aged 18-30 years were screened for HCV antibodies; prevalence was 27%. Seronegative participants were tested for HCV antibodies at baseline, at 6 months, and at 12 months. During 290 person-years of follow-up, 29 participants seroconverted (incidence: 10.0/100 person-years). The adjusted relative hazard of seroconversion, controlling for demographic and drug-use covariates, was highest for sharing "cookers" (relative hazard = 4.1, 95% confidence interval: 1.4, 11.8), followed by sharing cotton filters (relative hazard = 2.4, 95% confidence interval: 1.1, 5.0). Risks associated with syringe-sharing and sharing of rinse water were elevated but not significant. After adjustment for syringe-sharing, sharing cookers remained the strongest predictor of seroconversion (relative hazard = 3.5, 95% confidence interval: 1.3, 9.9). The authors conclude that sharing of injection equipment other than syringes may be an important cause of HCV transmission between IDUs.

We compared injection-related risk practices between urban and suburban injection drug users (IDUs) in a large cross-sectional sample of young IDUs. From 1997 to 1999, we recruited 700 active IDUs aged 18 to 30 years in Chicago and its suburbs. A suburban residence was reported by 38% of participants. Participants were interviewed at four urban locations and screened for HIV and hepatitis C virus antibodies. Receptive sharing of syringes and other paraphernalia by urban and suburban IDUs in the preceding 6 months was compared using univariable and multivariable models. Sharing injection paraphernalia in the total sample was high, with 50% of participants reporting receptive syringe sharing and 70% reporting sharing cotton, cookers, and/or rinse water. After adjusting for demographic characteristics, injection settings, frequency, and duration of injection as well as ease of acquiring new syringes, suburban IDUs were significantly more likely than urban IDUs to share syringes (adjusted odds ratio = 1.7; 95% confidence interval: 1.1-2.5); however, the likelihood of sharing cotton, cookers, or rinse water was roughly equal. Despite overall higher risk profiles among suburban IDUs, HIV and hepatitis C prevalence levels were significantly lower than among urban participants. Current high levels of injection risk behaviors in suburban groups represent a potential for rapid dissemination of infection.

OBJECTIVES:To assess HIV prevalence, incidence, and associated risk factors among IDUs in Chicago. METHODS:Seven hundred ninety-four street-recruited IDUs ranging in age from 18 to 50 years, who were not in drug treatment at study enrollment, were interviewed and tested for HIV at baseline and at two follow-ups scheduled 6 and 12 months after baseline. Questionnaires assessed respondents' demographic characteristics, medical and drug treatment histories, drug use, and sexual practices. RESULTS:HIV seroprevalence at baseline was 18%. Logistic regression identified the following determinants of prevalent HIV infection: Puerto Rican ethnicity, homosexual or bisexual self-identification, injecting for 4 or more years, and having smoked crack cocaine in the past 6 months. Follow-up data were collected from 584 (73.6%) participants. Mean duration of follow-up was 16.5 months, indicating that most subjects had follow-up intervals longer than the scheduled 6 and 12 months. Seven HIV seroconversions were observed in 632 person years of risk, yielding an incidence rate of 1.1 per 100 person years of risk. Injection for 3 or less years was positively associated with HIV seroconversion. CONCLUSIONS:The findings provide evidence of a decline in HIV incidence among IDUs, though newer injectors remain at elevated risk for infection.