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.

EDITOR: The pharmacologic treatment of the behavioral and psychological symptoms of dementia (BPSD) has been affected by the Food and Drug Administration's black-box warning about the use of atypical antipsychotics (AAs) in dementia 1 Kuehn BM FDA warns antipsychotic drugs may be risky for elderly. JAMA. 2005; 293: 2462 Crossref PubMed Scopus (3) Google Scholar and by the results of the Clinical Antipsychotic Trials of Intervention Effectiveness–Alzheimer Disease (CATIE–AD) study. 2 Schneider LS Tariot PN Dagerman KS et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease. N Engl J Med. 2006; 355: 1525-1538 Crossref PubMed Scopus (966) Google Scholar The Food and Drug Administration warning has identified an increased risk of all-cause mortality among patients with dementia who are treated with AAs. Although the CATIE–AD study did find minimal efficacy of AAs in dementia (26%–32%) compared with placebo (22%), the effectiveness of drug did not differ from placebo when rates of discontinuance of medication (due to side effects or perceived ineffectiveness) were considered.

We analyzed data from 6341 injection drug users (IDUs) entering detoxification or methadone maintenance treatment in New York City between 1990 and 2004 to test the hypothesis that alcohol use and intoxication is associated with increased HIV sexual risk behaviors. Two types of associations were assessed: (1) a global association (i.e., the relationship between HIV sexual risk behaviors during the 6 months prior to the interview and at-risk drinking in that period, defined as more than 14 drinks per week for males or 7 drinks per week for females), and (2) an event-specific association (i.e., the relationship between HIV sexual risk behaviors during the most recent sex episode and alcohol intoxication during that episode). Sexual risk behaviors included multiple sex partners and engaging in unprotected sex. After adjusting for the effects of other variables, at-risk-drinkers were more likely to report multiple sex partners and engaging in unprotected sex with casual sex partners (both global associations). IDUs who reported both they and their casual partners were intoxicated during the most recent sex episode were more likely to engage in unprotected sex (an event-specific association). We also observed two significant interactions. Among IDUs who did not inject cocaine, moderate-drinkers were more likely to report multiple partners. Among self-reported HIV seropositive IDUs, when both primary partners were intoxicated during the most recent sex episode they were more likely to engage in unprotected sex. These observations indicate both global and event-specific associations of alcohol and HIV sexual-risk behaviors.

Background A number of studies suggest females may be more likely to engage in injection and sex risk behavior than males. Most data on gender differences come from industrialized countries, so data are needed in developing countries to determine how well gender differences generalize to these understudied regions. Methods Between 1999 and 2003, 2512 male and 672 female current injection drug users (IDUs) were surveyed in ten sites in developing countries around the world (Nairobi, Beijing, Hanoi, Kharkiv, Minsk, St. Petersburg, Bogotá, Gran Rosario, Rio, and Santos). The survey included a variety of questions about demographics, injecting practices and sexual behavior. Results Females were more likely to engage in risk behaviors in the context of a sexual relationship with a primary partner while males were more likely to engage in risk behaviors in the context of close friendships and casual sexual relationships. After controlling for injection frequency, and years injecting, these gender differences were fairly consistent across sites. Conclusion Gender differences in risk depend on the relational contexts in which risk behaviors occur. The fact that female and male risk behavior often occurs in different relational contexts suggests that different kinds of prevention interventions which are sensitive to these contexts may be necessary.

AIMS:To characterize heroin and cocaine users in New York City who have changed from injection to non-injection drug administration and to identify factors associated with long-term non-injection use.DESIGN:Two cross-sectional studies of heroin and cocaine users in New York City.SETTINGS AND PARTICIPANTS:New admissions were recruited at drug abuse treatment programs (2000-04) and respondent-driven sampling was used to recruit drug users from the community (2004). Both injecting and non-injecting drug users participated in each study. 'Former injectors' were defined operationally as people who had used heroin and/or cocaine in the 6 months prior to the interview and who had injected illicit drugs in the past, but whose most recent injection was more than 6 months before the study interview. 'Current' injectors were defined as people who had injected heroin and/or cocaine in the 6 months prior to the interview.MEASUREMENTS:A structured interview on drug use history was administered, and a serum sample was collected and tested for the human immunodeficiency virus (HIV).FINDINGS:A total of 104 former injectors was recruited for the drug abuse treatment program study, and 229 current injectors were recruited for the community recruitment study; 160 former injectors and 1731 current injectors were recruited from the drug abuse treatment study. Compared with the current injectors, former injectors were older and more likely to be African American. The former injectors reported long intervals since their most recent injection, a mean of 8 years in the drug abuse treatment program study and a mean of 12 years in the community recruitment study. The most common reasons for stopping injection drug use included concerns about health, social stigmatization and self-image, and preference for intranasal use as a route of drug administration. The results were highly consistent across the two studies.CONCLUSIONS:The transition from injection to non-injection use appears to be relatively stable behavior change for many former injectors, who report a decade or more without injecting. Developing a greater understanding of the transition from injection to stable non-injection drug use may provide insights into the natural histories of drug use and addiction.

Syringe exchange programs (SEPs) provide free sterile syringes in exchange for used syringes to reduce transmission of bloodborne pathogens among injection-drug users (IDUs). SEPs in the United States began as a way to prevent the spread of human immunodeficiency virus (HIV) and other bloodborne infections such as hepatitis B and hepatitis C. The National Institute on Drug Abuse recommends that persons who continue to inject drugs use a new, sterile syringe for each injection. Monitoring syringe exchange activity is an important part of assessing HIV prevention measures in the United States. As of November 2007, a total of 185 SEPs were operating in 36 states, the District of Columbia (DC), and Puerto Rico (North American Syringe Exchange Network [NASEN], unpublished data, 2007). This report summarizes a survey of SEP activities in the United States during 2005 and compares the findings with previous SEP surveys (Beth Israel Medical Center [BIMC], unpublished data, 2000 and 2004). The findings indicated an increase in overall funding for SEPs, including an increase in public funding, and a stabilization in both the number of SEPs operating and the number of syringes exchanged since 2004. This report also documents an expansion of services offered by SEPs, a trend that resulted from an increase in state and local funding. These expanded services are helping protect IDUs and their communities from the spread of bloodborne pathogens and are providing access to health services for a population at high risk. Monitoring of syringe exchange activity should continue.

Background Successful cross-national research requires methods that are both standardized across sites and adaptable to local conditions. We report on the development and implementation of the methodology underlying the survey component of the WHO Drug Injection Study Phase II – a multi-site study of risk behavior and HIV seroprevalence among Injecting Drug Users (IDUs). Methods Standardized operational guidelines were developed by the Survey Coordinating Center in collaboration with the WHO Project Officer and participating site Investigators. Throughout the duration of the study, survey implementation at the local level was monitored by the Coordinating Center. Surveys were conducted in 12 different cities. Prior rapid assessment conducted in 10 cities provided insight into local context and guided survey implementation. Where possible, subjects were recruited both from drug abuse treatment centers and via street outreach. While emphasis was on IDUs, non-injectors were also recruited in cities with substantial non-injecting use of injectable drugs. A structured interview and HIV counseling/testing were administered. Results Over 5,000 subjects were recruited. Subjects were recruited from both drug treatment and street outreach in 10 cities. Non-injectors were recruited in nine cities. Prior rapid assessment identified suitable recruitment areas, reduced drug users' distrust of survey staff, and revealed site-specific risk behaviors. Centralized survey coordination facilitated local questionnaire modification within a core structure, standardized data collection protocols, uniform database structure, and cross-site analyses. Major site-specific problems included: questionnaire translation difficulties; locating affordable HIV-testing facilities; recruitment from drug treatment due to limited/selective treatment infrastructure; access to specific sub-groups of drug users in the community, particularly females or higher income groups; security problems for users and interviewers, hostility from local drug dealers; and interference by local service providers. Conclusion Rapid assessment proved invaluable in paving the way for the survey. Central coordination of data collection is crucial. While fully standardized methods may be a research ideal, local circumstances may require substantial adaptation of the methods to achieve meaningful local representation. Allowance for understanding of local context may increase rather than decrease the generalizability of the data.

Objective: To compare HIV prevalence among injecting and non-injecting heroin and cocaine users in New York City. As HIV is efficiently transmitted through the sharing of drug-injecting equipment, HIV infection has historically been higher among injecting drug users.Design: Two separate cross-sectional surveys, both with HIV counseling and testing and drug use and HIV risk behavior questionnaires.Methods: Injecting and non-injecting heroin and cocaine users recruited at detoxification and methadone maintenance treatment from 2001-2004 (n =2121) and recruited through respondent-driven sampling from a research storefront in 2004 (n=448).Results: In both studies, HIV prevalence was nearly identical among current injectors (injected in the last 6 months) and heroin and cocaine users who had never injected: 13% [95% confidence interval (CI),12-15%] among current injectors and 12% (95% Cl, 9-16%) among never-injectors in the drug treatment program study, and 15% (95% Cl, 11-19%) among current injectors and 17% (95% Cl, 12-21%) among never injectors in the respondent driven sampling storefront study. The 95% CIs overlapped in all gender and race/ethnicity subgroup comparisons of HIV prevalence in both studies.Conclusions: The very large HIV epidemic among drug users in New York City appears to be entering a new phase, in which sexual transmission is of increasing importance. Additional prevention programs are needed to address this transition. (c) 2007 Lippincott Williams & Wilkins.

OBJECTIVES:We sought to estimate HIV incidence among injection drug users (IDUs) in New York City from 1990 to 2002 to assess the impact of an expansion of syringe exchange services. Syringe exchange increased greatly during this period, from 250,000 to 3,000,000 syringes exchanged annually.METHODS:Serum samples were obtained from serial cross-sectional surveys of 3,651 IDUs. HIV-positive samples were tested with the Serologic Test Algorithm for Recent HIV Seroconversion (STARHS) assay to identify recent HIV infections and to estimate HIV incidence. Consistency with other incidence studies was used to assess strengths and limitations of STARHS.RESULTS:HIV incidence declined from 3.55/100 person-years at risk (PYAR) from 1990-1992, to 2.63/100 PYAR from 1993-1995, to 1.05/100 PYAR from 1996-1998, and to 0.77/100 PYAR from 1999-2002 (P<.001). There was a very strong negative linear relationship (r= -.99, P<.005) between the annual numbers of syringes exchanged and estimated HIV incidence. These results were highly consistent with a large number of shorter incidence studies among IDUs conducted during the time period.CONCLUSIONS:STARHS testing of samples from large serial cross-sectional surveys can provide important data for the assessment of community-level HIV prevention.

Objective:To assess trends in HIV, hepatitis C virus (HCV) and HIV/HCV infection among injecting drug users (IDU) from 1990 to 2001 in New York City. The 1990–2001 time period included a very large expansion of syringe exchange in New York City, from 250 000 to 3 000 000 syringes exchanged annually. Methods:Cross-sectional seroprevalence surveys of IDU entering drug abuse treatment in New York City, with sample sizes for HCV of 72 in 1990–1991 and 412 in 2000–2001. A structured risk behavior questionnaire was administered, and HIV and HCV testing were conducted. HCV testing was performed on de-linked stored serum samples. Results:Over the 1990–2001 period, HIV prevalence declined from 54 to 13%. HCV prevalence declined from 80 to 59% among HIV-seronegative individuals, and from 90 to 63% overall. The estimated HCV incidence in 2000–2001 among new injectors was 18 per 100 person-years at risk. Conclusions:The large-scale expansion of syringe exchange was temporally associated with large reductions in both HIV and HCV prevalence. The prevalence and incidence of HCV, however, still remain at high levels among IDU in New York City.

Objectives. We evaluated the World Health Organization’s rapid assessment and response (RAR) method of assessing injection drug use and its associated health problems, focusing on knowledge gain, capacity building, and whether RAR leads to the development of interventions reducing the health effects of injection drug use. Methods. Data were derived from RAR studies conducted in Beijing, China; Bogotá, Colombia; Greater Rosario, Argentina; Hanoi, Vietnam; Kharkiv, Ukraine; Minsk, Belarus; Nairobi, Kenya; Penang, Malaysia; St. Petersburg, Russia; and Tehran, Iran. Results. Substantial gains in knowledge and response capacity were reported at all of the study sites. Before RAR initiation, prevention and intervention programs had been absent or inadequate at most of the sites. The RARs resulted in many new or modified interventions; 7 sites reported 24 health-related interventions that were subsequently developed and influenced by the RARs. Conclusions. RARs, which require relatively little external funding, appear to be effective in linking assessment to development of appropriate interventions. The present results add to the evidence that rapid assessment is an important public health tool.

OBJECTIVE:To assess recent developments in the HIV epidemic in injecting drug users (IDUs) in New York City. With >50,000 cases of AIDS in IDUs, New York has experienced the largest HIV/AIDS epidemic in IDUs of any city in the world. METHODS:Serial cross-sectional surveys conducted continuously from 1990 to 2001 of IDUs entering the Beth Israel Medical Center (BIMC) drug detoxification program in New York City. HIV serostatus, use of prevention services, and risk behaviors were measured. Individuals were permitted to participate multiple times in the surveys but not more than once in any year. RESULTS:Two thousand eight hundred eighty-seven individuals contributed 3100 observations from 1990 to 2001. There was a substantial and consistent decline in the prevalence of HIV infection among IDUs entering the BIMC detoxification program, from 54% (165/304) in 1991 to 13% (39/303) in 2001 (P < 0.0001). The decline was highly linear, with r2 = 0.92 and a slope of -3.7% in seroprevalence per year. The decline occurred for both males and females, both short and long-term IDUs, and the three largest racial/ethnic subgroups (all P < 0.001 by Cochran-Armitage testing). Use of HIV prevention services increased substantially, particularly syringe exchange and voluntary HIV counseling and testing. General reductions in injection risk behaviors occurred, but substantial numbers of IDUs continued to engage in both receptive and distributive syringe sharing. Two conditional types of risk reduction not currently recommended by health authorities were reported: "informed altruism," in which persons who knew that they were HIV seropositive reduced transmission behavior, and "partner restriction," in which persons who shared needles and syringes primarily confined this sharing within small social networks. CONCLUSIONS:HIV infection continues to decline in this population of IDUs in New York City, suggesting the possibility of bringing very high prevalence epidemics under control. Risk elimination may not be required; rather, multiple forms of risk reduction may be effective in reducing HIV transmission within a local population of IDUs.

This article estimates the population prevalence of current injection drug users (IDUs) in 96 large US metropolitan areas to facilitate structural analyses of its predictors and sequelae and assesses the extent to which drug abuse treatment and human immunodeficiency virus (HIV) counseling and testing are made available to drug injectors in each metropolitan area. We estimated the total number of current IDUs in the United States and then allocated the large metropolitan area total among large metropolitan areas using four different multiplier methods. Mean values were used as best estimates, and their validity and limitations were assessed. Prevalence of drug injectors per 10,000 population varied from 19 to 173 (median 60; interquartile range 42–87). Proportions of drug injectors in treatment varied from 1.0% to 39.3% (median 8.6%); and the ratio of HIV counseling and testing events to the estimated number of IDUs varied from 0.013 to 0.285 (median 0.082). Despite limitations in the accuracy of these estimates, they can be used for structural analyses of the correlates and predictors of the population density of drug injectors in metropolitan areas and for assessing the extent of service delivery to drug injectors. Although service provision levels varied considerably, few if any metropolitan areas seemed to be providing adequate levels of services.

Cohort studies of young (aged 18-30 years) injecting drug users recruited in 1997-1999 in the Harlem and Lower East Side areas of New York City, New York, were used to assess the incidence of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). The authors found that HIV incidence was low at both sites: 0.8/100 person-years at the Harlem site and 0/100 person-years at the Lower East Side site. In contrast, HBV incidence was moderate (12.2/100 person-years) at the Harlem site and high (30.7/100 person-years) at the Lower East Side site. Similarly, HCV incidence was moderate (9.3/100 person-years) at the Harlem site and high (34.0/100 person-years) at the Lower East Side site. Results show that high rates of HBV and HCV transmission do not imply high rates of HIV transmission, even within an area of high HIV seroprevalence.

Objective: To assess HIV risk behaviour among participants in syringe exchanges in five Central/Eastern European cities: Prague (Czech Republic), Budapest (Hungary), Skopje (Former Yugoslavian Republic of Macedonia), Krakow (Poland) and Poltava (Ukraine), and five Russian cities: Nizhniy Novgorod, Pskov, Rostov-Na-Donu, St. Petersburg, and Volgograd. Design: Cross-sectional survey with questions on injection risk behaviours for the 30 days prior to first use of the syringe exchange programme and for the 30 days prior to interview (while using the syringe exchange programme). Methods: Respondents were recruited from participants of the syringe exchanges. Structured questionnaires covering drug use and HIV risk behaviour were administered by trained interviewers. Results: 1671 respondents were interviewed across the ten programmes. Participants in the programmes tended to be young and relatively recent initiates into drug injection. Relatively low percentages of participants reported receptive syringe sharing (‘injecting with needles and syringes used by others’) in the past 30 days, from 1 to 29% across the ten programmes. These represented statistically significant reductions from the percentages of respondents reporting receptive syringe sharing in the 30 days prior to first use of the syringe exchange—from 7 to 47%. Conclusions: IDUs participating in the exchanges appear to be responding very positively in reducing sharing of needles and syringes. Syringe exchange and other HIV prevention programmes for injecting drug users (IDUs) in this geographic region should be expanded rapidly.

This study assessed trends in HIV seroprevalence and needle-sharing behaviors among Puerto Rican injection drug users (IDUs) in Puerto Rico and New York. Data from two studies of IDUs conducted from 1992 through 1995 and 1998 through 1999 in Bayamón, Puerto Rico, and East Harlem, New York, were examined to assess trends over this period. Separate analyses were conducted for IDUs who were current crack smokers. Significant decreasing trends in seroprevalence were found among IDUs in the New York and Puerto Rico samples (p <.001). Significant decreasing trends in receptive and distributive needle sharing were found in the New York sample, and a significant decline in receptive sharing was found in the Puerto Rico sample. Overall, higher levels of needle-sharing behaviors were reported in Puerto Rico compared with New York. Decreasing trends in needle sharing and seroprevalence in both communities are an encouraging finding. Ongoing epidemiologic studies to monitor the epidemic and continued prevention efforts to help maintain or further these declines are needed, particularly to address the higher rates of needle sharing in Puerto Rico.

OBJECTIVES:This study sought to assess relations of laws prohibiting over-the-counter syringe sales (anti-OTC laws) to population prevalence of injection drug users and HIV prevalence or incidence among 96 US metropolitan areas.METHODS:A cross-sectional analysis was used.RESULTS:Metropolitan areas with anti-OTC laws had a higher mean HIV prevalence (13.8% vs 6.7%) than other metropolitan areas (pseudo-P < .001). In 83 metropolitan areas with HIV prevalence of less than 20%, anti-OTC laws were associated with HIV incidence rates of 1% or greater (pseudo-P < .001). Population proportions of injection drug users did not vary by presence of anti-OTC laws.CONCLUSIONS:Anti-OTC laws are not associated with lower population proportions of injection drug users. Laws restricting syringe access are associated with HIV transmission and should be repealed.

OBJECTIVES:This study assessed trends in HIV risk behaviors among injection drug users in New York City from 1990 to 1997.METHODS:Injection drug users were recruited continuously from a large drug detoxification treatment program (N = 2588) and a research storefront located in a high-drug-use area (N = 2701). Informed consent was obtained, and a trained interviewer administered a structured interview covering sociodemographics, drug use history, HIV risk behavior, and participation in syringe exchange.RESULTS:Trends were assessed for 5 risk behaviors in the 6-month period before the interview. The 3 injection risk behaviors declined significantly over time at each site (all P < .01). When data were pooled across sites, all 5 risk behaviors declined significantly over time (all P < .01). Participation in syringe exchange programs and in HIV counseling and testing increased greatly from 1990 to 1997.CONCLUSIONS:The continuing risk reduction among injection drug users indicates a "declining phase" in the large HIV epidemic in New York City. HIV prevention programs appear to be making an important contribution to the declining phase.