Injection Drug Users In Baltimore Research Articles

Physical and Sexual Intimate Partner Violence and Psychological Distress Among Injection Drug Users in Baltimore

Substance use and intimate partner violence (IPV) are both associated with psychological distress. This study examines the association between IPV victimization and psychological distress among peo...

Associations of Circulating Soluble Tumor Necrosis Factor-α Receptors 1 and 2 with Interleukin-6 Levels in an Aging Cohort of Injection Drug Users with or at High Risk for HIV Infection.

Chronic inflammation marked by elevated interleukin (IL)-6, soluble tumor necrosis factor (TNF)-α receptor (sTNFR)-1, and sTNFR-2 levels may play a detrimental role in aging and HIV infection. This study aimed to evaluate the relationships of circulating IL-6 with sTNFR-1 and sTNFR-2 levels in an aging cohort of injection drug users (IDUs) with or at high risk for HIV infection. The AIDS Linked to the Intravenous Experience (ALIVE) study is a community-recruited, prospective observational study of former and current IDUs in Baltimore, Maryland. Serum IL-6, sTNFR-1, and sTNFR-2 levels were measured using standard ELISA. Multivariate linear regression analysis was employed, adjusting for age, sex, HIV status, injection drug use, comorbidities, as well as HIV viral load, CD4 T cell counts, and antiretroviral therapy where appropriate. The analysis included 1,178 participants (316 HIV positive and 862 HIV negative). In the adjusted model, sTNFR-1 and sTNFR-2 were individually associated with IL-6 (regression coefficient: 0.877 and 0.556, respectively, for all participants; 0.607 and 0.407 for HIV positives; and 0.999 and 0.628 for HIV negatives, all p < 0.0001). In the model combining sTNFR-1 and sTNFR-2, the associations for sTNFR-1 remained significant (0.693 for all participants, p < 0.0001; 0.417 for HIV positives, p < 0.05; and 0.840 for HIV negatives), while those for sTNFR-2 were no longer significant. sTNFR-1 and sTNFR-2 were positively associated with IL-6 in ALIVE participants. These findings provide initial insight into the in vivo relationship between TNF-α activation and IL-6 and a basis for further investigations into potential mechanisms underlying chronic inflammation in aging and HIV infection.

A Brief Screening Tool to Assess the Risk of Contracting HIV Infection Among Active Injection Drug Users.

To incorporate preexposure prophylaxis and other biomedical or intensive behavioral interventions into the care of injection drug users (IDUs), health care providers need validated, rapid, risk screening tools for identifying persons at highest risk of incident HIV infection. To develop and validate a brief screening tool for assessing the risk of contracting HIV (ARCH), we included behavioral and HIV test data from 1904 initially HIV-uninfected men and women enrolled and followed in the AIDS Linked to the Intravenous Experience prospective cohort study between 1988 and 2008. Using logistic regression analyses with generalized estimating equations, we identified significant predictors of incident HIV infection, then rescaled and summed their regression coefficients to create a risk score. The final logistic regression model included age, engagement in a methadone maintenance program, and a composite injection risk score obtained by counting the number of the following 5 behaviors reported during the past 6 months: injection of heroin, injection of cocaine, sharing a cooker, sharing needles, or visiting a shooting gallery. The area under the receiver operating characteristic curve was 0.720; possible scores on the index ranged from 0 to 100 and a score 46 or greater had a sensitivity of 86.2% and a specificity of 42.5%, appropriate for a screening tool. We developed an easy to administer 7-question screening tool with a cutoff that is predictive of incident HIV infection in a large prospective cohort of IDUs in Baltimore. The ARCH-IDUs screening tool can be used to prioritize persons who are injecting illicit drugs for consideration of preexposure prophylaxis and other intensive HIV prevention efforts.

The role of neighborhoods in shaping perceived norms: An exploration of neighborhood disorder and norms among injection drug users in Baltimore, MD

A large literature suggests that social norms contribute to HIV and substance use related behaviors. Less attention has been given to neighborhood factors that may contribute to the development of norms about risky behaviors. We examined the cross-sectional associations between perceptions of one’s neighborhood and norms of perceived prevalence of, and peer support for sex exchange and risky injection behaviors. The sample consisted of 719 people who reported injecting heroin and cocaine and did not move in the past 6 months in Baltimore, MD. Living in a neighborhood with disorder was associated with believing that others exchanged sex, practiced risky injection behaviors (descriptive norms) and approved of risky injection behavior (injunctive norms).

High rates of abscesses and chronic wounds in community-recruited injection drug users and associated risk factors.

Abscesses and chronic wounds are common among injection drug users (IDUs) though chronic wounds have been understudied. We assessed the risk factors associated with both acute and chronic wounds within a community-based population of IDUs frequenting the Baltimore City Needle Exchange Program (BNEP). We performed a cross-sectional study of BNEP clients aged 18 years or more who completed an in-person survey regarding active or prior wounds including abscesses (duration <8 weeks) and chronic wounds (duration ≥8 weeks), injection practices, and skin care. Factors associated with wounds were analyzed using univariate and multivariate logistic regressions. Of the 152 participants, 63.2% were men, 49.3% were white, 44.7% were African American, 34.9% had any type of current wound, 17.8% had an active abscess, and 19.7% had a current chronic wound. Abscesses were more common in women (odds ratio [OR], 2.56; 95% confidence interval [CI], 1.10-5.97) and those reporting skin-popping (OR, 5.38; 95% CI, 1.85-15.67). In a multivariate model, risk factors for an abscess included injecting with a family member/partner (adjusted OR [AOR], 4.06; 95% CI, 0.99-16.58). In a multivariable analysis of current chronic wounds, cleaning skin with alcohol before injection was protective (AOR, 0.061; 95% CI, 0.0064-0.58). Abscesses and chronic wounds were prevalent among a sample of IDUs in Baltimore. Abscesses were associated with injection practices, and chronic wounds seemed linked to varying skin and tool cleaning practices. There is a pressing need for wound-related education and treatment efforts among IDUs who are at greatest risk for skin-related morbidity.

HIV Risk, Health, and Social Characteristics of Sexual Minority Female Injection Drug Users in Baltimore.

Female injection drug users (IDU) who report sex with women are at increased risk for HIV and social instability, but it is important to assess whether these disparities also exist according to sexual minority identity rather than behaviorally defined categories. Within a sample of current IDU in Baltimore, about 17% of female study participants (n=307) identified as gay/lesbian/bisexual. In controlled models, sexual minorities were three times as likely to report sex exchange behavior and four times as likely to report a recent STI. Injection risk did not differ significantly, but sexual minority women reported higher prevalence of socio-economic instability, negative health indicators, and fewer network financial, material, and health support resources. There is a need to identify and address socio-economic marginalization, social support, and health issues among female IDUs who identify as lesbian or bisexual.

Putting risk compensation to rest

Putting risk compensation to rest

Smoking, HIV Status, and HIV Risk Behaviors in a Respondent-Driven Sample of Injection Drug Users in Baltimore, Maryland: The BeSure Study

Tobacco use is the largest preventable cause of death in the United States. Associations between cigarette smoking and HIV risk behaviors were examined among 669 injection drug users (IDU) in the 2006 wave of the National HIV Behavioral Surveillance System in Baltimore, Maryland, using respondent-driven sampling. The adjusted prevalence of smoking among IDU was 92.1%, with 32.7% smoking < 1 pack of cigarettes per day (light smoking) and 59.3% smoking ≥ 1 packs per day (heavy smoking). Self-reported HIV prevalence decreased as smoking frequency increased (p = 0.001). In multivariate analysis, heavy smokers were more likely to report painkiller use and binge drinking and less likely to report anal sex or health care use in the past year than light smokers. Results suggest that health care use mediates the relationship between heavy smoking and self-reported HIV. Integrating smoking cessation with HIV prevention services could address unmet health needs in IDU.

Association between obstructive lung disease and markers of HIV infection in a high-risk cohort

BackgroundEvidence suggests an association between HIV infection and the presence of obstructive lung disease (OLD). However, the associations between specific markers of HIV infection and OLD remain unclear. A study...

Incarceration Predicts Virologic Failure for HIV-Infected Injection Drug Users Receiving Antiretroviral Therapy

Incarceration may lead to interruptions in antiretroviral therapy (ART) for persons receiving treatment for human immunodeficiency virus (HIV) infection. We assessed whether incarceration and subsequent release were associated with virologic failure for injection drug users (IDUs) who were previously successfully treated with ART. ALIVE is a prospective, community-based cohort study of IDUs in Baltimore, Maryland. IDUs receiving ART during 1998-2009 who successfully achieved an HIV RNA level below the limit of detection (<400 copies/mL) were followed up for development of virologic failure at the subsequent semiannual study visit. Logistic regression with generalized estimating equations was used to assess whether incarceration was independently associated with virologic failure. Of 437 HIV-infected IDUs who achieved undetectable HIV RNA for at least one study visit, 69% were male, 95% were African-American, and 40% reported at least one incarceration during follow-up. Virologic failure occurred at 26.3% of visits after a median of 6 months since achieving undetectable HIV RNA. In multivariate analysis accounting for demographic characteristics, drug use, and HIV disease stage, brief incarceration was strongly associated with virologic failure (adjusted odds ratio, 7.7; 95% confidence interval, 3.0-19.7), although incarceration lasting >30 days was not (odds ratio, 1.4; 95% confidence interval, .8-2.6). Among IDUs achieving viral suppression while receiving ART, virologic failure occurred with high frequency and was strongly associated with brief incarceration. Efforts should be made to ensure continuity of care both during and after incarceration to improve treatment outcomes and prevent viral resistance in this vulnerable population.

Lung Cancer Incidence and Mortality Among HIV-Infected and HIV-Uninfected Injection Drug Users

To examine the impact of HIV on lung cancer incidence and survival. : Prospective study of 2495 HIV-infected and HIV-uninfected injection drug users in Baltimore, MD. Cancer data were obtained from the Maryland Cancer Registry. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for lung cancer in 2 strata of packs of cigarettes smoked per day by HIV serostatus, and for mortality by HIV serostatus. HIV-infected participants had twice the risk (HR = 2.3; 95% CI: 1.1 to 5.1) of lung cancer. There was no evidence of an interaction between HIV and packs of cigarettes smoked per day (P interaction = 0.18). Compared with participants who smoked <1.43 packs per day, among HIV-uninfected individuals lung cancer risk was 6 times greater (HR = 5.9; 95% CI: 2.1 to 17) and among HIV-infected individuals lung cancer risk was doubled (HR = 2.1; 95% CI: 0.63 to 6.8) in persons who smoked ≥1.43 per day. Additionally, HIV was associated with 4 times the risk of death (HR = 3.8; 95% CI: 0.92 to 15) in lung cancer cases. HIV was associated with increased risk of lung cancer, after adjusting for smoking. However, no evidence was observed for synergistic effects of HIV and smoking. Further, HIV was associated with poorer lung cancer survival after accounting for cancer stage.

The STEP into Action study: a peer‐based, personal risk network‐focused HIV prevention intervention with injection drug users in Baltimore, Maryland

To assess the effectiveness of a peer-based, personal risk network-focused HIV prevention intervention to (i) train injection drug users (IDUs) to reduce injection and sex risk behaviors, (ii) conduct outreach to behaviorally risky individuals in their personal social networks [called risk network members (RNM)], and (iii) reduce RNM HIV risk behaviors. Randomized controlled trial with prospective data collection at 6, 12 and 18 months. Intervention condition consisted of five group sessions, one individual session and one session with Index and the RNM. This study was conducted in Baltimore, Maryland from March 2004 to March 2006. (i) Index participants were aged ≥ 18 years and self-reported injection drug use in the prior 6 months and (ii) their RNM who were aged ≥ 18 years and drug users or sex partners of Index. Outcomes included: (i) injection risk based on sharing needles, cookers and cotton for injection and drug splitting, (ii) sex risk based on number of sex partners, condom use and exchanging sex and (iii) Index HIV outreach behaviors. A total of 227 Index participants recruited 336 RNM. Retention of Index at 18-month follow-up exceeded 85%. Findings suggest that the experimental condition was efficacious at 18 months in reducing Index participant injection risk [odds ratio (OR) = 0.38; 95% confidence interval (CI) = 0.18-0.77), drug-splitting risk (OR = 0.46; 95% CI = 0.25-0.88) and sex risk among Index (OR = 0.53; 95% CI = 0.34-0.86). Significant intervention effect on increased condom use among female RNM was observed (OR = 0.34; 95% CI = 0.18-0.62). Training active IDU to promote HIV prevention with behaviorally risky individuals in their networks is feasible, efficacious and sustainable.

Temporal Trends in Highly Active Antiretroviral Therapy Initiation among Injection Drug Users in Baltimore, Maryland, 1996–2008

We characterized temporal trends in highly active antiretroviral therapy (HAART) initiation (1996-2008) among treatment-eligible persons in a community-based cohort of current and former injection drug users (IDUs) in Baltimore, Maryland. The AIDS Linked to the IntraVenous Experience (ALIVE) cohort has been observing human immunodeficiency virus (HIV)-positive IDUs since 1988. HAART eligibility was defined as the first visit after 1 January 1996 at which the patient's CD4(+) cell count was <350 cells/microL. Temporal trends and predictors of HAART initiation were examined using chi(2) tests for trend and lognormal survival models. The median age of 582 HAART-eligible IDUs was 41 years; 75% of the subjects were male, 97% were African American, and 60% were active IDUs. Of these 582 individuals, 345 initiated HAART over 1803 person-years (19.2 subjects per 100 person-years; 95% confidence interval, 17.2-21.3 subjects per 100 person-years); there was no statistically significant temporal trend in HAART initiation. Independent predictors of delayed initiation included heavy injection drug use; having a prior AIDS diagnosis, having a lower CD4(+) cell count, having a usual source of care, and having health insurance were predictors of more-rapid initiation. The delay between eligibility and initiation decreased among those who became eligible most recently (2003-2007), compared with those in earlier periods (1996-2002); however, a substantial number of patients who became eligible in recent years either initiated HAART after a substantial delay or did not initiate HAART at all. We failed to observe substantial improvement in HAART initiation among current and former IDUs over a 12-year period; heavy use of injection drugs remains the major barrier to HAART initiation and to consistent HIV care. The fact that many IDUs initiate HAART after a significant delay or do not initiate it at all raises concern that disparities in HIV care for IDUs remain at a time of simplified antiretroviral regimens and increasing adoption of earlier treatment.

Perceived Serosorting of Injection Paraphernalia Sharing Networks among Injection Drug users in Baltimore, MD

We examined perceived serosorting of injection paraphernalia sharing networks among a sample of 572 injection drug users (IDUs). There was evidence for serosorting of high-risk injection behaviors among HIV-negative IDUs, as 94% of HIV-negative IDUs shared injection paraphernalia exclusively with perceived HIV-negative networks. However, 82% of HIV-positive IDUs shared injection paraphernalia with perceived HIV-negative networks. The findings indicate a potential risk of rapid HIV transmission. Future prevention efforts targeting IDUs should address the limitation of serosorting, and focus on preventing injection paraphernalia sharing regardless of potential sharing networks' perceived HIV status.

The association between planning abilities and sharing injection drug use equipment among injection drug users in Baltimore, MD

Injection drug use continues to be a significant public health problem due to the association with HIV, Hepatitis C, and other infectious diseases. Harm reduction programmes aim to reduce sharing of injection equipment among injection drug users (IDUs). This study explored the association between performance on the Tower of London (TOL), a cognitive measure of planning ability, and the sharing of injection equipment among current IDUs. Data from 225 IDUs from the Baltimore NEURO-Study were used. Logistic regression analyses indicated that performance on the Total Moves Score of the TOL moderated the association between frequency of injection drug use and sharing of injection drug use equipment within the past 6 months. Findings suggest that impaired planning ability moderates the association between frequency of injection use and risky injection practices. Executive functioning abilities are potentially useful constructs to consider when developing harm reduction strategies.

Nonstructured Treatment Interruptions Among Injection Drug Users in Baltimore, MD

We characterized patterns of highly active antiretroviral therapy (HAART) use and predictors of nonstructured treatment interruptions (NTIs) among injection drug users (IDUs) in Baltimore, MD. Three hundred thirty-five IDUs who initiated HAART from 1996 to 2006 were studied. NTIs were defined as any subsequent 6-month interval where HAART was not reported. Predictors of the first NTI and subsequent restart of HAART were examined using Cox regression. Two hundred sixty (78%) reported > or =1 NTI. Of 215 with > or =1 follow-up visit after the NTI, 44 (20%) never restarted HAART, 62 (29%) restarted and remained on HAART, and 109 (51%) reported multiple NTIs. NTIs were less likely among those who initiated HAART in later calendar years and had a recent outpatient visit and more likely among women, persons with detectable HIV RNA at the prior visit, and those who reported injecting daily. Among those with NTIs, interuptions occurred earlier in persons who were younger, who did not have a prior AIDS diagnosis, and who were actively injecting; NTIs lasted longer in persons who had higher HIV RNA levels, in persons who were incarcerated, and in persons drinking alcohol. A recent outpatient visit and not actively injecting were associated with restarting HAART. NTIs were common in this population and occurred most frequently in the setting of active drug use and disruption of health care. Effective linkages between primary care for HIV and substance abuse treatment may improve HAART outcomes in this population.

The association between planning abilities and sharing injection drug use equipment among injection drug users in Baltimore, MD

The association between planning abilities and sharing injection drug use equipment among injection drug users in Baltimore, MD

Factors related to correctional facility incarceration among active injection drug users in Baltimore, MD

Aim We investigated the moderating effect of impulse control on the association between drug use and incarceration among active injection drug users (IDU). Methods The study sample consisted of 282 IDUs aged 15–50 years from the Baltimore metropolitan region who reported injection drug use within the past 6 months and indicated that heroin or speedball was their drug of choice. Impulse control was measured using commission error standardized scores from the Test of Variables of Attention (TOVA). Incarceration was obtained using self-reported lifetime history of incarceration in correctional facilities. Results Findings indicated that impulse control moderated the association between years of injection drug use and incarceration in correctional facilities adjusting for ethnicity, gender, estimated pre-morbid intelligence, and age of first injection use. Specifically, among individuals who were intact in impulse control, four or more years of injection drug use was associated with incarceration (AOR = 4.97, 95% CI: 2.02–12.23). This finding was not observed among individuals with impaired impulse control (AOR = 0.57, 95% CI: 0.10–3.23). Furthermore, impulse control moderated the association between regular cocaine use and incarceration. Among individuals who had a history of cocaine use, individuals with low impulse control but not impaired were more likely to have reported time in a correctional facility (AOR = 6.28, 95% CI: 1.68-23.60). There was no association among individuals with impaired or intact impulse control. Conclusion Results highlight the importance of considering cognitive measures of impulse control in addressing negative outcomes associated with drug use.

Effect of Micronutrients and Iron Supplementation on Hemoglobin, Iron Status, and Plasma Hepatitis C and HIV RNA Levels in Female Injection Drug Users

Iron deficiency is common among female injection drug users, but it is unclear whether iron supplementation can reduce anemia and improve iron status without increasing plasma hepatitis C virus (HCV) or HIV RNA levels. We conducted a phase 3, double-blind, randomized, controlled clinical trial of daily micronutrients with 18 mg of iron (iron group) versus micronutrients without iron (control group) for 12 months among hepatitis C-positive female injection drug users in Baltimore, Maryland. The main outcome measures were hemoglobin, markers of iron status, plasma HCV RNA, plasma HIV RNA, and liver enzymes at 6 and 12 months of follow-up. Four hundred fifty-eight women (320 HIV-negative and 138 HIV-positive) enrolled in the trial. There were no significant differences in the proportion of women with anemia, ferritin<30 ng/mL, log10 plasma HCV RNA, or log10 plasma HIV RNA between treatment groups at enrollment. The proportion with anemia in the iron and control groups, respectively, was 20.7% versus 31.3% (P=0.026) at 6 months and 26.2% versus 30.4% (P=0.5) at 12 months; with ferritin<30 ng/mL, the proportion was 29.2% versus 55.5% (P<0.0001) at 6 months and 26.2% versus 46.9% (P=0.0018) at 12 months. In the iron and control groups, respectively, mean log10 plasma HCV RNA (IU/mL) was 5.2 versus 5.2 (P=0.86) at 6 months and 5.4 versus 5.3 (P=0.6) at 12 months. Among HIV-positive subjects, mean log10 plasma RNA (copies/mL) in the iron and placebo groups, respectively, was 3.8 versus 3.7 (P=0.75) at 6 months and 3.7 versus 4.1 (P=0.19) at 12 months. There were no significant differences in liver enzyme levels between the treatment groups at enrollment, 6 months, and 12 months. A daily micronutrient supplement with iron can reduce anemia and improve iron status in female injection drug users without increasing plasma HCV or HIV RNA levels or altering liver enzymes.

Methods to recruit and retain a cohort of young-adult injection drug users for the Third Collaborative Injection Drug Users Study/Drug Users Intervention Trial (CIDUS III/DUIT)

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.