Respondents were predominantly male and non-Hispanic black. The mean age was 42 years, and this was consistent among gender and race/ethnicity categories. Overall, education achievement was relatively low (only 58% graduated from high school), and approximately half (47%) of all respondents had an annual income <$5000. Most were unemployed (95%) and had a history of incarceration (71%). Many had been homeless in the past year (36%). Most participants had known their HIV-positive status for >5 years (76%), and 6% of participants had been diagnosed for <2 years.
Most (79%) respondents reported use of noninjected stimulant drugs in the past 3 months, and 36% reported having been admitted to a hospital for substance abuse treatment in the past 6 months. Almost 80% reported a primary health care visit for HIV in the past 6 months.
Several significant bivariate correlates of lending needles/syringes were identified. Demographic and socioeconomic factors associated with risk included younger age, lower education level, less income, and homelessness in the past year. Lending needles/syringes was also associated with years since HIV diagnosis and injecting with >1 person in the past 3 months. Health care services correlates included having been admitted to the hospital for drug treatment (more likely to engage in risky behavior) and use of HAART (less likely to engage in risky behavior). Psychosocial factors associated with high-risk injecting practices were lower responsibility scores, lower perceived peer norms for safe drug use, lower empowerment scores, and more psychiatric symptoms.
At a time when many epidemiologists discuss that injection drug use is contributing less to HIV incidence in the United States2 and when behavioral scientists suggest that it is easier to change injection risk behaviors compared with sexual risk behaviors,35,36 the present study's findings are alarming. Almost one fifth (17.8%) of the 738 HIV-positive IDUs in this analysis self-reported having lent their needles/syringes to HIV-negative or unknown status injection partners. Sharing of paraphernalia was more common than lending needles/syringes, which is consistent with the findings of other studies of risk practices among IDUs.37,38 This difference in rates of needle lending compared with sharing of paraphernalia may reflect misunderstandings of the risks associated with the sharing of injection paraphernalia. More than half of study participants who engaged in these high-risk injecting practices reported that they did not know the HIV status of their injection partners. Previous research has reported that HIV-positive IDUs who engage in high-risk behaviors frequently assume that their injection and sex partners are also HIV-positive.39 Thirty-four percent of study participants report lending their needles/syringes to injection partners who they knew were HIV-negative, however. These data are of high concern and also deserve attention in that it is possible for HIV-positive IDUs to transmit drug-resistant HIV to their injection partners.40,41 Additionally, another concern is related to hepatitis C virus (HCV), because most HIV-positive IDUs are HCV-positive and HCV is much easier to transmit compared with HIV.42 HIV-positive IDUs who perceived peer norms that were supportive of safe drug use were less likely to engage in lending/sharing injection behaviors with their HIV-negative and unknown status partners. This is encouraging and supports the importance of conducting group, peer-based, and social network interventions with HIV-positive IDUs to emphasize safe injection practices and to help change peer norms. One of the foci for these interventions could be on increasing knowledge and teaching new skills related to the sharing of drug paraphernalia, including cookers, cottons, and rinse water. Previous research has shown that placing IDUs in the pro-social roles of peer educator or community outreach worker heightens and reinforces their awareness of their own risk behaviors, ultimately leading to decreases in sexual and drug risk behaviors.43,44 Intervention strategies addressing peer norms for safe drug use might also consider intervening with close friends and sexual partners of IDUs. Previous studies have shown that IDUs tend to engage in higher risk behaviors when their shooting partners are also sex partners or close friends.31,45
Having >1 injection partner was strongly associated with HIV-positive IDUs lending/sharing needles/syringes and paraphernalia with their HIV-negative and unknown status injection partners. This finding is consistent with those of previous studies showing that IDUs were more likely to engage in unsafe injection behaviors if they are members of large social networks of IDUs.45,46 Injecting with more people is a risk behavior in and of itself; therefore, it is not surprising that those who inject with more people are also less safe with regard to potential HIV transmission practices. Reducing the number of injecting partners is an important prevention message that should be conveyed to IDUs who are infected or at risk for HIV. Additionally, targeting HIV-positive IDUs who are in large and dense networks may be an effective strategy for prevention with HIV-positive IDUs vis-à-vis the importance of peer norms for safe drug use.
Psychiatric symptoms were significantly associated with risky behavior, which is consistent with previous studies showing psychiatric comorbidity to be associated with needle-sharing behaviors.47-51 The finding that psychiatric symptoms are related to risky behaviors with HIV-negative and unknown status partners underscores the fact that mental health should be evaluated and treated in HIV-positive persons.
One drug use and 2 background/demographic variables were associated with lending/sharing risk behaviors. First, IDU participants who were admitted to the hospital for drug treatment were more likely to engage in high-risk behaviors. Although it is important to recognize that we do not know the nature of the hospital-based treatment, it is possible that these individuals had the most severe drug abuse problems, and thus were more likely to engage in high-risk behaviors. This result suggests the importance of integrating HIV prevention programs for HIV-positive persons into drug treatment programs. Although approximately half of drug treatment programs offer HIV voluntary counseling and testing to their drug abuse clients,52 HIV-positive IDUs are often excluded from counseling because they are already HIV-positive and these programs may not offer more extensive prevention services for HIV-positive persons. Finally, consistent with previous studies, younger IDUs were more likely to engage in high-risk injecting behaviors16-18,53-55 and those with less than a high school education18 were more likely to engage in these injecting risk behaviors than other groups.
Several study limitations should be recognized. First, these data are from a convenience sample of HIV-positive IDUs recruited from clinic and community venues in 4 large urban areas; thus, generalizations to other IDUs in urban and rural areas or other countries should be made with caution. Using a multisite sample with multiple recruitment venues strengthens potential generalizability, however. Second, these data are based on self-report. Thus, the reporting of stigmatized behaviors such as lending needles/syringes with HIV-negative and unknown status injection partners may have been underreported. Also, the reports of injection drug use may be underreported because of socially desirable response biases. To diminish this concern, we used computerized data collection methods that have been shown to enhance reporting of sensitive risk behaviors among IDU samples.56 Nevertheless, it should be noted that any underreporting bias would suggest that the estimates of risk behavior reported in this study may be low. Finally, the analysis was cross-sectional; thus, time order could not be established. Strengths of this study were the large numbers of HIV-positive injectors recruited from 4 cities in the United States, the use of psychometric scales that performed well with the present sample, and the ability to focus on lending practices by HIV-positive IDUs with HIV-negative and unknown status partners.
Despite these limitations, the high levels of continued unsafe injection practices shown in this analysis suggest that intervention strategies are needed to address continued injection risk behaviors among HIV-positive IDUs. Intervention strategies should focus on not lending/sharing needles and paraphernalia with HIV-negative and unknown status partners and reducing the number of sharing partners. Within the counseling context, it would be important to recognize that lending needles/syringes is not only related to characteristics of the individual, but is influenced by their peer injectors and mental health characteristics. Additionally, intervention strategies addressing HIV prevention needs of HIV-positive IDUs should focus on sexual risks among IDUs; previously published analyses from the INSPIRE study showed that approximately one third of HIV-positive male IDUs and more than half of HIV-positive female IDUs reported having engaged in unprotected vaginal and/or anal sex with HIV-negative or unknown status opposite-gender partners.57,58 Finally, counseling and community-level intervention messages could try to build on Des Jarlais and colleagues' notion of informed altruism by emphasizing peer and societal norms related to safe injection drug use.29 An advantage of this approach is that it emphasizes the protection of family members and friends in addition to protecting oneself. This approach may be more appropriate in working with HIV-positive IDUs.
In summary, these findings demonstrate that there are considerable injection risk behaviors practiced by this sample of HIV-positive IDUs in 4 cities in the United States. These behaviors are of utmost concern because lending needles/syringes may transmit HIV and other blood-borne pathogens to HIV-negative and unknown status individuals. At a time when there is more concern about HIV transmission through sexual risk behaviors, it is important not to forget the need to continue intervention strategies that address injection risk behaviors with HIV-positive IDUs.
The INSPIRE Study Team includes the following people: Carl Latkin, Amy Knowlton, and Karin Tobin (Baltimore); Lisa Metsch, Eduardo Valverde, James Wilkinson, and Martina DeVarona (Miami); Mary Latka, Dave Vlahov, Phillip Coffin, Marc Gourevitch, Julia Arnsten, and Robert Gern (New York); Cynthia Gomez, Kelly Knight, Carol Dawson Rose, Starley Shade, and Sonja Mackenzie (San Francisco); David Purcell, Yuko Mizuno, Scott Santibanez, Richard Garfein, and Ann O'Leary (Centers for Disease Control and Prevention); and Lois Eldred and Kathleen Handley (Health Resources and Services Administration).
The authors acknowledge the following people for their contributions to this research: Susan Sherman, Roeina Marvin, Joanne Jenkins, Donny Gann, and Tonya Johnson (Baltimore); Clyde McCoy, Rob Malow, Wei Zhao, Lauren Gooden, Sam Comerford, Virginia Lo Cascio, Curtis Delford, Laurel Hall, Henry Boza, and Cheryl Riles (Miami); George Fesser, Victoria Frye, Carol Gerran, Laxmi Modali, and Diane Thornton (New York); Caryn Pelegrino, Barbara Garcia, Jeff Moore, Erin Rowley, Debra Allen, Dinah Iglesia-Usog, Gilda Mendez, Paula Lum, and Greg Austin (San Francisco); Gladys Ibanez, Hae-Young Kim, Toni McWhorter, Jan Moore, Lynn Paxton, and John Williamson (Centers for Disease Control and Prevention); and Lee Lam, Jeanne Urban, Stephen Soroka, Zilma Rey, Astrid Ortiz, Sheila Bashirian, Marjorie Hubbard, Karen Tao, Bharat Parekh, and Thomas Spira (Centers for Disease Control and Prevention Laboratory).
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