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.
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).
1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2004
, vol. 16. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2005.
2. Santibanez SS, Garfein RS, Swartzendruber A, et al. Update and overview of practical epidemiologic aspects of HIV
/AIDS among injection drug users in the United States. J Urban Health
3. Schoenbaum EE, Hartel D, Selwyn PA, et al. Risk factors for human immunodeficiency virus infection in intravenous drug users. N Engl J Med
4. Chaisson RE, Moss AR, Onishi R, et al. Human immunodeficiency virus infection in heterosexual intravenous drug users in San Francisco. Am J Public Health
5. Jose B, Friedman SR, Neaigus A, et al. Syringe-mediated drug-sharing (backloading): a new risk factor for HIV
among injecting drug users. AIDS
6. Samuels ME, Koop CE, Hartsock PI. Single-use syringes. N Engl J Med
7. Wiebel WW, Jimenez A, Johnson W, et al. Risk behavior and HIV
seroincidence among out-of-treatment injection drug users: a 4-year prospective study. J Acquir Immune Defic Syndr Hum Retrovirol
8. Vlahov D, Khabbaz RF, Cohn S, et al. Incidence and risk factors for human T-lymphotropic virus type II seroconversion among injecting drug users in Baltimore, Maryland, U.S.A. J Acquir Immune Defic Syndr Hum Retrovirol
9. Thorpe LE, Ouellet LJ, Hershow R, et al. Risk of hepatitis C virus infection among young adult injection drug users who share injection equipment. Am J Epidemiol
10. Hagan H, Thiede H, Weiss NS, et al. Sharing of drug preparation equipment as a risk factor for hepatitis C. Am J Public Health
11. Marmor M, Des Jarlais DC, Cohen H, et al. Risk factors for infection with human immunodeficiency virus among intravenous drug abusers in New York City. AIDS
12. Battjes RJ, Leukefeld CG, Pickens RW. Age at first injection and HIV
risk among intravenous drug users. Am J Drug Alcohol Abuse
13. Derogatis LR, Spencer PM. The Brief Symptom Inventory (BSI): Administration, Scoring, and Procedure Manual-1
. Baltimore, MD: John Wiley; 1982.
14. Gibson DR, Choi KH, Catania JA, et al. Psychosocial predictors of needle sharing among intravenous drug users. Int J Addict
15. Koester S, Booth RE, Zhang Y. The prevalence of additional injection-related HIV
risk behaviors among injection drug users. J Acquir Immune Defic Syndr Hum Retrovirol
16. Nelson KE, Vlahov D, Solomon L, et al. Temporal trends of incident human immunodeficiency virus infection in a cohort of injecting drug users in Baltimore, MD. Arch Intern Med
17. Nicolosi A, Leite ML, Musicco M, et al. Parenteral and sexual transmission of human immunodeficiency virus in intravenous drug users: a study of seroconversion. The Northern Italian Seronegative Drug Addicts (NISDA) study. Am J Epidemiol
18. Strathdee SA, Galai N, Safaiean M, et al. Sex differences in risk factors for HIV
seroconversion among injection drug users: a 10-year perspective. Arch Intern Med
19. Nelson KE, Galai N, Safaeian M, et al. Temporal trends in the incidence of human immunodeficiency virus infection and risk behavior among injection drug users in Baltimore, Maryland, 1988-1998. Am J Epidemiol
20. Avants SK, Warburton LA, Hawkins KA, et al. Continuation of high-risk behavior by HIV
-positive drug users. Treatment implications. J Subst Abuse Treat
21. Brogly SB, Bruneau J, Lamothe F, et al. HIV
-positive notification and behavior changes in Montreal injection drug users. AIDS Educ Prev
22. Deren S, Beardsley M, Tortu S, et al. HIV
serostatus and changes in risk behaviors among drug injectors and crack users. AIDS Behav
23. Diaz T, Chu SY, Weinstein B, et al. Injection and syringe sharing among HIV
-infected injection drug users: implications for prevention of HIV
transmission. Supplement to HIV
/AIDS Surveillance Group. J Acquir Immune Defic Syndr Hum Retrovirol
. 1998;18(Suppl 1):S76-S81.
24. Metsch LR, McCoy CB, Lai S, et al. Continuing risk behaviors among HIV
chronic drug users in Miami, Florida. AIDS Behav
25. Kwiatkowski CF, Booth RE. HIV
drug users and unprotected sex. AIDS Behav
26. Inciardi JA, Surratt HL, Kurtz SP, et al. The effect of serostatus on HIV
risk behaviour change among women sex workers in Miami, Florida. AIDS Care
. 2005;17(Suppl 1):S88-S101.
27. Dolezal C, Meyer-Bahlburg HF, Liu X, et al. Longitudinal changes in sexual risk behavior among HIV
+ and HIV
-male injecting drug users. Am J Drug Alcohol Abuse
28. McGowan JP, Shah SS, Ganea CE, et al. Risk behavior for transmission of human immunodeficiency virus (HIV
) among HIV
individuals in an urban setting. Clin Infect Dis
29. Des Jarlais DC, Perlis T, Arasteh K, et al. “Informed altruism” and “partner restriction” in the reduction of HIV
infection in injecting drug users entering detoxification treatment in New York City, 1990-2001. J Acquir Immune Defic Syndr
30. Purcell DW, Metsch LR, Latka M, et al. Interventions for seropositive
injectors-research and evaluation: an integrated behavioral intervention with HIV
-positive injection drug users to address medical care, adherence, and risk reduction. J Acquir Immune Defic Syndr
. 2004;37(Suppl 2):S110-S118.
31. Unger JB, Kipke MD, De Rosa CJ, et al. Needle-sharing among young IV drug users and their social network members: the influence of the injection partner's characteristics on HIV
risk behavior. Addict Behav
32. Wolitski RJ, Bailey CJ, O'Leary A, et al. Self-perceived responsibility of HIV
men who have sex with men for preventing HIV
transmission. AIDS Behav
33. Rogers ES, Chamberlin J, Ellison ML, et al. A consumer-constructed scale to measure empowerment among users of mental health services. Psychiatr Serv
34. Hosmer DW, Lemeshow S. Applied Logistic Regression
. 2nd ed. New York: Wiley-Interscience; 2000.
35. Coyle SL, Needle RH, Normand J. Outreach-based HIV
prevention for injecting drug users: a review of published outcome data. Public Health Rep
. 1998;113(Suppl 1):19-30.
36. Semaan S, Des Jarlais DC, Malow R. Behavior change and health-related interventions for heterosexual risk reduction among drug users. Subst Use Misuse
37. Koester S, Glanz J, Baron A. Drug sharing among heroin networks: implications for HIV
and hepatitis B and C prevention. AIDS Behav
38. McCoy CB, Metsch LR, Chitwood DD, et al. Parenteral transmission of HIV
among injection drug users: assessing the frequency of multiperson use of needles, syringes, cookers, cotton, and water. J Acquir Immune Defic Syndr Hum Retrovirol
. 1998;18(Suppl 1):S25-S29.
39. Fisher JD, Misovich SJ, Kimble DL, et al. Dynamics of HIV
risk behavior in HIV
-infected injection drug users. AIDS Behav
40. Kozal MJ, Amico KR, Chiarella J, et al. HIV
drug resistance and HIV
transmission risk behaviors among active injection drug users. J Acquir Immune Defic Syndr
41. Sethi AK, Celentano DD, Gange SJ, et al. High-risk behavior and potential transmission of drug-resistant HIV
among injection drug users. J Acquir Immune Defic Syndr
42. Sulkowski MS, Thomas DL. Epidemiology and natural history of hepatitis C virus infection in injection drug users: implications for treatment. Clin Infect Dis
. 2005;40(Suppl 5):S263-S269.
43. Latkin CA, Sherman S, Knowlton A. HIV
prevention among drug users: outcome of a network-oriented peer outreach intervention. Health Psychol
44. Friedman SR, Maslow C, Bolyard M, et al. Urging others to be healthy: “intravention” by injection drug users as a community prevention goal. AIDS Educ Prev
45. Valente TW, Vlahov D. Selective risk taking among needle exchange participants: implications for supplemental interventions. Am J Public Health
46. Latkin C, Mandell W, Oziemkowska M, et al. Using social network analysis to study patterns of drug use among urban drug users at high risk for HIV
/AIDS. Drug Alcohol Depend
47. Lundgren LM, Amodeo M, Chassler D. Mental health status, drug treatment use, and needle sharing among injection drug users. AIDS Educ Prev
48. Johnson ME, Yep MJ, Brems C, et al. Relationship among gender, depression, and needle sharing in a sample of injection drug users. Psychol Addict Behav
49. Mandell W, Kim J, Latkin C, et al. Depressive symptoms, drug network, and their synergistic effect on needle-sharing behavior among street injection drug users. Am J Drug Alcohol Abuse
50. Hawkins WE, Latkin C, Mandel W, et al. Do actions speak louder than words? Perceived peer influences on needle sharing and cleaning in a sample of injection drug users. AIDS Educ Prev
51. Metzger D, Woody G, De Philippis D, et al. Risk factors for needle sharing among methadone-treated patients. Am J Psychiatry
52. Brown LS Jr, Kritz SA, Goldsmith RJ, et al. Characteristics of substance abuse treatment programs providing services for HIV
/AIDS, hepatitis C virus infection, and sexually transmitted infections: The National Drug Abuse Treatment Clinical Trials Network. J Subst Abuse Treat
53. Lum PJ, Sears C, Guydish J. Injection risk behavior
among women syringe exchangers in San Francisco. Subst Use Misuse
54. Bogart LM, Kral AH, Scott A, et al. Sexual risk among injection drug users recruited from syringe exchange programs in California. Sex Transm Dis
55. Deren S, Kang SY, Colon HM, et al. HIV
incidence among high-risk Puerto Rican drug users: a comparison of East Harlem, New York, and Bayamon, Puerto Rico. J Acquir Immune Defic Syndr
56. Des Jarlais DC, Paone D, Milliken J, et al. Audio-computer interviewing to measure risk behaviour for HIV
among injecting drug users: a quasi-randomised trial. Lancet
57. Latka MH, Metsch LR, Mizuno Y, et al. Unprotected sex among HIV
-positive injection drug-using women and their serodiscordant male partners: role of personal and partnership influences. J Acquir Immune Defic Syndr
58. Purcell DW, Mizuno Y, Metsch LR, et al. Unprotected sexual behavior among heterosexual HIV
-positive injection drug using men: associations by partner type and partner serostatus. J Urban Health