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Objective: To investigate rates and predictors of change in bone mineral density (BMD) in a cohort of aging men with or at risk for HIV infection., Design: A prospective cohort study among 230 HIV-infected and 159 HIV-uninfected men aged at least 49 years., Methods: Longitudinal analyses of annual change in BMD at the femoral neck, total hip, and lumbar spine., Results: At baseline, 46% of men had normal BMD, 42% had osteopenia, and 12% had osteoporosis. Of those men with normal BMD, 14% progressed to osteopenia and 86% continued to have normal BMD. Of the men initially with osteopenia, 12% progressed to osteoporosis and 83% continued to have osteopenia. Osteopenia incidence per 100 person-years at risk was 2.6 for HIV-uninfected men and 7.2 for HIV-infected men; osteoporosis incidence was 2.2 per 100 person-years at risk among men with osteopenia, regardless of HIV status. In multivariable analysis of annual change in BMD at the femoral neck, we found a significant interaction between heroin use and AIDS diagnosis, such that the greatest bone loss occurred with both AIDS and heroin use (adjusted predicted mean annual bone loss 0.0196 g/cm). Hepatitis C virus seropositivity was also associated with femoral neck bone loss (P = 0.04). The interaction between AIDS and heroin use also was associated with bone loss at the total hip, as was current methadone use (P < 0.01)., Conclusion: We found an association of heroin use and AIDS with BMD change, suggesting that heroin users with AIDS may be at particular risk for bone loss. more...

No adequate data exist on patterns of injection drug use (IDU) prevalence over time within racial/ethnic groups in U.S. geographic areas. The absence of such prevalence data limits our understanding of the causes and consequences of IDU and hampers planning efforts for IDU-related interventions. Here, we (1) describe a method of estimating IDU prevalence among non-Hispanic Black and non-Hispanic White adult residents of 95 large U.S. metropolitan statistical areas (MSAs) annually over an 11-year period (1992--2002); (2) validate the resulting prevalence estimates; and (3) document temporal trends in these prevalence estimates. IDU prevalence estimates for Black adults were calculated in several steps: we (1) created estimates of the proportion of injectors who were Black in each MSA and year by analyzing databases documenting injectors' encounters with the healthcare system; (2) multiplied the resulting proportions by previously calculated estimates of the total number of injectors in each MSA and year (Brady et al., 2008); (3) divided the result by the number of Black adults living in each MSA each year; and (4) validated the resulting estimates by correlating them cross-sectionally with theoretically related constructs (Black- and White-specific prevalences of drug-related mortality and of mortality from hepatitis C). We used parallel methods to estimate and validate White IDU prevalence. We analyzed trends in the resulting racial/ethnic-specific IDU prevalence estimates using measures of central tendency and hierarchical linear models (HLM). Black IDU prevalence declined from a median of 279 injectors per 10,000 adults in 1992 to 156 injectors per 10,000 adults in 2002. IDU prevalence for White adults remained relatively flat over time (median values ranged between 86 and 97 injectors per 10,000 adults). HLM analyses described similar trends and suggest that declines in Black IDU prevalence decelerated over time. Both sets of IDU estimates correlated cross-sectionally adequately with validators, suggesting that they have acceptable convergent validity (range for Black IDU prevalence validation: 0.27 < r < 0.61; range for White IDU prevalence: 0.38 < r < 0.80). These data give insight, for the first time, into IDU prevalence trends among Black adults and White adults in large U.S. MSAs. The decline seen here for Black adults may partially explain recent reductions in newly reported cases of IDU-related HIV evident in surveillance data on this population. Declining Black IDU prevalence may have been produced by (1) high AIDS-related mortality rates among Black injectors in the 1990s, rates lowered by the advent of HAART; (2) reduced IDU incidence among Black drug users; and/or (3) MSA-level social processes (e.g., diminishing residential segregation). The stability of IDU prevalence among White adults between 1992 and 2002 may be a function of lower AIDS-related mortality rates in this population; relative stability (and perhaps increases in some MSAs) in initiating IDU among White drug users; and social processes. Future research should investigate the extent to which these racial/ethnic-specific IDU prevalence trends (1) explain, and are explained by, recent trends in IDU-related health outcomes, and (2) are determined by MSA-level social processes. more...

This paper estimates the prevalence of current injection drug users (IDUs) in 96 large U.S. metropolitan statistical areas (MSAs) annually from 1992 to 2002. Multiplier/allocation methods were used to estimate the prevalence of injectors because confidentiality restrictions precluded the use of other commonly used estimation methods, such as capture-recapture. We first estimated the number of IDUs in the U.S. each year from 1992 to 2002 and then apportioned these estimates to MSAs using multiplier methods. Four different types of data indicating drug injection were used to allocate national annual totals to MSAs, creating four distinct series of estimates of the number of injectors in each MSA. Each series was smoothed over time; and the mean value of the four component estimates was taken as the best estimate of IDUs for that MSA and year (with the range of component estimates indicating the degree of uncertainty in the estimates). Annual cross-sectional correlations of the MSA-level IDU estimates with measures of unemployment, hepatitis C mortality prevalence, and poisoning mortality prevalence were used to validate our estimates. MSA-level IDU estimates correlated moderately well with validators, demonstrating adequate convergence validity. Overall, the number of IDUs per 10,000 persons aged 15-64 years varied from 30 to 348 across MSAs (mean 126.9, standard deviation 65.3, median 106.6, interquartile range 78-162) in 1992 and from 37 to 336 across MSAs (mean 110.6, standard deviation 57.7, median 96.1, interquartile range 67-134) in 2002. A multilevel model showed that overall, across the 96 MSAs, the number of injectors declined each year until 2000, after which the IDU prevalence began to increase. Despite the variation in component estimates and methodological and component data set limitations, these local IDU prevalence estimates may be used to assess: (1) predictors of change in IDU prevalence; (2) differing IDU trends between localities; (3) the adequacy of service delivery to IDUs; and (4) infectious disease dynamics among IDUs across time. more...

Aims: A prior study concluded that drug treatment coverage, defined as the percentage of injection drug users in drug treatment, varied from 1 percent to 39 percent (median 9 percent) in 96 metropolitan statistical areas (MSAs) in the United States. Here, we determine which metropolitan area characteristics are associated with drug treatment coverage., Methods: We conducted secondary analysis of official data, including the number of injection drug users in treatment and other variables, for 94 large US MSAs. We estimated the number of injection drug users in these metropolitan areas using previously described methods. We used lagged cross-sectional analyses where the independent variables, chosen on the basis of a Theory of Community Action, preceded the dependent variable (drug treatment coverage) in time. Predictors were determined using ordinary least squares multiple regression and confirmed with robust regression., Results: Independent predictors of higher drug treatment coverage for injectors were: presence of organisations that support treatment (unstandardized beta=1.64; 95 percent CI .59 to 2.69); education expenditures per capita in the MSA (unstandardized beta=.12; 95 percent CI -.34 to 2.69); lower percentage of drug users in treatment who are non-injection drug users (unstandardized beta=-0.18; 95 percent CI -0.24 to -0.12); higher percentage of the population who are non-Hispanic White (unstandardized beta=.14; 95 percent CI .08 to .20); lower per capita long-term debt of governments in the metropolitan area (unstandardized beta=-0.93; 95 percent CI -1.51 to -0.35)., Conclusions: In conditions of scarce treatment coverage for drug injectors, an indicator of epidemiologic need (the per capita extent of AIDS among injection drug users) does not predict treatment coverage, and competition for treatment slots by non-injectors may reduce injectors' access to treatment. Metropolitan finances limit treatment coverage. Political variables (racial structures, the presence of organisations that support drug treatment, and budget priorities) may be important determinants of treatment coverage for injectors. Although confidence in these results would be higher if we had used a longitudinal design, these results suggest that further research and action that address structural, political, and other barriers to treatment expansion are sorely needed. more...

Early acquisition of hepatitis C virus (HCV) infection appears to affect a substantial proportion of injection drug users (IDUs)--between 20 percent and 90 percent. Analysing the range of HCV prevalence estimates in new injectors may help identify factors that can be modified to reduce HCV transmission. The HCV Synthesis Project is a meta-analysis of studies of HCV epidemiology and prevention in drug users worldwide. In this preliminary analysis, we examined data from 127 studies of IDUs that reported HCV prevalence in relation to age or year since onset of drug injection, analysing heterogeneity and calculating summary statistics where appropriate. Six studies reported gender-specific HCV prevalence rates among young or new injectors; the group mean prevalence was 47 percent for men and 44 percent for women (NS). Group mean age for HCV-negatives was 24.7 years (range 24-28) and 26.1 years (range 21-31) for HCV-positives (n=8 studies). Data were examined from 13 studies that compared HCV prevalence among young injectors to older injectors using 5-year age categories; substantial variation was present within these categories such that measures of central tendency were not calculated. Similarly, among studies reporting HCV prevalence among IDUs in relation to 1-year intervals of duration of injection (<1 year, <2 years, and <3 years), considerable variability was observed. Notably, there were studies in each category that reported prevalence of 70 percent or higher among recent-onset drug injectors. Our findings confirm previous studies reporting high risk of acquiring HCV shortly after onset of injection; thus, HCV prevention programmes must emphasize methods to reach new injectors. Future research should (1) report data on time to infection in depth, (2) provide detailed information on study methodology, and (3) characterize the research setting with respect to underlying factors that affect injection practices and networks. This will permit synthesis of a greater number of studies and may lead to the identification of factors that impede HCV transmission. more...

Objective: To understand associations of punitive policies to the population prevalence of injection drug users and to HIV seroprevalence among injectors., Design and Methods: A lagged-cross-sectional analysis of metropolitan statistical area data. Estimates of drug injectors per capita and of HIV seroprevalence among injectors in 89 large US metropolitan areas were regressed on three measures of legal repressiveness (hard drug arrests per capita; police employees per capita; and corrections expenditures per capita) controlling for other metropolitan area characteristics., Results: No legal repressiveness measures were associated with injectors per capita; all three measures of legal repressiveness were positively associated with HIV prevalence among injectors., Conclusions: These findings suggest that legal repressiveness may have little deterrent effect on drug injection and may have a high cost in terms of HIV and perhaps other diseases among injectors and their partners--and that alternative methods of maintaining social order should be investigated. more...

Sexual relations between drug injectors (IDUs) and crack smokers (CS), and non-drug users are a major means of HIV spread to the broader population. However there is little literature describing community processes that regulate sexual and social partnerships among these groups. We describe these relationships in Bushwick, a low-income, mainly Latino neighbourhood in Brooklyn, NY. In this community, IDU and CS are heavily stigmatized, both by non-users and by some users. Known IDU/CS may find it harder to start and maintain social and sexual relationships, and to get jobs or support. Partially as a result of this stigma, IDU/CS attempt to 'keep it together' and hide either their drug use or its extent from other residents. Nevertheless, other residents believe, sometimes falsely, that they can distinguish users from nonusers. We describe some potential negative consequences of these beliefs and interactions, including their effects on risk for HIV and other sexually transmitted diseases. more...

This article estimates HIV prevalence rates among injection drug users (IDUs) in 95 large US metropolitan areas to facilitate social and policy analyses of HIV epidemics. HIV prevalence rates among IDUs in these metropolitan areas were calculated by taking the mean of two estimates: (1) estimates based on regression adjustments to Centers for Disease Control and Prevention (CDC) Voluntary HIV Counseling and Testing data and (2) estimates based on the ratio of the number of injectors living with HIV to the number of injectors living in the metropolitan area. The validity of the resulting estimates was assessed. HIV prevalence rates varied from 2 to 28% (median 5.9%; interquartile range 4.0-10.2%). These HIV prevalence rates correlated with similar estimates calculated for 1992 and with two theoretically related phenomena: laws against over-the-counter purchase of syringes and income inequality. Despite limitations in the accuracy of these estimates, they can be used for structural analyses of the correlates, predictors and consequences of HIV prevalence rates among drug injectors in metropolitan areas and for assessing and targeting the service needs for drug injectors. more...

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. more...

New entrants to methadone maintenance treatment programs (MMTP) have been reported to have different drug use patterns than re-admissions. This study assesses differences between 211 re-admissions and 128 new admissions to a NYC MMTP. Those new to MMTP were found to be less likely to have ever injected drugs, have used more types of drugs, and used heroin at higher frequencies in the 30 days prior to admission. Within the first three months of treatment, new admissions dropped out at a higher rate than the re-admissions (31% vs. 20%, p < 0.05). The most frequent reasons for dropout, for both groups, included "lost to contact" and incarceration. Further research on strategies to address polydrug use of MMTP admissions is needed. Efforts to identify concerns of new admissions early in treatment, and programs to continue drug treatment services to incarcerated clients, are indicated. more...