Lloyd A Goldsamt

Abstract

Background: Surveillance studies have noted intravenous injection of promethazine hydrochloride (PHC) among populations that use heroin in south and southeast Asia. However, little is known about onset and initiation of PHC use and its relationship to habitual heroin use. Methods: As part of a longitudinal study of heroin initiation, a sample of 179 new heroin users, aged 15-27 years, were interviewed between October 2005 and December 2006 in Hanoi, Vietnam. Cox proportional hazard regression analysis was used to characterize age at promethazine initiation and its association with relevant covariates. Results: 76% reported lifetime use of PHC. Mean age of PHC initiation was 21.3 years, on average 6 months following onset of heroin injection. In multivariate analysis, lifetime use of diazepam [HR = 1.69 (1.17, 2.44); p-value = .01] and injecting heroin for more than 1.58 years [HR = 1.46 (1.04, 2.06); p-value = .03] were associated with PHC initiation. Conclusion: Intravenous injection of PHC is a relatively common practice among young injection heroin users in Hanoi, Vietnam who use it on a situational basis to substitute for heroin (when heroin is not available or when heroin is too costly) or to augment the effects of an inadequate heroin dosing (delaying onset of heroin withdraw). Existing drug prevention strategies in Vietnam are focused primarily on heroin and most new heroin users initiate PHC use without prior knowledge of its high risk for serious vein damage. Future research is needed on the PHC use among heroin users, including long-term medical consequences of PHC exposure.

Abstract

HCV infection continues to spread at an alarming rate among IDU populations. The available evidence suggests that HCV is acquired relatively quickly following onset of injection. However, there are few prospective studies of HCV acquisition, particularly among IDU populations in resource-poor settings. A sample of young male heroin injectors with recent onset of injection (<4 years) was recruited in Hanoi, Vietnam for a prospective assessment of the early course of injection (n=179). Both behavioral and biological assessments (including detailed retrospective assessment of injection initiation) were conducted at baseline and repeated at 6-month intervals for a period of 16 months. Variables associated with HCV infection (p value<0.05) in bivariate analyses were considered for inclusion in logistic regression models to identify risk factors independently associated with HCV infection. HCV incidence was calculated by using the incidence density approach and was expressed in terms of person-years of observation. The baseline of prevalence of HCV was 46%. HCV significantly increased in relation to time since first injection, from 30% in subjects with ≤10 months of injection risk to 70% in subjects with ≥30 months injection risk (p value=0.0005). In multivariate logistic regression analysis, increasing age, incarceration in a drug detention facility (OR=2.54; 95%CI 1.05, 6.15), and time since first injection remained significantly associated with HCV infection. Use of injection as primary mode of administration (OR=2.56; 95%CI 0.98, 6.69) achieved marginal significance. After 16 months of follow-up, the incidence rate of HCV was 23.35 per 100 person-years and the mean time between first injection and first positive HCV test was 1.2 years. HCV is acquired much more rapidly among new injector populations than previously recognized, demonstrating the need for early behavioral intervention among new heroin-user populations. Particularly critical are interventions that target new heroin user populations, including interventions that improve understanding of viral transmission dynamics, that promote alternative strategies for drug sharing, and that delay initiation of injection.

Abstract

Background: Preventing the onset of injecting drug use is an important public health objective yet there is little understanding of the process that leads to injection initiation. This paper draws extensively on narrative data to describe how injection initiation is influenced by social environment. We examine how watching other people inject can habitualise non-injectors to administering drugs with a needle and consider the process by which the stigma of injecting is replaced with curiosity. Method: In-depth interviews (n = 54) were conducted as part of a 2-year longitudinal study examining the behaviours of new injecting drug users. Results: Among our sample, injection initiation was the result of a dynamic process during which administering drugs with a needle became acceptable or even appealing. Most often, this occurred as a result of spending time with current injectors in a social context and the majority of this study's participants were given their first shot by a friend or sexual partner. Initiates could be tenacious in their efforts to acquire an injection trainer and findings suggest that once injecting had been introduced to a drug-using network, it was likely to spread throughout the group. Conclusion: Injection initiation should be viewed as a communicable process. New injectors are unlikely to have experienced the negative effects of injecting and may facilitate the initiation of their drug-using friends. Prevention messages should therefore aim to find innovative ways of targeting beginning injectors and present a realistic appraisal of the long-term consequences of injecting. Interventionists should also work with current injectors to develop strategies to refuse requests from non-injectors for their help to initiate.

Abstract

The present study describes complex drug and sexual risk in a group of male sex workers (n = 79) who were recruited in the context of a larger study of young heroin users in Hanoi, Vietnam (n = 1270). Male sex workers were significantly more likely than male non-sex workers to be migrants (P < 0.001) and to have unstable housing (P < 0.001), to have lifetime exposure to marijuana (P < 0.001), 3,4 methylenedioxymethamphetamine (MDMA, ecstasy) (P < 0.01), amphetamines (P < 0.05), cocaine (P < 0.01) and morphine (P < 0.001). Male sex workers are more likely to currently use MDMA (P < 0.05), amphetamines (P < 0.001), morphine (P < 0.05) and to 'smoke' as their most frequent mode of heroin administration (P < 0.01). Male sex workers are more likely to have both male and female concurrent sex partners (P < 0.001), to have a history of sexual victimisation (P < 0.001), to have had more than three different sex partners in the past 30 days (P < 0.001), and to have had partners who injected drugs before sex (P < 0.001) or who used drugs during sex (P < 0.01). In their last sexual encounter with a client partner, approximately one-third (31.1%) reported having had receptive anal sex. In nearly three-quarters of these exchanges (71.4%), no condom was used. Similarly, in their last sexual encounter with a client partner, 42.2% reported having had insertive anal sex and in nearly half (47.4%) of these encounters no condom was used. Consistent with recent data from elsewhere in the region, there is an urgent need for additional research on male sex work in South-east Asia in order to properly situate behavioural interventions for male sex workers in this region.

Abstract

Background: This paper describes injection risk in an out-of-treatment population of young heroin users in Hanoi, Vietnam, including use of a soft-tissue portal known as a "cay ma" (injection sac). Methods: Data from a large cross-sectional survey (N=1270) are used to describe the prevalence of this practice and its association with disease. Additionally, data from an ethnographic substudy on injectors serve to elaborate injectors' rationales for this injection practice. Results: This practice was common in this sample, appearing soon after initiation of habitual injection. Injectors report that this allows rapid and reliable access to a vein; strategic advantages in a dense urban environment where rapid injection, typically in public settings, is necessary to avoid discovery or arrest. Additionally, this practice is believed to mitigate risk for vein damage from co-morbid promethazine hydrochloride injection. Conclusions: This practice may draw lymphocytes to injection sites, thereby increasing risk for transmission of bloodborne pathogens. Structural and behavioral interventions are needed for young heroin users in Vietnam.

Abstract

This paper describes findings from a study of young men who have sex with men (YMSM) in New York City. Using a cross-sectional design and a community-based targeted sampling approach, a total of 569 YMSM were recruited during 2000 and 2001 for a structured survey interview. High rates of lifetime exposure to a variety of club drugs (including methamphetamine, ketamine, and MDMA) are observed in the overall sample. Among those who use club drugs on a chronic basis (N = 145), we found high rates of a prior suicide attempt (including high rates of multiple suicide attempts), high rates of lifetime exposure to multiple types of drugs, high rates of current poly drug use (including multiple types of club drugs), and high rates of current depressive symptoms. Chronic club drug users had a mean CES-D score of 8.5 and nearly two-thirds had a score of 7 or more. Although high rates of condom use are reported in some types of sexual exchanges, data show multiple types of sexual risk among chronic club drug users, including high rates of unprotected anal intercourse (UAI) with most frequent partners and comorbid drug use among both YMSM and their sexual partners.

Abstract

The objective of this article was to examine drug and sexual risk in four salient groups of men who have sex with men (MSM) in New York City (NYC): (1) nonhomeless young MSM (YMSM), (2) homeless YMSM, (3) adult MSM Speed users, and (4) HIV-positive "POZ Party" MSM. Lifetime and current exposure to drugs, drug injection, and selected drug-sex interactions are highlighted in each group. Data derive from recently completed field-based, ethnoepidemiological studies that used venue-oriented/targeted sampling and semistructured interviews. Across all four groups, findings show that both drug and sexual risk remain prevalent in the MSM population in NYC. This is especially troubling given the already high background prevalence of HIV and other sexually transmitted diseases in NYC and the widespread suffering and death already wrought by HIV/AIDS among MSM. These findings suggest that available public health interventions today are, in many respects, failing to reach, engage, and affect critical risk groups within the NYC MSM population.

Abstract

Objective: To develop a preliminary epidemiological description of a men who have sex with men (MSM) "POZ Party," an emerging sex environment for HIV+ MSM. Methods: As part of a pilot study in New York City in 2003, data were collected using a brief, behavioural intercept survey at entry to POZ Party events. Domains include demographic characteristics, history of HIV infection, motivations for attending POZ parties, lifetime and recent exposure to drugs (including use during POZ Party events), and recent sexual practices (both within both POZ Party venues as well as in non-POZ Party venues). Results: Predominantly white and over the age of 30, subjects in the sample include a broad range of years living with HIV infection. Motivations for using a POZ Party venue for sexual partnering include relief from burdens for serostatus disclosure, an interest in not infecting others, and opportunities for unprotected sexual exchange. High rates of unprotected sex with multiple partners are prevalent in the venue. Although the sample evidences high rates of lifetime exposure to illicit drugs, relatively little drug use was reported in these sexual environments. These reports are consistent with evidence from direct observation at the venues themselves, in which no drug use was apparent. Conclusion: Serosorting among HIV+ MSM may reduce new HIV infections, a stated interest of both POZ Party organisers and participants alike. However, high rates of unprotected anal intercourse within these venues signal continued risk for STIs. Additionally, unprotected sexual contact with HIV partners and status unknown partners outside POZ Party venues heightens concern for diffusion of HIV superinfection.

Abstract

The objective of this paper is to profile the role of homelessness in drug and sexual risk in a population of young men who have sex with men (YMSM). Data are from a cross-sectional survey collected between 2000 and 2001 in New York City (N = 569). With the goal of examining the import of homelessness in increased risk for the onset of drug and sexual risk, we compare and contrast three subgroups: (1) YMSM with no history of homelessness, (2) YMSM with a past history of homelessness but who were not homeless at the time of the interview, and (3) YMSM who were currently homeless. For each group, we describe the prevalence of a broad range of stressful life events (including foster care and runaway episodes, involvement in the criminal justice system, etc.), as well as selected mental health problems (including past suicide attempts, current depression, and selected help-seeking variables). Additionally, we examine the prevalence of selected drug and sexual risk, including exposure to a broad range of illegal substances, current use of illegal drugs, and prevalence of lifetime exposure to sex work. Finally, we use an event history analysis approach (time-event displays and paired t-test analysis) to examine the timing of negative life experiences and homelessness relative to the onset of drug and sexual risk. High levels of background negative life experiences and manifest mental health distress are seen in all three groups. Both a prior experience of homelessness and currently being homeless are both strongly associated with both higher levels of lifetime exposure to drug and sexual risk as well as higher levels of current drug and sexual risk. Onset of these risks occur earlier in both groups that have had an experience of housing instability (e.g., runaway, foster care, etc.) but are delayed or not present among YMSM with no history of housing instability. Few YMSM had used drug prior to becoming homeless. While causal inferences are subject to the limitations of a cross-sectional design, the findings pose an empirical challenge to the prevailing assumption that prior drug use is a dominant causal factor in YMSM becoming homeless. More broadly, the data illustrate the complexity of factors that must be accounted for, both in advancing our epidemiological understanding of the complexity of homelessness and its relationship to the onset of drug and sexual risk among high risk youth populations.

Abstract

In order to explore the relationship between use of club drugs (crystal methamphetamine, ecstasy, GHB, ketamine), and use of other drugs, survey data collected from 23,780 middle school students in New York City during 2002-2003 was examined. Results of HGLM analyses (a generalization of HLM to accomodate nonlinear outcomes), controlling for the effect of school, indicate that Black students are less likely than White students to use club drugs depending on the timeframe of use. The use of alcohol and/or marijuana predict club drug use regardless of the timeframe of use, and lifetime cigarette use predicts lifetime club drug use. Recommendations for future research and prevention efforts are discussed.