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1.  Motivational Interviewing to Enhance Nicotine Patch Treatment for Smoking Cessation among Homeless Smokers: A Randomized Controlled Trial 
Addiction (Abingdon, England)  2013;108(6):1136-1144.
AIMS
To assess the effects of adding motivational interviewing (MI) counseling to nicotine patch for smoking cessation among homeless smokers.
DESIGN
Two-group randomized controlled trial with 26-week follow-up.
PARTICIPANTS AND SETTING
430 homeless smokers from emergency shelters and transitional housing units in Minneapolis/St. Paul, Minnesota, USA.
INTERVENTION AND MEASUREMENTS
All participants received 8-week treatment of 21mg nicotine patch. In addition, participants in the intervention group received six individual sessions of MI counseling which aimed to increase adherence to nicotine patch and to motivate cessation. Participants in the Standard Care control group received one session of brief advice to quit smoking. Primary outcome was seven-day abstinence from cigarette smoking at 26 weeks as validated by exhaled carbon monoxide and salivary cotinine.
FINDINGS
Using intention-to-treat analysis, verified seven-day abstinence rate at week 26 for the intervention group was non-significantly higher than for the control group (9.3% vs. 5.6%, p=0.15). Among participants that did not quit smoking, reduction in number of cigarettes from baseline to week 26 was equally high in both study groups (−13.7 ±11.9 for MI vs. −13.5 ±16.2 for Standard Care).
CONCLUSIONS
Adding motivational interviewing counseling to nicotine patch did not significantly increase smoking rate at 26-week follow-up for homeless smokers.
doi:10.1111/add.12140
PMCID: PMC3651796  PMID: 23510102
2.  Smoking Characteristics and Comorbidities in the Power To Quit Randomized Clinical Trial for Homeless Smokers 
Nicotine & Tobacco Research  2012;15(1):22-28.
Introduction:
Smoking prevalence in homeless populations is strikingly high (∼70%); yet, little is known about effective smoking cessation interventions for this population. We conducted a community-based clinical trial, Power To Quit (PTQ), to assess the effects of motivational interviewing (MI) and nicotine patch (nicotine replacement therapy [NRT]) on smoking cessation among homeless smokers. This paper describes the smoking characteristics and comorbidities of smokers in the study.
Methods:
Four hundred and thirty homeless adult smokers were randomized to either the intervention arm (NRT + MI) or the control arm (NRT + Brief Advice). Baseline assessment included demographic information, shelter status, smoking history, motivation to quit smoking, alcohol/other substance abuse, and psychiatric comorbidities.
Results:
Of the 849 individuals who completed the eligibility survey, 578 (68.1%) were eligible and 430 (74.4% of eligibles) were enrolled. Participants were predominantly Black, male, and had mean age of 44.4 years (S D = 9.9), and the majority were unemployed (90.5%). Most participants reported sleeping in emergency shelters; nearly half had been homeless for more than a year. Nearly all the participants were daily smokers who smoked an average of 20 cigarettes/day. Nearly 40% had patient health questionnaire-9 depression scores in the moderate or worse range, and more than 80% screened positive for lifetime history of drug abuse or dependence.
Conclusions:
This study demonstrates the feasibility of enrolling a diverse sample of homeless smokers into a smoking cessation clinical trial. The uniqueness of the study sample enables investigators to examine the influence of nicotine dependence as well as psychiatric and substance abuse comorbidities on smoking cessation outcomes.
doi:10.1093/ntr/nts030
PMCID: PMC3611988  PMID: 22589422
3.  HOSPITAL- VERSUS COMMUNITY–BASED SYRINGE EXCHANGE: A RANDOMIZED CONTROLLED TRIAL 
This study examined the effect of syringe exchange program setting on the injection practices, health status, and health service utilization patterns of injection drug users (IDUs) recruited from a public urban hospital. One hundred sixty-six participants were randomized to either community– or hospital–based syringe exchange services. Poisson regression models were used to compare service utilization between groups. In both conditions, risky drug use practices decreased, and physical health functioning improved over time. Hospital–based syringe exchange program (SEP) attendees had 83% more inpatient admissions (p < .0001) and 22% more ambulatory care visits (p < .0001) than those assigned to the community–based SEP condition. Syringe exchange services that are integrated into public hospital settings may serve as a valuable strategy to engage hard to reach IDU populations in behavioral interventions designed to reduce HIV risk transmission behaviors and increase access to, or engagement in, the use of secondary and tertiary preventive medical care.
doi:10.1521/aeap.2007.19.2.97
PMCID: PMC3853200  PMID: 17411413
4.  Role of sexual transmission of HIV among young non-injection and injection opiate users: A respondent driven sampling study 
Sexually transmitted diseases  2011;38(12):1161-1166.
Background
Little research has investigated sexual transmissibility of HIV among young drug users in China. The objective of this study was to examine the role of sexual transmission on HIV infection among injection drug users (IDUs) and non-injection drug users (NIDUs).
Methods
Respondent-driven sampling (RDS) was used to recruit 426 young heroin/opium drug users in Yunnan, China. Logistic regression modeling was performed to examine interrelationships among risky sexual behaviors, drug-use modes, and drug-use practices.
Results
Substantial proportions of NIDUs and IDUs reported engagement in risky sexual behaviors including: (1) multiple sexual partners (42% of NIDUs vs. 37% of IDUs); (2) concurrent sexual partnerships (48% vs. 46%); (3) commercial sex partners (23% vs. 24%) and sex partners who were NIDUs (14% vs. 17 %). Both NIDUs and IDUs reported low levels of condom use with non-regular partners (48% vs. 42%) and regular partner (24% vs. 27%), and having a history of recent methamphetamine use (21% vs. 18%). Compared to IDUs, NIDUs reported having had fewer sex partners who were IDUs, fewer IDU network peers, more NIDU network peers, and having lower levels of HIV knowledge and self-perceived HIV risk.
Conclusions
Generalization of the HIV epidemic from high-risk groups to the general population may be driven by risky sexual behavior among drug users. Reducing sexual transmission of HIV among both IDUs and NIDUs is the next major challenge for HIV intervention among drug users in China.
doi:10.1097/OLQ.0b013e3182315772
PMCID: PMC3229029  PMID: 22082729
HIV; Injection drug use; Non-Injection drug use; Sexual behavior; China
5.  The epidemiology of viral hepatitis among people who inject drugs: Results of global systematic reviews 
Lancet  2011;378(9791):571-583.
Background
Injecting drug use (IDU) is an important risk for viral hepatitis transmission. Detailed, transparent estimates of the scale of the problem at regional and global levels have never been made. We report national, regional and global prevalence and population size estimates for hepatitis C (HCV) and hepatitis B (HBV) among people who inject drugs.
Methods
Systematic search of peer-reviewed (Medline/Embase/PsycINFO) and grey literature databases, conference abstracts and online resources, with a widely distributed call for additional data. From 4386 peer-reviewed and 1019 grey literature sources, 1125 were reviewed in full. Studies were extracted to a customised database and graded according their methods. Serological reports of HCV antibodies/anti-HCV, HBV antibodies/anti-HBc, and/or HBV surface antigen/HBsAg among IDUs samples with n>40 participants, <100% HIV-positive, and sampling frames that did not exclude participants on the basis of age or sex were included. Using endorsed decision rules, prevalence estimates were calculated with anti-HCV and anti-HBV as proxies for exposure and HBsAg for current infection. These were combined with IDU population sizes to estimate the number of HBV and HCV positive IDUs.
Findings
Eligible reports of anti-HCV among IDUs were located for 77 countries. Prevalence was 60–80% in 26 countries and >80% in 12. We estimate worldwide about 10.0 million (range 6.0–15.2M) IDUs might be anti-HCV positive. China, (1.6M), the USA (1.5M) and the Russian Federation (1.3M) had by far the largest such populations. HBsAg reports were found for 59 countries, ranging from 5–10% in 21 countries and over 10% in 10. Worldwide, 6.4 million IDU might be anti-HBc positive (2.3–9.7M), and 1.2 million (0.3–2.7M) HBsAg positive.
Interpretation
The prevalence of anti-HCV among IDUs is far greater than HIV. Viral hepatitis clearly poses a challenge to public health. Variation in the coverage and quality of existing research creates uncertainty around estimates. Better and more complete data and reporting are required to estimate the scale of the problem, to inform efforts to prevent and treat HCV and HBV among IDUs.
doi:10.1016/S0140-6736(11)61097-0
PMCID: PMC3285467  PMID: 21802134
6.  HCV-Specific T-Cell Immune Responses in Seronegative Injection Drug Users 
Journal of viral hepatitis  2008;16(1):10-20.
Background/Aims
T-cell responses to HCV antigens have been reported in high-risk HCV seronegative persons, suggesting that an effective cellular immune response might be able to clear infection without the development of antibodies. Such findings, however, could be explained by waning antibody or cross-reactivity to other antigens. To address these issues, we assessed T-cell responses in high-risk, seronegative, young IDUs to multiple peptide mixes spanning the entire HCV genome.
Methods
We evaluated HCV-specific T-cell responses in 26 young (age 18-33 years) aviremic, seronegative IDUs (median duration of injection, 6 years) by interferon-γ ELISpot assay using 429 overlapping HCV peptides pooled in 21 mixes. Seventeen aviremic, seropositive IDUs (spontaneous resolvers) and 15 healthy people were used as positive and negative controls, respectively.
Results
The percentage of patients with HCV-specific cellular immune responses was similar in seronegative and seropositive aviremic IDUs (46% versus 59%, p=0.4), while these responses were not detected in any of the negative controls. Among the seronegative IDUs, 6 (23%) had intermediate to very strong responses to 10-20 peptide mixes and another 6 (23%) had moderately strong responses to 2 to 6 mixes. The 12 seronegative IDUs with HCV-specific T-cell responses had higher demographic and behavioral risk profiles than the 14 IDUs without T-cell responses (estimated risk of HCV infection, 0.47 vs. 0.26, p <0.01).
Conclusions
HCV-specific T-cell responses are common among high-risk, seronegative IDUs. The responses are broad and are associated with risk factors for HCV exposure, suggesting that they reflect true exposure to HCV in seronegative persons.
doi:10.1111/j.1365-2893.2008.01016.x
PMCID: PMC2997348  PMID: 18647233
7.  Should Pharmacists have a Role in Harm Reduction Services for IDUs? A Qualitative Study in Tallinn, Estonia 
Despite the high number of injecting drug users (IDUs) in Estonia, little is known about involving pharmacies into human immunodeficiency virus (HIV) prevention activities and potential barriers. Similarly, in other Eastern European countries, there is a need for additional sources for clean syringes besides syringe exchange programmes (SEPs), but data on current practices relating to pharmacists’ role in harm reduction strategies is scant. Involving pharmacies is especially important for several reasons: they have extended hours of operation and convenient locations compared to SEPs, may provide access for IDUs who have avoided SEPs, and are a trusted health resource in the community. We conducted a series of focus groups with pharmacists and IDUs in Tallinn, Estonia, to explore their attitudes toward the role of pharmacists in HIV prevention activities for IDUs. Many, but not all, pharmacists reported a readiness to sell syringes to IDUs to help prevent HIV transmission. However, negative attitudes toward IDUs in general and syringe sales to them specifically were identified as important factors restricting such sales. The idea of free distribution of clean syringes or other injecting equipment and disposal of used syringes in pharmacies elicited strong resistance. IDUs stated that pharmacies were convenient for acquiring syringes due to their extended opening hours and local distribution. IDUs were positive toward pharmacies, although they were aware of stigma from pharmacists and other customers. They also emphasized the need for distilled water and other injection paraphernalia. In conclusion, there are no formal or legislative obstacles for providing HIV prevention services for IDUs at pharmacies. Addressing negative attitudes through educational courses and involving pharmacists willing to be public health educators in high drug use areas would improve access for HIV prevention services for IDUs.
doi:10.1007/s11524-009-9400-5
PMCID: PMC2791822  PMID: 19921542
Injecting drug users; Pharmacists; Harm reduction services
8.  High-prevalence and high-estimated incidence of HIV infection among new injecting drug users in Estonia: need for large scale prevention programs 
Objective
To examine HIV risk behavior and HIV infection among new injectors in Tallinn, Estonia.
Design and methods
Data from two cross-sectional surveys of injecting drug users (IDUs) recruited from a syringe exchange program (N = 162, Study 1) or using respondent driven sampling (N = 350, Study 2). Behavioral surveys were administered; serum samples were collected for HIV testing. Subjects were categorized into new injectors (injecting ≤ 3 years) and long-term injectors (injecting > 3 years).
Results
Twenty-eight of 161 (17%, Study 1) and 73/350 (21%, Study 2) of the study subjects were new injectors. HIV infection was substantial among the newer injectors: HIV prevalence was 50% (Study 1) and 34% (Study 2), and estimated HIV incidence 31/100 PY and 21/100 PY, respectively. In Study 2, new injectors were more likely to be female and ethnic Estonian and less likely to be injecting daily compared with long-term injectors. No significant difference was found among two groups on sharing injecting equipment or reported number of sexual partners.
Conclusions
A continuing HIV epidemic among new injectors is of critical public health concern. Interventions to prevent initiation into injecting drug use and scaling up HIV prevention programs for IDUs in Estonia are of utmost importance.
doi:10.1093/pubmed/fdn014
PMCID: PMC2925676  PMID: 18308743
Estonia; HIV; IDU; injection drug use; new injecting drug users
9.  Exploring drug users’ attitudes and decisions regarding hepatitis C (HCV) treatment in the U.S 
Individuals with a history of injecting drugs are at the highest risk of becoming infected with the hepatitis C virus (HCV), with studies of patients in methadone maintenance treatment programmes (MMTPs) reporting that 60–90% of intravenous drug users (IDUs) have the virus. Fortunately, HCV therapy has been shown to be effective in 42–82% of all patients with chronic HCV infection, including IDUs. While the decision to start HCV therapy requires significant consideration, little research exists that explores the attitudes of drug users toward HCV therapy. Therefore, this paper examines how drug users perceive the treatment, as well as the processes by which HCV-positive individuals examined the advantages and disadvantages of starting the HCV medications. Interviews were conducted with 164 patients from 14 drug treatment programmes throughout the United States, and both uninfected and HCV-positive drug users described a pipeline of communication among their peers that conveys largely negative messages about the medications that are available to treat HCV. Although many of the HCV-positive individuals said that these messages heightened their anxiety about the side effects and difficulties of treatment, some patients said that their peers helped them to consider and/or initiate HCV treatment. Gaining a better understanding of drug users’ perceptions of HCV treatment is important, because so many of them, particularly IDUs, are already infected with HCV and may benefit from support in addressing their HCV treatment needs. In addition, currently uninfected drug users will likely remain at high risk for contracting HCV and may need to make decisions about whether or not to start the HCV medical regimen in the future.
doi:10.1016/j.drugpo.2007.02.003
PMCID: PMC2698452  PMID: 18312822
hepatitis C; substance abuse; drug treatment programmes; medical treatment

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