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1.  Longitudinal trends in sexual behaviors without a condom among sexual minority youth: the P18 cohort study 
AIDS and behavior  2015;19(12):2152-2161.
Given the heightened risk for HIV and other STIs among young men who have sex with men (YMSM) as well as the racial/ethnic disparities in HIV/STI risk, an understanding of longitudinal trends in sexual behaviors is warranted as YMSM emerge into adulthood. Drawing from an ongoing prospective cohort study, the present analysis employed latent growth curve modeling to examine trends in distinct types of sexual activity without condoms over time in sample of YMSM and examine differences by race/ethnicity and perceived familial SES. Overall, White and Mixed race YMSM reported more instances of oral sex without condom as compared to other racial/ethnic groups with rates of decline over time noted in Black YMSM. White YMSM also reported more receptive and insertive anal sex acts without a condom than Black YMSM. Declines over time in both types of anal sex acts without condoms among Black men were noted when compared to White men, while increases over time were noted for mixed race YMSM for condomless insertive anal sex. The effects for race/ethnicity were attenuated with the inclusion of perceived familial SES in these models. These findings build on previous cross sectional studies showing less frequent sex without condoms among Black YMSM despite higher rates of HIV incidence in emerging adulthood, as well as the importance of considering economic conditions in such models. Efforts to understand racial/ethnic disparities in HIV/STIs among YMSM must move beyond examination of individual-level sexual behaviors and consider both race/ethnicity and socioeconomic conditions in order to evaluate how these factors shape the sexual behaviors of YMSM.
PMCID: PMC4610826  PMID: 26319222
2.  Demographic, Mental Health, Behavioral, and Psychosocial Factors Associated with Cigarette Smoking Status Among Young Men Who Have Sex with Men: The P18 Cohort Study 
LGBT Health  2016;3(5):379-386.
Purpose: Young sexual minority men smoke at higher rates relative to heterosexual peers. The purpose of this study was to examine correlates of smoking in a sample of young gay, bisexual, and other men who have sex with men (MSM) who might differ from more general and age-diverse samples of sexual minority individuals and, thus, inform tailored approaches to addressing tobacco use within this population.
Methods: Data on smoking status were examined in relation to demographics, mental health, substance use behavior, and psychosocial factors. Using multinomial logistic regression, factors were identified that differentiate current and former smokers from never smokers.
Results: In bivariate analysis, smoking status was related to demographic, mental health, substance use, and psychosocial factors. Most significantly, smoking status was associated with school enrollment status, current alcohol and marijuana use, and symptoms of depression. Multivariate modeling revealed that, compared to being a never smoker, the odds of current or former smoking were highest among those currently using either alcohol or marijuana. The odds of both current and former smoking were also higher among those reporting greater levels of gay community affinity. Finally, the odds of being a former smoker were higher for those reporting internalized antihomosexual prejudice.
Conclusion: This study identifies several factors related to smoking status in a diverse sample of young sexual minority males. These findings should encourage investigations of smoking disparities among younger MSM to look beyond common smoking risk factors in an attempt to understand etiologies that may be unique to this group. Such findings may indicate multiple points of potential intervention aimed at decreasing cigarette smoking within this vulnerable population.
PMCID: PMC5073225  PMID: 27158762
adolescence; health disparities; men who have sex with men (MSM); tobacco use
3.  Intimate partner violence and substance use risk among young men who have sex with men: The P18 Cohort Study 
Drug and alcohol dependence  2015;154:54-62.
Substance use is prevalent among young men who have sex with men (YMSM) and may be associated with intimate partner violence (IPV). Experiences of IPV are associated with several adverse health conditions among adult MSM, but there is a gap in knowledge about this relationship among YMSM which warrants further investigation.
This study employs baseline data from a prospective cohort study to examine lifetime experiences of IPV in relation to substance use in the previous 30 days among n=528 YMSM in New York City from 2009-11. To examine the extent to which IPV (any experiences, victimization, and perpetration) are related to substance use (alcohol, marijuana, stimulant, and other drugs) in the last 30 days, distinct 2-step multinomial logistic regression models, controlling for sociodemographic differences, were constructed.
44.3% reported lifetime IPV experience, with 39.2% of reporting victimization and 30.5% reporting perpetration. IPV is associated with a 1.6 increased odds of 2 or more instances of alcohol use, a 1.6–1.8 increased odds of 2 or more instances of marijuana use, a 1.8–2.5 increased odds of 2 or more instances of stimulant use, and a 4.1–6.1 increased odds of 2 or more instances of other substance use.
Findings highlight the strong association between IPV and increased frequency of substance use among YMSM and provide support that violence may exist as part of a syndemic facing YMSM. Prevention and intervention strategies may be improved by addressing substance use in the context of IPV and other related health challenges.
PMCID: PMC4536185  PMID: 26130334
Intimate partner violence; substance use; YMSM
4.  Incidence of HIV infection in Young Gay, Bisexual, and other YMSM: The P18 Cohort Study 
HIV infections continue to rise in a new generation of young, gay, bisexual and other men who have sex with men (YMSM) despite three decades of HIV prevention and recent biomedical technologies to deter infection.
To examine the incidence of HIV and the demographics, behavioral, and structural factors associated with incident infections.
Cohort study.
600 YMSM who were ages 18-19 at baseline.
At baseline 6 prevalent cases of HIV were detected. Over the course of 36 months and six additional waves of data collection, we identified 43 (7.2%) incident cases of HIV. Incident infections were marginally higher among those residing in neighborhoods with higher rates of HIV prevalence. Using Cox proportional hazards models we detected that hazard ratios for time to HIV seroconversion were significantly higher for Black YMSM (HR = 7.46) and Mixed/Other race YMSM (HR = 7.99), and older age at sexual debut with another man was associated with a lower risk of HIV seroconversion (HR = 0.50), while low perceived familial SES was marginally associated with an increased risk for HIV seroconversion (HR = 2.45).
These findings support the disparities for HIV that exist within the population of sexual minority men and suggest that we attend to behavioral, structural and social conditions to effectively tailor HIV prevention for a new generation of YMSM with a keen eyes to the conditions faced by racial and ethnic minority YMSM which heightened their risk for acquiring HIV.
PMCID: PMC4484878  PMID: 26115438
HIV; incidence; gay and bisexual men; YMSM; cohort study; prevention
5.  Racial/Ethnic Differences in the Association between Arrest and Unprotected Anal Sex among Young Men Who Have Sex with Men: The P18 Cohort Study 
This analysis aimed to determine whether the relationship between a history of arrest and unprotected anal sex (UAS) is the same for Black/Latino gay, bisexual, and other young men who have sex with men (YMSM) as compared to White/Asian/Pacific Islander (API) YMSM in New York City (NYC). Baseline audio-computer-assisted self-interview (ACASI) and interviewer-administered survey data from a sample of 576 YMSM aged 18–19 years old who self-reported being HIV-negative were analyzed. Data included history of arrest and incarceration as well as UAS in the past 30 days. Race/ethnicity was an effect modifier of the association between arrest and UAS among YMSM: White/API YMSM with a lifetime arrest history were more than three times as likely to report UAS, and Black/Latino YMSM with a lifetime history of arrest were approximately 70 % less likely to report UAS as compared with White/API YMSM with no reported arrest history. Race/ethnicity may modify the relationship between arrest and sexual risk behavior because the etiology of arrest differs by race, as partially evidenced by racial/ethnic disparities in police stop, arrest, and incarceration rates in NYC. Arrest could not only be an indicator of risky behavior for White/API YMSM but also an indicator of discrimination for Black/Latino YMSM. Further research is needed to assess whether the differential associations observed here vis-à-vis race/ethnicity are robust across different populations and different health outcomes.
PMCID: PMC4524845  PMID: 25677880
Homosexuality; Male; Arrest; Sexual behavior; Race; Ethnicity
6.  Body Dissatisfaction in a Diverse Sample of Young Men Who Have Sex With Men: The P18 Cohort Study 
Archives of sexual behavior  2015;45(5):1227-1239.
Young men who have sex with men (YMSM) may be at greater risk for body dissatisfaction, compared to their heterosexual peers. However, differences within YMSM populations are understudied, precluding the identification of YMSM who are at greatest risk. This study examined body dissatisfaction in a racially/ethnically diverse sample of YMSM ages 18–19 in New York City. Using cross-sectional data from the baseline visit of a longitudinal cohort study of YMSM (N = 591), body dissatisfaction was assessed using the Male Body Attitudes Scale. Three outcomes were modeled using linear regression: (1) overall body dissatisfaction, (2) muscularity dissatisfaction, and (3) body fat dissatisfaction. Covariates in the models included race/ethnicity, sexual orientation, BMI, gay community affiliation, and internalized homonegativity. White YMSM experienced greater body dissatisfaction across the three models. Internalized homonegativity was a statistically significant predictor of dissatisfaction across the three models, though its association with body dissatisfaction was relatively small. The findings point to future avenues of research, particularly qualitative research to explore demographic and cultural nuances in body attitudes among YMSM.
PMCID: PMC4791207  PMID: 26370403
Body image; Body dissatisfaction; Gay; Bisexual; MSM; Internalized homonegativity; Sexual orientation
7.  A longitudinal investigation of syndemic conditions among young gay, bisexual, and other MSM: The P18 Cohort Study 
AIDS and behavior  2015;19(6):970-980.
The persistence of disparities in STI/HIV risk among a new generation of emerging adult gay, bisexual, and other men who have sex with men (YMSM) warrant holistic frameworks and new methodologies for investigating the behaviors related to STI/HIV in this group. In order to better understand the continued existence of these disparities in STI/HIV risk among YMSM, the present study evaluated the presence and persistence of syndemic conditions among YMSM by examining the co-occurrence of alcohol and drug use, unprotected sexual behavior, and mental health burden over time. Four waves of data, collected over the first 18 months of a 7 wave, 36-month prospective cohort study of YMSM (n=598) were used to examine the extent to which measurement models of drug use, unprotected sexual behavior, and mental health burden remained consistent across time using latent class modeling. Health challenges persisted across time as these YMSM emerged into young adulthood and the measurement models for the latent constructs of drug use and unprotected sexual behavior were essentially consistent across time whereas models for mental health burden varied over time. In addition to confirming the the robustness of our measurement models which capture a more holistic understandings of the health conditions of drug use, unprotected sex, and mental health burden, these findings underscore the ongoing health challenges YMSM face as they mature into young adulthood. These ongoing health challenges, which have been understood as forming a syndemic, persist over time, and add further evidence to support ongoing and vigilant comprehensive health programming for sexual minority men that move beyond a sole focus on HIV.
PMCID: PMC4362859  PMID: 25192900
Gay and bisexual men; Emerging adulthood; Syndemic; HIV; Structural equation modeling; prospective cohort study
8.  Feasibility and Acceptability of Global Positioning System (GPS) Methods to Study the Spatial Contexts of Substance Use and Sexual Risk Behaviors among Young Men Who Have Sex with Men in New York City: A P18 Cohort Sub-Study 
PLoS ONE  2016;11(2):e0147520.
No global positioning system (GPS) technology study has been conducted among a sample of young gay, bisexual, and other men who have sex with men (YMSM). As such, the purpose of this study was to evaluate the feasibility and acceptability of using GPS methods to understand the spatial context of substance use and sexual risk behaviors among a sample of YMSM in New York City, a high-risk population.
Data came from a subsample of the ongoing P18 Cohort Study (n = 75). GPS feasibility and acceptability among participants was measured with: 1) a pre- and post-survey and 2) adherence to the GPS protocol which included returning the GPS device, self-report of charging and carrying the GPS device as well as objective data analyzed from the GPS devices. Analyses of the feasibility surveys were treated as repeated measures as each participant had a pre- and post-feasibility survey. When comparing the similar GPS survey items asked at baseline and at follow-up, we present percentages and associated p-values based on chi-square statistics.
Participants reported high ratings of pre-GPS acceptability, ease of use, and low levels of wear-related concerns in addition to few concerns related to safety, loss, or appearance, which were maintained after baseline GPS feasibility data collection. The GPS return rate was 100%. Most participants charged and carried the GPS device on most days. Of the total of 75 participants with GPS data, 75 (100%) have at least one hour of GPS data for one day and 63 (84%) had at least one hour on all 7 days.
Results from this pilot study demonstrate that utilizing GPS methods among YMSM is feasible and acceptable. GPS devices may be used in spatial epidemiology research in YMSM populations to understand place-based determinants of health such as substance use and sexual risk behaviors.
PMCID: PMC4769145  PMID: 26918766
9.  Modeling substance use in emerging adult gay, bisexual, and other YMSM across time: The P18 cohort study 
Drug and alcohol dependence  2014;0:209-216.
To examine patterns of substance use over time in a new generation of emerging adult gay, bisexual, and other young men who have sex with men (YMSM).
Data were drawn from the first four waves of on ongoing prospective cohort study of YMSM who were ages 18 to19 at baseline and were assessed each 6 months for substance use via calendar based methods. Latent growth curve modeling was utilized to assess changes over time for four drug use categories: alcohol, marijuana, inhalant nitrates, and other drugs (e.g., cocaine, ecstasy) and between groups (race/ethnicity, perceived familial socioeconomic status; SES).
Use of all substances increased steadily across the follow-up period. White YMSM demonstrated higher levels of alcohol use at the 18-mo follow-up visit compared to other racial/ethnic groups, while rates of change across groups were similar. Marijuana use at 18 months was highest for Hispanics who also indicated the highest rate of change. Finally, YMSM who reported higher perceived SES reported the lowest use and lowest rates of change for other drug use. Controlling for perceived SES, differences in patterns of drug use by race/ethnicity were evident but differences were not as large.
Increases in substance use in the emerging adulthood of YMSM indicate the need for structural and behavioral interventions tailored to address substance use in these young men before chronic patterns of use develop. Differences in patterns of drug use across racial/ethnic and SES groups suggest that interventions need to consider person-level differences.
PMCID: PMC4254590  PMID: 25456332
Gay And Bisexual Men; YMSM; Alcohol and Other Drugs; Emerging Adulthood; Longitudinal; Latent Growth Curve Modeling
Pre-exposure prophylaxis (PrEP) is considered an effective biomedical approach for HIV prevention. However, there is limited understanding of PrEP uptake among racially/ethnically and socioeconomically diverse young men who have sex with men (YMSM). This study examined attitudes and perceptions toward PrEP uptake among YMSM by conducting semistructured interviews with a sample (N = 100) of YMSM in New York City. Thematic analysis was employed to explore key issues related to attitudes and perceptions toward PrEP utilization. Findings suggest that self-perceived risk for HIV transmission, enjoying unprotected sex, and being in a romantic relationship were associated with PrEP uptake. The most prominent barriers to PrEP uptake included costs, adherence regimen, and access. In summary, these findings underscore the importance of addressing behavioral and structural factors in maximizing the effectiveness of PrEP. In addition, PrEP implementation programs ought to consider the role of social and structural challenges to PrEP uptake and adherence among YMSM.
PMCID: PMC4550097  PMID: 25915697
11.  Associations between social support network characteristics and receipt of emotional and material support among a sample of male sexual minority youth 
Few studies have examined how social support network characteristics are related to perceived receipt of social support among male sexual minority youth. Using egocentric network data collected from a study of male sexual minority youth (n=592), multivariable logistic regression analyses examined distinct associations between individual and social network characteristics with receipt of (1) emotional and (2) material support. In multivariable models, frequent communication and having friends in one’s network yielded a two-fold increase in the likelihood of receiving emotional support whereas frequent communication was associated with an almost three-fold higher likelihood of perceived material support. Finally, greater internalized homophobia and personal experiences of gay-related stigma were inversely associated with perceived receipt of emotional and material support, respectively. Understanding the evolving social context and social interactions of this new generation of male sexual minority youth is warranted in order to understand the broader, contextual factors associated with their overall health and well-being.
PMCID: PMC4157518  PMID: 25214756
social support; social networks; youth/adolescents; sexual minority
12.  Examination of Spatial Polygamy among Young Gay, Bisexual, and Other Men Who Have Sex with Men in New York City: The P18 Cohort Study 
The few previous studies examining the influence of the neighborhood context on health and health behavior among young gay, bisexual, and other men who have sex with men (YMSM) have predominantly focused on residential neighborhoods. No studies have examined multiple neighborhood contexts among YMSM or the relationships between sociodemographic characteristics, psychosocial factors, social support network characteristics, health behaviors, and neighborhood concordance. In this study, we assessed spatial polygamy by determining the amount of concordance between residential, social, and sex neighborhoods (defined as boroughs) in addition to examining individual-level characteristics that may be associated with neighborhood concordance. These data come from the baseline assessment of Project 18, a cohort of racially and ethnically diverse YMSM residing in the New York City metropolitan area. Participants (N = 598) provided information on their residential, social, and sex boroughs as well as information on their sociodemographic characteristics, psychosocial factors, social support network characteristics, and health behaviors (e.g., substance use and condomless sex). Descriptive analyses were conducted to examine the distribution of boroughs reported across all three contexts, i.e., residential, social, and sex boroughs. Next, concordance between: (1) residential and social boroughs; (2) residential and sex boroughs; (3) social and sex boroughs; and (4) residential, social, and sex boroughs was assessed. Finally, bivariable analyses were conducted to examine the relationships between sociodemographic characteristics, psychosocial factors, social support network characteristics, and health behaviors in relation to borough concordance. Approximately two-thirds of participants reported concordance between residential/socializing, residential/sex, and sex/socializing boroughs, whereas 25% reported concordance between all three residential/socializing/sex boroughs. Borough concordance varied by some individual-level characteristics. For example, White YMSM and YMSM reporting lower perceived socioeconomic status were significantly more likely to report residential/socializing/sex borough concordance (p < 0.001). With regard to psychosocial factors, YMSM who reported experiencing gay-related stigma in public forums were more likely to report discordant socializing/sex and residential/socializing/sex boroughs (p < 0.001). Greater frequency of communication with network members (≥weekly) was associated with less residential/social borough concordance (p < 0.05). YMSM who reported residential/socializing/sex borough concordance were more likely to report recent (last 30 days) alcohol use, recent marijuana use, and recently engaging in condomless oral sex (all p < 0.05). These findings suggest that spatial polygamy, or an individual moving across and experiencing multiple neighborhood contexts, is prevalent among urban YMSM and that spatial polygamy varies by multiple individual-level characteristics. Future research among YMSM populations should consider multiple neighborhood contexts in order to provide a more nuanced understanding of how and which neighborhood contexts influence the health and well-being of YMSM. This further examination of spatial polygamy (and individual-level characteristics associated with it) may increase understanding of the most appropriate locations for targeted disease prevention and health promotion interventions (e.g., HIV prevention interventions).
PMCID: PMC4199000  PMID: 25170685
spatial polygamy; neighborhoods; gay men’s health
13.  Illicit Drug Use, Depression and their Association with Highly Active Antiretroviral Therapy in HIV-Positive Women 
Drug and alcohol dependence  2007;89(1):74-81.
We examined the interaction of illicit drug use and depressive symptoms, and how they affect the subsequent likelihood of highly active antiretroviral therapy (HAART) use among women with HIV/AIDS.
Subjects included 1,710 HIV-positive women recruited from six sites in the U.S. including Brooklyn, Bronx, Chicago, Los Angeles, San Francisco/Bay Area, and Washington, DC. Cases of probable depression were identified using depressive symptom scores on the Centers for Epidemiologic Studies Depression Scale. Crack, cocaine, heroin, and amphetamine use were self-reported at 6-month time intervals. We conducted multivariate logistic random regression analysis of data collected during sixteen waves of semiannual interviews conducted from April 1996 through March 2004.
We found an interaction effect between illicit drug use and depression that acted to suppress subsequent HAART use, controlling for virologic and immunologic indicators, socio-demographic variables, time, and study site.
This is the first study to document the interactive effects of drug use and depressive symptoms on reduced likelihood of HAART use in a national cohort of women. Since evidence-based behavioral health and antiretroviral therapies for each of these three conditions are now available, comprehensive HIV treatment is an achievable public health goal.
PMCID: PMC4009351  PMID: 17291696
HIV; depression; HAART; drug use
14.  Sexual Health Screening Among Racially/Ethnically Diverse Young Gay, Bisexual, and Other Men Who Have Sex with Men 
Screening for sexually transmitted infections is a crucial element of improving health and reducing disparities, and young men who have sex with men (YMSM) face high rates of both STIs and HIV. We examined sexual health screening among a diverse sample of adolescent YMSM living in New York City.
Between 2009 – 2011, cross-sectional data were collected from 590 YMSM in New York City. Separate multivariable logistic regression models were used to assess the relationship between sociodemographic, psychosocial, and health and healthcare related factors and two main outcomes: having sought a recent sexual health screening (past 6 months) and having a rectal sexual health screening (lifetime).
Overall, 46% reported a sexual health screening in the prior 6 months, but only 16% reported ever having a rectal screening for STIs. Rates were higher among ethnic minority YMSM and men who accessed care at clinics. Multivariable results indicated that gay community affiliation, recent unprotected anal sex, and number of lifetime male partners were also associated with seeking a recent screening.
Though half of the sample reported recent general screening, rates of lifetime rectal screening are low. Efforts to increase screening may focus on improving provider knowledge and guideline adherence, and educating and encouraging YMSM to access sexual health check-ups.
PMCID: PMC3634893  PMID: 23298989
adolescent; gay and bisexual; sexual health; sexually transmitted infections
15.  Individual, Psychosocial, and Social Correlates of Unprotected Anal Intercourse in a New Generation of Young Men Who Have Sex With Men in New York City 
American journal of public health  2013;103(5):889-895.
We examined associations of individual, psychosocial, and social factors with unprotected anal intercourse (UAI) among young men who have sex with men in New York City.
Using baseline assessment data from 592 young men who have sex with men participating in an ongoing prospective cohort study, we conducted multivariable logistic regression analyses to examine the associations between covariates and likelihood of recently engaging in UAI with same-sex partners.
Nineteen percent reported recent UAI with a same-sex partner. In multivariable models, being in a current relationship with another man (adjusted odds ratio [AOR] = 4.87), an arrest history (AOR = 2.01), greater residential instability (AOR = 1.75), and unstable housing or homelessness (AOR = 3.10) was associated with recent UAI. Although high levels of gay community affinity and low internalized homophobia were associated with engaging in UAI in bivariate analyses, these associations did not persist in multivariable analyses.
Associations of psychosocial and socially produced conditions with UAI among a new generation of young men who have sex with men warrant that HIV prevention programs and policies address structural factors that predispose sexual risk behaviors.
PMCID: PMC3660046  PMID: 23488487
16.  Predictors and effects of alcohol use on liver function among young HCV-infected injection drug users in a behavioral intervention 
Journal of hepatology  2010;55(1):45-52.
Background & Aims
Hepatitis C virus (HCV) screening can provide opportunities to reduce disease progression through counseling against alcohol use, but empirical data on this issue are sparse. We determined the efficacy of a behavioral intervention in reducing alcohol use among young, HCV-infected injection drug users (IDUs) (n=355) and assessed whether changes in liver enzymes were associated with changes in alcohol consumption.
Both the intervention and attention-control groups were counseled to avoid alcohol use, but the intervention group received enhanced counseling. Logistic regression, ANOVA, and continuous time Markov models were used to identify factors associated with alcohol use, changes in mean ALT and AST levels and change in alcohol use post-intervention.
Six months post-intervention, alcohol abstinence increased 22.7% in both groups, with no difference by intervention arm. Transition from alcohol use to abstinence was associated with a decrease in liver enzymes, with a marginally greater decrease in the intervention group (p=0.05 for ALT; p=0.06 for AST). In multivariate Markov models, those who used marijuana transitioned from alcohol abstinence to consumption more rapidly than non-users (RR=3.11); those who were homeless transitioned more slowly to alcohol abstinence (RR=0.47); and those who had ever received a clinical diagnosis of liver disease transitioned more rapidly to abstinence (RR=1.88).
Although, behavioral counseling to reduce alcohol consumption among HCV-infected IDUs had a modest effect, reductions in alcohol consumption were associated with marked improvements in liver function. Interventions to reduce alcohol use among HCV-infected IDUs may benefit from being integrated into clinical care and monitoring of HCV infection.
PMCID: PMC3094600  PMID: 21145862
17.  The relationship between non-injection drug use behaviors on progression to AIDS and death in a cohort of HIV seropositive women in the era of highly active antiretroviral therapy use 
Addiction (Abingdon, England)  2005;100(7):990-1002.
To evaluate the effects of longitudinal patterns and types of non-injection drug use (NIDU) on HIV progression in the highly active antiretroviral therapy (HAART) era.
Women’s Interagency HIV Study (WIHS), a prospective cohort study conducted at six US sites.
Data were collected semi-annually from 1994 to 2002 on 1046 HIV+ women. Multivariate Cox proportional hazards modeling was used to estimate relative hazards for developing AIDS and for death by pattern and type of NIDU.
During follow-up, 285 AIDS events and 287 deaths, of which 177 were AIDS-related, were reported. At baseline, consistent and former NIDU was associated with CD4+ counts of < 200 cells/μl (43% and 46%, respectively) and viral load > 40 000 copies/ml (53% and 55%, respectively). Consistent NIDU reported less HAART use (53%) compared with other NIDU patterns. Stimulant use was associated with CD4+ cell counts of < 200 cells/μl (53%) and lower HAART initiation (63%) compared with other NIDU types. In multivariate analyses, progression to AIDS was significantly higher among consistent (RH = 2.52), inconsistent (RH = 1.63) and former (RH = 1.56) users compared with never users; and for stimulant (RH = 2.04) and polydrug (RH = 1.65) users compared with non-users. Progression to all-cause death was higher only among former users (RH = 1.48) compared with never users in multivariate analysis. NIDU behaviors were not associated with progression to AIDS-related death.
In this study, pattern and type of NIDU were associated with HIV progression to AIDS and all-cause mortality. These differences were associated with lower HAART utilization among consistent NIDU and use of stimulants, and poor baseline immunological and virological status among former users.
PMCID: PMC3128378  PMID: 15955015
Acquired immunodeficiency syndrome; highly active anti-retroviral therapy; human immunodeficiency virus; mortality; non-injection drug use
18.  Design and Feasibility of a Randomized Behavioral Intervention to Reduce Distributive Injection Risk and Improve Health-Care Access Among hepatitisC virus Positive Injection Drug Users: The Study to Reduce Intravenous Exposures (STRIVE) 
Journal of Urban Health   2007;84(1):99-115.
Hepatitis C virus (HCV) is hyperendemic among injection drug users (IDUs). However, few scientifically proven interventions to prevent secondary transmission of HCV from infected IDUs to others exist. This report describes the design, feasibility, and baseline characteristics of participants enrolled in the Study to Reduce Intravenous Exposure (STRIVE). STRIVE was a multisite, randomized-control trial to test a behavioral intervention developed to reduce distribution of used injection equipment (needles, cookers, cottons, and rinse water) and increase health-care utilization among antibody HCV (anti-HCV) positive IDUs. STRIVE enrolled anti-HCV positive IDU in Baltimore, New York City, and Seattle; participants completed behavioral assessments and venipuncture for HIV, HCV-RNA, and liver function tests (LFTs) and were randomized to attend either a six-session, small-group, peer-mentoring intervention workshop or a time-matched, attention-control condition. Follow-up visits were conducted at 3 and 6 months. At baseline, of the 630 HCV-positive IDUs enrolled (mean age of 26 years, 60% white, 76% male), 55% reported distributive needle sharing, whereas 74, 69, and 69% reported sharing cookers, cottons, and rinse water, respectively. Health-care access was low, with 41% reporting an emergency room as their main source of medical care. Among those enrolled, 66% (418/630) were randomized: 53% (222/418) and 47% (196/418) to the intervention and control conditions, respectively. Follow-up rates were 70 and 73% for the 3- and 6-month visits, respectively. As distributive sharing of used injection equipment was common while reports of receiving HCV care were low, these findings indicate an urgent need for HCV-related interventions with IDUs and demonstrate the acceptability and feasibility to do so.
PMCID: PMC2078252  PMID: 17200799
Behavioral intervention; Health-care utilization; hepatitis C virus;  Injection drug user; Randomized trial
19.  Self-Reported Hepatitis C Virus Antibody Status and Risk Behavior in Young Injectors 
Public Health Reports  2006;121(6):710-719.
This study was conducted to assess the accuracy of self-reported hepatitis C virus (HCV) antibody (anti-HCV) serostatus in injection drug users (IDUs), and examine whether self-reported anti-HCV serostatus was associated with recent injection risk behavior.
In five U.S. cities (Baltimore, Chicago, Los Angeles, New York, and Seattle), 3,004 IDUs from 15 to 30 years old were recruited for a baseline interview to determine eligibility for a randomized controlled trial of a behavioral intervention. HIV and HCV antibody testing were performed, and subject data (e.g., demographics, drug and sexual risk behavior, and history of HIV and HCV testing) were collected via audio computer-administered self-interview. Risk behavior during the previous three months was compared to self-reported anti-HCV serostatus.
Anti-HCV prevalence in this sample of young IDUs was 34.1%. Seventy-two percent of anti-HCV-positive and 46% of anti-HCV-negative IDUs in this sample were not aware of their HCV serostatus. Drug treatment or needle exchange use was associated with increased awareness of HCV serostatus. Anti-HCV-negative IDUs who knew their serostatus were less likely than those unaware of their status to inject with a syringe used by another IDU or to share cottons to filter drug solutions. Knowledge of one's positive anti-HCV status was not associated with safer injection practices.
Few anti-HCV-positive IDUs in this study were aware of their serostatus. Expanded availability of HCV screening with high quality counseling is clearly needed for this population to promote the health of chronically HCV-infected IDUs and to decrease risk among injectors susceptible to acquiring or transmitting HCV.
PMCID: PMC1781913  PMID: 17278406
20.  Screening for depressive symptoms among HCV-infected injection drug users: Examination of the utility of the CES-D and the beck depression inventory 
The prevalence of depression is high among injection drug users (IDUs) and among those infected with the hepatitis C virus (HCV). Moreover, one of the drugs used in the standard treatment for HCV infection (interferon) has been known to exacerbate, underlying psychiatric disorders such as depression and has been associated with the development of major, depressive disorder among HCV-infected patients. For these reasons, the most recent National Institutes of Health consensus statement on the management of HCV infection recommends the identification and treatment of depression prior to the start of HCV treatment. This study aimed to examine the extent of current moderate/severe depressive symptoms in a cohort of HCV-infected IDUs as measured by two screening tools, the Center for Epidemiologic Studies Depression Scale (CES-D) and the Beck Depression Inventory (BDI). Subjects were participants in a multisite behavioral intervention trial among HCV-seropositive, human immunodeficiency virus-negative IDUs aged 18–35 years; the trial was designed to prevent secondary transmission of HCV and to enhance uptake of HCV treatment. Baseline data on demographics, risk behaviors, depression, alcohol use, and health care utilization were measured via audio computer-assisted self-interview. A factor analysis was conducted on each scale to examine the clustering of items used in each to measure depressive symptoms. Baseline depressive symptoms, as measured via the CES-D and the BDI, were also compared using Pearson’s correlation coefficient. Of 193 HCV-infected individuals enrolled to date, 75,6% were male, and 65.3% were white. Median age was 25.8 years. Factor analyses revealed that these scales measured depression differently; a distinct somatic component was present in the BDI, but not the CES-D. Using cutoff scores of 23 for the CES-D and 19 for the BDI, 44.0% and 41.5% of the participants were identified as having moderate/severe depressive symptoms, respectively. Over half (56.0%) were identified as having depressive symptoms
PMCID: PMC3456451  PMID: 15136661

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