Widespread diversion of antiretroviral (ARV) medications to illicit markets has recently been documented among indigent patients in South Florida. The recent approval of ARVs for pre-exposure prophylaxis (PrEP) has the potential to broaden these illicit markets, as high risk individuals seek ARVs without a prescription or medical supervision. Non-adherence among diverters and unsupervised use of ARVs for treatment or PrEP increase risks of treatment failure, drug resistance, and disease transmission. We report the scope of ARV diversion among substance using men who have sex with men in South Florida. Structured interviews (N=515) queried demographics, HIV status, mental distress, substance dependence, and sexual risks. HIV-positive participants answered questions about medical care, treatment, and ARV adherence and diversion. Median age was 39. Of 46.4% who were HIV-positive, 79.1% were prescribed ARVs. Of these, 27% reported selling/trading ARVs. Reasons for diversion were sharing/trading with friends, sale/trade for money/drugs, and sale/trade of unused medications. ARV diverters, compared to non-diverters, were more likely to be substance dependent (74.5% vs. 58.7%, p=.046) and have traded sex for money/drugs (60.8% vs. 32.6%, p<.001); and less likely to be adherent to ARVs (54.9% vs. 73.9%, p=.012). ARV diversion should be a particular concern in communities of high risk MSM, as uninfected men in such communities are likely to benefit most from PrEP but unlikely to have access to PrEP and necessary ancillary services through the health care system. The implications of diversion for increased risks of treatment failure, disease transmission, and PrEP failure should be carefully considered in developing policy and behavioral supports to scaling up treatment as prevention and PrEP.
ARV; PrEP; MSM; diversion
This paper reports on changes in substance use and substance dependence symptoms - without intervention - among young adult multidrug users in the club scene, ages 18–29, (N=444) who participated in a natural history study. Computer-assisted personal interviews at baseline and 6-, 12-, and 18-month follow-ups included well-tested measures of substance use and dependence. Changes in substance dependence symptoms and drug use frequencies were calculated using the Cohen’s d statistic. Mean age was 22; 40% were female; 58% Hispanic, 17% White, and 21% Black. At 18-month follow-up assessment, participants reported significantly fewer days of cocaine (d= −.85 at 18 months), ecstasy (d= −.93), benzodiazepine (d= −.82), and prescription opioid (d= −.81) use, as well as reduced substance dependence symptoms (d= −.42). These results, together with data from focus groups with completers, suggest that comprehensive health and social risk assessments may have quite strong intervention effects among young adult multidrug users.
substance use; club drugs; young adult; reactive effects; intervention
Research on street-based female sex workers documents a multitude of problems faced by these women, such as, substance use, HIV risk, mental health problems, victimization, and homelessness. The presence of problems such as these is understood as a syndemic, or co-occurrence of two or more risk factors that act synergistically to create an excess burden of disease. However, the syndemic framework has not previously incorporated the examination of resilience to understand what protective factors enable female sex workers to cope with syndemic risk. Using 562 baseline interviews from street-based African American female sex workers enrolled in a randomized intervention trial, this study is the first to investigate expressions of resilience among this vulnerable population. Specifically, these analyses examine high levels of resilience, as measured by personal mastery, in order to understand the contributions of syndemic risk factors and protective factors on the expression of resilience. In bivariate logistic regression models, women with high resilience reported significantly higher odds of high school education, greater access to transportation, and more social support, in addition to lower odds of foster care history, homelessness, substance dependence, severe mental distress, victimization, and HIV risk. In the multivariate model, higher odds of high school education and increased social support, in addition to lower odds of mental distress and HIV risk remained associated with high resilience. The findings suggest specific targets for intervention to assist female sex workers in coping syndemic risk factors and achieving better health outcomes. These include the prioritizing education and training opportunities and the enhancement of social support.
syndemic; resilience; women; sex work; personal mastery
Although emerging Treatment as Prevention models can be effective in reducing HIV incidence among high-risk populations, many HIV infected individuals remain undiagnosed or fail to engage in HIV care.
This study examined the factors associated with HIV testing and care among a population of substance using female sex workers.
Recent HIV testing was associated with higher education level, having a regular health care provider or clinic, recent crack use, and higher sexual risk behaviors; HIV treatment utilization was associated with higher levels of social support, having a regular health care provider or clinic, housing stability and insurance coverage. Qualitative data revealed HIV-related stigma, denial, social isolation, and substance use as barriers to HIV testing and treatment; social support and accessibility of services were key enablers.
Improving HIV testing and linkage to treatment among female sex workers will require structural initiatives to reduce stigma and increase service seeking support.
HIV testing; HIV prevention; HIV treatment; female sex workers; barriers
Serosorting is commonly employed by MSM to reduce HIV risk. We hypothesize that MSM perceive serosorting to be effective, and that serosorting is predicted by resilience and inversely related to syndemic characteristics. Surveys included 504 substance-using MSM. Logistic regression models examined syndemic and resilience predictors of serosorting, separately by serostatus. For HIV-positive men, positive coping behaviors (P = .015) and coping self-efficacy (P = .014) predicted higher odds, and cognitive escape behaviors (P = .003) lower odds, of serosorting. For HIV-negative men, social engagement (P = .03) and coping self-efficacy (P = .01) predicted higher odds, and severe mental distress (P = .001), victimization history (P = .007) and cognitive escape behaviors (P = .006) lower odds, of serosorting. HIV-negative serosorters reported lower perceptions of risk for infection than non-serosorters (P < .000). Although high risk HIV-negative men may perceive serosorting to be effective, their high rates of UAI and partner change render this an ineffective risk reduction approach. Relevant public health messages are urgently needed.
Although street-based female sex workers (FSWs) are highly vulnerable to HIV, they often lack access to needed health services and medical care. This paper reports the results of a recently completed randomized intervention trial for FSWs in Miami, Florida, which tested the relative efficacy of two case management interventions that aimed to link underserved FSWs with health services and to reduce risk behaviors for HIV. Participants were recruited using targeted sampling strategies and were randomly assigned to: a Strengths-Based/Professional Only (PO) or a Strengths-Based/Professional-Peer condition (PP). Follow-up data were collected 3 and 6 months post-baseline. Outcome analyses indicated that both intervention groups displayed significant reductions in HIV risk behaviors and significant increases in services utilization; the Professional-Peer condition provided no added benefit. HIV seropositive FSWs responded particularly well to the interventions, suggesting the utility of brief strengths-based case management interventions for this population in future initiatives.
female sex workers; HIV interventions; service utilization; peers; drug use
Benzodiazepines (BZs) are among the most frequently prescribed drugs with the potential for abuse. Young adults ages 18–29 report the highest rates of BZ misuse in the United States. The majority of club drug users are also in this age group, and BZ misuse is prevalent in the nightclub scene. BZ dependence, however, is not well documented. This paper examines BZ dependence and its correlates among multidrug users in South Florida’s nightclub scene.
Data were drawn from structured interviews with men and women (N=521) who reported regular attendance at large dance clubs and recent use of both club drugs and BZs.
Prevalences of BZ-related problems were 7.9% for BZ dependence, 22.6% BZ abuse, and 25% BZ abuse and/or dependence. In bivariate logistic regression models, heavy cocaine use (OR 2.27; 95% CI 1.18, 4.38), severe mental distress (OR 2.63; 95% CI 1.33, 5.21), and childhood victimization history (OR 2.43; 95% CI 1.10, 5.38) were associated with BZ dependence. Heavy cocaine use (OR 2.14; 95% CI 1.10, 4.18) and severe mental distress (OR 2.16; 95% CI 1.07, 4.37) survived as predictors in the multivariate model.
BZ misuse is widespread among multidrug users in the club scene, who also exhibit high levels of other health and social problems. BZ dependence appears to be more prevalent in this sample than in other populations described in the literature. Recommendations for intervention and additional research are described.
benzodiazepine; young adult; club drugs; drug dependence
Compared with men who have sex with men only (MSMO), men who have sex with men and women (MSMW) consistently report higher rates of two HIV risk behaviors: transactional sex (TS) and concurrent substance use and sex (CSS). Within MSMW, little is known about how synergistic epidemics (“syndemics”) affect TS and CSS. Using a sample of substance-using MSM (n = 515) in South Florida, we compared TS and CSS among MSMO and MSMW; examined whether, within MSMW (n = 86), TS and CSS predict unprotected anal intercourse with partners of serodiscordant/unknown HIV status (SU-UAI); and tested whether syndemics predict TS and CSS. MSMW reported higher rates of engaging in both TS and CSS (AOR = 1.7; 95 % CI 1.0–3.0). Within MSMW, engagement in both TS and CSS predicted SU-UAI (AOR = 3.3; 95 % CI 1.2–9.6); and syndemics predicted TS and CSS involvement (p < 0.01). Substance-using MSMW may benefit from interventions targeting TS, CSS, and background syndemics.
HIV/AIDS; Bisexuality; Transactional sex; Concurrent substance use and sex; Syndemics
Substance-using men who have sex with men (MSM) are among the groups at highest risk for HIV infection in the United States. We report the results of a randomized trial testing the efficacy of a small group sexual and substance use risk reduction intervention based on empowerment theory compared to an enhanced efficacious control condition among 515 high risk not-in-treatment MSM substance users. Effect sizes for sexual risk and substance use outcomes were moderate to large: HIV transmission risk frequency, d = 0.71 in the control versus 0.66 in the experimental group; number of anal sex partners, d = 1.04 versus 0.98; substance dependence symptoms, d = 0.49 versus 0.53; significant differences were not observed between conditions. Black MSM reduced their risks at a greater rate than White or Latino men. The findings point to a critically important research agenda to reduce HIV transmission among MSM substance users.
MSM; HIV; Substance use; Sexual risk; Behavioral intervention
Gay and bisexual men continue to suffer the highest burden of HIV/AIDS in the U.S. Since the beginning of the epidemic, substance abuse has been shown to be one of the strongest predictors of sexual risk behaviors and seroconversion among this population. Recent research has focused on additional aspects of health risk disparities among gay and bisexual men, including depression and other mental health problems, childhood sexual abuse, and adult victimization, suggesting that these men are impacted by a syndemic of health risks. The involvement of gay and bisexual men with the criminal justice system is largely absent from the literature. This article describes the nature, extent and predictors of the arrest histories of a sample of gay and bisexual substance users at very high risk for HIV infection and/or transmission. These histories are surprisingly extensive, and are strongly associated with poverty, severe mental distress, substance abuse and dependence, and victimization. The involvement of gay and bisexual men in the criminal justice system deserves a stronger research focus because of the unique challenges facing such men and also because arrests are yet another marker for a host of health risks among them.
arrest history; gay men; HIV/AIDS; MSM; syndemic theory
Little is known regarding the demographic and behavioral characteristics of nonmedical prescription drug users (NMPDUs) entering substance abuse treatment settings, and information on the HIV-related risk profiles of NMPDUs is especially lacking. Participation in substance abuse treatment provides a critical opportunity for HIV prevention and intervention, but successful initiatives will require services appropriately tailored for the needs of NMPDUs.
This paper compares the HIV risk profiles of NMPDUs in public (n = 246) and private (n = 249) treatment facilities. Participants included in the analysis reported five or more recent episodes of nonmedical prescription drug use, a prior HIV negative test result, and current enrollment in a substance abuse treatment facility. A standardized questionnaire was administered by trained interviewers with questions about demographics, HIV risk, and substance use.
Private treatment clients were more likely to be non-Hispanic White, younger, and opioid and heroin users. Injection drug use was higher among private treatment clients, whereas public clients reported higher likelihood of trading or selling sex. Public treatment clients reported higher rates of HIV testing and availability at their treatment facilities compared to private clients.
Findings suggest differing demographics, substance use patterns, profiles of HIV risk and access to HIV testing between the two treatment samples. Population tailored HIV interventions, and increased access to HIV testing in both public and private substance treatment centers, appear to be warranted.
HIV; Substance treatment; Nonmedical prescription drug use
Health and social disparities are widespread among men who have sex with men (MSM). Although literature indicates that Black MSM (BMSM) are no more likely than other MSM to report sexual risk behaviors, such as unprotected anal intercourse, studies have reported that buying and trading sex appear to be important risk factors for BMSM. Substance use generally is not significantly greater among BMSM than other MSM, studies have found that BMSM report more powder and crack cocaine use than other MSM. The lack of adequate coping skills and social support for BMSM has also been documented. This paper examines differences in substance use, sexual risk behaviors and social support among Black and non-black MSM, in a sample of 515 men participating in a randomized intervention trial. BMSM reported higher rates of substance dependence (72.2% vs. 59.5%, P=.015) and buying sex (49.1% vs. 17.4%, P<.000) than non-Black MSM. BMSM also reported lower levels of social support than other MSM on all measures included in the study; e.g., getting help and emotional support from others (38.0% vs. 52.8%, P<.006). Mediation analyses showed that BMSM’s higher rates of substance dependence and buying sex are partially mediated by lower levels of social support. Our data appear to show that lack of social support is an important influence on risk behaviors among BMSM. Qualitative data also supported these findings. Sexual risk and substance use prevention interventions should address BMSM’s capacity to build adequate and supportive relationships.
African American; MSM; substance use; sexual risk behavior; social support
To examine the demographic, physical, and mental health characteristics; current drug use patterns; motivations for use; and diversion sources among elderly prescription opioid misusers.
Mixed methods design.
Research field offices, or senior or community center offices in South Florida.
Individuals aged 60 and over reporting past 90-day prescription medication misuse; only prescription opioid misusers (N = 88) were included in the final analysis.
The Global Appraisal of Individual Needs was the main survey instrument. A subsample of elderly reporting substantial prescription drug misuse were chosen for the in-depth interview (N = 30).
The mean age was 63.3. Fifty percent reported ever being admitted to a drug treatment program; several endorsed recent illicit drug use: powder cocaine and/or crack (35.2%), marijuana (30.7%), heroin (14.8%). The majority reported past year severe physical pain and discomfort (86.4%), and misuse of their primary opioid for pain (80.7%); over half (52.3%) obtained their primary opioid from their regular doctor. Qualitative data highlight the misuse of prescription opioids due to untreated or undertreated pain. Participants with primary opioid misuse for pain had over 12 times higher odds of obtaining the medication from their regular doctor (odds ratio [OR] = 12.22, P = 0.002) and had lower odds of using a dealer (OR = 0.20, P = 0.005).
Findings suggest that this group of elderly participants often misuse their own prescriptions for pain management. This study highlights the need to educate prescribing professionals on appropriate pain management for older adults while still being sensitive to issues of substance abuse and dependence.
Older Adults; Pain Management; Substance Abuse; Opioids
Foster care has been associated with increased HIV risk behaviors among youth, yet long-term association with HIV infection has not been examined. This study explored the associations between foster placement, victimization, mental health, onset of sex work and HIV infection among highly vulnerable female sex workers. 562 drug-involved African American women were enrolled into an intervention study to increase health services utilization and reduce HIV risk. Seventeen percent reported a history of foster placement. Foster history was associated with significantly lower educational attainment, higher victimization, and more severe mental health problems. Women with foster histories reported significantly earlier entry into paid sex work, with some 62% active in the sex trade before age 18. Multivariate analyses found that foster care was independently associated with HIV seropositivity, and that early sex work partially mediated this association. The potential long-term health vulnerabilities associated with foster placement are understudied and warrant additional research.
women; sex workers; HIV; foster care
Street-based female sex workers constitute a vulnerable population for HIV, as they are often enmeshed in chronic patterns of substance use, sexual risk, homelessness, and violent victimization. This study examined the specific contributions of victimization history and abuse-related traumagenic factors to mental health functioning and sexual risk behaviors, while considering the impact of environmental risk factors as well. Using targeted sampling strategies, we enrolled 562 Miami-based female sex workers into an intervention trial testing the relative effectiveness of two alternative case management conditions in establishing linkages with health services and reducing risk for HIV. Lifetime prevalence of abuse was extremely elevated at 88%. Nearly half reported abuse before the age of 18, while 34% reported violent encounters with “dates” or clients in the past 90 days. Serious mental illness (SMI) was quite common, with 74% reporting severe symptoms of depression, anxiety, or traumatic stress. For those with histories of abuse, SMI appeared to mediate the association between abuse-related trauma and unprotected sex behaviors. Mental health treatment would appear to be an important component of effective HIV prevention among this vulnerable group, and should form part of a compendium of services offered to female sex workers.
Using a sample of 482 ethnically diverse current substance using men who have sex with men (MSM) who reported recent unprotected anal intercourse (UAI), this study compared health risk behaviors – substance use and sexual HIV risk – and one health protective factor – prosocial activities - between men who live in a gay neighborhood and those who do not. Data are drawn from comprehensive health and social risk assessments administered in South Florida. In a multivariate logistic regression model, methamphetamine use, high rates of receptive UAI, and lower levels of prosocial engagement were found to be risk factors associated with gay neighborhood residence. Compared to living elsewhere, gay neighborhood residence appeared to be protective against cocaine use and substance dependence. Implications of the findings for prevention interventions are discussed, as is the need for further research regarding decisions about neighborhood residence and how neighborhood risk and protective factors emerge and are sustained.
MSM; neighborhoods; substance use; sex risk; risk factors
This research examined the following questions: (1) how do drug dealers acquire their inventories of prescription medications? and (2) which types of prescription medications do dealers most commonly sell? Data are drawn from a National Institute on Drug Abuse-funded research study that examined prescription drug diversion and abuse in South Florida. In-depth semi-structured interviews (n = 50) were conducted with an ethnically diverse sample of prescription drug dealers from a variety of milieus to assess patterns of diversion. Audiotapes of the interviews were transcribed, coded, and thematically analysed using the NVivo 8 software program. Dealers relied on a wide array of diversion methods including visiting multiple pain clinics, working with pharmacy employees to steal medications from pharmacies, and purchasing medications from indigent patients. The type of medication most commonly sold by dealers was prescription opioid analgesics, and to a lesser extent benzodiazepines such as alprazolam. These findings inform public health policy makers, criminal justice officials, the pharmaceutical industry and government regulatory agencies in their efforts to reduce the availability of diverted prescription drugs in the illicit market. Specifically, these data support the need for statewide prescription drug monitoring programs and increased training for healthcare workers who have access to controlled medications.
Modern desistance research has examined many facets of desistance, in terms of theoretical predictors of desistance and recidivism, and in terms of differing types of offending. Though predicting desistance from illegal drug use is among these topics, no research to date has examined the predictors of desisting from prescription opioid abuse. This study uses longitudinal data from 318 prescription opioid users to analyze the effects of various predictors of desistance on declining nonmedical prescription opioid use, with an emphasis on gender differences among participants. Results indicate that theoretical and demographic characteristics correspond with differing rates of decline and further vary by gender.
Prescription drug abuse; opioids; desistance
Route of administration is an important contributor to the adverse health consequences of prescription medication abuse. The present study examines characteristics associated with non-oral routes of administration among a large sample of prescription opioid abusers, and explores needle related
HIV risk behaviors as well. 791 opioid abusers completed a one-time, structured interview including complete histories of illicit and prescription drug abuse, and route of drug administration. The most common method of pill use was oral (91%), followed by intranasal (53.1%), injection (23.8%), and smoking (14.5%). The youngest prescription opioid abusers, ages 18–24, displayed significantly higher odds of employing alternate route of administration, and also of re-using nonsterile needles for injection. HIV prevention programming should be developed for young prescription opioid injectors.
prescription opioid abuse; route of administration; HIV
Numerous national surveys and surveillance programs have shown a substantial rise in the abuse of prescription opioids over the past 15 years. Accessibility of these drugs to non-patients is the result of their unlawful channeling from legal sources to the illicit marketplace (diversion). Empirical data on diversion remain absent from the literature. This paper examines abusers’ sources of diverted drugs from two large studies: 1) a national sample of opioid treatment clients (N=1983), and 2) a South Florida study targeting diverse populations of opioid abusers (N=782). The most common sources of diverted medications were dealers, sharing/trading, legitimate medical practice (e.g., unknowing medical providers), illegitimate medical practice (e.g., pill mills), and theft, in that order. Sources varied by users’ age, gender, ethnicity, risk-aversiveness, primary opioid of abuse, injection drug use, physical health, drug dependence, and either access to health insurance or relative financial wealth. Implications for prescription drug control policy are discussed.
Ecstasy and LSD use is widespread in large Brazilian cities, but there is limited information on their use among young, middle-class, club goers in Brazil. We conducted standardized face-to-face interviews with 200 male and female ecstasy and/or LSD users, focusing on drug use and sexual history, current risk behaviors, and psychiatric symptomatology. Participants with early sexual debut (before 14) were more likely to report lifetime use of marijuana and powder and crack cocaine than those with later sexual initiation. Early sexual debut was associated with past year sexual risk behaviors, including having sex while high (Prevalence Ratio (PR)=1.3), having two or more sex partners (PR=1.3), as well as history of sexual abuse (PR=13.6). Depression and anxiety scores were similar by age of sexual initiation. The implications of these findings are discussed.
Anal sexual intercourse represents the highest transmission risk for infection with the human immunodeficiency virus (HIV), yet much of what we know about anal sex is based on men who have sex with men (MSM). Less is known about heterosexual adults who practice anal sex, especially those who may be at risk for HIV such as substance users. The present study examined the demographic, sexual behaviors, substance use, and psychosocial correlates of recent anal intercourse among a heterosexual young adult sample of nightclub goers who also use substances. Data were drawn from an on-going natural history study of participants (n=597) in Miami's club scene who use club drugs, use prescription medications for non-medical reasons, and were regular attendees of nightclubs. Participants who reported anal sex (n=118) were more likely to be male, of moderate income, Latino, trade sex, have unprotected sex, and report victimization. Event-based and qualitative studies are needed to better understand the context in which anal sex occurs. Interventions that target heterosexual populations should include discussion about the risks of anal sex.
Anal sex; Drug use; Heterosexual; Mental health; Sexual risk
Adopting socioecological, intersectionality, and lifecourse theoretical frameworks may enhance our understanding of the production of syndemic adverse health outcomes among gay, bisexual and other men who have sex with men (MSM). From this perspective, we present preliminary data from three related studies that suggest ways in which social contexts may influence the health of MSM. The first study, using cross-sectional data, looked at migration of MSM to the gay resort area of South Florida, and found that amount of time lived in the area was associated with risk behaviors and HIV infection. The second study, using qualitative interviews, observed complex interactions between neighborhood-level social environments and individual-level racial and sexual identity among MSM in New York City. The third study, using egocentric network analysis with a sample of African American MSM in Baltimore, found that sexual partners were more likely to be found through face-to-face means than the Internet. They also observed that those who co-resided with a sex partner had larger networks of people to depend on for social and financial support, but had the same size sexual networks as those who did not live with a partner. Overall, these findings suggest the need for further investigation into the role of macro-level social forces on the emotional, behavioral, and physical health of urban MSM.
Homosexuality; Male; Urban health; Social environment