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1.  Stimulant Use and Progression to AIDS or Mortality After The Initiation of Highly Active Anti-Retroviral Therapy 
HIV-positive persons who use stimulants (e.g., methamphetamine) experience profound health disparities, but it remains unclear if these persist after highly active anti-retroviral therapy (HAART) initiation. Conducted within the Multicenter AIDS Cohort Study, this investigation examined if stimulant use is associated with progression to AIDS or all-cause mortality after the initiation of HAART.
Using marginal structural modeling, the cumulative proportion of visits where any stimulant use was reported (i.e., 0%, 1 – 49%, 50 – 99%, and 100%) was examined as a time-varying predictor of: 1) all-cause mortality; and 2) AIDS or all-cause mortality.
Among the 1,313 men who have sex with men (MSM) who initiated HAART, findings showed no significant association of any level of stimulant use with all-cause mortality. A competing risks analysis indicated that no level of stimulant use was associated with increased AIDS-related or non-AIDS mortality separately. Among the 648 participants without AIDS at HAART initiation, a secondary analysis indicated that stimulant use at 50% or more of study visits was associated with a 1.5-fold increase in the odds of progression to AIDS or all-cause mortality (Adjusted OR = 1.54; 95% CI = 1.02 – 2.33, p < .05).
HIV-positive, stimulant-using MSM receiving HAART appear to face no greater overall risks for all-cause, AIDS-related, or non-AIDS mortality compared to non-users. However, men without AIDS at HAART initiation who more frequently reported stimulant use demonstrated modestly increased odds of progression to AIDS or all-cause mortality. Comprehensive approaches are needed to optimize the effectiveness of HAART with stimulant-using MSM.
PMCID: PMC4232455  PMID: 25271387
Cocaine; HIV/AIDS; Methamphetamine; Mortality; Treatment as Prevention
2.  Hepatitis C and HIV incidence and harm reduction program use in a conflict setting: an observational cohort of injecting drug users in Kabul, Afghanistan 
Armed conflict may increase the risk of HIV and other pathogens among injecting drug users (IDUs); however, there are few prospective studies. This study aimed to measure incidence and potential predictors, including environmental events and needle and syringe distribution and collection program (NSP) use, of hepatitis C virus (HCV) and HIV among IDUs in Kabul, Afghanistan.
Consenting adult IDUs completed interviews quarterly in year 1 and semi-annually in year 2 and HCV and HIV antibody testing semi-annually through the cohort period (November 2007–December 2009). Interviews detailed injecting and sexual risk behaviors, NSP service use, and conflict-associated displacement. Quarters with peak conflict or local displacement were identified based on literature review, and key events, including insurgent attacks and deaths, were reported with simple counts. Incidence and predictors of HCV and HIV were measured with Cox proportional hazards models.
Of 483 IDUs enrolled, 385 completed one or more follow-up visits (483.8 person-years (p-y)). All participants were male with a median age of 28 years and a median duration of injecting of 2 years. Reported NSP use among the participants ranged from 59.9 to 70.5 % in the first year and was 48.4 and 55.4 % at 18 and 24 months, respectively. There were 41 confirmed deaths, with a crude death rate of 93.4/1000 p-y (95 % confidence interval (CI) 67.9–125) and overdose as the most common cause. HCV and HIV incidence were 35.6/100 p-y (95 % CI 28.3–44.6) and 1.5/100 p-y (95 % CI 0.6–3.3), respectively. Changing from injecting to smoking was protective for HCV acquisition (adjusted hazard ratio (AHR) = 0.53, 95 % CI 0.31–0.92), while duration of injecting (AHR = 1.09, 95 % CI 1.01–1.18/year) and sharing syringes (AHR = 10.09, 95 % CI 1.01–100.3) independently predicted HIV infection.
There is high HCV incidence and high numbers of reported deaths among male Kabul IDUs despite relatively consistent levels of harm reduction program use; peak violence periods did not independently predict HCV and HIV risk. Programming should increase awareness of HCV transmission and overdose risks, prepare clients for harm reduction needs during conflict or other causes of displacement, and continue efforts to engage community and police force support.
PMCID: PMC4608295  PMID: 26472126
Injecting drug use; Armed conflict; Afghanistan; Hepatitis C virus; HIV; Harm reduction
Violence against women  2014;20(7):799-824.
We assessed relations among neighborhood characteristics and sexual intimate partner violence against women (SIPVAW), among low-income, drug-involved, women (N=360) and men (N=670) in New York City between 2005 and 2009. Six percent of women (n=22) and 5% of men (n=33) reported experiencing and perpetrating SIPVAW in the past year with a main partner. In adjusted mixed models among women, neighborhood ethnic heterogeneity was significantly, negatively associated with SIPVAW victimization. In adjusted logistic models among men, neighborhood collective efficacy was significantly, positively associated with SIPVAW perpetration. Novel theoretical frameworks are needed to guide research on neighborhoods and partner violence.
PMCID: PMC4516172  PMID: 25062819
sexual violence; neighborhoods; intimate partner violence; social disorganization; multilevel modeling; collective efficacy
4.  Intimate Partner Violence Perpetration and Condom Use-Related Factors: Associations with Heterosexual Men’s Consistent Condom Use 
AIDS and behavior  2011;15(1):153-162.
Intimate partner violence victimization has been linked to sexual HIV risk behavior among heterosexual women. The unique role of perpetration of intimate partner violence (IPV) in sexual risk behavior among men has not been studied as well. Based on interviews with 518 heterosexual men recruited via street-intercept between 2005 and 2007 in New York City, we assessed the relationship between perpetration of IPV against a main female partner and inconsistent condom use with that same partner, while controlling for condom use-related factors. Multivariate logistic regression revealed that men who perpetrated physical IPV were half as likely to report consistent condom use as compared with men who did not use violence, while controlling for sociodemographic, condom use-related and other factors. Physical IPV perpetration by heterosexual men makes an independent contribution to consistent condom use. Designing interventions for heterosexual men that simultaneously address both IPV and sexual risk behaviors is critical.
PMCID: PMC4423735  PMID: 20069447
HIV; Sexual risk behavior; Condom use; Intimate partner violence
5.  Understanding Prolonged Cessation From Heroin Use: Findings From a Community-Based Sample 
Journal of psychoactive drugs  2014;46(2):123-132.
There is abundant literature describing heroin initiation, co-morbidities, and treatment. Few studies focus on cessation, examining the factors that motivate and facilitate it.
The CHANGE study utilized mixed methods to investigate heroin cessation among low-income New York City participants. This paper describes findings from qualitative interviews with 20 former and 11 current heroin users. Interviews focused on background and current activities, supports, drug history, cessation attempts, and motivators and facilitators to cessation.
Participants found motivation for cessation in improved quality of life; combination of treatment, strategic avoidance of triggers, and engagement in alternative activities, including support groups, exercise, and faith-based practice. Several reported that progress toward goals served as motivators that increased confidence and facilitated cessation. Ultimatums were key motivators for some participants. Beyond that, they could not articulate factors that distinguished successful from unsuccessful cessation attempts, although data suggest that those who were successful could describe more individualized and concrete—rather than general—motivators and strategies.
Our findings indicate that cessation may be facilitated by multifaceted and individualized strategies, suggesting a need for personal and comprehensive approaches to treatment.
PMCID: PMC4112471  PMID: 25052788
heroin; cessation; treatment; methadone; recovery; abstinence
6.  Racial Susceptibility for QT Prolongation in Acute Drug Overdoses Authors 
Journal of electrocardiology  2013;47(2):244-250.
Background and Purpose
QT prolongation independently predicts adverse cardiovascular events in suspected poisoning. We aimed to evaluate the association between race and drug-induced QT prolongation for patients with acute overdose.
This was a cross-sectional observational study at two urban teaching hospitals. Consecutive adult ED patients with acute drug overdose were prospectively enrolled over a two year period. The primary outcome, long-QT, was defined using standard criteria: QTc >470ms in females and >460ms in males. The association between race and drug-induced QT prolongation was tested, considering several confounding variables.
In 472 patients analyzed (46% female, mean age 42.3), QT prolongation occurred in 12.7%. Blacks had two-fold increased odds of drug-induced QT prolongation (OR 2.01, CI 1.03-3.91) and Hispanics had 48% decreased odds of drug-induced QT prolongation (OR 0.52, CI 0.29-0.94).
We found significant racial susceptibility to drug-induced QT prolongation in this large urban study of acute overdoses.
PMCID: PMC3951924  PMID: 24438862
Overdose; QT prolongation; racial differences
7.  Methodology for Evaluating a Partially Controlled Longitudinal Treatment Using Principal Stratification, With Application to a Needle Exchange Program 
We consider studies for evaluating the short-term effect of a treatment of interest on a time-to-event outcome. The studies we consider are only partially controlled in the following sense: (1) Subjects’ exposure to the treatment of interest can vary over time, but this exposure is not directly controlled by the study; (2) subjects’ follow-up time is not directly controlled by the study; and (3) the study directly controls another factor that can affect subjects’ exposure to the treatment of interest as well as subjects’ follow-up time. When factors 1 and 2 are both present in the study, evaluating the treatment of interest using standard methods, including instrumental variables, does not generally estimate treatment effects. We develop the methodology for estimating the effect of treatment 1 in this setting of partially controlled studies under explicit assumptions using the framework for principal stratification for causal inference. We illustrate our methods by a study to evaluate the efficacy of the Baltimore Needle Exchange Program to reduce the risk of human immunodeficiency virus (HIV) transmission, using data on distance of the program’s sites from the subjects.
PMCID: PMC4332568  PMID: 25705065
Causal inference; HIV; Needle exchange; Partially controlled studies; Potential outcomes; Principal stratification
Addictive behaviors  2013;38(12):2868-2873.
There are few systematic assessments of street-obtained buprenorphine use from community-based samples in the United States. The objective of this study was to characterize the prevalence, correlates, and reasons for street-obtained buprenorphine use among current and former injection drug users (IDUs) in Baltimore, Maryland.
In 2008, participants of the ALIVE (AIDS Linked to the IntraVenous Experience) study, a community-based cohort of IDUs, were administered a survey on buprenorphine. Street-obtained buprenorphine represented self-reported use of buprenorphine obtained from the street or a friend in the prior three months.
602 respondents were predominantly male (65%), African-American (91%), and 30% were HIV-positive. Overall, nine percent reported recent street-obtained buprenorphine use, and only 2% reported using to get high. Among active opiate users, 23% reported recent use of street-obtained buprenorphine. Use of buprenorphine prescribed by a physician, injection and non-injection drug use, use of street-obtained methadone and prescription opiates, homelessness, and opioid withdrawal symptoms were positively associated, while methadone treatment, health insurance, outpatient care, and HIV-infection were negatively associated with recent street-obtained buprenorphine use in univariate analysis. After adjustment, active injection and heroin use were positively associated with street-obtained buprenorphine use. Ninety-one percent reported using street-obtained buprenorphine to manage withdrawal symptoms.
While 9% reported recent street-obtained buprenorphine use, only a small minority reported using buprenorphine to get high, with the majority reporting use to manage withdrawal symptoms. There is limited evidence of diversion of buprenorphine in this sample and efforts to expand buprenorphine treatment should continue with further monitoring.
PMCID: PMC3805723  PMID: 24018232
buprenorphine; injection drug use; drug treatment; diversion
9.  Neighborhood-Level Correlates of Consistent Condom Use among Men Who have Sex with Men: A Multi-Level Analysis 
AIDS and behavior  2008;14(4):974-985.
There is growing evidence that the neighborhood environment influences sexual behavior and related outcomes, but little work has focused specifically on men who have sex with men (MSM). Using interview data from a probability sample of 385 young MSM living in New York City, recruited at public venues in 1999 and 2000 as part of the Young Men’s Survey-New York City, and data on neighborhood characteristics obtained from the U.S. Census 2000, we conducted multi-level analyses of the associations between neighborhood-level characteristics and consistent condom use during anal intercourse, while controlling for individual-level sociodemographic and other factors. After adjusting for individual-level factors, neighborhood-level gay presence remained significantly and positively associated with consistent condom use during anal intercourse. This finding suggests that neighborhoods with a significant gay presence may have norms that act to discourage high risk sexual activity.
PMCID: PMC4226223  PMID: 18712593
Sexual HIV risk behavior; MSM; Urban neighborhood; Multi-level analysis; Condom use; Neighborhood environment
10.  Prescription opioid mortality trends in New York City, 1990–2006: Examining the emergence of an epidemic☆ 
Drug and alcohol dependence  2013;132(0):53-62.
The drug overdose mortality rate tripled between 1990 and 2006; prescription opioids have driven this epidemic. We examined the period 1990–2006 to inform our understanding of how the current prescription opioid overdose epidemic emerged in urban areas.
We used data from the Office of the Chief Medical Examiner to examine changes in demographic and spatial patterns in overdose fatalities induced by prescription opioids (i.e., analgesics and methadone) in New York City (NYC) in 1990–2006, and what factors were associated with death from prescription opioids vs. heroin, historically the most prevalent form of opioid overdose in urban areas.
Analgesic-induced overdose fatalities were the only types of overdose fatalities to increase in 1990–2006 in NYC; the fatality rate increased sevenfold from 0.39 in 1990 to 2.7 per 100,000 persons in 2006. Whites and Latinos were the only racial/ethnic groups to exhibit an increase in overdose-related mortality. Relative to heroin overdose decedents, analgesic and methadone overdose decedents were more likely to be female and to concurrently use psychotherapeutic drugs, but less likely to concurrently use alcohol or cocaine. Analgesic overdose decedents were less likely to be Black or Hispanic, while methadone overdose decedents were more likely to be Black or Hispanic in contrast to heroin overdose decedents.
The distinct epidemiologic profiles exhibited by analgesic and methadone overdose fatalities highlight the need to define drug-specific public health prevention efforts.
PMCID: PMC3748247  PMID: 23357743
Mortality; Opioid analgesics; Methadone; Overdose; Prescription drugs; Epidemiology; Urban health
11.  On the Role of Genetic Testing for Personalized Drug Overdose Management 
Journal of Medical Toxicology  2013;9(3):294-295.
PMCID: PMC3770995  PMID: 23860728
12.  Medical examiner and medical toxicologist agreement on cause of death 
Forensic science international  2010;206(0):71-76.
Poisoning is a significant public health threat as the second leading cause of injury-related death in the US. Disagreements on cause of death determination may have widespread implications across several realms of public health including policy and prevention efforts, interpretation of the poisoning literature, epidemiologic data analysis, medical-legal case outcomes, and individualized autopsy interpretation. We aimed to test agreement between the cause of death determined by the medical examiner (ME) and a medical toxicologist (MT) adjudication panel (MTAP) in cases of poisoning. This retrospective 7-year study evaluated all deaths attributed to poisoning in one large urban catchment area. Cross-matched data were obtained from Department of Vital Statistics and the Poison Control Center (PCC). Out of >380,000 deaths in the catchment area over the study period, there were 7050 poisonings in the Vital Statistics database and 414 deaths reported to PCC. Cross-matching yielded 321 cases for analysis. The ME and MTAP concurred on cause of death in 66%, which was only fair agreement (κ 0.25, CI 0.14–0.38). Factors associated with the likelihood of agreement were peri-mortem fire exposures, prehospital cardiac arrest, and timing of drug toxicity (chronic versus acute). In conclusion, agreement for poisoning cause of death between specialties was much lower than expected. We recommend an improved formal process of information sharing and consultation between specialties to assure that all existing information is analyzed thoroughly to enhance cause of death certainty.
PMCID: PMC4094358  PMID: 20655675
Poisoning; Medical examiner; Toxicology; Cause of death
13.  Utility of serum lactate to predict drug-overdose fatality 
Poisoning is the second leading cause of injury-related fatality in the United States. An elevated serum lactate concentration identifies medical and surgical patients at risk for death; however, its utility in predicting death in drug overdose is controversial and unclear.
We aimed to evaluate the prognostic utility of serum lactate concentration for fatality in emergency department (ED) patients with acute drug overdose.
Materials and Methods
This was a case–control study at two urban university teaching hospitals affiliated with a regional poison control center. Data were obtained from electronic medical records, poison center data, and the office of the chief medical examiner. Controls were consecutive acute drug overdoses over a 1-year period surviving to hospital discharge. Cases were subjects over a 7-year period with fatality because of drug overdose. Serum lactate concentration was obtained from the initial blood draw in the ED and correlated with fatality.
During the study period, 873 subjects were screened with 50 cases and 100 controls included. Drug exposures and baseline characteristics were similar between groups. Mean lactate concentration (mmol/L) was 9.88 ± 6.7 for cases and 2.76 ± 2.9 for controls (p < 0.001). The receiver operating characteristic area under the curve for prediction of fatality was 0.87 (95% CI: 0.81–0.94). The optimal lactate cutpoint was 3.0 mmol/L (84% sensitivity, 75% specificity), which conferred a 15.8-fold increase in odds of fatality (p < 0.001).
In this derivation study, serum lactate concentration had excellent prognostic utility to predict drug-overdose fatality. Prospective validation in the ED evaluation of drug overdoses is warranted.
PMCID: PMC4091774  PMID: 20704455
Overdose; Fatality; Acute poisoning
14.  HIV Infection Is Associated with an Increased Risk for Lung Cancer, Independent of Smoking 
Human immunodeficiency virus (HIV)–infected persons have an elevated risk for lung cancer, but whether the increase reflects solely their heavy tobacco use remains an open question.
The Acquired Immunodeficiency Syndrome (AIDS) Link to the Intravenous Experience Study has prospectively observed a cohort of injection drug users in Baltimore, Maryland, since 1988, using biannual collection of clinical, laboratory, and behavioral data. Lung cancer deaths were identified through linkage with the National Death Index. Cox proportional hazards regression was used to examine the effect of HIV infection on lung cancer risk, controlling for smoking status, drug use, and clinical variables.
Among 2086 AIDS Link to the Intravenous Experience Study participants observed for 19,835 person-years, 27 lung cancer deaths were identified; 14 of the deaths were among HIV-infected persons. All but 1 (96%) of the patients with lung cancer were smokers, smoking a mean of 1.2 packs per day. Lung cancer mortality increased during the highly active antiretroviral therapy era, compared with the pre–highly active antiretroviral therapy period (mortality rate ratio, 4.7; 95% confidence interval, 1.7–16). After adjusting for age, sex, smoking status, and calendar period, HIV infection was associated with increased lung cancer risk (hazard ratio, 3.6; 95% confidence interval, 1.6–7.9). Preexisting lung disease, particularly noninfectious diseases and asthma, displayed trends for increased lung cancer risk. Illicit drug use was not associated with increased lung cancer risk. Among HIV-infected persons, smoking remained the major risk factor; CD4 cell count and HIV load were not strongly associated with increased lung cancer risk, and trends for increased risk with use of highly active antiretroviral therapy were not significant.
HIV infection is associated with significantly increased risk for developing lung cancer, independent of smoking status.
PMCID: PMC4078722  PMID: 17554710
16.  Effectiveness of Highly Active Antiretroviral Therapy among Injection Drug Users with Late-Stage Human Immunodeficiency Virus Infection 
American journal of epidemiology  2005;161(11):999-1012.
Highly active antiretroviral therapy (HAART) has been shown to be effective in different populations, but data among injection drug users are limited. Human immunodeficiency virus-infected injection drug users recruited into the Acquired Immunodeficiency Syndrome Link to Intravenous Experiences (ALIVE) Study as early as 1988 were tested semiannually to identify their first CD4-positive T-lymphocyte cell count below 200/μl; they were followed for mortality through 2002. Visits were categorized into the pre-HAART (before mid-1996) and the HAART eras and further categorized by HAART use. Survival analysis with staggered entry was used to evaluate the effect of HAART on acquired immunodeficiency syndrome-related mortality, adjusting for other medications and demographic, clinical, and behavioral factors. Among 665 participants, 258 died during 2,402 person-years of follow-up. Compared with survival in the pre-HAART era, survival in the HAART era was shown by multivariate analysis to be improved for both those who did and did not receive HAART (relative hazards = 0.06 and 0.33, respectively; p < 0.001). Inferences were unchanged after restricting analyses to data starting with 1993 and considerations of lead-time bias and human immunodeficiency viral load. The annual CD4-positive T-lymphocyte cell decline was less in untreated HAART-era participants than in pre-HAART-era participants (— 10/μl vs. —37/μl, respectively), suggesting that indications for treatment may have contributed to improved survival and that analyses restricted to the HAART era probably underestimate HAART effectiveness.
PMCID: PMC4078731  PMID: 15901620
antiretroviral therapy; highly active; HIV; substance abuse; intravenous; substance-related disorders; survival; treatment outcome
17.  Alcohol consumption trajectory patterns in adult women with HIV infection 
AIDS and behavior  2013;17(5):1705-1712.
HIV-infected women with excessive alcohol consumption are at risk for adverse health outcomes, but little is known about their long-term drinking trajectories. This analysis included longitudinal data, obtained from 1996–2006, from 2791 women with HIV from the Women’s Interagency HIV Study. Among these women, the proportion in each of five distinct drinking trajectories was: continued heavy drinking (3%), reduction from heavy to non-heavy drinking (4%), increase from non-heavy to heavy drinking (8%), continued non-heavy drinking (36%), and continued non-drinking (49%). Depressive symptoms, other substance use (crack/cocaine, marijuana, and tobacco), co-infection with HCV, and heavy drinking prior to enrollment were associated with trajectories involving future heavy drinking. In conclusion, many women with HIV change their drinking patterns over time. Clinicians and those providing alcohol-related interventions might target those with depression, current use of tobacco or illicit drugs, HCV infection, or a previous history of drinking problems.
PMCID: PMC3534826  PMID: 22836592
Alcohol consumption; women; HIV-infection; trajectories
18.  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
19.  Neighborhoods and HIV: A Social Ecological Approach to Prevention and Care 
The American psychologist  2013;68(4):210-224.
Neighborhood factors have been linked to HIV risk behaviors, HIV counseling and testing, and HIV medical care. However, the social–psychological mechanisms that connect neighborhood factors to HIV-related behaviors have not been fully determined. In this paper we review the research on neighborhood factors and HIV-related behaviors, approaches to measuring neighborhoods, and mechanism that may help to explain how the physical and social environment within neighborhoods may lead to HIV related behaviors. We then discuss organizational, geographic, and social network approaches to intervene in neighborhoods to reduce HIV transmission and facilitate HIV medical care with the goal of reducing morbidity and mortality and increasing social and psychological well-being.
PMCID: PMC3717355  PMID: 23688089
HIV; Neighborhoods; Intervention; Prevention; Theory; IDU; MSM
20.  Revisiting the Role of the Urban Environment in Substance Use: The Case of Analgesic Overdose Fatalities 
American journal of public health  2013;103(12):2252-2260.
We examined whether neighborhood social characteristics (income distribution and family fragmentation) and physical characteristics (clean sidewalks and dilapidated housing) were associated with the risk of fatalities caused by analgesic overdose.
In a case-control study, we compared 447 unintentional analgesic opioid overdose fatalities (cases) with 3436 unintentional nonoverdose fatalities and 2530 heroin overdose fatalities (controls) occurring in 59 New York City neighborhoods between 2000 and 2006.
Analgesic overdose fatalities were less likely than nonoverdose unintentional fatalities to have occurred in higher-income neighborhoods (odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.70, 0.96) and more likely to have occurred in fragmented neighborhoods (OR = 1.35; 95% CI = 1.05, 1.72). They were more likely than heroin overdose fatalities to have occurred in higher-income (OR = 1.31; 95% CI = 1.12, 1.54) and less fragmented (OR = 0.71; 95% CI = 0.55, 0.92) neighborhoods.
Analgesic overdose fatalities exhibit spatial patterns that are distinct from those of heroin and nonoverdose unintentional fatalities. Whereas analgesic fatalities typically occur in lower-income, more fragmented neighborhoods than nonoverdose fatalities, they tend to occur in higher-income, less unequal, and less fragmented neighborhoods than heroin fatalities.
PMCID: PMC3828967  PMID: 24134362
21.  Limited Uptake of Hepatitis C Treatment among Injection Drug Users 
Journal of community health  2008;33(3):126-133.
We characterized HCV treatment knowledge, experience and barriers in a cohort of community-based injection drug users (IDUs) in Baltimore, MD. In 2005, a questionnaire on HCV treatment knowledge, experience and barriers was administered to HCV-infected IDUs. Self-reported treatment was confirmed from medical records. Of 597 participants, 71% were male, 95% African-American, 31% HIV co-infected and 94% were infected with HCV genotype 1; 70% were aware that treatment was available, but only 22% understood that HCV could be cured. Of 418 who had heard of treatment, 86 (21%) reported an evaluation by a provider that included a discussion of treatment of whom 30 refused treatment, 20 deferred and 36 reported initiating treatment (6% overall). The most common reasons for refusal were related to treatment-related perceptions and a low perceived need of treatment. Compared to those who had discussed treatment with their provider, those who had not were more likely to be injecting drugs, less likely to have health insurance, and less knowledgeable about treatment. Low HCV treatment effectiveness was observed in this IDU population. Comprehensive integrated care strategies that incorporate education, case-management and peer support are needed to improve care and treatment of HCV-infected IDUs.
PMCID: PMC3800027  PMID: 18165889
Hepatitis C virus; Injection drug use; Antiviral therapy; Health care access
22.  Non-fatal overdose and subsequent drug treatment among injection drug users 
Drug and alcohol dependence  2005;83(2):104-110.
Overdose is a leading cause of death among illicit drug users. 924 injection drug users (IDUs) in Baltimore, Maryland, were interviewed to characterize overdose events and determine the circumstances under which they lead to drug treatment. Overall, 366 (39.7%) reported at least one non-fatal drug overdose. Most (96.2%) used heroin on the day of their last overdose and almost half (42.6%) used heroin and alcohol but few (4.1%) used tranquilizers or benzodiazepines. Five percent were in drug treatment when the overdose occurred and 7.1% had been incarcerated two weeks prior. One in four IDUs (26.2%) sought drug treatment within 30 days after their last overdose of whom 75% enrolled. Speaking with someone about drug treatment after the overdose was associated with treatment seeking (AOR 5.22; 95% CI: 3.12, 8.71). Family members were the most commonly cited source of treatment information (53.7%) but only those who spoke with spouses, crisis counselors and hospital staff were more likely to seek treatment. Not being ready for treatment (69.6%) and not viewing drug use as a problem (30.7%) were the most common reasons for not seeking treatment and being placed on a waiting list was the most common reason for not subsequently enrolling in treatment (66.7%). Of the IDUs treated by emergency medical technicians, emergency room staff, or hospital staff, only 17.3%, 26.2% and 43.2% reported getting drug treatment information from those sources, respectively. Interventions that provide drug treatment information and enhance motivation for treatment in the medical setting and policies that reduce barriers to treatment entry among motivated drug users are recommended.
PMCID: PMC3711523  PMID: 16310322
23.  Incidence of Adverse Cardiovascular Events in Adults Following Drug Overdose 
Academic Emergency Medicine  2012;19(7):843-849.
Drug overdose is a leading cause of cardiac arrest and is currently the second leading cause of overall injury-related fatality in the United States. Despite these statistics, the incidence of adverse cardiovascular events (ACVEs) in emergency department (ED) patients following acute drug overdose is unknown. With this study, we address the 2010 American Heart Association Emergency Cardiovascular Care update calling for research to characterize the incidence of in-hospital ACVE following drug overdose.
This was a prospective cohort study at two tertiary care hospitals over 12 months. Consecutive adult ED patients with acute drug overdose were prospectively followed to hospital discharge. The main outcome was occurrence of in-hospital ACVE, defined as the occurrence of one or more of the following: myocardial injury, shock, ventricular dysrhythmia, and cardiac arrest.
There were 459 ED patients with suspected drug overdose, of whom 274 acute drug overdose qualified and were included for analysis (mean [±SE] age = 40.3 [±1.0] years; 63% male). Hospital course was complicated by ACVE in 16 patients (some had more than one): 12 myocardial injury, three shock, two dysrhythmia, and three cardiac arrest. The incidence of ACVE was 5.8% overall (95% confidence interval [CI] = 3.6% to 9.3%) and 10.7% (95% CI = 6.6% to 16.9%) among inpatient admissions, with all-cause mortality at 0.7% (95% CI = 0.2% to 2.6%).
Based on this study of adult patients with acute drug overdose, ACVE may occur in up to 9.3% overall and up to 16.9% of hospital admissions. Implications for the evaluation and triage of ED patients with acute drug overdose require further study with regard to optimizing interventions to prevent adverse events.
PMCID: PMC3399948  PMID: 22725631
24.  Changes in sexual and drug-related risk behavior following antiretroviral therapy initiation among HIV-infected injection drug users 
AIDS (London, England)  2012;26(18):2383-2391.
To evaluate whether HAART is associated with subsequent sexual and drug-related risk behavior compensation among injection drug users (IDUs).
A community-based cohort study of 362 HIV-infected IDUs initiating HAART in Baltimore, Maryland.
HAART use and risk behavior was assessed at 8316 biannual study visits (median 23). Using logistic regression with generalized estimating equations (GEE), we examined the effect of HAART initiation on changes in risk behavior while adjusting for sociodemographics, alcohol use, CD4+ cell count, year of initiation and consistency of HAART use.
At HAART initiation, participants were a median of 44.4 years old, 71.3% men and 95.3% African–American. In multivariable analysis, HAART initiation was associated with a 75% reduction in the likelihood of unprotected sex [adjusted odds ratio (aOR) 0.25; 95% confidence interval (CI), 0.19–0.32] despite no change in overall sexual activity (aOR 0.95; 0.80–1.12). Odds of any injecting decreased by 38% (aOR 0.62; 0.51–0.75) after HAART initiation. Among the subset of persistent injectors, needle-sharing increased nearly two-fold (aOR 1.99; 1.57–2.52). Behavioral changes were sustained for more than 5 years after HAART initiation and did not differ by consistency of HAART use. Reporting specific high-risk behaviors in the year prior to initiation was a robust predictor of engaging in those behaviors subsequent to HAART.
Overall, substantial declines in sexual risk-taking and active injecting argue against significant behavioral compensation among IDUs following HAART initiation. These data also provide evidence to support identifying persons with risky pre-HAART behavior for targeted behavioral intervention.
PMCID: PMC3678983  PMID: 23079804
antiretroviral therapy; HIV prevention; injecting; injection drug users; risk compensation; sexual behavior
25.  Factors associated with differential uptake of seasonal influenza immunizations among underserved communities during the 2009–2010 influenza season 
Journal of Community Health  2012;37(2):282-287.
Influenza vaccination coverage remains low and disparities persist. In New York City, a community-based participatory research project (Project VIVA) worked to address this issue in Harlem and the South Bronx by supplementing existing vaccination programs with non- traditional venues (i.e., community-based organizations). We conducted a ten minute survey to assess access to influenza vaccine as well as attitudes and beliefs towards influenza vaccination that could inform intervention development for subsequent seasons. Among 991 participants recruited using street intercept techniques, 63% received seasonal vaccine only, 11% seasonal and H1N1, and 26% neither; 89% reported seeing a health care provider (HCP) during the influenza season. Correlates of immunization among those with provider visits during influenza season included being U.S.-born, interest in getting the vaccine, concern about self or family getting influenza, an HCP’s recommendation and comfort with government. Among those without an HCP visit, factors associated with immunization included being U.S. born, married, interest in getting the vaccine, understanding influenza information, and concern about getting influenza. Factors associated with lack of interest in influenza vaccine included being born outside the U.S., Black and uncomfortable with government. In medically underserved areas, having access to routine medical care and understanding the medical implications of influenza play an important role in enhancing uptake of seasonal influenza vaccination. Strategies to improve vaccination rates among Blacks and foreign-born residents need to be addressed. The use of non-traditional venues to provide influenza vaccinations in underserved communities has the potential to reduce health disparities.
PMCID: PMC3369692  PMID: 21785857
influenza; vaccination; community-based participatory research; health disparities

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