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1.  Access to treatment for substance-using women in the Republic of Georgia: Socio-cultural and structural barriers 
The International journal on drug policy  2013;24(6):10.1016/j.drugpo.2013.05.004.
Background
In the Republic of Georgia, women comprise under 2% of patients in substance use treatment and to date there has been no empirical research to investigate what factors may facilitate or hinder their help-seeking behavior or access to treatment services.
Methods
This study included secondary analysis of in-depth interviews with 55 substance-using women and 34 providers of health-related services.
Results
The roles and norms of women in Georgian society were identified as major factors influencing their help-seeking behavior. Factors that had a negative impact on use of drug treatment services included an absence of gender-specific services, judgmental attitudes of service providers, the cost of treatment and a punitive legal position in regard to substance use. Having a substance-using partner served as an additional factor inhibiting a woman’s willingness to seek assistance.
Conclusions
Within the context of orthodox Georgian society, low self-esteem, combined with severe family and social stigma play a critical role in creating barriers to the use of both general health and substance-use-treatment services for women. Education of the public, including policy makers and health care providers is urgently needed to focus on addiction as a treatable medical illness. The need for more women-centered services is also critical to the provision of effective treatment for substance-using women.
doi:10.1016/j.drugpo.2013.05.004
PMCID: PMC3797849  PMID: 23756037
treatment policies; women; substance abuse; barriers; Republic of Georgia
2.  Results of a pilot test of a brief computer-assisted tailored HIV prevention intervention for use with a range of demographic and risk groups 
AIDS and behavior  2013;17(9):10.1007/s10461-013-0557-2.
There is a need for brief HIV prevention interventions that can be disseminated and implemented widely. This article reports the results of a small randomized field experiment that compared the relative effects of a brief 2-session counselor-delivered computer-tailored intervention and a control condition. The intervention is designed for use with African American, non-Hispanic white and Hispanic males and females who may be at risk of HIV through unprotected sex, selling sex, male to male sex, injecting drug use or use of stimulants. Participants (n=120) were recruited using a quota sampling approach and randomized using block randomization, which resulted in 10 male and 10 female participants of each racial/ethnic group (i.e. African-American, non-Hispanic white and Hispanic) being assigned to either the intervention or a control arm. In logistic regression analyses using a generalized estimating equations approach, at 3-month followup, participants in the intervention arm were more likely than participants in the control arm to report condom use at last sex (Odds ratio [OR] = 4.75; 95% Confidence interval [C.I.] = 1.70, 13.26; p = 0.003). The findings suggest that a brief tailored intervention may increase condom use. Larger studies with longer followups are needed to determine if these results can be replicated.
doi:10.1007/s10461-013-0557-2
PMCID: PMC3812346  PMID: 23872994
HIV prevention; brief interventions; computer-tailored; African-Americans; Hispanics; males; females
3.  The biobehavioral Women’s Health CoOp in Pretoria, South Africa: study protocol for a cluster-randomized design 
BMC Public Health  2014;14(1):1074.
Background
South Africa has 6.4 million adults over the age of 15 living with HIV. Gender inequality issues continue to drive the HIV epidemic in South Africa, where Black African women bear the greatest HIV burden. Limited access to services; little capacity to negotiate sex and condom use; and other legal, social, and economic inequities make women highly vulnerable to HIV infection. Behavioral interventions have been shown to decrease risk behaviors, but they have been less successful in reducing HIV incidence. Conversely, biomedical prevention strategies have proven to be successful in reducing HIV incidence, but require behavioral interventions to increase uptake and adherence. Consequently, there is a need for integrated approaches that combine biomedical and behavioral interventions. Effective combination prevention efforts should comprise biomedical, behavioral, and structural programming proven in randomized trials that focuses on the driving forces and key populations at higher risk of HIV infection and transmission.
Methods/Design
This prospective, geographically clustered randomized field experiment is enrolling participants into two arms: a control arm that receives standard HIV testing and referral for treatment; and an intervention arm that receives an evidence-based, woman-focused behavioral intervention that emphasizes risk reduction and retention, the Women’s Health CoOp. We divided the city of Pretoria into 14 mutually exclusive geographic zones and randomized these zones into either the control arm or the intervention arm. Outreach workers are recruiting drug-using women from each zone. At baseline, eligible participants complete a questionnaire and biological testing for HIV, recent drug use, and pregnancy. Follow-up interviews are completed at 6 and 12 months.
Discussion
The biobehavioral intervention in this study merges an efficacious behavioral HIV prevention intervention for women with biomedical prevention through HIV treatment as prevention using a Seek, Test, Treat and Retain strategy. This combination biobehavioral intervention is designed to (1) improve the quality of life and reduce HIV infectiousness among women who are HIV positive, and (2) reduce HIV risk behaviors among women regardless of their HIV status. If efficacious, this intervention could help control the HIV epidemic in South Africa.
Trial registration
Trial registration no: NCT01497405.
doi:10.1186/1471-2458-14-1074
PMCID: PMC4287508  PMID: 25318563
Vulnerable women; HIV; South Africa; Combined biobehavioral intervention; Women’s Health CoOp; Seek, test, treat and retain paradigm; Cluster-randomized design
4.  Current Interventions to Reduce Sexual Risk Behaviors and Crack Cocaine Use among HIV-Infected Individuals 
Current HIV/AIDS reports  2012;9(4):385-393.
The dual global epidemics of crack cocaine use and HIV have resulted in a large number of people living with HIV who use crack cocaine, many of whom continue to engage in unprotected sex. Crack use also increases the rate of HIV progression. Consequently, there is an urgent need for effective interventions to decrease crack use and unprotected sex and to improve antiretroviral therapy (ART) adherence in this population. This article reviews the recent published literature on interventions for reducing crack use and unprotected sex among people living with HIV. Only a few intervention outcome studies targeting exclusively HIV positive crack cocaine users were identified, whereas other studies used a mixed sample. Some interventions focused on reducing crack use and several focused on reducing sex-risk behaviors. Consequently, there is a critical need for efficacious interventions that address crack use, risky sex and ART adherence among people living with HIV.
doi:10.1007/s11904-012-0131-y
PMCID: PMC4180174  PMID: 22872433
HIV-positive crack users; interventions; outcomes; substance abuse; sexual risk; Behavioral Aspects of HIV Management; antiretroviral therapy; sexual risk behaviors
5.  Process and Product in Cross-Cultural Treatment Research: Development of a Culturally Sensitive Women-Centered Substance Use Intervention in Georgia 
Journal of Addiction  2014;2014:163603.
Women who inject drugs (WID) are highly marginalized and stigmatized and experience ongoing discrimination in Georgia. Few opportunities exist for WID to receive publicly funded treatment for substance use disorders. The IMEDI (Investigating Methods for Enhancing Development in Individuals) project was developed in response to the need for women-specific and women-centered treatment services. This paper described our approach to understanding the Georgian culture—and WID within that culture—so that we could integrate two interventions for substance use found effective in other Western and non-Western cultures and to outline how we refined and adapted our integrated intervention to yield a comprehensive women-centered intervention for substance use. Reinforcement Based Treatment (RBT) and the Women's CoOp (WC) were adapted and refined based on in-depth interviews with WID (N = 55) and providers of health services (N = 34) to such women and focus groups [2 with WID (N = 15) and 2 with health service providers (N = 12)]. The resulting comprehensive women-centered intervention, RBT+WC, was then pretested and further refined in a sample of 20 WID. Results indicated positive pre-post changes in urine screening results and perceived needs for both RBT+WC and a case management control condition. The approach to treatment adaptation and the revised elements of RBT+WC are presented and discussed.
doi:10.1155/2014/163603
PMCID: PMC4190114  PMID: 25332836
6.  Twice Stigmatized: Provider’s Perspectives on Drug-Using Women in the Republic of Georgia 
This study examined attitudes and perspectives of 34 health service providers through in-depth interviews in the Republic of Georgia who encountered an injection drug-using woman at least once in the past two months. Most participants’ concept of drug dependence treatment was detoxification, as medication-assisted therapy was considered part of harm reduction, although it was thought to have relatively better treatment outcomes compared to detoxification. Respondents reported that drug dependence in women is much more severe than in men. They also expressed less tolerance towards drug-using women, as most providers view such women as failures as a good mother, wife, or child. Georgian women are twice stigmatized, once by a society that views them as fulfilling only a limited purposeful role and again by their male drug-using counterparts. Further, the vast majority of respondents were unaware of the availability of specific types of drug-treatment services in their city, and even more did not seek connections with other service providers, indicating a lack of linkages between drug-related and other services. The need for women-specific services and a comprehensive network of service linkages for all patients in drug treatment is critical. These public health issues require immediate consideration by policy makers, and swift action to address them.
doi:10.1080/02791072.2013.763554
PMCID: PMC4115446  PMID: 23662326
injection drug use; Republic of Georgia; service providers; stigma; women
7.  Factors That Influence HIV Risk among Hispanic Female Immigrants and Their Implications for HIV Prevention Interventions 
Hispanics are the fastest growing minority group in North Carolina with increasing incidence of HIV infection. Gender roles, cultural expectations, and acculturation of women may explain some of Hispanic women's risks. The perspectives of Hispanic female immigrants and community-based providers were sought to identify services they offer, understand HIV risk factors, and support the adaptation of a best-evidence HIV behavioural intervention for Hispanic women. Two sets of focus groups were conducted to explicate risks and the opportunities to reach women or couples and the feasibility to conduct HIV prevention in an acceptable manner. Salient findings were that Hispanic female immigrants lacked accurate HIV/AIDS and STI knowledge and that traditional gender roles shaped issues surrounding sexual behaviour and HIV risks, as well as condom use, partner communication, and multiple sexual partnerships. Intervention implications are discussed such as developing and adapting culturally appropriate HIV prevention interventions for Hispanics that address gender roles and partner communication.
doi:10.1155/2012/876381
PMCID: PMC3296155  PMID: 22518308
8.  Double jeopardy--drug and sex risks among Russian women who inject drugs: initial feasibility and efficacy results of a small randomized controlled trial 
Background
With HIV prevalence estimated at 20% among female injecting drug users (IDUs) in St. Petersburg, Russia, there is a critical need to address the HIV risks of this at-risk population. This study characterized HIV risks associated with injecting drug use and sex behaviors and assessed the initial feasibility and efficacy of an adapted Woman-Focused intervention, the Women's CoOp, relative to a Nutrition control to reduce HIV risk behaviors among female IDUs in an inpatient detoxification drug treatment setting.
Method
Women (N = 100) were randomized into one of two one-hour long intervention conditions--the Woman-Focused intervention (n = 51) or a time and attention-matched Nutrition control condition (n = 49).
Results
The results showed that 57% of the participants had been told that they were HIV-positive. At 3-month follow-up, both groups showed reduced levels of injecting frequency. However, participants in the Woman-Focused intervention reported, on average, a lower frequency of partner impairment at last sex act and a lower average number of unprotected vaginal sex acts with their main sex partner than the Nutrition condition.
Conclusion
The findings suggest that improvements in sexual risk reduction are possible for these at-risk women and that more comprehensive treatment is needed to address HIV and drug risks in this vulnerable population.
doi:10.1186/1747-597X-7-1
PMCID: PMC3298463  PMID: 22233728
HIV; women; female IDUs; Woman-Focused intervention; Russia
9.  Racial Differences in Acquisition of Syringes from Pharmacies under Conditions of Legal but Restricted Sales 
Background
Injecting drug users (IDUs) are at increased risk of acquiring and transmitting HIV and other bloodborne pathogens through the multi-person use of syringes. Although research has shown that increased access to syringes through syringe exchange programs (SEPs) is an effective strategy to reduce risky injection practices many areas of the United States still do not have SEPs. In the absence of SEPs, legislation allowing pharmacies over-the-counter sales of syringes has also been shown to reduce syringe sharing. The success of pharmacy sales however is limited by other legal stipulations, such as drug paraphernalia laws, which in turn may contribute to fear among IDUs about being caught purchasing and carrying syringes.
Methods
Between 2003 and 2006, 851 out-of-treatment IDUs were recruited using street outreach in the Raleigh-Durham (North Carolina) area. Data were collected using audio-computer assisted interview (ACASI) technology. Multiple logistic regression analyses were performed to assess factors associated with purchasing syringes from pharmacies.
Results
In our study sample, African-American IDUs were one-fifth as likely as white IDUs to report pharmacies as their primary source of syringes.
Conclusions
Given the absence of syringe exchange programs and the relatively high prevalence of HCV and HIV among IDUs in the Raleigh-Durham area, the limited use of pharmacies as a source of syringes among African-American IDUs in this study sample is problematic. The study findings support the need for effective multilevel interventions to increase access to clean needles in this population, as well as for policy interventions, such as legalization of SEPs and elimination of penalties for carrying syringes, to reduce harm and eliminate the health threats posed by receptive syringe sharing.
doi:10.1016/j.drugpo.2009.12.006
PMCID: PMC2926201  PMID: 20097052
Injecting drug users; African-Americans; purchasing syringes; carrying syringes
10.  Methamphetamine (“tik”) Use and Its Association with Condom Use among Out-of-School Females in Cape Town, South Africa 
Background
Little is known about the association between methamphetamine use and sexual risk behaviors among young South African women between 13 and 20 years of age.
Objective
To examine the association between methamphetamine use and condom use among out-of-school South African female adolescents.
Methods
Black and Coloured female adolescents were interviewed and categorized into methamphetamine user (n = 261) or non-user (n = 188) groups.
Results
Methamphetamine use was reported by 58% of the total sample. Higher methamphetamine rates were found among young Coloured females (87%) than among young Black females (11%). In a multiple logistic regression analysis that adjusted for relevant confounders and included an interaction term for race and methamphetamine use, Coloured female methamphetamine users were over six times more likely than other participants to report not using a condom the last time they had sex (OR = 6.21; 95% CI = 1.21, 31.94).
Conclusions and Scientific Significance
Efforts are needed to reduce methamphetamine use and related sexual risk among adolescent females in Coloured communities and to prevent the spread of methamphetamine use in Black African communities.
doi:10.3109/00952990.2010.493592
PMCID: PMC3131685  PMID: 20560840
Adolescent females; methamphetamine use; sexual risk behavior; South Africa
12.  Preliminary Findings of an Adapted Evidence-Based Woman-Focused HIV Intervention on Condom Use and Negotiation Among At-Risk Women in Pretoria, South Africa 
This article presents the results of a randomized trial in South Africa of an adapted evidence-based Woman-Focused intervention on condom use with primary sex partners. The preliminary findings show that regardless of HIV status, condom negotiation was significantly associated with condom use at the 3- and 6-month follow-ups. By intervention group, significant intervention effects were found at 6-month follow-up for HIV-positive and HIV-unknown status women in the Woman-Focused intervention who were more likely than women in the Standard intervention to report condom use with a primary male partner. Among HIV-positive women, those in the Woman-Focused group and those with greater sexual control were more likely to report condom use at the 6-month follow-up. The findings indicate that gender-based interventions for women may result in increased condom negotiation skills.
doi:10.1080/10852351003640799
PMCID: PMC3129984  PMID: 20391060
condom negotiation; condom use; HIV risk; sex workers; sexual control; South Africa; woman-focused intervention
13.  Sustainability of Intervention Effects of an Evidence-based HIV Prevention Intervention for African American Women who Smoke Crack Cocaine* 
Drug and alcohol dependence  2010;109(1-3):205-212.
Background
HIV prevention intervention efficacy is often assessed in the short term. Thus, we conducted a long-term (mean 4.4 years) follow-up of a Woman-Focused HIV intervention for African American crack smokers, for which we had previously observed beneficial short-term gains.
Methods
455 out-of-treatment African American women in central North Carolina participated in a randomized field experiment and were followed up to determine sustainability of intervention effects across three conditions: the Woman-Focused intervention, a modified NIDA intervention, and a delayed treatment control condition. We compared these groups in terms of HIV risk behavior at short-term follow-up (STFU; 3–6 months) and long-term follow-up (LTFU; average 4 years).
Results
The analyses revealed two distinct groups at STFU: women who either eliminated or greatly reduced their risk behaviors (low-risk class) and women who retained high levels of risk across multiple risk domains (high-risk class). At STFU, women in the Woman-Focused intervention were more likely to be in the low HIV-risk group than the women in control conditions, but this effect was not statistically significant at LTFU. However, low-risk participants at STFU were less likely to be retained at LTFU, and this retention rate was lowest among women in the Woman-Focused intervention.
Conclusions
Short-term intervention effects were not observed over four years later, possibly due to differential retention across conditions. The retention of the highest risk women presents an opportunity for extending intervention effects through the booster sessions for those who need it the most.
doi:10.1016/j.drugalcdep.2010.01.014
PMCID: PMC2875347  PMID: 20219294
Intervention effects; sustainability; HIV prevention; crack cocaine; African American women
14.  Pregnant and Nonpregnant Women in Cape Town, South Africa: Drug Use, Sexual Behavior, and the Need for Comprehensive Services 
The multiple risks associated with methamphetamine use are of serious concern for women. These risks and consequences are magnified during pregnancy. This secondary analysis of a parent study compared 26 pregnant to 356 nonpregnant women in Cape Town, South Africa, on selected demographic, psychosocial, and HIV-risk domains to identify their treatment service needs. Proportionally, more pregnant than nonpregnant women are using methamphetamine, P = .01, although a very high rate of women used methamphetamine. Women reported similar monthly rates of sexual intercourse, but pregnant women were significantly less likely to report condom use, P < .0001, maintaining their risky behavior. Both groups reported elevated Center for Epidemiological Studies Depression Scale CES-D means, suggesting a need for depression treatment. Results demonstrate a pervasive need for women's comprehensive treatment, regardless of pregnancy status. Moreover, findings support the urgent need for women-focused and pregnancy-specific treatment services for methamphetamine use. Finally, a job-skills training/employment component focus is suggested.
doi:10.1155/2011/353410
PMCID: PMC3083847  PMID: 21541067
15.  Effects of an HCV Risk Reduction Motivational Intervention on Alcohol Use, Injection and Sexual Risk Behaviors 
American journal of public health  2009;99(Suppl 1):S180-S186.
Objectives
Hepatitis C virus (HCV) is the most prevalent bloodborne infection in the United States, and alcohol use increases HCV progression. We compared the effects of two interventions on alcohol use, injection risk, and sexual risk in a community sample of injecting drug users.
Methods
Eight hundred fifty-one out-of-treatment injecting drug users were recruited through street outreach and randomized to either a 6-session educational intervention or a 6-session motivational intervention. Intervention effects were examined at 6 and 12 months post enrollment.
Results
In multiple logistic regression analyses, adjusted for baseline alcohol use and HCV status, participants assigned to the motivational intervention were significantly less likely than participants in to be drinking at 6-month follow-up (odds ratio = 0.67, 95% confidence interval = 0.46, 0.97). There were no significant between group differences in injection risk or sexual risk at either follow-up.
Conclusions
The motivational intervention was more effective than the educational intervention in reducing alcohol use at 6-month follow-up. Reducing alcohol use among people with HCV may slow disease progression and provide important health benefits.
doi:10.2105/AJPH.2007.126854
PMCID: PMC2724936  PMID: 19218179
16.  The Relative Role of Perceived Partner Risks in Promoting Condom Use in a Three-City Sample of High-Risk, Low-Income Women 
AIDS and Behavior  2010;15(7):1347-1358.
We examined the effect of women’s perceptions of sexual partner risks on condom use. Women from three US cities (n = 1,967) were recruited to provide data on HIV risks. In univariate models, increased odds of condom use were associated with perceiving that partners had concurrent partners and being unaware of partners': (a) HIV status, (b) bisexuality, (c) concurrency; and/or (d) injection drug use. In multivariate models, neither being unaware of the four partner risk factors nor perceiving a partner as being high risk was associated with condom use. Contextual factors associated with decreased odds of condom use were having sex with a main partner, homelessness in the past year, alcohol use during sex, and crack use in the past 30 days. Awareness of a partner’s risks may not be sufficient for increasing condom use. Contextual factors, sex with a main partner in particular, decrease condom use despite awareness of partner risk factors.
doi:10.1007/s10461-010-9840-7
PMCID: PMC3180610  PMID: 20976538
Perceptions of partner HIV risk behaviors; Condom use; HIV transmission to women; Crack; Alcohol
17.  Secrecy and risk among MSM in Tbilisi, Georgia 
AIDS care  2009;21(5):591-597.
There is concern that the tremendous economic, social, and political upheavals that the Republic of Georgia has undergone in the years since the fall of the Soviet Union may have created an environment fertile for HIV transmission. Notably absent from official statistics and HIV-related research in Georgia is discussion of men who have sex with men (MSM) and, therefore, little is known about the MSM population or its potential to acquire or transmit HIV. Data were collected from 30 MSM recruited through a testing and counseling center in Tbilisi, the capital of Georgia. Two focus groups with six men each and 18 individual in-depth interviews were conducted between October 2006 and February 2007. The study participants described a Georgian culture that is largely intolerant of sexual contact between men. In describing the various forms of discrimination and violence that they would face should their sexual identities be discovered, the MSM in this sample described a variety of behaviors that they and other Georgian MSM undertake to conceal their sexual behavior. Many of these could put these men and their partners at risk for HIV. Although official HIV rates in Georgia are still low, results from this qualitative study indicate that efforts to educate and to provide unobtrusive and anonymous testing and counseling services to MSM may be critical to the deterrence of an HIV epidemic in the Republic of Georgia.
doi:10.1080/09540120802385587
PMCID: PMC2932655  PMID: 19444667
HIV; Eastern Europe; MSM
18.  Behaviorally Bisexual Men and their Risk Behaviors with Men and Women 
Gay and bisexual men are often treated as a homogenous group; however, there may be important differences between them. In addition, behaviorally bisexual men are a potential source of HIV infection for heterosexual women. In this study, we compared 97 men who have sex with men only (MSM) to 175 men who have sex with men and women (MSMW). We also compared the 175 MSMW to 772 men who have sex with women only (MSW). Bivariate and multiple logistic regression analyses were performed to assess correlates of MSMW risk behaviors with men and with women as well as whether MSMW, compared with MSW, engaged in more risky behaviors with women. Compared with MSM, MSMW were less likely to be HIV-positive or to engage in unprotected receptive anal intercourse. In contrast, MSMW were more likely than MSW to be HIV-positive and to engage in anal intercourse with their female partners; however, rates of unprotected anal intercourse were similar. The study findings suggest that there may be important differences in HIV risk behaviors and HIV prevalence between MSM and MSMW as well as between MSMW and MSW.
doi:10.1007/s11524-009-9366-3
PMCID: PMC2705485  PMID: 19513854
Behaviorally bisexual men; Men who have sex with men; Risk behaviors; HIV
19.  Transactional Sex among Men and Women in the South at High Risk for HIV and Other STIs 
Transactional sex refers to selling sex (exchanging sex for money, drugs, food, shelter, or other items) or purchasing sex (exchanging money, drugs, food, shelter, or other items for sex). These activities have been associated with a higher risk for HIV and other sexually transmitted infections in a variety of populations and settings. This paper examines correlates of purchasing and selling sex in a large sample of drug users, men who have sex with men, and sex partners of these groups. Using respondent-driven sampling, participants were recruited between 2005 and 2008 in two urban and two rural counties in North Carolina. We used multiple logistic regressions to examine separate models for selling and purchasing sex in men and women. In addition, we estimated direct and indirect associations among independent variables in the logistic regression models and transactional sex using structural equation models. The analysis shows that factors associated with women selling and buying sex include being homeless, use of stimulants, bisexual behavior, and neighborhood disorder. There was also a significant difference by race. For men, the factors associated with selling and buying sex include being homeless, bisexual behavior, and not being in a relationship. Although neighborhood violence and disorder show significance in bivariate associations with the outcome, these associations disappear in the structural equation models.
doi:10.1007/s11524-009-9368-1
PMCID: PMC2705487  PMID: 19513853
Transactional sex; Sex trading; Sexual risk; Men who have sex with men; Women; HIV
20.  High Dead-Space Syringes and the Risk of HIV and HCV Infection among Injecting Drug Users 
Drug and alcohol dependence  2008;100(3):204-213.
This study examines the association between using and sharing high dead-space syringes (HDSSs)—which retain over 1,000 times more blood after rinsing than low dead-space syringes (LDSSs)—and prevalent HIV and hepatitis C virus (HCV) infections among injecting drug users (IDUs). A sample of 851 out-of-treatment IDUs was recruited in Raleigh-Durham, North Carolina, between 2003 and 2005. Participants were tested for HIV and HCV antibodies. Demographic, drug use, and injection practice data were collected via interviews. Data were analyzed using multiple logistic regression analysis. Participants had a mean age of 40 years and 74% percent are male, 63% are African American, 29% are non-Hispanic white, and 8% are of other race/ethnicity. Overall, 42% of participants had ever used an HDSS and 12% had shared one. HIV prevalence was 5% among IDUs who had never used an HDSS compared with 16% among IDUs who had shared one. The HIV model used a propensity score approach to adjust for differences between IDUs who had used an HDSS and those who had never used one. The HCV models included all potential confounders as covariates. A history of sharing HDSSs was associated with prevalent HIV (Odds Ratio = 2.50; 95% Confidence Interval = 1.01, 6.15). Use and sharing of HDSSs were also associated with increased odds of HCV infection. Prospective studies are needed to determine if sharing HDSSs is associated with increased HIV and HCV incidence among IDUs.
doi:10.1016/j.drugalcdep.2008.08.017
PMCID: PMC2654245  PMID: 19004579
High dead-space syringes; Hepatitis C virus; HIV; Injecting drug users; Risk factors
21.  Using a Modified Intervention Mapping Approach to Develop and Refine a Single-Session Motivational Intervention for Methamphetamine-Using Men Who Have Sex With Men 
The Open AIDS Journal  2010;4:132-140.
There is an ongoing need for the development and adaptation of behavioral interventions to address behaviors related to acquisition and transmission of infectious diseases and for preventing the onset of chronic diseases. This paper describes the application of an established systematic approach to the development of a behavioral intervention to reduce sexual risk behaviors for HIV among men who have sex with men and who use methamphetamine. The approach includes six steps: (1) a needs assessment; (2) preparing matrices of proximal program objectives; (3) selecting theory-based methods and practical strategies; (4) producing program components and materials; (5) planning for program adoption, implementation, and sustainability; and (6) planning for evaluation. The focus of this article is on the intervention development process; therefore the article does not describe steps 5 and 6. Overall the process worked well, although it had to be adapted to fit the sequence of events associated with a funded research project. This project demonstrates that systematic approaches to intervention development can be applied even in research projects where some of the steps occur during the proposal writing process rather than during the actual project. However, intervention developers must remain flexible and be prepared to adapt the process to the situation. This includes being ready to make choices regarding intervention efficacy versus feasibility and being willing to select the best intervention that is likely to be delivered with available resources rather than an ideal intervention that may not be practical.
doi:10.2174/1874613601004030132
PMCID: PMC2908891  PMID: 20657716
Intervention development; intervention mapping; motivational interviewing; formative work; methamphetamine.
22.  Simultaneous Recruitment of Drug Users and Men Who Have Sex with Men in the United States and Russia Using Respondent-Driven Sampling: Sampling Methods and Implications 
The Sexual Acquisition and Transmission of HIV Cooperative Agreement Program (SATHCAP) examined the role of drug use in the sexual transmission of the human immunodeficiency virus (HIV) from traditional high-risk groups, such as men who have sex with men (MSM) and drug users (DU), to lower risk groups in three US cities and in St. Petersburg, Russia. SATHCAP employed respondent-driven sampling (RDS) and a dual high-risk group sampling approach that relied on peer recruitment for a combined, overlapping sample of MSM and DU. The goal of the sampling approach was to recruit an RDS sample of MSM, DU, and individuals who were both MSM and DU (MSM/DU), as well as a sample of sex partners of MSM, DU, and MSM/DU and sex partners of sex partners. The approach efficiently yielded a sample of 8,355 participants, including sex partners, across all four sites. At the US sites—Los Angeles, Chicago, and Raleigh–Durham—the sample consisted of older (mean age = 41 years), primarily black MSM and DU (both injecting and non-injecting); in St. Petersburg, the sample consisted of primarily younger (mean age = 28 years) MSM and DU (injecting). The US sites recruited a large proportion of men who have sex with men and with women, an important group with high potential for establishing a generalized HIV epidemic involving women. The advantage of using the dual high-risk group approach and RDS was, for the most part, the large, efficiently recruited samples of MSM, DU, and MSM/DU. The disadvantages were a recruitment bias by race/ethnicity and income status (at the US sites) and under-enrollment of MSM samples because of short recruitment chains (at the Russian site).
doi:10.1007/s11524-009-9365-4
PMCID: PMC2705484  PMID: 19472058
Respondent-driven sampling; HIV; MSM; MSMW; DU; IDU; SATHCAP
23.  Substance abuse, treatment needs and access among female sex workers and non-sex workers in Pretoria, South Africa 
Background
This study examined cross-sectional data collected from substance-using female sex workers (FSW) and non-sex workers (non-SW) in Pretoria, South Africa, who entered a randomized controlled trial.
Methods
Women who reported alcohol use and recently engaging in sex work or unprotected sex were recruited for a randomized study. The study sample (N = 506) comprised 335 FSW and 171 female non-SW from Pretoria and surrounding areas. Self-reported data about alcohol and other drug use as well as treatment needs and access were collected from participants before they entered a brief intervention.
Results
As compared with female non-SW, FSW were found to have a greater likelihood of having a past year diagnosis of alcohol or other drug abuse or dependence, having a family member with a history of alcohol or other drug abuse, having been physically abused, having used alcohol before age 18, and having a history of marijuana use. In addition, the FSW were more likely to perceive that they had alcohol or other drug problems, and that they had a need for treatment and a desire to go for treatment. Less than 20% of participants in either group had any awareness of alcohol and drug treatment programs, with only 3% of the FSW and 2% of the non-SW reporting that they tried but were unable to enter treatment in the past year.
Conclusion
FSW need and want substance abuse treatment services but they often have difficulty accessing services. The study findings suggest that barriers within the South African treatment system need to be addressed to facilitate access for substance-using FSW. Ongoing research is needed to inform policy change that fosters widespread educational efforts and sustainable, accessible, woman-sensitive services to ultimately break the cycle for current and future generations of at-risk South African women.
doi:10.1186/1747-597X-4-11
PMCID: PMC2693506  PMID: 19473505
24.  THE IMPACT OF ILLICIT DRUG USE AND HARMFUL DRINKING ON QUALITY OF LIFE AMONG INJECTION DRUG USERS AT HIGH RISK FOR HEPATITIS C INFECTION 
Drug and alcohol dependence  2007;89(2-3):251-258.
Background
Heavy alcohol use, hepatitis C and illicit drug use each have been shown to have negative impacts on health‐related quality of life (HRQL). To date, considerations of HRQL have not played a prominent role in the design and measurement of intervention strategies for out‐of‐treatment at‐risk populations.
Methods
Data were collected from out‐of‐treatment IDUs recruited through street outreach in North Carolina. Multiple linear regression analyses were used to examine the independent effects of HCV status, harmful drinking (AUDIT), and illicit drug use on HRQL (SF‐36).
Results
Fifty‐one percent of 619 study participants tested HCV‐positive; 57% met criteria for harmful or hazardous drinking and 63% reported daily use of hard drugs. HRQL scores for this population were significantly lower than those of the general population. Multiple linear regression analyses demonstrated that harmful levels of alcohol consumption and use of methamphetamine in the past month had the strongest associations with reduced HRQL.
Conclusions
Given the high rates of HCV in most IDU communities, new harm reduction approaches are needed for these populations which focus beyond prevention to the functioning and well‐being of those already infected. In particular, reducing heavy alcohol use in addition to slowing HCV progression shows promise for improving HRQL.
doi:10.1016/j.drugalcdep.2007.01.006
PMCID: PMC1974852  PMID: 17320314
Health‐related quality of life; Hepatitis C; AUDIT; Injection drug use
25.  African-American crack abusers and drug treatment initiation: barriers and effects of a pretreatment intervention 
Background
Individual and sociocultural factors may pose significant barriers for drug abusers seeking treatment, particularly for African-American crack cocaine abusers. However, there is evidence that pretreatment interventions may reduce treatment initiation barriers. This study examined the effects of a pretreatment intervention designed to enhance treatment motivation, decrease crack use, and prepare crack abusers for treatment entry.
Methods
Using street outreach, 443 African-American crack users were recruited in North Carolina and randomly assigned to either the pretreatment intervention or control group.
Results
At 3-month follow-up, both groups significantly reduced their crack use but the intervention group participants were more likely to have initiated treatment.
Conclusion
The intervention helped motivate change but structural barriers to treatment remained keeping actual admissions low. Policy makers may be interested in these pretreatment sites as an alternative to treatment for short term outcomes.
doi:10.1186/1747-597X-2-10
PMCID: PMC1847815  PMID: 17394653

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