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1.  Law Enforcement Practices Associated with HIV Infection Among Injection Drug Users in Odessa, Ukraine 
AIDS and behavior  2013;17(8):2604-2614.
Despite HIV prevention efforts over the past 10 years in Odessa, Ukraine, HIV rates among injection drug users (IDUs) remain high. We explored whether IDUs’ experiences with the police and court system in Odessa were associated with HIV serostatus, after controlling for other factors. Qualitative methods, including semi-structured interviews with the police and members of court (N = 19), and focus groups with IDUs (N = 42), were employed to aid in developing a survey instrument for a larger quantitative phase and to assist in interpreting the findings from the quantitative phase, which included 200 participants who were interviewed and tested for HIV. Overall, 55 % tested positive for HIV. Negative experiences with the police were noted by 86 % and included having preloaded syringes taken (66 %), rushed injections due to fear of the police (57 %), police planting drugs (18 %), paying police to avoid arrest (61 %) and threatened by the police to inform on other IDUs (23 %). HIV positive participants were more likely than those who were negative to report these experiences. In a multiple logistic regression, the most significant correlate of HIV infection was rushed injections due to fear of the police. Police actions in Odessa may be contributing to the continued escalation of HIV among IDUs, underscoring the need for structural interventions.
PMCID: PMC3787985  PMID: 23754613
Injection drug user (IDU); Law enforcement; Ukraine
2.  Gender Differences in Chronic Medical, Psychiatric, and Substance-Dependence Disorders Among Jail Inmates 
American journal of public health  2009;100(3):476-482.
We investigated whether there were gender differences in chronic medical, psychiatric, and substance-dependence disorders among jail inmates and whether substance dependence mediated any gender differences found.
We analyzed data from a nationally representative survey of 6982 US jail inmates. Weighted estimates of disease prevalence were calculated by gender for chronic medical disorders (cancer, hypertension, diabetes, arthritis, asthma, hepatitis, and cirrhosis), psychiatric disorders (depressive, bipolar, psychotic, posttraumatic stress, anxiety, and personality), and substance-dependence disorders. We conducted logistic regression to examine the relationship between gender and these disorders.
Compared with men, women had a significantly higher prevalence of all medical and psychiatric conditions (P≤.01 for each) and drug dependence (P<.001), but women had a lower prevalence of alcohol dependence (P<.001). Gender differences persisted after adjustment for sociodemographic factors and substance dependence.
Women in jail had a higher burden of chronic medical disorders, psychiatric disorders, and drug dependence than men, including conditions found more commonly in men in the general population. Thus, there is a need for targeted attention to the chronic medical, psychiatric, and drug-treatment needs of women at risk for incarceration, both in jail and after release.
PMCID: PMC2820077  PMID: 19696388
3.  Interventions with Injection Drug Users in Ukraine 
Addiction (Abingdon, England)  2009;104(11):1864-1873.
To assess the effectiveness of a brief HIV testing and counseling intervention compared to a more time-consuming and expensive street-based intervention with injection drug users (IDUs).
Crossover experimental design in which 600 IDUs were recruited, followed by a “wash out” period with no recruitment, a reversal of intervention assignment areas and an additional recruitment of 600 IDUs with baseline and six-month follow-up assessments.
Kiev, Odessa and Makeevka/Donesk Ukraine.
1,798 IDUs.
HIV testing and audio-computer assisted self-interview (ACASI) data on socio-demographics, drug use and injection and sex-related risk behaviors.
Participants in both conditions significantly reduced their injection and sex risks, however, there was little difference in outcomes between conditions. IDUs who knew they were HIV infected at baseline were significantly more likely to practice safe sex than those unaware or HIV negative; those who first learned they were infected at baseline changed their safe sex practices significantly more than those who already knew they were infected at baseline and those who were HIV negative. Younger IDUs and those injecting for a shorter period of time reported higher injection and sex risk behaviors following interventions.
Awareness of HIV infection by street-recruited drug injectors is associated with reduced sex risks. Additional interventions are required for younger IDUs and those injecting for shorter periods of time.
PMCID: PMC3725954  PMID: 19681800
Injection drug users; Ukraine; HIV testing and counseling
4.  The Feasibility of Interventions to Reduce HIV Risk and Drug Use among Heterosexual Methamphetamine Users 
Journal of AIDS & clinical research  2012;Suppl 1(10):6953.
This paper reports on a feasibility study that examined contingency management among out-of-treatment, heterosexual methamphetamine users and the reduction of drug use and HIV risk. Fifty-eight meth users were recruited through street outreach in Denver from November 2006 through March 2007. The low sample size reflects that this was a pilot study to see if CM is feasible in an out-of-treatment, street-recruited population of meth users. Secondary aims were to examine if reductions and drug use and risk behavior could be found. Subjects were randomly assigned to contingency management (CM) or CM plus strengths-based case management (CM/SBCM), with follow-up at 4 and 8 months. Participants were primarily White (90%), 52% male and averaged 38 years old. Eighty-three percent attended at least one CM session, with 29% attending at least fifteen. All participants reduced meth use significantly at follow-up. Those who attended more sessions submitted more stimulant-free urines than those who attended fewer sessions. Participants assigned to CM/SBCM attended more sessions and earned more vouchers than clients in CM. Similarly, participants reported reduced needle-sharing and sex risk. Findings demonstrate that CM and SBCM may help meth users reduce drug use and HIV risk.
PMCID: PMC3595065  PMID: 23493796
Methamphetamine; HIV risks; Sex; Contingency management; Strengths-based case management
5.  NIDA’s Clinical Trials Network: An Opportunity for HIV Research in Community Substance Abuse Treatment Programs 
HIV continues to be a significant problem among substance users and their sexual partners in the United States. The National Drug Abuse Treatment Clinical Trials Network (CTN) offers a national platform for effectiveness trials of HIV interventions in community substance abuse treatment programs. This article presents the HIV activities of the CTN during its first 10 years.
While emphasizing CTN HIV protocols, this article reviews the (1) HIV context for this work; (2) the collaborative process among providers, researchers, and National Institute on Drug Abuse CTN staff, on which CTN HIV work was based; (3) results of CTN HIV protocols and HIV secondary analyses in CTN non-HIV protocols; and (4) implications for future HIV intervention effectiveness research in community substance abuse treatment programs.
While the feasibility of engaging frontline providers in this research is highlighted, the limitations of small to medium effect sizes and weak adoption and sustainability in everyday practice are also discussed.
PMCID: PMC3361073  PMID: 21854270
Clinical Trials Network; effectiveness research; HIV/AIDS; substance abuse
6.  Reducing HIV-Related Risk Behaviors Among Injection Drug Users in Residential Detoxification 
AIDS and behavior  2011;15(1):30-44.
This study of 632 drug injectors enrolled in eight residential detoxification centers within the National Drug Abuse Treatment Clinical Trials Network tested three interventions to reduce drug and sex risk behaviors. Participants were randomized to: (a) a two-session, HIV/HCV counseling and education (C&E) model added to treatment as usual (TAU), (b) a one-session, therapeutic alliance (TA) intervention conducted by outpatient counselors to facilitate treatment entry plus TAU, or (c) TAU. Significant reductions in drug and sex risk behaviors occurred for all three conditions over a 6-month follow-up period. C&E participants reported significantly greater rates of attending an HIV testing appointment, but this was not associated with better risk reduction outcomes. Reporting treatment participation within 2 months after detoxification and self-efficacy to practice safer injection behavior predicted reductions in injection risk behaviors. Findings indicate that participation in detoxification was followed by significant decreases in drug injection and risk behaviors for up to 6-months; interventions added to standard treatment offered no improvement in risk behavior outcomes.
PMCID: PMC3023839  PMID: 20652630
Drug injection; Risk reduction; Treatment entry; Detoxification
7.  Return to drug use and overdose after release from prison: a qualitative study of risk and protective factors 
Former inmates are at high risk for death from drug overdose, especially in the immediate post-release period. The purpose of the study is to understand the drug use experiences, perceptions of overdose risk, and experiences with overdose among former prisoners.
This qualitative study included former prison inmates (N = 29) who were recruited within two months after their release. Interviewers conducted in-person, semi-structured interviews which explored participants' experiences and perceptions. Transcripts were analyzed utilizing a team-based method of inductive analysis.
The following themes emerged: 1) Relapse to drugs and alcohol occurred in a context of poor social support, medical co-morbidity and inadequate economic resources; 2) former inmates experienced ubiquitous exposure to drugs in their living environments; 3) intentional overdose was considered "a way out" given situational stressors, and accidental overdose was perceived as related to decreased tolerance; and 4) protective factors included structured drug treatment programs, spirituality/religion, community-based resources (including self-help groups), and family.
Former inmates return to environments that strongly trigger relapse to drug use and put them at risk for overdose. Interventions to prevent overdose after release from prison may benefit from including structured treatment with gradual transition to the community, enhanced protective factors, and reductions of environmental triggers to use drugs.
PMCID: PMC3414824  PMID: 22966409
Drug use; Overdose; Prisoners; Relapse; Prison re-entry
8.  Synovial Fluid Biomarkers for Periprosthetic Infection 
We have previously described a unique gene expression signature exhibited by synovial fluid leukocytes in response to bacterial infection, identifying a number of potential biomarkers for infection. However, the diagnostic performance of these potential biomarkers in an immunoassay format is unknown.
We therefore evaluated the sensitivity, specificity, and accuracy of several potential synovial fluid biomarkers for infection, and compared them to current standards of testing for periprosthetic infection.
We prospectively collected synovial fluid from 14 patients classified as having a periprosthetic infection and 37 patients classified as having an aseptic failure. The synovial fluid samples were tested for 23 potential biomarkers for periprosthetic infection. We then determined differences in biomarker levels between infected and aseptic groups, then computed the sensitivity, specificity, positive predictive value, negative predictive value and accuracy for select biomarkers, and finally compared those to current standard tests for infection.
Twelve synovial fluid biomarkers had substantially higher average levels in the synovial fluid of infected versus aseptic patients. Synovial fluid levels of IL-1 were a mean of 258 times higher in patients with a periprosthetic infection compared to patients having revision for aseptic diagnoses. Synovial fluid IL-1 and IL-6 levels correctly classified all patients in this study with a sensitivity, specificity, positive predictive value, negative predictive value and accuracy equal to 1. Several markers tested in this study outperformed the ESR and CRP tests.
Patients with a periprosthetic infection have elevated levels of numerous synovial fluid biomarkers, when compared to patients with aseptic diagnoses. Several of these biomarkers exhibited nearly ideal sensitivity, specificity, and accuracy in this study, suggesting that synovial fluid biomarkers could be a valuable tool for diagnosing periprosthetic infection.
Level of Evidence
Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC2895851  PMID: 20300901
9.  Predicting Outpatient Treatment Entry Following Detoxification for Injection Drug Use: The Impact of Patient and Program Factors 
Journal of substance abuse treatment  2010;38(Suppl 1):S87-S96.
This paper examines variables that predicted outpatient treatment entry within six months of residential detoxification. Patient data were collected from 632 injection drug users enrolled in a randomized trial conducted at 8 detoxification programs within the National Drug Abuse Treatment Clinical Trials Network (CTN) with follow-up assessments conducted at 2, 8, 16,and 24 weeks. Detoxification program characteristics were collected during this study and from a survey of CTN treatment organizations. Survival analysis found that estimated proportions of reported outpatient treatment entry varied across sites from .06 to .72. A model-building approach determined variables significantly associated with outpatient treatment entry. The best predictive model contained five program-level variables: accreditation, fewer beds, longer stays, shorter distance between detoxification and outpatient unit, and larger city population. Results suggest the importance of detoxification program characteristics in facilitating further treatment and the need for systems modifications to improve continuity of care.
PMCID: PMC2847860  PMID: 20307800
10.  The effect of methadone maintenance on positive outcomes for opiate injection drug users 
This study examined outcome variables for 160 opiate injection drug users (IDUs) who entered methadone maintenance between baseline and 6 month follow-up. Outcome variables of interest included drug use, productivity and HIV risk behaviors. Participants were recruited through street outreach in Denver, Colorado from 2000 through 2004 using targeted sampling. The sample was primarily male, 48% White, averaged 39 years of age and had been injecting drugs for an average of nearly 20 years. Significant improvements were found in univariate tests. Logistic regression revealed that spending more time in treatment was a significant predictor of positive outcomes on drug use and HIV risk behaviors. The results underscore the importance of retaining IDUs in methadone maintenance in order to maximize their treatment success. Results from this study show that time in treatment can affect many aspects of the participant’s life in a positive way, including reduction of HIV risk.
PMCID: PMC2741097  PMID: 19150202
11.  Facilitating outpatient treatment entry following detoxification for injection drug use: A multi-site test of three interventions 
A multisite, randomized trial within the National Drug Abuse Treatment Clinical Trials Network (CTN) was conducted to test three interventions to enhance treatment initiation following detoxification: 1) a single session, therapeutic alliance intervention (TA) added to usual treatment, 2) a 2- session, counseling and education, HIV/HCV risk reduction intervention (C&E), added to usual treatment and 3) treatment as usual (TAU) only. Injection drug users (n = 632) enrolled in residential detoxification at 8 community treatment programs were randomized to 1 of the 3 study conditions. There was a significant difference between TA participants and those receiving TAU in reported outpatient treatment entry. TA participants reported entering outpatient treatment sooner and in greater numbers than TAU participants. Reported treatment entry for C&E fell between TA and TAU with no significant differences between C&E and the other conditions. There were no differences among the interventions in retention, as measured by weeks of outpatient treatment for all participants who reported treatment entry. Alliance building interventions appear to be effective in facilitating transfer from detoxification to outpatient treatment, but additional treatment engagement interventions may be necessary to improve retention.
PMCID: PMC2779725  PMID: 19586142
detoxification; treatment entry; therapeutic alliance
12.  Predictors of Methamphetamine Injection in Out-of-Treatment IDUs 
Substance use & misuse  2009;44(3):332-342.
From 2004-2006, 439 injection drug users were recruited in Denver, Colorado, to participate in a study of drug use and HCV risk. Over two-thirds were male, more than half were white, and 28% were methamphetamine injectors. The Risk Behavior Assessment, which assesses demographics, drug use, and HIV risk behaviors, was used. Variables were assessed for association with methamphetamine (MA) injection. A logistic regression model was built using forward stepwise method to determine independent associations between variables of interest and MA injection. The study's limitations are noted, and implications are described.
PMCID: PMC2758071  PMID: 19212925
methamphetamine; HIV risk; Hepatitis C; drug injection; peer education

Results 1-12 (12)