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We investigated the presence of a single-nucleotide polymorphism designated rs12979860 in the interferon λ4 (IFNλ4) gene among 345 people who inject drugs (PWID) and 495 blood donors to evaluate associations between the rs12979860 genotypes and human immunodeficiency virus/hepatitis C virus (HIV/HCV). The rs12979860 TT genotype was over-represented among HIV+ PWID than HIV- PWID and blood donors (16% vs 8% and 10%, P = 0.03, respectively). PWID with TT genotype had approximately twice the probability of being HIV+ (odds ratio [OR], 2.19; 95% confidence interval [CI], 1.11 to 4.33) than PWID without TT. Every additional year of intravenous drug use (IVDU) decreased the OR 1.16 times (OR, 0.86; 95% CI, 0.75 to 0.98). This suggests that rs12979860 TT increases susceptibility to HIV and this impact decreases with increasing duration of IVDU.

Background and aims HIV has reached high prevalence in many non-injecting drug user (NIDU) populations. The aims of this study were to (1) examine the trend in HIV prevalence among non-injecting cocaine and heroin NIDUs in New York City, (2) identify factors potentially associated with the trend and (3) estimate HIV incidence among NIDUs. Design Serial-cross sectional surveys of people entering drug treatment programs. People were permitted to participate only once per year, but could participate in multiple years. Setting Mount Sinai Beth Israel drug treatment programs in New York City, USA. Participants We recruited 3298 non-injecting cocaine and heroin users from 2005 to 2014. Participants were 78.7% male, 6.1% white, 25.7% Hispanic and 65.8% African American. Smoking crack cocaine was the most common non-injecting drug practice. Measures Trend tests were used to examine HIV prevalence, demographics, drug use, sexual behavior and use of antiretroviral treatment (ART) by calendar year; χ2 and multivariable logistic regression were used to compare 2005–10 versus 2011–14. Findings HIV prevalence declined approximately 1% per year (P

Aims To (i) describe an intervention implemented in response to the HIV-1 outbreak among people who inject drugs (PWIDs) in Greece (ARISTOTLE programme), (ii) assess its success in identifying and testing this population and (iii) describe socio-demographic characteristics, risk behaviours and access to treatment/prevention, estimate HIV prevalence and identify risk factors, as assessed at the first participation of PWIDs. Design A ‘seek, test, treat, retain’ intervention employing five rounds of respondent-driven sampling. Setting Athens, Greece (2012–13). Participants A total of 3320 individuals who had injected drugs in the past 12 months. Intervention ARISTOTLE is an intervention that involves reaching out to high-risk, hard-to-reach PWIDs (‘seek’), engaging them in HIV testing and providing information and materials to prevent HIV (‘test’) and initiating and maintaining anti-retroviral and opioid substitution treatment for those testing positive (‘treat’ and ‘retain’). Measurements Blood samples were collected for HIV testing and personal interviews were conducted. Findings ARISTOTLE recruited 3320 PWIDs during the course of 13.5 months. More than half (54%) participated in multiple rounds, resulting in 7113 visits. HIV prevalence was 15.1%. At their first contact with the programme, 12.5% were on opioid substitution treatment programmes and the median number of free syringes they had received in the preceding month was 0. In the multivariable analysis, apart from injection-related variables, homelessness was a risk factor for HIV infection in male PWIDs [odds ratio (OR) yes versus no = 1.89, 95% confidence interval (CI) = 1.41, 2.52] while, in female PWIDS, the number of sexual partners (OR for > 5 versus one partner in the past year = 4.12, 95% CI = 1.93, 8.77) and history of imprisonment (OR yes versus no = 2.76, 95% CI = 1.43, 5.31) were associated with HIV. Conclusions In Athens, Greece, the ARISTOTLE intervention for identifying HIV-positive people among people who inject drugs (PWID) facilitated rapid identification of a hidden population experiencing an outbreak and provided HIV testing, counselling and linkage to care. According to ARISTOTLE data, the 2011 HIV outbreak in Athens resulted in 15% HIV infection among PWID. Risk factors for HIV among PWID included homelessness in men and history of imprisonment and number of sexual partners in women.

Aims The Ethnic Minority Meta-Analysis (EMMA) aims to assess racial/ethnic disparities in HIV infection among people who inject drugs (PWID) across various countries. This is the first report of the data. Methods Standard systematic review/meta-analysis methods were utilized, including searching for, screening and coding published and unpublished reports and meta-analytical statistics. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement and Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines for reporting methods. Disparities were measured with the odds ratio (OR) for HIV prevalence among ethnic minority PWID compared to ethnic majority PWID; an OR >1.0 indicated higher prevalence among ethnic minorities. Results Racial/ethnic disparities in HIV prevalence among PWID were examined in 131 prevalence reports, with 214 racial/ethnic minority to majority comparisons, comprising 106 715 PWID. Overall, the pooled OR indicates an increased likelihood of higher HIV prevalence among racial/ethnic minority compared to racial/ethnic majority PWID [OR = 2.09, 95% confidence interval (CI): 1.92–2.28]. Among 214 comparisons, 106 produced a statistically significant higher OR for minorities; in 102 comparisons the OR was not significantly different from 1.0; six comparisons produced a statistically significant higher OR for majority group members. Disparities were particularly large in the United States, pooled OR = 2.22 (95% CI: 2.03–2.44). There was substantial variation in ORs—I2 = 75.3%: interquartile range = 1.38–3.56—and an approximate Gaussian distribution of the log ORs. Conclusions Among people who inject drugs, ethnic minorities are approximately twice as likely to be HIV seropositive than ethnic majorities. The great heterogeneity and Gaussian distribution suggest multiple causal factors and a need to tailor interventions to local conditions.

Hepatitis C virus (HCV) infection is endemic among injection drug users (IDUs) [1], and is transmitted through shared injection syringes [2]. In addition, seroincidence studies have demonstrated transmission of HCV through the shared use of drug preparation equipment [3–6]. Estimation of infection risk is complicated by the frequent co-occurrence of sharing behaviors [7, 8]. A recent multi-site incidence study found that co-occurrence of sharing drug cookers, filtration cottons, rinse water, or of “backloading” (a syringe-mediated form of sharing prepared drugs) ranged from 86% to 96% [3]. In many IDU populations, syringe sharing has declined since HIV was first recognized, but shared use of drug preparation equipment has persisted, with 50–70% of IDUs reporting recent sharing of cookers or cotton, or backloading [3–6, 9–11]. Synthesizing knowledge on the relative risk of HCV infection associated with sharing behaviors, and estimating the relative importance of these behaviors is important, as it may be used to guide the development of more effective HCV prevention programs and information. Previous research syntheses of risk behaviors in regard to HCV acquisition have included an insufficient number of studies for quantitative analysis of distinct risk behaviors. One such synthesis grouped data from 10 studies regarding shared drug preparation equipment into a single meta-analysis [12]. Their analysis showed that risks associated with sharing drug preparation equipment generally ranged from 2.0 to 5.9, but that substantial heterogeneity precluded calculation of an overall effect. Heterogeneity of effects could have arisen for a number of reasons, including variability in the concentration of virus and amount of contaminated blood by equipment type. Such heterogeneity could be reduced by stratifying analyses by the specific type of equipment that was shared, but there were few studies included that reported effects with such detail. In this study, we examined the associations between shared syringes and drug preparation equipment with HCV seroconversion using data from the HCV Synthesis Project, a systematic review and meta-analysis of published and unpublished research studies of HCV epidemiology and prevention in drug users throughout the world [13]. Using pooled estimates, and data on the proportions of IDUs engaging in sharing behaviors, we calculated population attributable risk percentages reflecting the percentage of HCV seroconversions that could be prevented by eliminating specific sharing behaviors.

Noninjection drug use, although recognized as an emerging risk factor for acquisition of other blood-born pathogens, is still unconfirmed as a route of hepatitis C virus (HCV) transmission. Our goal was to measure HCV exposure and prevalence in noninjection drug users (NIDUs). Fifty-seven NIDUs were screened by extensive questionnaire to exclude prior injection drug use and evaluated for HCV-specific serologic and cellular immune responses. HCV-specific T-cell responses were measured using interferon-gamma (IFN-γ) enzyme-linked immunospot (ELISpot) assay with overlapping HCV peptides covering the entire HCV genome. Fifteen individuals who never used illicit drugs served as negative controls. Eleven people with no history of injecting drug use (19.3%) were HCV seropositive: seven with chronic HCV infection and four with previously resolved infection. Of 51 NIDUs with ELISpot results, HCV-specific cellular immunity was detected in 5 (9.8%). These responses were relatively weak and narrow. We did not find significant associations between HCV-specific immune responses and noninjection drug use practices. Subjects with HCV-specific immunity, however, were significantly more likely to have bought sex in the past 6 months, to have had more casual partners of the opposite sex in the last 6 months, and those partners were more likely to have ever injected drugs compared to subjects without HCV-specific immunity. In summary, we found serologic or cellular HCV-specific immune responses in 27.5% of NIDUs. Our results suggest that sexual behaviour associated with noninjection drug use might be a risk factor for HCV acquisition. Additional studies are needed to precisely determine the practices that lead to HCV exposure among this population.

The aim of this study was to assess the attitudes of Italian physicians regarding buprenorphine and its clinical use approximately 6 years after the medication was introduced into clinical practice. The sample consisted of 305 randomly selected physicians, working in public centers of drug addiction. In Italy buprenorphine seems a valid tool in the field of drug addiction treatment, although it is far from replacing methadone even though it seems to guarantee better compliance. Interviewees follow clinical experience more than international guidelines, with pharmaceutical company representatives as the most cited source for information about the medication. The data also suggests a need for the development of formal guidelines for treatment with buprenorphine in Italy.

Objective To assess trends in injecting and non-injecting drug use after implementation of large-scale syringe exchange in New York City. The belief that implementation of syringe exchange will lead to increased drug injecting has been a persistent argument against syringe exchange. Methods Administrative data on route of administration for primary drug of abuse among patients entering the Beth Israel methadone maintenance program from 1995 to 2007. Approximately 2000 patients enter the program each year. Results During and after the period of large-scale implementation of syringe exchange, the numbers of methadone program entrants reporting injecting drug use decreased while the numbers of entrants reporting intranasal drug use increased (P

Aims This paper reviews the evolution of government policies in China and Vietnam regarding harm reduction interventions for human immunodeficiency virus (HIV) prevention, such as needle/syringe provision and opioid substitution treatment. Methods The work is based upon the authors' experiences in and observations of these policy developments, as well as relevant government policy documents and legislation. Results Both countries are experiencing HIV epidemics driven by injection drug use and have maintained generally severe policies towards injection drug users (IDUs). In recent years, however, they have also officially endorsed harm reduction. We sought to understand how and why this apparently surprising policy evolution took place. Factors associated with growing support for harm reduction were similar but not identical in China and Vietnam. These included the emergence of effective ‘champions’ for such policies, an ethos of pragmatism and receptivity to evidence, growing collaboration across public health, police and other sectors, the influence of contingent events such as the severe acute respiratory syndrome (SARS) epidemic and pressure from donors and international organizations to adopt best practice in HIV prevention. Conclusions Ongoing challenges and lessons learned include the persistence of tensions between drug control and harm reduction that may have negative effects on programs until a fully harmonized policy environment is established. Excessive reliance on law enforcement and forced detoxification will not solve the problems of substance abuse or of HIV among drug users. Ongoing evaluation of harm reduction programs, as well as increased levels of multi-sectoral training, collaboration and support are also needed.

Aims To assess audio computer-assisted self-interviewing (A-CASI) as a mode of data collection with injecting drug users (IDUs) entering two drug treatment programs in New York City. A-CASI has been found to increase reporting of sensitive items among a variety of population subgroups. Design A field test of A-CASI data collection conducted within an ongoing cross-sectional study of drug use and HIV risk behaviors among IDUs entering drug treatment. Participants were assigned without bias to either a computer-assisted interviewer-administered personal interview (CAPI) or to a mixed CAPI/A-CASI interview. In the latter, ‘sensitive’ portions (dealing with stigmatized behavior) of the questionnaire were self-administered through A-CASI, while the remaining portions were interviewer-administered. Setting The Detoxification Program and the Methadone Maintenance Treatment Program (MMTP) at Beth Israel Medical Center in New York City. Participants Seven hundred and eighty-three IDUs entering drug treatment. Measurements Odds ratios and adjusted odds ratios (controlling for demographic differences) for comparison of A-CASI versus CAPI responses on 111 sensitive questions. Findings Twenty-three statistically significant differences (each at P

The study assessed rates and predictor variablesof hepatitis C virus (HCV) infection among drug usersreceiving pharmacological treatment for opiates addiction.There was a large cohort study in 16 public centres fordrug users in north-eastern Italy, with data collected bystandardized face-to-face interviews between February 2001and August 2001.Of 1095 participants, 74.2% were HCV seropositive.Anti-HCV status was independently associated with dur-ation of drug use of over 10 years, injecting as a route ofdrug administration, and hepatitis B virus (HBV) andhuman immunodeficiency virus (HIV) seropositivity.Further statistical analysis was conducted by dividing thesubjects on the basis of the duration of heroin use: more or

Aims To determine relationships between drug use ‘hardness’ (defined in increasing order of hardness as no drug use, marijuana use, non-injected heroin or cocaine use, crack smoking and injection drug use) and prevalences of several sexually transmissible infections among young adults in a high-risk neighbourhood. Drug users, particularly injection drug users and crack smokers, may be a core group for some sexually transmitted infections. Design Cross-sectional survey and assays of young adults from (a) a household probability sample and (b) a targeted sample of youth who have used injected drugs, crack, other cocaine or heroin. Setting Bushwick, an impoverished New York City minority neighbourhood with major drug markets. Participants A total of 363 18–24-year-olds from a household probability sample; 165 Bushwick 18–24-year-olds who have used injected drugs, crack, other cocaine or heroin. Measurements Drug use by self-report; serum- and urine-based assays for HIV, hepatitis B and C, syphilis, gonorrhoea, chlamydia and herpes simplex (type 2). Findings Household-sample prevalences: HIV, hepatitis C and syphilis, 1%; gonorrhoea 3%; chlamydia 5%; past or present hepatitis B infection 8%; herpes simplex (type 2) 18%. In combined household and targeted samples, hepatitis C and HIV were concentrated among drug injectors. Herpes simplex (type 2), syphilis and hepatitis B increased among women with ‘hardest drug ever used’. Conclusions Using ‘harder’ drugs is associated with some but not all of these infections. Prevention efforts should help youth avoid unsafe sex and higher-risk drugs.

Aims To investigate the feasibility of hepatitis B vaccination among heroin users, assessing adherence to the vaccination schedules and identifying factors associated with antibody response. Design and participants A large cohort study in nine public centres for drug users (PCDUs) in north-eastern Italy, with data collected between January 1989 and December 1998. A total of 1175 heroin users were selected and vaccinated with a recombinant vaccine using two schedules (0–1–6 months and 0–1–2 months). Findings Eighty-eight per cent of patients completed the vaccination series and a protective antibody response occurred in 77% of subjects. Completion of the vaccination series was not related to the length of the vaccination schedule or whether the patient was still in drug abuse treatment at the end of the series, but was related strongly to the number of patients enrolled at each PCDU (Spearman correlation = – 0.93, P < 0.001). Four variables were significantly associated with lack of seroconversion in response to vaccination: older age (AOR = 0.91 per year, 95% CI 0.88–0.94, P < 0.001), 2-month vaccination schedule (AOR = 3.10, 95% CI 2.06–4.68, P < 0.001), HCV seropositivity (AOR = 0.69, 95% CI 0.47–0.99, P = 0.04), HIV seropositivity (AOR = 0.27, 95% CI 0.10–0.77, P = 0.01). Conclusions A large-scale, multi-site hepatitis B vaccination programme for heroin users proved feasible and effective. The factors associated with a lack of antibody response may be useful in identifying patients who would benefit most from routine post-vaccination testing, with booster doses for non-responders. These results suggest that hepatitis B vaccination for drug users should become a routine public health practice.

Aims. To compare potential risk factors for the transition to injecting among non-injecting heroin users (NIUs) with different injecting histories. Design. Cross-sectional data from baseline structured interviews with NIUs in a study on transitions to injecting. Sample recruited by outreach or chain-referral in New York City (NYC), 1996-1998. Setting. Recruitment of sample and interviews conducted in a NYC neighborhood where many drug users reside and/or use drugs. Participants. Of 575 NIUs, 67% had never injected; 16% had injected one to nine times (infrequent former injectors (IFI)); and 18% 10 or more times (frequent former injectors (FFI)). Measurements. Controlling for age and race/ethnicity, adjusted odds ratios were estimated in multivariate logistic regression, and differences in means tested by ANCOVA. Findings. FFI (compared to never injectors and IFI) were more likely: to be homeless; to be unemployed; to be long-time users; to be younger at first heroin use; to not have initiated heroin use through non-injected routes; to not be afraid of injecting themselves with needles; to sniff heroin with former IDUs; and, for both men and women separately, to have sex partners who were former IDUs. Both FFI and IFI were twice as likely as never injectors to perceive that their friends thought that it was "OK" to inject drugs. Conclusions. FFI have multiple individual and network characteristics that may increase their risk of injecting drugs. Interventions among NIUs to prevent transitions to injecting need to ascertain NIUs' injecting history and address the many potential risks that FFI have for resuming injecting drug use.

The current World Health Organization guidelines (1992) suggest that the presence of > or = 30% normal sperm forms (i.e. PAP criteria) is consistent with normal semen quality. Critical evaluation of sperm morphology (CE; Kruger classification) has shown an excellent correlation with human in vitro fertilization. Utilizing Kruger criteria, > 14% normal sperm forms has been proposed as indicative of normal semen quality. We have performed a retrospective analysis on 261 individuals to assess the agreement between PAP and Kruger criteria for normal sperm morphology (NSM). When the threshold for NSM by PAP was set at 30%, a significant agreement was found between the percentage normal forms of both criteria (Kappa coefficient = 0.37; p 50%) may obviate the need for Kruger assessment. However, when WHO morphology is between 30 and 50%, the addition of Kruger evaluation may provide meaningful information to help better diagnose a patient and plan his treatment.

In an ideal world, data on illicit drug use, theoretical understanding of the causes of illicit drug use and policies to reduce the health and social problems associated with illicit drug use would be strongly integrated. There would be: (i) multiple sources of data that converged, (ii) strong (falsifiable) theories for interpreting the data and (iii) evidence-based policies. The paper by Caulkins et al. in this issue [1] illustrates how far we currently are from such a utopia. Caulkins and colleagues present a convincing case that, during the last decade, cocaine use has decreased dramatically (approximately a 50% decrease) and marijuana use has increased almost as dramatically in the United States (approximately a 30% increase). Caulkins and colleagues were able to develop a plausible explanation for the decrease in cocaine use. They believe that a decrease in the supply of cocaine to the United States was important, although they are not certain what supply factors, perhaps eradication efforts, perhaps interorganizational warfare among drug trafficking organizations in Mexico, or perhaps in criminal organizations in Columbia switching from smuggling cocaine to smuggling gasoline, are causing this decrease in supply. With respect to the increase in marijuana use, Caulkins and colleagues do not select a most plausible explanation: 'We do not know why there was such a large increase in the number of daily/near daily users'. It is interesting to note what Caulkins and colleagues did not consider as possible explanations. Our current dominant policy with respect to limiting the use of marijuana and cocaine is criminalization of the sale and use of these drugs. In the most recently available Federal Bureau of Investigation (FBI) arrest data there were 1 552 432 drug-related arrests (12.7% of all arrests in 2012); of the drug-related arrests, 6.1% were for heroin and/or cocaine possession and 42.4%were for marijuana possession. An additional 5.9% were for the sale or manufacture of marijuana. Caulkins and colleagues do not consider the possibility that cocaine use is decreased because arresting people for cocaine possession has been effective in reducing use, nor do they consider the possibility that marijuana use is increased because we are not arresting enough people for marijuana possession. Enough said and not said? The situation in which we have imperfect but convincing data on important drug use trends has, at best, partial understanding of the trends, and where the trends are clearly not related to our dominant public policy with respect to illicit drug use sounds pretty dire. [more...] [1] Caulkins J., Kilmer B., Reuter P., Midgette G. Cocaine's fall and marijuana's rise: questions and insights based on new estimates of consumption and expenditures in US drug markets. Addiction 2015; 110: 728-36. Language: en

Aims. Drug scenes (social and spatial drug-using and drug-selling environments) have complex role structures. Many drug injectors earn money or drugs as drug or syringe sellers, hit doctors (people who help others to inject) commercial sex workers, or in other roles. This paper aims to measure "role behaviors" of drug injectors; describe which drug injectors are more likely to engage in such role behaviors; and to determine whether roles are related to elements of HIV risk . Design. Cross-sectional study of drug injectors . Setting. Bushwick, a section of Brooklyn, New York, a major location for injection drug use and drug sales . Participants. Seven hundred and sixty-seven street-recruited drug injectors . Measurements. Participants were interviewed about their roles, behaviors, socio-demographics and risk networks; sera were collected and assayed for HIV and hepatitis B core antibody . Findings. Socio-demographic variables are related to role-holding in complex ways. Economic need is generally associated with engaging in drug-scene role behaviors. Holders of these roles are at greater behavioral and network risk for HIV and other blood-borne infections than are other drug injectors. They also engage in extensive communication with other drug users, including discussion of HIV risk reduction . Conclusion. Role behaviors can be measured in quantitative studies, and seem to be related to HIV risk. Role-holders may be strategic targets for risk-reduction campaigns. It seems feasible and advisable to measure drug scene role-holding in research on drug users.

HIV infection among injecting drug users has become a world-wide public health problem. This raises fundamental questions about the modifiability of drug-using behavior and of the influence of different national settings upon the modification of drug use behavior. Data from the World Health Organization Multi-site Study of HIV and Injecting Drug Use and studies of HIV among drug injectors in New York City (the US component of the WHO study) are used to address these questions. There is no clear relationship between HIV seroprevalence and current levels of risk behavior in the WHO cities, and the range in seroprevalence is much greater than the range in current risk behavior. Nonetheless, historical trend data enable us to discern at least two broad patterns in different cities. HIV epidemics appear to have been successfully prevented among IDUs in some cities, in that seroprevalence has remained low and stable over several years. These cities are characterized by community outreach programs and good access to sterile injection equipment. On the other hand, high-servoprevalence epidemics have also occurred in many different cities. Stabilization of seroprevalence has eventually also occurred in these cities, but this still includes moderate rates of new HIV infections. How to reverse high-seroprevalence situations remains one of the more difficult questions in HIV epidemiology. The epidemiology of HIV infection among injecting drug users also needs to include analyses of the impacts of decisions by political and public health leaders. A three-category scheme for classifying political decisions is offered: data-free decisions, data-based decisions, and data-proof decisions.

Although European and Australian studies of syringe exchange programs have reported safer injection among participants and no increase in drug use, the generalizability of these findings to the US is uncertain. We report on the operations and potential effectiveness of the longest-operating syringe exchange in the US and compare our results to studies of exchange programs outside the US. The sample of 204 study subjects reported no change in the frequency of injection, from 155 to 152 injections per month, and a decline in the frequency of unsafe injections, from 56 to 30 times per month, while participating in the program. In all studies, participants report reduction in unsafe injections, and no increase in illicit drug use. However, the comparison also suggests that a high proportion of Tacoma exchangers have higher initial rates of drug injection, unsafe injection and homelessness, all of which were associated with unsafe injection while using the exchange. These indicate a need for additional services but that the Tacoma program is no less effective than European and Australian programs.

In this specially commissioned BJA series experienced clinicians will be giving their personal and frontline views as to how the practical business of treating people with substance problems is best handled. Abstract In 1984, outreach to injecting drug users and their female sexual partners was initiated as pan of HIV behavioral research projects. HIV, health, drug treatment and family planning information and services were provided in addition to recruiting subjects to the research program. Such outreach also poses certain problems—especially potential disruption of neighborhood day-to-day life and clashes with police. This paper discusses an outreach program to injecting drug users and their female sexual partners that was initiated in New York City to provide HIV-related information and services. We examine the successes of the program and problems that were involved in conducting outreach to persons who are typically not accessible through formal institutional channels.

Many drug injectors continue to engage in behaviors that lead them to become infected with HIV in spite of a wide variety of public health programs. In addition, many persons have begun to inject drugs in spite of knowing the risks of AIDS. The inadequacy of current efforts to prevent these behaviors suggests that additional forms of intervention should be attempted. We suggest that social interventions be tried to complement current programs (almost all of which have an individual focus). Evidence that social factors such as peer pressure and the social relations of race affect risk behavior is presented. Social interventions that are discussed include organizing drug injectors against AIDS in ways analogous to those in which gays organized against the epidemic, and finding ways to change large-scale social relationships that predispose people to inject drugs.

This paper examines findings and trends from the first decade of research on AIDS among injecting drug users as a basis for projecting into the next decade. One of the most disturbing aspects of AIDS and HIV infection among injecting drug users which emerged in the first decade is the globalization of the problem. Further geographic spread can be expected, particularly in developing countries. Rapid spread of HIV among drug injectors has occurred in many different cities, with a lack of AIDS awareness and mechanisms for efficient mixing of the at-risk population appearing to be important contributing factors. Drug injectors have modified their behavior in response to a wide variety of AIDS prevention programs. No single type of prevention program should be viewed as a panacea, and a comprehensive system of programs will undoubtedly be needed. Changing sexual risk behavior has proven to be considerably more difficult than changing drug injection risk behavior, and is an area in need of much more research.

Anyone who has visited several syringe exchange programs (SEPs) is likely to be convinced that there are meaningful differences among the programs. Syringe exchange programs vary in their staffing, operating characteristics, characteristics of the participants and in their legal, cultural and economic environments [1‐3]. Epidemiological research indicates that some of these differences may be very important. Syringe exchange programs have been associated with preventing HIV epidemics among drug injectors [4‐7] and with reducing HIV incidence in high seroprevalence HIV epidemics [8,9], but there are also instances in which the presence of a syringe exchange program was not sufficient to prevent high incidence rates among local IDUs [10]. In this issue, Bluthenthal and colleagues [11] report on a comparison of three different US syringe exchange programs—in Hartford, Connecticut, Chicago, Illinois and Oakland, California. The major findings are certainly plausible: that police contact with drug injectors is associated positively with living in an area with no legal possession of syringes and that the lack of a cap on syringes to be exchanged is associated with less re-use of syringes. However, it is very important to recognize that comparisons of syringe exchanges in different cities involve many different dimensions and that this study had a sample of only three programs. For example, Hartford had the lowest rate of police contact with IDUs and also had the highest rate of receptive sharing (see Table 1 of Bluthenthal et al. in this issue). Additional research is needed urgently on the relationships between characteristics of syringe exchange programs, the participants in those programs, the legal/social/economic environment and actual HIV infection among IDUs in the area. This should include both risk behavior and actual HIV infection rates among program participants. There is a need for both additional case studies and quantitative syntheses of data from large numbers of programs. Statistical techniques of meta-analysis [12] and hierarchical linear modeling [13] may be very useful in quantitative syntheses of data from moderate to large numbers of programs. Qualitative studies, including case studies, can provide better understanding of complex or potentially anomalous findings, and enable development of new hypotheses.

Parenteral drug abusers are at risk for acquired immunodeficiency syndrome (AIDS), which is caused by human immunodeficiency virus (HIV). We tested stored sera for antibody to HIV (anti-HIV) using two enzyme-linked immunosorbent assay (ELISA) methods and Western blot. The patients were parenteral drug abusers who had undergone percutaneous liver biopsy for chronic liver disease. Current or former alcohol abuse was noted in 88 (80%) of the 110 patients. The sensitivities of the two ELISA tests in comparison with Western blot, the more specific test for HIV, were 100 and 94%, respectively; the specificities were 94 and 99%. Western blot was positive in 36 (33%) of 110 patients. False-positive ELISA reactions for anti-HIV were seen in five (7%) of 70 patients with negative Western blot analyses. Compared to true-negatives, false-positives had significantly more years of alcohol abuse, younger ages of onset of alcohol abuse, greater frequencies of jaundice and edema, higher levels of alkaline phosphatase, total billirubin, total protein, and globulins, and lower levels of serum albumin. In a stepwise logistic regression, only hyperglobulinemia was significantly associated with a false-positive anti-HIV. We conclude that: (a) ELISA tests for anti-HIV are useful for screening abusers of alcohol and parenteral drugs with chronic liver disease for HIV infection, but positive results must be confirmed with more specific tests such as Western blot; (b) false-positive ELISA reactions in this population are associated with hyperglobulinemia; and (c) studies of HIV testing are needed in other populations of patients with alcoholism or liver disease.

The acquired immune deficiency syndrome (AIDS) has rapidly become the most serious medical consequence of injecting illicit drugs. Its potential impact on intravenous (IV) drug use is enormous. Human immunodeficiency virus (HIV, also known as HTLV-III and LAV), the virus that causes AIDS, appears, usually, to lead to lifelong infection. At present there is no effective treatment, and the treatments under development may require lifelong antiviral therapy. Since most of the antibody produced in response to HIV infection does not neutralize the virus, and since there is substantial genetic variation in the virus, it will be difficult to develop a vaccine. Even after vaccines are developed, testing their safety and efficacy will be formidable problems. Until either effective treatment or vaccines are developed, control of the epidemic among IV drug users must be attempted through behavior change/prevention efforts. In this paper we will review the epidemiology of AIDS among IV drug users and characteristics of the IV drug-use subculture relevant to prevention efforts. We will then identify different target groups for these prevention efforts, present available evidence about behavior change in these groups, and then briefly discuss how to prevent transmission of HIV to heterosexual partners who are not themselves IV drug users and to the children of IV drug users.