Theoretical models used to guide NIDA's cooperative agreement research and intervention efforts. National Institute on Drug Abuse.

NIDA's Cooperative Agreement program to reach out-of-treatment drug users and provide HIV prevention to reduce HIV drug and sexual risks was initiated in September of 1990. By August, 1994 the program included 23 sites which used various theoretical models to guide prevention strategies, add conceptual coherence to many aspects of behavior change, and allow for clearer interpretation of why behavior change occurs. This article reviews the theoretical models used at each of the NIDA Cooperative Agreement sites, the perceived helpfulness of the models, and recommendations for future initiatives.

Temporal trends in HIV risk behaviors of out-of-treatment injection drug users and injection drug users who smoke crack.

This study compared the baseline sociodemographic characteristics and HIV risk behaviors of two groups of out-of-treatment injection drug users (IDUs): 366 who concurrently smoked crack (smoking IDUs) and 212 who did not smoke crack (IDUs) in the past 30 days. Temporal trends in recent risk behaviors were also assessed for each drug user group over an 18-month period, January 1992 through June 1994. Baseline data were collected in South Philadelphia before the implementation of a multisite HIV intervention research project funded by the National Institute on Drug Abuse. For the temporal trend analysis, the sample was grouped into four intake periods based on the date of the baseline interview. The results indicated that although both groups were economically disadvantaged and at high risk of HIV infection and transmission, smoking injectors had fewer economic resources and were at a moderately greater risk because of higher levels of sexual risk behaviors. Analysis of temporal trends revealed few reductions in drug risk behaviors and none in sexual risk behaviors. This study points to the need for examining differences between types of drug users, developing appropriate multidrug treatment programs and assessing the characteristics of communities so that theory-based interventions can be tailored for maximum effectiveness.

Correlates of HIV seropositivity and HIV testing among out-of-treatment drug users.

This study: 1) examined the rate and correlates of human immunodeficiency virus (HIV) seropositivity; and 2) assessed whether self-selection in HIV testing influenced the rate and correlates of HIV seropositivity in a group of out-of-treatment drug users. Data were collected from 856 out-of-treatment drug users in Philadelphia between January 1993 and August 1994. Seventy-four percent of the sample elected to take an HIV test that was included in the project in which the drug users were enrolled, and of these, 11% were HIV positive. Multivariate analyses indicated that those who were younger, those who had an injection-drug-using sex partner, and those who reported no recent sexual activity were more likely to be HIV positive. An examination of the multivariate correlates of HIV testing indicated that subjects who took an HIV test had higher rates of participation in some risk behaviors than did subjects who did not take an HIV test, but lower rates for other risk behaviors. None of the correlates of HIV seropositivity were correlates of HIV testing. Although the generalizability of the HIV seroprevalence rate is unclear, it is probable that the correlates of HIV seropositivity are generalizable to the total sample. The results of this study indicate the importance of interventions that target sexual risk behavior among out-of-treatment drug users, and of assessing the impact of self-selection bias whenever the rate and correlates of HIV seropositivity are examined.

Effectiveness of an HIV risk reduction counseling intervention for out-of-treatment drug users.

This study examined and compared the effectiveness of two counseling interventions designed to reduce the HIV drug and sexual risk behaviors of 684 out-of-treatment drug users recruited from South Philadelphia, PA. All study participants received a standard intervention and one half were randomly assigned to also receive the enhanced intervention. The standard intervention provided HIV risk reduction education, HIV testing with pretest and posttest counseling, and training in condom use and needle cleaning. The enhanced intervention provided additional information on STD risk reduction. Both interventions were effective in influencing behavior change between baseline and 6-month follow-up. A higher proportion of persons reduced their drug risk behaviors compared to their sexual risk behaviors. As sexual risk behaviors are more resistant to change, there is a need for tailored interventions that target out-of-treatment drug users.

Crack users in east Harlem, New York and Philadelphia, Pennsylvania: HIV-related risk behaviors and predictors of serostatus.

Crack use has been associated with increased risk for HIV seropositivity. This study was undertaken to examine HIV-related risk behaviors among crack users in East Harlem, New York and Philadelphia, Pennsylvania, two northeastern communities which have reported extensive crack use. Crack users recruited in East Harlem (n = 1434) and Philadelphia (n = 694) were compared on demographics, drug and sex-related risk behaviors, health-related behaviors, and HIV serostatus. Many significant differences were found, and seropositivity was higher in the New York sample (25% vs. 11%, chi 2 = 36.28, p < .001). Being a recent drug injector was a significant predictors of seropositivity in both communities, and differences between communities were found in additional predictors of serostatus. Results suggest that tailored HIV interventions may be needed for different communities. In addition, aggregate data across communities, even those that may be in geographical proximity, may obfuscate differences important to incorporate in developing prevention/intervention efforts.

Pennsylvania's medically uninsured population: findings from a statewide survey.

Pennsylvania is currently considering legislative options to expand coverage and improve access to medical care for state residents who lack health insurance. Relevant data are presented from a telephone survey of 10,809 Pennsylvania households. Almost nine percent (8.5%) of the state's population lacks health insurance, representing over one million people. Those most likely to be uninsured are children and young adults, non-whites and the poor. A substantial number of poor people are not covered by the state's Medicaid program. The uninsured report poorer health status, more obstacled to receiving care and greater use of hospital services for primary care.

Neighborhood variations in the use of city-supported primary health care services by an elderly population.

The purpose of this paper is to examine the elderly's use of city-supported primary health care services. The provision of free or low cost health care to the elderly population is a major health policy issue, especially as the size of the elderly population increases and there is a concomitant increase in the need for health services and increases in the out-of-pocket cost of health care. The data analyzed here are based on client records for approximately 6,000 persons 65 and older who utilized the City of Philadelphia's Family Medical Care Program in 1982. Demographic and socioeconomic characteristics, diagnoses and types of services used are examined for all clients citywide and by neighborhood. Elderly clients of the city primary care system tended to be 65-74, female and black. Most clients had low incomes, with about 75-87% having incomes below $6,000. The problems for which care is sought involve long-term, ongoing care. The data show that the elderly are underrepresented in the city-supported primary care system relative to their numbers in the general population. Our findings on diagnosis and services utilization characteristics of those elderly who do use city-supported primary health care services indicate that the elderly are likely to place demands on the existing system for a substantial amount of resources. The demands for such services are likely to increase especially as the size of the elderly population increases.

Defining drug use: a model for the integration of measures through the census tract.

The nature and severity of drug use has been measured both directly and indirectly by various studies employing different indicators, although the majority of studies still tend to use single measures of drug use. The need to employ multiple measures in examining drug abuse is constrained by the fact that available data may have been collected through diverse methodologies and measured on different levels or units. The purpose of this study was to develop and test in Philadelphia a model using qualitatively different types of data integrated by the common geographic unit of a census tract. The types of data used included: archival data, key informant data, and survey data. Using this approach the paper examines the relationships of drug use measures to each other, to the social environment, and to drug market factors. Major findings of the analysis indicate that there are several independent measures of drug use as reflected in five composite indicators which differentiate behavioral activities or consequences of drug use. Moreover, heroin use indicators exhibit relationships with social-environmental characteristics and drug market factors which are different from those existing with amphetamine or synthetic drug use.