Les communautés thérapeutiques en milieu carcéral

The author focuses on therapeutic communities, particularly the KEY and CREST programs, applied in the state of Delaware since 1988. There programs are aimed at substance users living either in correctional settings (KEY) or on probation (CREST). This research tries to evaluate both programs according to the subject's relapse rate after 6 months. Based on the results, it has been determined that the subjects who participated in these programs successively had better chances of never using drugs again than those who had been in only one of the two programs, or neither. Other American experiments of the same kind have shown similar results

Foster Care History and HIV Infection Among Drug-Using African American Female Sex Workers

Foster care has been associated with increased HIV risk behaviors among youth, yet long-term association with HIV infection has not been examined. This study explored the associations between foster placement, victimization, mental health, onset of sex work and HIV infection among highly vulnerable female sex workers. 562 drug-involved African American women were enrolled into an intervention study to increase health services utilization and reduce HIV risk. Seventeen percent reported a history of foster placement. Foster history was associated with significantly lower educational attainment, higher victimization, and more severe mental health problems. Women with foster histories reported significantly earlier entry into paid sex work, with some 62% active in the sex trade before age 18. Multivariate analyses found that foster care was independently associated with HIV seropositivity, and that early sex work partially mediated this association. The potential long-term health vulnerabilities associated with foster placement are understudied and warrant additional research

HIV Stigma Among Substance Abusing People Living with HIV/AIDS: Implications for HIV Treatment

HIV-related stigma has a major impact on quality of life and health among people living with HIV and AIDS (PLWHA). This study examines demographic, mental health, behavioral, contextual, and HIV care-related correlates of HIV stigma among 503 substance abusing PLWHA. Stigma was measured with the HIV Internalized Stigma Measure which has four subscales: stereotypes about HIV, self-acceptance, disclosure concerns, and social relationships. Severe substance dependence (55.3%) and depression (54.7%) were associated with higher HIV stigma across all domains. 49.9% of the sample reported antiretroviral (ARV) medication diversion (the unlawful sale and trading of ARV medications); diverters endorsed significantly higher stigma related to disclosure. 54.1% of the sample reported ≥95% ARV adherence; these individuals reported significantly lower stigma for self-acceptance, disclosure, and social relationships. Multivariate linear regression showed that depression and social support demonstrated significant main effects across stigma domains. Findings suggest that interventions to decrease HIV related stigma may be an important component of initiatives to increase engagement in HIV care

Prescription Opioid Abuse among Drug-Involved Street-Based Sex Workers

National population surveys and individual studies over the past decade have documented the escalating abuse of a variety of prescription medications, particularly prescription opioids. Although surveillance data provide important information for estimating the prevalence of prescription opioid abuse in the general population, studies documenting the patterns of prescription drug abuse among chronic street-drug-using populations are extremely rare. This paper examines the abuse of prescription opioids among drug-involved street-based sex workers in Miami, Florida. The data for this study were drawn from an ongoing HIV intervention trial initiated in 2001, designed to test the relative effectiveness of two alternative HIV prevention protocols for this population. Participants in the study were recruited through traditional targeted sampling strategies, and complete data are available on 588 street-based sex workers. In terms of prescription drug abuse, 12.2 percent of the sample reported using at least one opioid analgesic in the past 90 days without having a legitimate prescription. Logistic regression analyses were conducted to examine the associations between prescription opioid abuse and its predictors. In the multivariate model, factors positively associated with prescription opioid abuse included: Caucasian race (OR = 2.53; 95 percent CI 1.30 to 4.91), current powder cocaine use (OR = 2.28; 95 percent CI 1.28 to 4.08), current heroin use (OR = 2.08; 95 percent CI 1.10 to 3.92), 90-day physical abuse/victimization (OR = 2.07; 95percent CI 1.18 to 3.61), and shorter sex-work involvement (OR = 1.98; 95 percent CI 1.13 to 3.48). In contrast, daily crack smoking was negatively associated with prescription opioid abuse (OR = 0.61; 95 percent CI 0.33 to 1.10). This study provides some of the first empirical evidence to indicate that prescription opioid abuse is emerging in a heretofore unstudied community of marginalized drug-using sex workers. In addition, data on this population\u27s mechanisms of access to prescription opioids clearly suggest that there is an active black market for these drugs. These findings warrant intensive study to determine the relative contribution of each mechanism of diversion to the illicit market

HIV, HBV, and HCV Infections among Drug-Involved, Inner-City, Street Sex Workers in Miami, Florida

This study describes the rates of HIV, HBV, and HCV seropositivity among drug-involved, female street sex workers in low-income, inner-city sections of Miami, Florida; further, their sociodemographic characteristics, drug use, and sexual risk behaviors were assessed; and predictors of infection were reported. A sample of 586 sex workers was recruited through targeted sampling methods, interviewed, and counseled and tested for the presence of antibody to HIV, HBV, and HCV. Respondents\u27 median age was 38 years, median time in sex work was 14 years, all were heavily involved in the use of alcohol and drugs, and 42% were homeless. More than half (51.0%) had engaged in unprotected vaginal sex in the past month. Prevalences were HIV, 22.4%; HBV, 53.4%; HCV, 29.7%. A multidimensional public health program must address not only issues related to unsafe sex, but also the problems of drug abuse, homelessness, and other lifestyle factors that contribute to risk behaviors

Resilience and Syndemic Risk Factors among African-American Female Sex Workers

Research on street-based female sex workers documents a multitude of problems faced by these women, such as substance use, HIV risk, mental health problems, victimization, and homelessness. The presence of problems such as these is understood as a syndemic, or co-occurrence of two or more risk factors that act synergistically to create an excess burden of disease. However, the syndemic framework has not previously incorporated the examination of resilience to understand what protective factors enable female sex workers to cope with syndemic risk. Using 562 baseline interviews from street-based African-American female sex workers enrolled in a randomized intervention trial, this study is the first to investigate expressions of resilience among this vulnerable population. Specifically, these analyses examine high levels of resilience, as measured by personal mastery, in order to understand the contributions of syndemic risk factors and protective factors on the expression of resilience. In bivariate logistic regression models, women with high resilience reported significantly higher odds of high school education, greater access to transportation, and more social support, in addition to lower odds of foster care history, homelessness, substance dependence, severe mental distress, victimization, and HIV risk. In the multivariate model, higher odds of high school education and increased social support, in addition to lower odds of mental distress and HIV risk remained associated with high resilience. The findings suggest specific targets for intervention to assist female sex workers in coping with syndemic risk factors and achieving better health outcomes. These include the prioritizing of education and training opportunities and the enhancement of social support

Risk and Protective Factors associated with Personal Mastery among Sexual Minority African-American Female Sex Workers

Research among sexual minorities has traditionally examined problems such as substance use, HIV risk, mental health problems, and victimization. Among sexual minority street-based female sex workers, these vulnerabilities can be magnified. Grounded in theories of resilience, this study examines risk and protective factors associated with a high level of personal mastery among a vulnerable population of women. Data are drawn from baseline interviews from street-based African American female sex workers enrolled in a randomized intervention trial in Miami, Florida. We compare sexual minority (N=197) and heterosexual (N=365) women on measures of risk and protective factors; among sexual minority women we present logistic regression analyses which reveal that severe mental distress and HIV transmission risk are associated with low levels of personal mastery, while protective factors of transportation access and social support are associated with high levels of personal mastery. These findings suggest that these protective factors may potentially facilitate the development of personal mastery and represent beneficial avenues for intervention efforts

Patterns of Prescription Medication Diversion among Drug Dealers

This research examined the following questions: (1) how do drug dealers acquire their inventories of prescription medications? and (2) which types of prescription medications do dealers most commonly sell? Data are drawn from a National Institute on Drug Abuse-funded research study that examined prescription drug diversion and abuse in South Florida. In-depth semi-structured interviews (n = 50) were conducted with an ethnically diverse sample of prescription drug dealers from a variety of milieus to assess patterns of diversion. Audiotapes of the interviews were transcribed, coded, and thematically analysed using the NVivo 8 software program. Dealers relied on a wide array of diversion methods including visiting multiple pain clinics, working with pharmacy employees to steal medications from pharmacies, and purchasing medications from indigent patients. The type of medication most commonly sold by dealers was prescription opioid analgesics, and to a lesser extent benzodiazepines such as alprazolam. These findings inform public health policy makers, criminal justice officials, the pharmaceutical industry and government regulatory agencies in their efforts to reduce the availability of diverted prescription drugs in the illicit market. Specifically, these data support the need for statewide prescription drug monitoring programs and increased training for healthcare workers who have access to controlled medications

Alternate Routes of Administration and Risk for HIV Among Prescription Opioid Abusers

Route of administration is an important contributor to the adverse health consequences of prescription medication abuse. The current study examines characteristics associated with non-oral routes of administration among a large sample of prescription opioid abusers and explores needle-related human immunodeficiency virus (HIV) risk behaviors as well. In the study, 791 opioid abusers completed a one-time structured interview, including complete histories of illicit and prescription drug abuse and route of drug administration. The most common method of pill use was oral (91%), followed by intranasal (53.1%), injection (23.8%), and smoking (14.5%). The youngest prescription opioid abusers, ages 18-24, displayed significantly higher odds of using alternate routes of administration and of reusing nonsterile needles for injection. HIV prevention programming should be developed for young prescription opioid injectors

Vulnerable Infected Populations and Street Markets for ARVs: Potential Implications for PrEP Rollout in the USA

Widespread diversion of antiretroviral (ARV) medications to illicit markets has recently been documented among indigent patients in South Florida. The recent approval of ARVs for pre-exposure prophylaxis (PrEP) has the potential to broaden these illicit markets, as high-risk individuals seek ARVs without a prescription or medical supervision. Nonadherence among diverters and unsupervised use of ARVs for treatment or PrEP increase risks of treatment failure, drug resistance, and disease transmission. We report the scope of ARV diversion among substance-using men who have sex with men in South Florida. Structured interviews (N = 515) queried demographics, HIV status, mental distress, substance dependence, and sexual risks. HIV-positive participants answered questions about medical care, treatment, and ARV adherence and diversion. Median age was 39. Of 46.4% who were HIV-positive, 79.1% were prescribed ARVs. Of these, 27% reported selling/trading ARVs. Reasons for diversion were sharing/trading with friends, sale/trade for money/drugs, and sale/trade of unused medications. ARV diverters, compared to nondiverters, were more likely to be substance dependent (74.5% vs. 58.7%, p = 0.046) and have traded sex for money/drugs (60.8% vs. 32.6%, p \u3c 0.001), and less likely to be adherent to ARVs (54.9% vs. 73.9%, p = 0.012). ARV diversion should be a particular concern in communities of high-risk men who have sex with men as uninfected men in such communities are likely to benefit most from PrEP but unlikely to have access to PrEP and necessary ancillary services through the health-care system. The implications of diversion for increased risks of treatment failure, disease transmission, and PrEP failure should be carefully considered in developing policy and behavioral supports to scaling up treatment as prevention and PrEP