June 2000 volume 16 number 6 Division of Public Health http://health.state.ga.us The Georgia Epidemiology Report is a publication of the Epidemiology Section of the Epidemiology and Health Information Branch, Division of Public Health, Georgia Department of Human Resources HIV Seroprevalence in Cocaine Users Treated at an Atlanta Drug Treatment Center BACKGROUND During the past few decades, cocaine has been used in various ways. Before the mid-1980s, the most common method of cocaine use was intranasal snorting of the powdered form of the drug. In the mid-1980s, crack, a smokable form of cocaine, became widely used in many urban areas of the United States (U.S.) because of its easy availability in single doses, low cost, and immediate intense euphoric effect.1 Crack is considered more addicting than the powdered form of cocaine because the euphoria subsides within a few minutes and leaves the user with an intense craving for more. Many users combine crack with a second drug to ease the post-euphoric craving or to experience a different euphoric effect. Despite a decrease in crack use among many U.S. cities, crack has remained a problem in Atlanta during the 1990s.2 In 1998, Atlanta had the highest proportion of adult male arrestees testing positive for cocaine (51%) among 35 cities participating in the Arrestee Drug Abuse Monitoring (ADAM) program.3 Cocaine, especially crack, is associated with the human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs), primarily because users tend to have higher numbers of sex partners and sexual encounters, increased high-risk sexual behaviors, and involvement with the practice of trading sex for drugs.4 Because of the large public health impact of cocaine and other drug use, special studies are helpful to further describe the epidemiology of drug use and HIV/STDs. The anonymous HIV seroprevalence survey described in this report was funded by the Centers for Disease Control and Prevention (CDC) and conducted by the Georgia Department of Human Resources (DHR), Division of Public Health, and the Fulton County Alcohol and Drug Treatment Center (FCADTC). Before the start of the survey, the DHR Institutional Review Board approved the study. Director Kathleen E. Toomey, M.D., M.P.H. Epidemiology and Health Information Branch Acting Director Kathleen E. Toomey, M.D., M.P.H. Acting State Epidemiologist Paul A. Blake, M.D., M.P.H. Epidemiology Section Chief Paul A. Blake, M.D., M.P.H. Public Health Advisor Mel Ralston Georgia Epidemiology Report Editorial Board Carol A. Hoban, M.S., M.P.H. - Editor Kathryn E. Arnold, M.D. Paul A. Blake, M.D., M.P.H. Susan Lance-Parker, D.V.M., Ph.D. Kathleen E. Toomey, M.D., M.P.H. Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphics The FCADTC offers drug and alcohol counseling and treatment, HIV counseling and testing (HIV C&T), and referrals for other medical and social services. Primary types of inpatient services include 7-day detoxification, 14-day rehabilitation, and 21-day comprehensive treatment. The clinic was selected for participation in the survey on the basis of the ability to meet the minimum sample size, client characteristics, and the willingness of staff to conduct the standardized survey protocol. The objectives of this report are to show HIV seroprevalence trends from 1990 through 1998 among female and male clients at the FCADTC and describe the data from 1998 in detail. METHODS From 1989 through 1998, the FCADTC participated in an anonymous HIV seroprevalence survey that was conducted on an ongoing basis throughout each year. Eligibility for the survey required that the client had used an illicit drug in the previous year and that blood was being drawn for purposes other than HIV testing, i.e., for syphilis testing. Clients for whom alcohol was the only drug used in the previous year were not eligible. According to clinic protocol, persons are permitted one admission per year, and all clients have blood drawn at the time of admission. Before HIV testing, demographic and risk information was abstracted from clinic records and documented on a study form that had a study number which could not be linked to the client; no client-identifying information such as name, address, phone number, or medical record number was abstracted for this survey. The study form was then sent to the state epidemiology office. Residual blood specimens, which otherwise would have been discarded, were sent to the state public health laboratory with the study Georgia Department of Human Resources Division of Public Health, Epidemiology Section Epidemiology & Health Information Branch Two Peachtree St., N.W., Atlanta, GA 30303 - 3186 Phone: (404) 657-2588 Fax: (404) 657-2608 number that matched the study form. Serum from each specimen was screened for HIV-1 antibody with an enzyme immunoassay (EIA). Reactive EIAs were repeated in duplicate to verify the initially reactive test results, and all repeatedly reactive EIA tests (i.e., two or more reactive EIAs) were confirmed by the Western Blot assay. HIV test results and the corresponding study numbers were then forwarded to the state epidemiology office. Neither the test results nor the demographic and risk information could be linked to individuals. Staff at the state epidemiology office matched the study form and lab results with the unique study number and then used Epi Info (CDC, Atlanta, Ga) to enter, clean, and analyze the data. This analysis includes variables related to demographic information, drug use, sexual behavior, and HIV C&T. The Chi square for linear trend was calculated for yearly HIV infection rates, and the odds ratio (OR) was used to estimate associations between potential predictor variables and HIV status. P-values less than .05 and 95% confidence intervals (95% CI) which did not include 1.00 were considered statistically significant. Although the survey protocol did not allow persons with repeat visits from year to year to be determined, a variable which was used in the survey from 1990 through 1996 was analyzed to determine whether or not a client had been admitted to the clinic in a previous year. For this report, indeterminate HIV test results were excluded from the analysis. RESULTS From 1990 through 1998, information was collected on 12,811 clients, for whom there is known laboratory information for 12,683 (99%). The number of matched study and laboratory forms collected each year ranged from 525 to 2,384. A significant increase in the HIV infection rate occurred from 1990 through 1998 (p<.05) among both men and women. In 1998, the HIV infection rate was 17% (67/395) in women and 18% (93/508) in men. In 1998, results were available for 903 clients who received treatment for cocaine use. Of these 903 clients, 395 (44%) were women, 151 (17%) were 15 to 29 years old, 743 (82%) were African American, 126 (14%) were White, 68 (8%) had ever injected drugs, and 738 (82%) had ever received or given money or drugs for sex. Of the 903 clients, the drug of choice in the past year for non-injected drugs was crack (89%), heroin (5%), cocaine (3%), marijuana (2%), heroin and cocaine combined (0.4%), and amphetamines (0.1%); similar proportions were found in men and women. The most frequently used drug in addition to the drug of choice was marijuana (86%), followed by crack (2%) and cocaine (1%). Of the 903 clients, 782 (87%) received confidential HIV C&T during the visit, and 333 (37%) had previously received HIV C&T, of whom 60 were known to be HIV-infected. Most clients were at least 30 years old, African American, had never injected drugs, had received or given money or drugs for sex, and received voluntary, confidential HIV C&T during their visit (Table 1). For women, there were no clear predictors of HIV infection, and for men predictors of HIV infection included being homosexual/bisexual and having received or given money or drugs for sex(Table 2). From 1990 through 1996, the proportion of persons enrolled in the survey who had been previously admitted to the clinic in a prior year increased from 4% to 42%. DISCUSSION The results show increasing rates of HIV infection from 1990 through 1998 among both men and women being treated for cocaine use at the FCADTC. This trend may reflect changing drug use behaviors that put persons at higher risk for acquiring HIV. In the last year of the survey, the HIV rate was higher than any previous year, marijuana was commonly used as an additional drug, and a substantial majority of clients received confidential HIV C&T. Although there were no significant predictors of HIV infection for women, younger women had a higher rate than older ones. For men, predictors of HIV infection were being homosexual/bisexual and having exchanged money or drugs for sex. Although injection drug use is known to be a risk factor for acquiring HIV, it is interesting to note that persons in this survey of cocaine and crack users who ever injected drugs had lower HIV infection rates in 1998. A previous study also found lower HIV rates in crack cocaine-using injection drug users.5 The authors postulated that crack cocaine-using injection drug users may represent a distinct subpopulation with unique drug use patterns and social networks and concluded that the persons with whom one engages in these behaviors should be considered in future HIV studies. Certain precautions are needed when interpreting data from anonymous surveys. Although the anonymity of this survey removes self-selection and self-deferral bias, for example, when persons decide whether or not to participate in a study, the data may not necessarily reflect the HIV seroprevalence of all cocaine-using persons who are in the clinics population catchment area. The results represent information about cocaine-users who are in treatment at the FCADTC, and not necessarily cocaine-users who do not seek treatment or persons who use other drugs. Furthermore, the results are not generalizable to persons who use drugs in other metropolitan cities or rural areas. Cocaine-using young women, men who have sex with men, and persons who exchange money or drugs for sex had the highest HIV infection rates and should be receiving education and prevention messages that are tailored to their specific needs and behaviors. Persons who use cocaine and other drugs are at high risk for HIV, STDs, mental health disorders, problems with the criminal justice system, and for women, perinatal problems. Because drug use has a tremendous public health impact and is very costly to society, the support and expansion of programs for the treatment and prevention of substance abuse are critically important. Figure 1. HIV Seroprevalence Survey at an Atlanta Drug Treatment Clinic HIV infection by sex and year Percent HIV positive 20 15 # Males $ Females Total # # $ # # 10 # # # # # $ $ $ $ $ $ $ $ 5 0 Males Females Total 1990 9.7 7 9 1991 9.7 7.7 9.2 1992 10.8 8.3 10.1 1993 10.3 8.1 9.7 1994 11.3 7.2 9.9 1995 12.8 7.4 10.9 1996 16.5 9.6 13.9 1997 15.4 7.2 11.5 1998 18.3 16.9 17.7 -2 - Table 1 HIV Seroprevalence Survey at an Atlanta Drug Treatment Center in 1998: Characteristics of female and male clients receiving treatment for cocaine use Females (n=395) Number Percent Age group 15-29 74 19% >= 30 320 81% Race African American 326 84% White 51 13% Other 12 3% Sexual orientation Homosexual/Bisexual Male Heterosexual Male Ever injected drugs Yes 25 6% No 370 94% Ever received or given money or drugs for sex Yes 329 83% No 66 17% Received voluntary, confidential HIV counseling and testing* Yes 333 91% No 34 9% Males (n=508) Number Percent 77 15% 428 85% 417 82% 75 15% 15 5% 41 8% 465 92% 43 8% 463 92% 409 81% 99 19% 410 87% 61 13% * Data from the 60 clients known to be HIV positive from prior testing were excluded Table 2 HIV Seroprevalence Survey at an Atlanta Drug Treatment Center in 1998: Predictors of HIV infection for female and male clients receiving treatment for cocaine use Age group 15-29 >=30 Race African American White Sexual orientation Homosexual/Bisexual male Heterosexual male Ever injected drugs Yes No Ever received or given money or drugs for sex Yes No Received voluntary, confidential HIV counseling and testing* Yes No Females HIV positivity, OR (95% CI) 24% 1.8 (0.91-3.4) 15% Reference 18% 1.4 (0.57-3.8) 14% Reference - 8% 0.41 (0.06-1.9) 18% Reference 17% 1.2 (0.54-2.6) 15% Reference 13% 1.5 (0.45-8.2) 9% Reference Males HIV positivity, OR (95% CI) 14% 0.71 (0.34-1.5) 19% Reference 19% 1.5 (0.70-3.3) 13% Reference 32% 2.2 (1.04-4.8) 17% Reference 16% 0.86 (0.34-2.1) 18% Reference 20% 2.3 (1.1-4.9) 10% Reference 13% 0.84 (0.37-2.0) 15% Reference * Data from the 60 clients known to be HIV positive from previous testing were excluded References 1. United States General Accounting Office. The crack cocaine epidemic: health consequences and treatment. Washington, D.C. January, 1991 (GAO/HRD-91-55FS). 2. Golub AL, Johnson BD. Cracks decline: some surprises across U.S. cities. Washington, DC: U.S. Department of Justice, National Institute of Justice. July, 1997 (NCJ 165707). 3. 1998 Annual Report on Cocaine Use Among Arrestees. Washington, DC: U.S. Department of Justice, National Institute of Justice. 1999 (NCJ 175657). 4. Institute of Medicine. Factors that contribute to the hidden epidemic. In: Eng TR, Butler WT, eds. The hidden epidemic: confronting sexually transmitted diseases. Washington, DC: National Academy Press, 1997:76-79. 5. Iguchi MY, Bux DA. Reduced probability of HIV infection among crack cocaine-using injection drug users. Am J Public Health 1997;87:1008-1012. Written by Drs. John Beltrami and Mahin Park Acknowledgment: Without the work and support of Romulo Morales, Ruby Hardy, Margaret Renfroe, Dr. Pradnya Tambe, and staff at the Fulton County Alcohol and Drug Treatment Center, this survey would not have been possible. -3 - The Georgia Epidemiology Report Epidemiology and Health Information Branch Two Peachtree St., NW Atlanta, GA 30303-3186 Bulk Rate U.S. Postage Paid Atlanta, Ga Permit No. 4528 June 2000 Volume 16 Number 6 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for March 2000 Selected Notifiable Diseases Campylobacteriosis Chlamydia genital infection Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other Syphilis - Congenital Tuberculosis Total Reported for March 2000 2000 38 2427 7 2 95 1336 9 12 17 1 0 4 1 2 0 77 28 15 33 66 35 3 56 Previous 3 Months Total Ending in March 1998 1999 2000 129 176 98 6173 5667 6640 27 60 41 2 1 4 206 280 281 4992 4080 4123 20 24 27 195 147 52 82 41 48 0 0 2 2 0 0 46 19 21 0 0 2 3 7 17 0 0 0 198 271 232 224 83 79 23 27 22 37 57 62 180 183 118 111 131 72 2 7 3 137 109 105 Previous 12 Months Total Ending in March 1998 1999 2000 782 816 647 13607 25061 32391 93 185 151 34 83 46 908 1289 1356 14147 19983 21990 44 73 83 846 831 387 276 172 237 6 8 7 10 3 0 118 76 74 6 2 6 13 42 62 0 0 0 1336 1912 1937 1175 997 280 143 130 139 301 256 294 1026 815 669 993 840 745 19 21 17 643 602 661 * The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia. ** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis. Report Period Latest 12 Months: 4/99 - 3/00 Five Years Ago: 4/94 - 3/95 Cumulative: 7/81 - 3/00 Total Cases Reported* Percent Female AIDS Profile Update Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown 1612 26.6 30.8 12.6 3.2 16.8 1.4 35.2 2449 18.4 44.7 22.6 6.2 13.9 1.9 10.6 21710 16.2 49.5 18.7 5.8 13 1.9 11.1 MSM - Men having sex with men IDU - Injection drug users HS - Heterosexual * Case totals are accumulated by date of report to the Epidemiology Section - 4 - Race Distribution (%) White Black Other 19.1 78.5 2.4 33.4 65 1.5 36.7 61.3 2.1