Risk Factors for Shooting Gallery Use and Cessation among ... - NCBI

Risk Factors for Shooting Gallery Use and Cessation among Intravenous Drug Users

o

--------------------------

.......I.......

David D. Celentano, ScD, David Vlahov, PhD, Sylvia Cohn, MPH, James C. Anthony, PhD, Liza Solomon, DrPH, and Kenrad E. Nelson, MD

Introduction

Methods

Behaviors that increase the risk of infection with human immunodeficiency virus, type 1 (HIV-1) among intravenous drug users (IVDUs) are primarily those involving transfer of blood through shared injection equipment.'-5 Use of shared equipment at shooting galleries is particularly high risk for acquiring HIV-1 infection.6-8 Shooting galleries are locations, generally clandestine, where IVDUs can rent, borrow, or purchase needles and syringes; frequently the injection equipment is used repeatedly and may contain contaminated blood. Repeated rental of syringes results in a sequential anonymous sharing of potentially contaminated equipment. Such sharing facilitates the transmission of blood-borne pathogens. I

Sample

Although needle sharing has been empirically demonstrated to be one of the principal AIDS risk behaviors among IVDUs,9"0 reports on the characteristics and behaviors of IVDUs who use shooting galleries are sparse. Ethnographic reports suggest that IVDUs go to shooting galleries for several reasons, including (1) the illegality of possession of drug injection equipment and consequent fears of arrest; (2) the scarcity of syringes, leading to an economic imperative to share injection equipment; and (3) the social context of intravenous drug use."I12 In this report, we used social survey methods on a large sample of currently active IVDUs to complement the findings from the published ethnographic reports to examine reasons for shooting gallery use and to identify reasons for cessation vs persistence in gallery use.

Between February 1988 and March

1989, IVDUs in Baltimore, Md, were recruited into a longitudinal investigation of the natural history of HIV-1 infection [the AIDS Links to the Intravenous Experience (ALIVE) Study]. Recruitment relied predominately on word-of-mouth by community outreach efforts (85%); referrals from drug abuse treatment programs, sexually transmitted disease clinics, local emergency departments, university hospital HIV-1/AIDS clinics, and shelters for the homeless also assisted with cohort recruitment. In order to be eligible for enrollment, IVDUs had to be age 18 or older and have self-reported illicit drug injection in the prior 10 years. The rationale and details of the sampling and data collection plan have been described elsewhere.13 A total of 2921 participants were enrolled in the ALIVE study and completed baseline interviews and venipuncture. In this analysis, we restricted the sample to the 2615 IVDUs who reported injecting illicit drugs within 6 months prior to interview. David D. Celentano is with the Department of Health Policy and Management, David Vlahov, Sylvia Cohn, Liza Solomon, and Kenrad E. Nelson are with the Department of Epidemiology, and James C. Anthony is with the Department of Mental Hygiene, The Johns Hopkins School of Hygiene and Public Health, Baltimore.

Requests for reprints should be sent to David D. Celentano, Department of Health Policy and Management, The Johns Hopkins University, School of Hygiene and Public Health, 624 N Broadway, Room 750, Baltimore, MD 21205. This paper was submitted to the journal July 13, 1990, and accepted with revisions March 7, 1991.

American Journal of Public Health 1291

Celetano et a.

Data Collection Procedures After providing voluntary informed consent, participating IVDUs were assigned a unique and confidential identifier and agreed to venipuncture for serum for HIV-1 antibody assays. Next, participants were questioned by a trained interviewer in a private room concerning demographic information, medical history, drug injection practices since 1977 on an annual basis, 10-year history of sexual activity, knowledge and attitudes about FHV-1 infection and AIDS, and use of medical care. A detailed description of the data-gathering procedures appears elsewhere14; a brief overview is presented here. The self-report demographic data analyzed here include age, gender and sexual orientation, race/ethnicity, education, current employment, receipt of public assistance, and occurrence of homelessness within the prior 10 years. Participants were asked to recall their drug use behavior in the 6 months prior to their last injection and also in the first 3 months of use. Drug injection frequency reported for the prior year was categorized as once or more a day or as less frequently. Other drug involvement factors analyzed included self-reports of treatment for drug abuse, being arrested and incarcerated within the prior 10 years, and duration of drug use as indicated by the year when drugs were first injected. Although there was a battery of questions on history of sexual practices, we restricted the analysis here to one indicator: whether any sexual partner was an IVDU. We inquired as to the use of shooting galleries on an annual basis (thereby determining never and ever use) beginning in 1977 or year of first drug use. Recent shooting gallery attendance was ascertained as follows: "During the 6 months before the last time you injected drugs, how many times did you go to a shooting gallery and use works borrowed, rented, or bought there?" For the analyses here we aggregated the responses into three categories: never went to a shooting gallery, former shooting gallery user but no use in the prior 6 months, and current user of shooting galleries (i.e., attendance within the prior 6 months).

Analysis To examine the associations of so-

ciodemographic and drug use characteristics with attendance at shooting galleries, we cross-classified current, former, and never users of shooting galleries with the 1292 American Journal of Public Health

predictor characteristics, using x2 statistics as an aid to interpretation. The strength of associations between these characteristics and practices and shooting gallery attendance was estimated by the odds ratio (OR), using the group of IVDUs who reported never going to a shooting gallery as the reference category. Logistic regression was used to examine the simultaneous association of these factors to lifetime shooting gallery use (comparing ever vs never), as well as to identify factors associated with persistence of this risk behavior (comparing current and former users). We used 95% confidence intervals (CIs) as an aid to statistical interpretation of results.

Resuls Of the 2615 IVDUs still injecting drugs enrolled in the ALIVE study, 32.9% (n=861) reported attendance at a shooting gallery within the prior 6 months, and 19.4% (n=507) reported having gone to a shooting gallery in the past but not within the prior 6 months. Slightly less than one half (47.7%; n=1247) of the respondents denied ever having injected drugs in a shooting gallery. The relationships between the demographic and drug use characteristics and lifetime shooting gallery attendance are presented in Table 1. Those IVDUs who have ever used shooting galleries were more likely to be male, homosexual! bisexual, slightly older, Black, and unemployed, to have received public assistance, and to report being homeless sometime in the prior decade, as compared to IVDUs who reported never injecting drugs in a shooting gallery. A review of drug involvement factors shows shooting gallery attenders were more likely to report an arrest or incarceration history, to have been in drug treatment as compared to never users, and to have initiated injection behavior earlier in their lives. With respect to current drug use, shooting gallery users were more likely to be daily drug users and to report sexual partners who were also IVDUs. Table 2 compares the characteristics of current shooting gallery users and IVDUs who reported stopping shooting gallery use. Current shooting gallery attenders were, again, male, homosexual/bisexual, younger, less educated, more often homeless in the prior decade, and had a history of injection behavior showing more recent initiation into this culture. No other drug involvement factor differentiated those

persisting in shootinggallery use and those who ceased this activity. Table 3 presents the results of two multiple logistic regression analyses: (1) ever vs never use of shooting galleries and (2) current vs former shooting gallery users. Age was deleted so that year of first IV drug use might be included in the equations. Using multiple regression to characterize those IVDUs who reported ever going to a shooting gallery compared with those with no self-report history of gallery attendance, we found that ever attenders were more likely to be male, homosexual! bisexual, Black, and homeless, to report arrests, drug treatment, and sex partners who were IVDUs, and to have a history of daily drug injection and of starting drug injection earlier, all other variables held constant. Compared to females, males, especially homosexuals or bisexuals, more commonly visited shooting galleries. The comparison of characteristics differentiating individuals who persist in injecting illicit drugs in shooting galleries and those who have stopped showed fewer distinguishing factors once other variables were held constant using multiple regression: recent gallery attenders had somewhat less education, more frequently reported homelessness, and more recently initiated IV drug use. The high OR for male homosexuals or bisexuals who persist in using shooting galleries is of concern because they may serve as a bridge for HIV-1 transmission from gay males who do not inject to heterosexual IVDUs.

Discussion These data indicate that shooting gallery use is associated with lower socioeconomic status, greater criminal involvement, and indicators ofheavier drug usecharacteristics congruent with prior ethnographic reports of street drug users.5-17 Our findings suggest that the use of shooting galleries is in part a pragmatic response to the contemporary context ofillicit drug use, namely, that IVDUs seek access to needles for injecting drugs that are illegal to possess.18 Shooting galleries provide needles in relatively clandestine locations, also reducing the threat of arrest for drug use and drug and drug paraphernalia possession.19,20 However, the lack of financial resources associated with shooting gallery use fails to differentiate IVDUs who have stopped using shooting galleries from those that persist in this behavior, with the exception of greater reports ofhomelessness among re-

October 1991, Vol. 81, No. 10

Shooing Galery Use among IVDUs cent shooting gallery users. Homeless individuals are more likely to frequent shooting galleries and to persist in this behavior, thereby providing some limited evidence supporting an hypothesis of economic necessity. The traditional view that needle sharing reflects a culturally entrenched ritual resistant to change2l has been expanded to acknowledge a pragmatic response of IVDUs to the restricted availability ofneedles and syringes.2 Lessons learned from studies of needle sharing offer some insights into the complexity of this social behavior but appear insufficient to fully explain its continued existence. While going to shooting galleries may be pragmatic from a sociolegal and economic perspective, using needles obtained from shooting galleries is associated with increased risk of acquiring HIV-1 infection. The extent of exposure to HIV-1 in shooting galleries was unknown until recently. Chitwood et al.23 obtained 148 needles and syringes from three shooting galleries in Miami, of which 10.1% tested positive for HIV-1 antibody. This relatively high rate of exposure found in shooting galleries may reflect frequent reuse of equipment as well as sharing equipment more frequently with strangers or acquaintances whose HIV-1 antibody status may be unknown (as compared to sharing needles among groups of close friends).2425 In our study, the odds of having antibody to HIV-1 among those who have ever gone to a shooting gallery were nearly twice the odds for those who had reported never attending a gallery.8 Vigorous prosecution of drug paraphernalia offenders may act to facilitate transmission of HIV-1 infection rather than reduce its spread. One public health approach to the problem of HIV-1 transmission in shooting galleries is to offer sterile needles through needle exchange programs.26-28 This approach generally has been considered incompatible with current policies on drug use in most US jurisdictions. A recent report7 discusses public health preventive interventions to reduce the risk of HIV-1 among users of shooting galleries in the context of the current legal climateeducating proprietors of shooting galleries to educate their clients and to improve needle sterilization practices. This approach requires the active participation of shooting gallery operators in creating "safer" galleries; additional studies will be required to determine the extent to which such interventions are feasible and effective. Ultimately, a goal for reducing


the transmission of HIV-1 infection among IVDUs would involve the cessation of shooting gallery use, rather than attempts to create "safer" galleries. Study results presented here suggest that although a large proportion (37%) of IVDUs reporting ever going to shooting galleries have recently stped the majority persist in this activity. Data on AIDS knowledge and attitudes posed to these participants demonstrated no trends differentiating these three groups of gallery users.

A focus on risk reduction among homosexual or bisexual males who inject drugs in shooting galleries seems to be of paramount importance. Although patterns of shooting gallery use fluctuate over time and our classification into three distinct groups based on recent history may be arbitrary, no distinct trends in use were detected as related to the risk factors assessed. Although other studies report behavior change among IVDUs in response to the HIV-1 epidemic,29 these


eetanod aL

less educated and impoverished. Paradoxically, those who persist in using shooting galleries are also likely to report a history of drug treatment, a characteristic shown to lead to reduced IV drug use34 although relapse is frequent.35 However, those who continue going to shooting galleries are not necessarily more frequent drug users than those who have stopped, suggesting that overall drug involvement is not a discriminating characteristic. HIV-1 prevention efforts must strive for greater access to IVDUs who use shooting galleries in order to appropriately target messages on cessation of shooting gallery use. Prevention efforts should also consider the approach suggested by Chitwood et al.2 and articulated by Des Jarlais and Friedman7 of making galleries safer for those who use them. [

U~~~~~~~~~~U

Ma

*LI

IIW*44~~~~~~~mma

--------------------i

Acknowledgents Supported in part by Public Health Service grants DA04334 and DA05911, awarded by the National Institute on Drug Abuse. This paper was presented in preliminary form at the Sixth International Conference on AIDS, San Francisco, Calif, June 23, 1990.

References

Yw

IL~~~~~~~~~~~~~~....... ....7.t ........8..

0.R...10. 8*~

...U 7* ......114....01 ...

.$.RI

~~~

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ JPublic Health 1987;77:169-172.

.......

788

1...............

*i

1. Friedland GH, Klein RS. Transmission of the human immunodeficiency virus. N EnglJ Med 1987;31:1125-1135. 2. DesJarlais DC, Friedman SR, Stonebumer RL. HIV infection and intravenous drug use: critical issues in transmission dynamics, infection outcomes, and prevention. Rev Infect Dis. 1988;10:151-158. 3. Chaisson RE, Moss AR, Onishi R, Osmond D, Carlson JR. Human immunodeficiency virus infection in heterosexual intravenous drug users in San Francisco.Am

0.14

4. Shoenbaum EE, Hartel D, Selwyn PA, et al. Risk factors for HIV-1 infection in intravenous drug abusers. N Engi J Med

1989;321:874-879.

... ..

Ma

.. .. ..

..

.. .. .. ..

.0.. .. ..

16.0

ye.

#10

16*10~~~~~~~~~~~~~~~~~~~~~~~~~~~.........

14

9*47~~~~~~~~~~~~......

5. Dolan MP, Black JL, Deford HA, Skinner JR, Robinowitz R. Characteristics of drug abusers that discriminate needle sharers. Public Health Rep. 1987;102:395-398. 6. Marmor M, Des Jarlais DC, Cohen H, et al. Risk factors for infection with human immunodeficiency virus among intravenous drug abusers in New York City. AIDS.

1987;1:39-44.

studies note that a substantial proportion of IVDUs persist in risk-increasing behaviors.3m Further, studies have shown that although some IVDUs who engage in needle sharing practices are knowledgeable about modes of transmission,31,32 they do not perceive themselves to be at high risk for infection.33 These data are consistent with previous reports29.30 indicating that a large propor1294 American Joumal of Public Health

tion of IVDUs continue to engage in higi risk behaviors, despite their knowledge about HIV-1. The characteristics of those who con. tinue to use shooting galleries suggest tha we need to target IVDUs earlier in thei careers, before this behavior becomes firmly entrenched, and to focus additiona interventions on an especially difficult-to access subset of IVDUs-those who are

7. Des Jarlais DC, Friedman SR. Shooting galleries and AIDS: infection probabilities and 'tough' policies. Am J Public Health. 1990;80:142-144. Editorial. 8. VlahovD, MunozA, AnthonyJC, Cohn S, Celentano DD, Nelson KE. Association of drug injection patterns with antibody to human immunodeficiency virus, type 1 among IVDUs in Baltimore. Am J Epide-

mioL 1990;132:847-856.

9. Chaisson RE, Bacchetti P, Osmond D, Brodie B, Sande MA, Moss AR. Cocaine use and WIV infection in WVDUs in San Francisco. JAMA4. 1989;261:561-565.


Shootng Gamlay Use among IVDUs

U

I 14R 2A4~~~~~~.............. 41

----------........4.

---------------

..........

........1..

.........1..............1

...

*AKM 1A 11.7A

OW..

a...

........46........h~

10. Turner CF, Miller HG, Moses LE, eds. AIDS, Seual Behavior, and Intravenou Drug Use. Washington, DC: National Academy Press; 1989. 11. Preble E, Casey JJ. Taking care of business-the heroin user's life on the street. Int JAddict. 1969;4:1-24. 12. Feldman HW. Ideological supports to becoming and remaining a heroin addict. J Health Soc Behav. 1968;9:131-139. 13. VlahovD,AnthonyJC,MunozA,etal.The ALIVE study: a longitudinal studyof HIV-1 infection in IVDUs; desciption of methods. In: Hartsock PI, Genser SG, eds. Longiudinal Stdies of HlVInfection amoqg IV DUs. National Institute on Drug Abuse Research Monograph 1991 (in press). 14. Anthony JC, Vlahov D, Celentano DD, et al. Self-report interview data for a study of HIV-1 infection among intravenous drug users: description of methods and preliminaryevidenceonvalidity.JDnqgIssues. In press. 15. Hanson B, Beschner G, Watters JM, Boville E. Life with Heain.: Voices fitm the Inner City. Lexington, Mass: D.C. Heath; 1985. 16. Fiddle S. Portraits frorm a Shooting Gallery. NewYork, NY: Harper& Row; 1967.


17. WattersJM. Observationsonthe importance ofsocial context in HIV tansmission among

IVDUs.JDnDgI&sues 198,199-26.

18. Murphy S. Intravenous drug use and AIDS: notes on the social economy of needle sharing. Contemp Dng Prb. 1987; 14:373-395. 19. Howard J, Borges P. Needle sharing in the Haight: some social and psychological functions. J Health Soc Behav. 1970;11: 220-230. 20. Ghodse AH, Treganza G, U M. Effect of fear on sharing injection equipment among drug abusers. BrJMed 1987;295:698-699. 21. Feldman HW, Biernacki P. The ethnography of needle sharing among IVDUs and implications for public policies and intervention strategies. In: Battjes RJ, Pickens RW, eds. Needle Sharing among IVD"Us: Natonal and Intermational Perspectives. Washington, DC: National Institute on Drug Abuse; 1988. NIDA Research Monograph No. 80:28-39. 22. Des Jarlais DC, Friedman SR, Strug D. AIDS and needle sharing within the IVdrug use subculture. In: Feldman DA, Johnson TM, eds. The Social Dienins ofAIDS: Method and 7heoiy. New York, NY: Praeger, 1986:111-125.

23. Chitwood DD, McCoy CB, Inciardi JA, et al. HIV seropositivity of needles from shooting galleries in South Florida. Am J Public Healt 1990;80:150-152. 24. Friedman SR, Des Jarlais DC, Sotheran JL. AIDS and self-organization among IVDUs. Int JAddict. 1987;22:201-219. 25. Battjes RJ, Pickens RW, eds.Neede Sharing among Intravenous Dng Users: National and International Perspectives. Washington, DC: National Institute on Drug Abuse; 1988. NIDA Research Monograph No. 80. 26. Stimson GV. Syringe-exchange programmes for injecting drug users. AIDS. 1989;3:253-260. 27. Hart GJ, Carvell ALM, Woodward N, Johnson AM, Williams P, Parry JV. Evaluation of needle exchange in central London: behavior change and anti-HIV status over one year. AIDS. 1989;3:261-265. 28. Donoghoe MC, Stimson GV, Dolan K, Alldritt L. Changes in HIV risk behaviour in clients of syringe-exchange schemes in England and Scotland. AIDS. 1989;3:267272. 29. VlahovD, AnthonyJC, Celentano DD, Solomon L, Chowdhury N. Trends of risk reduction among initiates into intravenous drug use 1982-1987. Am J Drug Alcohol Abuse. 1990;17:39-48. 30. Magura S, Grossman JI, Upton DS, et al. Determinants of needle sharing among intravenous drug users.AmJPublic Health

1989;79:459-462. 31. Friedman SR, Des Jarlais DC, Sotheran JL. AIDS health education for IVDUs. Health Educ Q. 1986;13:383-393. 32. Ginzburg HM, French J, Jackson J, Hartsock PI, MacDonald MG, Weiss SH. Health education and knowledge assessment of HTLV-uI diseases among IVDUs.

Health Educ Q. 1986;13:373-382. 33. Celentano DD, VlahovD, MenonAS, Polk BF. H1V knowledge and attitudes among IVDUs-omparisons to the US population and by drug use behaviors.JDLrgIssues. 1991;21:647-661. 34. Abdul-Quader AS, Friedman SR, Des Jarlais D, Marmor MM, Maslansky R, Bartelme S. Methadone maintenance and behavior by intravenous drug users that can transmit HIV. Contemp Drug Prob. 1987;11:425-434. 35. StrugDL, Hunt DE, Goldsniith DS, Upton DS, Prunt B. Patterns of cocaine use among methadone clients. Int J Addict.

1985;20:1163-1175.
