Courtney A McKnight

Courtney McKnight
Courtney A McKnight
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Clinical Assistant Professor of Epidemiology

Professional overview

Dr. Courtney McKnight is a Principal Investigator specializing in mixed methods research focused on the epidemiology of drug use, opioid overdose, HIV and HCV infection.  Dr. McKnight has over 20 years of experience conducting public health research related to drug use, as well as field experience as a harm reduction service provider.

Prior to joining NYU, Dr. McKnight served as the assistant director of research at the Chemical Dependency Institute at the Icahn School of Medicine at Mount Sinai, where she was an investigator and project director on numerous federally funded research studies, including evaluations of syringe services programs; investigations of the drivers that contribute to disparate rates of HIV and HCV; and interventions to increase access to HIV and HCV testing and care.

Previous to Dr. McKnight’s work in research, she directed a harm reduction program for women who use drugs and volunteered at a syringe services program in New Jersey.

Dr. McKnight received her DrPH from the City University of New York Graduate Center, her Master of Public Health from Hunter College, and her Bachelor of Arts in sociology from Rutgers University. Her dissertation examined the impact of Medicaid coverage of methadone and buprenorphine on treatment access for opioid dependent beneficiaries.

Dr. McKnight’s current research interests include examining the shifting landscape of illicit opioids, including the increasing prevalence of illicitly manufactured fentanyl, and risk environments of people who use drugs.

Education

BA, Women's Studies, Rutgers University, New Brunswick, NJ
MPH, Community Health Education, Hunter College, New York, NY
DrPH, The City University of New York, New York, NY

Areas of research and study

Behavioral Science
Drug addiction
Epidemiology
Harm reduction
Hepatitis
HIV/AIDS
Infectious Diseases
Mixed-Methods Research
Opioid
Qualitative Research
Social epidemiology
Substance Abuse

Publications

Publications

The New York 911 Good Samaritan Law and Opioid Overdose Prevention Among People Who Inject Drugs

Zadoretzky, C., McKnight, C., Bramson, H., Des Jarlais, D., Phillips, M., Hammer, M., & Cala, M. E. (n.d.).

Publication year

2017

Journal title

World Medical and Health Policy

Volume

9

Issue

3

Page(s)

318-340
Abstract
Abstract
This study examines how people who inject drugs (PWIDs) applied and experienced New York's Opioid Overdose Prevention Programs (OOPPs) and 911 Good Samaritan Law. Mixed-methods interviews were conducted with a community sample of New York syringe exchange participants (N = 225) and new admissions to methadone treatment (N = 75) in 2013 and 2014. Most participants were unaware of explicit protections provided by New York law to witnesses (85 percent) or overdose victims (83 percent) who called 911 for assistance. However, 75 percent called 911 upon last witnessing an overdose and 85 percent were very likely to call 911 for future victims. Calling 911 was associated with knowing relatives or friends who died of overdose (AOR = 2.57; 95%CI: 1.28, 5.19), OOPP training since implementation of the 911 Good Samaritan Law (AOR = 1.55; 95%CI: 1.07, 2.24), and perceived importance of calling 911 (AOR = 2.12; 95%CI: 1.02, 4.40). Thematic patterns in qualitative data revealed that participants fearing criminal penalties delayed calling 911 or abandoned overdose victims after calling 911, risking victim morbidity and fatality. Misunderstanding of New York law and fear of criminal penalties undermined participants’ efforts to save lives, even when 911 was called. Public health outcomes may benefit by investigating how PWIDs misunderstand the 911 Good Samaritan Law.

What happened to the HIV epidemic among non-injecting drug users in New York City?

Des Jarlais, D. C., Arasteh, K., McKnight, C., Feelemyer, J., Campbell, A. N., Tross, S., Cooper, H. L., Hagan, H., & Perlman, D. C. (n.d.).

Publication year

2017

Journal title

Addiction

Volume

112

Issue

2

Page(s)

290-298
Abstract
Abstract
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 < 0.001), with a decline from 16% in 2005–10 to 8% in 2011–14 (P < 0.001). The percentages of participants smoking crack and having multiple sexual partners declined and the percentage of HIV-positive people on ART increased. HIV incidence among repeat participants was 1.2 per 1000 person-years (95% confidence interval = 0.03/1000–7/1000). Conclusions: HIV prevalence has declined and a high percentage of HIV-positive non-injecting drug users (NIDUs) are receiving antiretroviral treatment, suggesting an end to the HIV epidemic among NIDUs in New York City. These results can be considered a proof of concept that it is possible to control non-injecting drug use related sexual transmission HIV epidemics.

Consistent estimates of very low HIV incidence among people who inject drugs: New York City, 2005-2014

Des Jarlais, D. C., Arasteh, K., McKnight, C., Feelemyer, J., Campbell, A. N., Tross, S., Smith, L., Cooper, H. L., Hagan, H., & Perlman, D. (n.d.).

Publication year

2016

Journal title

American journal of public health

Volume

106

Issue

3

Page(s)

503-508
Abstract
Abstract
Objectives. To compare methods for estimating low HIV incidence among persons who inject drugs. Methods. We examined 4 methods in New York City, 2005 to 2014: (1) HIV seroconversions among repeat participants, (2) increase of HIV prevalence by additional years of injection among new injectors, (3) the New York State and Centers for Disease Control and Prevention stratified extrapolation algorithm, and (4) newly diagnosed HIV cases reported to the New York City Department of Health and Mental Hygiene. Results. The 4 estimates were consistent: (1) repeat participants: 0.37 per 100 person-years (PY; 95% confidence interval [CI] = 0.05/100 PY, 1.33/100 PY); (2) regression of prevalence by years injecting: 0.61 per 100 PY (95% CI = 0.36/100 PY, 0.87/100 PY); (3) stratified extrapolation algorithm: 0.32 per 100 PY (95% CI = 0.18/100 PY, 0.46/100 PY); and (4)newly diagnosed cases of HIV: 0.14 per 100PY (95%CI = 0.11/100 PY, 0.16/100 PY). Conclusions. All methods appear to capture the same phenomenon of very low and decreasing HIV transmission among persons who inject drugs. Public Health Implications. If resources are available, the use ofmultiple methodswould provide better information for public health purposes.

From Long-Term Injecting to Long-Term Non-Injecting Heroin and Cocaine Use: The Persistence of Changed Drug Habits

Jarlais, D. C., Arasteh, K., Feelemyer, J., McKnight, C., Barnes, D. M., Tross, S., Perlman, D. C., Campbell, A. N., Cooper, H. L., & Hagan, H. (n.d.).

Publication year

2016

Journal title

Journal of Substance Abuse Treatment

Volume

71

Page(s)

48-53
Abstract
Abstract
Objectives Transitioning from injecting to non-injecting routes of drug administration can provide important individual and community health benefits. We assessed characteristics of persons who had ceased injecting while continuing to use heroin and/or cocaine in New York City. Methods We recruited subjects entering Mount Sinai Beth Israel detoxification and methadone maintenance programs between 2011 and 2015. Demographic information, drug use histories, sexual behaviors, and “reverse transitions” from injecting to non-injecting drug use were assessed in structured face-to-face interviews. There were 303 “former injectors,” operationally defined as persons who had injected at some time in their lives, but had not injected in at least the previous 6 months. Serum samples were collected for HIV and HCV testing. Results Former injectors were 81% male, 19% female, 17% White, 43% African-American, and 38% Latino/a, with a mean age of 50 (SD = 9.2), and were currently using heroin and/or cocaine. They had injected drugs for a mean of 14 (SD = 12.2) years before ceasing injection, and a mean of 13 (SD = 12) years had elapsed since their last injection. HIV prevalence among the sample was 13% and HCV prevalence was 66%. The former injectors reported a wide variety of reasons for ceasing injecting. Half of the group appeared to have reached a point where relapse back to injecting was no longer problematic: they had not injected for three or more years, were not deliberately using specific techniques to avoid relapse to injecting, and were not worried about relapsing to injecting. Conclusions Former injectors report very-long term behavior change toward reduced individual and societal harm while continuing to use heroin and cocaine. The behavior change appears to be self-sustaining, with full replacement of an injecting route of drug administration by a non-injecting route of administration. Additional research on the process of long-term cessation of injecting should be conducted within a “combined prevention and care” approach to HIV and HCV infection among persons who use drugs.

Providing ART to HIV Seropositive Persons Who Use Drugs: Progress in New York City, Prospects for “Ending the Epidemic”

Jarlais, D. C., Arasteh, K., McKnight, C., Feelemyer, J., Hagan, H., Cooper, H. L., Campbell, A. N., Tross, S., & Perlman, D. C. (n.d.).

Publication year

2016

Journal title

AIDS and Behavior

Volume

20

Issue

2

Page(s)

353-362
Abstract
Abstract
New York City has experienced the largest HIV epidemic among persons who use psychoactive drugs. We examined progress in placing HIV seropositive persons who inject drugs (PWID) and HIV seropositive non-injecting drug users (NIDU) onto antiretroviral treatment (ART) in New York City over the last 15 years. We recruited 3511 PWID and 3543 NIDU from persons voluntarily entering drug detoxification and methadone maintenance treatment programs in New York City from 2001 to 2014. HIV prevalence declined significantly among both PWID and NIDU. The percentage who reported receiving ART increased significantly, from approximately 50 % (2001–2005) to approximately 75 % (2012–2014). There were no racial/ethnic disparities in the percentages of HIV seropositive persons who were on ART. Continued improvement in ART uptake and TasP and maintenance of other prevention and care services should lead to an “End of the AIDS Epidemic” for persons who use heroin and cocaine in New York City.

Incidence and prevalence of hepatitis c virus infection among persons who inject drugs in New York City: 2006-2013

Jordan, A. E., Des Jarlais, D. C., Arasteh, K., McKnight, C., Nash, D., & Perlman, D. C. (n.d.).

Publication year

2015

Journal title

Drug and alcohol dependence

Volume

152

Page(s)

194-200
Abstract
Abstract
Background: Hepatitis C virus infection is a source of significant preventable morbidity and mortality among persons who inject drugs (PWID). We sought to assess trends in hepatitis C virus (HCV) infection among PWID from 2006 to 2013 in New York City (NYC). Methods: Annual cross-sectional surveys of PWID entering a large drug abuse treatment program were performed. Risk behavior questionnaires were administered, and HIV and HCV testing were conducted. Comparisons were made with prior prevalence and incidence estimates in 1990-1991 and 2000-2001 reflecting different periods of combined prevention and treatment efforts. Results: HCV prevalence among PWID (N: 1535) was 67% (95% CI: 66-70%) during the study period, and was not significantly different from that observed in 2000-2001. The estimated HCV incidence among new injectors (persons injecting for ≤6 years) during 2006-2013 was 19.5/100 PYO (95% CI: 17-23) and did not differ from that observed in 2000-2001 (18/100 PYO, 95% CI: 14-23/100). Conclusions: Despite the expansion of combined prevention programming between 2000-2001 and 2006-2013, HCV prevalence remained high. Estimated HCV incidence among new injectors also remained high, and not significantly lower than in 2000-2001, indicating that expanded combined prevention efforts are needed to control the HCV epidemic among PWID in NYC.

Longitudinal analysis of pain and illicit drug use behaviors in outpatients on methadone maintenance

Dhingra, L., Perlman, D. C., Masson, C., Chen, J., McKnight, C., Jordan, A. E., Wasser, T., Portenoy, R. K., & Cheatle, M. D. (n.d.).

Publication year

2015

Journal title

Drug and alcohol dependence

Volume

149

Page(s)

285-289
Abstract
Abstract
Background: Little is known about the experience of chronic pain and the occurrence of illicit drug use behaviors in the population enrolled in methadone maintenance treatment (MMT) programs. Methods: This is a secondary analysis of longitudinal data from two MMT samples enrolled in a randomized controlled trial of hepatitis care coordination. Patients completed pain, illicit drug use, and other questionnaires at baseline and 3, 9, and 12 months later. Associations were sought over time between the presence or absence of clinically significant pain (average daily pain ≥4 or mean pain interference ≥4 during the past week) and current illicit drug use (i.e., non-therapeutic opioid, cocaine or amphetamine use identified from self-report or urine drug screening). Results: Of 404 patients providing complete data, within-patient variability in pain and illicit drug use was high across the four assessment periods. While 263 denied pain at baseline, 118 (44.9%) later experienced clinically significant pain during ≥1 follow-up assessments. Of 180 patients (44.6%) without evidence of illicit drug use at baseline, only 109 (27.0%) had similar negative drug use at all follow-up assessments. Across four assessment periods, there was no significant association between pain group status and current illicit drug use. Conclusions: This one-year longitudinal analysis did not identify a significant association between pain and illicit drug use in MMT populations. This finding conflicts with some earlier investigations and underscores the need for additional studies to clarify the complex association between pain and substance use disorders in patients in MMT program settings.

Will "combined prevention" eliminate racial/ethnic disparities in HIV infection among persons who inject drugs in New York City?

Jarlais, D. D., Arasteh, K., McKnight, C., Feelemyer, J., Hagan, H., Cooper, H., Campbell, A., Tross, S., & Perlman, D. (n.d.).

Publication year

2015

Journal title

PloS one

Volume

10

Issue

5
Abstract
Abstract
It has not been determined whether implementation of combined prevention programming for persons who inject drugs reduce racial/ethnic disparities in HIV infection. We examine racial/ethnic disparities in New York City among persons who inject drugs after implementation of the New York City Condom Social Marketing Program in 2007. Quantitative interviews and HIV testing were conducted among persons who inject drugs entering Mount Sinai Beth Israel drug treatment (2007-2014). 703 persons who inject drugs who began injecting after implementation of large-scale syringe exchange were included in the analyses. Factors independently associated with being HIV seropositive were identified and a published model was used to estimate HIV infections due to sexual transmission. Overall HIV prevalence was 4%; Whites 1%, African-Americans 17%, and Hispanics 4%. Adjusted odds ratios were 21.0 (95% CI 5.7, 77.5) for African-Americans to Whites and 4.5 (95% CI 1.3, 16.3) for Hispanics to Whites. There was an overall significant trend towards reduced HIV prevalence over time (adjusted odd ratio = 0.7 per year, 95% confidence interval (0.6-0.8). An estimated 75% or more of the HIV infections were due to sexual transmission. Racial/ethnic disparities among persons who inject drugs were not significantly different from previous disparities. Reducing these persistent disparities may require new interventions (treatment as prevention, pre-exposure prophylaxis) for all racial/ethnic groups.

A perfect storm: Crack cocaine, HSV-2, and HIV among non-injecting drug users in New York City

Des Jarlais, D. C., McKnight, C., Arasteh, K., Feelemyer, J., Perlman, D. C., Hagan, H., Dauria, E. F., & Cooper, H. L. (n.d.).

Publication year

2014

Journal title

Substance Use and Misuse

Volume

49

Issue

7

Page(s)

783-792
Abstract
Abstract
Prevalence of human immunodeficiency virus (HIV) infection has reached 16% among non-injecting drug users (NIDU) in New York City, an unusually high prevalence for a predominantly heterosexual population that does not inject drugs. Using a long-term study (1983-2011, >7,000 subjects) among persons entering the Beth Israel drug-treatment programs in New York City, we identified factors that contributed to this high prevalence: a preexisting HIV epidemic among injectors, a crack cocaine epidemic, mixing between injectors and crack users, policy responses not centered on public health, and herpes-simplex virus 2 facilitating HIV transmission. Implications for avoiding high prevalence among NIDU in other areas are discussed.

Combined HIV prevention, the New York City Condom Distribution Program, and the evolution of safer sex behavior among persons who inject drugs in New York City

Des Jarlais, D. C., Arasteh, K., McKnight, C., Feelemyer, J., Hagan, H., Cooper, H. L., & Perlman, D. C. (n.d.).

Publication year

2014

Journal title

AIDS and Behavior

Volume

18

Issue

3

Page(s)

443-451
Abstract
Abstract
Examine long term sexual risk behaviors among persons who inject drugs (PWID) in New York City following implementation of "combined" prevention programming, including condom social marketing. Quantitative interviews and human immunodeficiency virus (HIV) testing were conducted among PWID entering Beth Israel Medical Center drug treatment programs 1990-2012. Data were analyzed by four time periods corresponding to the cumulative implementation of HIV prevention interventions. 7,132 subjects were recruited from 1990 to 2012; little change in sexual behavior occurred among HIV seronegative subjects, while HIV seropositive subjects reported significant decreases in being sexually active and significant increases in consistent condom use. HIV transmission risk (being HIV positive and engaging in unprotected sex) declined from 14 % in 1990-1995 to 2 % in 2007-2012 for primary sexual partners and from 6 to 1 % for casual partners. Cumulative implementation of combined prevention programming for PWID was associated with substantial decreases in sexual risk behavior among HIV seropositives.

Education and counseling in the methadone treatment setting improves knowledge of viral hepatitis

Larios, S. E., Masson, C. L., Shopshire, M. S., Hettema, J., Jordan, A. E., McKnight, C., Young, C., Khalili, M., Seewald, R. M., Min, A., Hengl, N., Sorensen, J. L., Des Jarlais, D. C., & Perlman, D. C. (n.d.).

Publication year

2014

Journal title

Journal of Substance Abuse Treatment

Volume

46

Issue

4

Page(s)

528-531
Abstract
Abstract
The aim of this study was to evaluate the effectiveness of an educational method of providing viral hepatitis education for methadone maintenance patients. Four hundred forty participants were randomly assigned to either a control or a motivationally-enhanced viral hepatitis education and counseling intervention. Viral hepatitis A (HAV), B (HBV), and C (HCV) knowledge tests were administered at baseline, following each of two education sessions (post-education), and at a 3-month follow-up assessment. Results indicated a significant increase in knowledge of HAV, HBV, and HCV over time. No differences were found in knowledge between the intervention groups in knowledge acquisition regarding any of the hepatitis viruses suggesting that a motivational interviewing style may not augment hepatitis knowledge beyond standard counseling. A two-session viral hepatitis education intervention effectively promotes hepatitis knowledge and can be integrated in methadone treatment settings.

HSV-2 co-infection as a driver of HIV transmission among heterosexual non-injecting drug users in New York City

Des Jarlais, D. C., Arasteh, K., McKnight, C., Perlman, D. C., Feelemyer, J., Hagan, H., & Cooper, H. L. (n.d.).

Publication year

2014

Journal title

PloS one

Volume

9

Issue

1
Abstract
Abstract
Objective: To examine herpes simplex virus 2 (HSV-2)/HIV co-infection as a contributing factor in the increase in HIV infection among non-injecting heroin and cocaine users in New York City. Methods: Subjects were recruited from the Beth Israel Medical Center drug detoxification and methadone maintenance programs in New York City in 1995-1999 and 2005-2011. All reported current heroin and/or cocaine use and no injection drug use. A structured questionnaire was administered and serum samples collected for HIV and HSV-2 testing. Population-attributable risk percentages (PAR%s) were estimated for associations between HSV-2 and increased susceptibility to and increased transmissibility of HIV among female NIDUs. Results: 785 subjects were recruited from 1995-1999, and 1764 subjects from 2005-2011. HIV prevalence increased from 7% to 13%, with nearly uniform increases among all demographic subgroups. HSV-2/HIV co-infection was common in both time periods, with an average (over the two time periods) of 80% of HIV negative females infected with HSV-2, an average of 43% of HIV negative males infected with HSV-2; an average of 97% of HIV positive females also infected with HSV-2 and an average of 67% of HIV positive males also infected with HSV-2. The increase in HIV prevalence was predominantly an increase in HSV-2/HIV co-infection, with relatively little HIV mono-infection in either time period. The estimated PAR%s indicate that approximately half of HIV acquisition among females was caused by HSV-2 infection and approximately 60% of HIV transmission from females was due to HSV-2 co-infection. Conclusions: The increase in HIV infection among these non-injecting drug users is better considered as an increase in HSV-2/HIV co-infection rather than simply an increase in HIV prevalence. Additional interventions (such as treatment as prevention and suppressing the effects of HSV-2 on HIV transmission) are needed to reduce further HIV transmission from HSV-2/HIV co-infected non-injecting drug users.

Transitions from injecting to non-injecting drug use: Potential protection against HCV infection

Des Jarlais, D. C., McKnight, C., Arasteh, K., Feelemyer, J., Perlman, D. C., Hagan, H., & Cooper, H. L. (n.d.).

Publication year

2014

Journal title

Journal of Substance Abuse Treatment

Volume

46

Issue

3

Page(s)

325-331
Abstract
Abstract
Transitions from injecting to non-injecting drug use have been reported from many different areas, particularly in areas with large human immunodeficiency virus (HIV) epidemics. The extent to which such transitions actually protect against HIV and HCV has not been determined. A cross-sectional survey with HIV and hepatitis C (HCV) testing was conducted with 322 former injectors (persons who had injected illicit drugs but permanently transitioned to non-injecting use) and 801 current injectors recruited in New York City between 2007 and 2012. There were no differences in HIV prevalence, while HCV prevalence was significantly lower among former injectors compared to current injectors. Years injecting functioned as a mediating variable linking former injector status to lower HCV prevalence. Transitions have continued well beyond the reduction in the threat of AIDS to injectors in the city. New interventions to support transitions to non-injecting drug use should be developed and supported by both drug treatment and syringe exchange programs.

Viral hepatitis among drug users in methadone maintenance: Associated factors, vaccination outcomes, and interventions

Perlman, D. C., Jordan, A. E., McKnight, C., Young, C., Delucchi, K. L., Sorensen, J. L., Des Jarlais, D. C., & Masson, C. L. (n.d.).

Publication year

2014

Journal title

Journal of Addictive Diseases

Volume

33

Issue

4

Page(s)

322-331
Abstract
Abstract
Drug users are at high risk of viral Hepatitis A, B, and C. The prevalence of Hepatitis A, Hepatitis B, and Hepatitis C, associated factors, and vaccine seroconversion among drug treatment program participants in a randomized controlled trial of hepatitis care coordination were examined. Of 489 participants, 44 and 47% required Hepatitis A/Hepatitis B vaccinations, respectively; 59% were Hepatitis C positive requiring linkage to care. Factors associated with serologic statuses, and vaccine seroconversion are reported; implications for strategies in drug treatment settings are discussed. Results suggest generalizable strategies for drug treatment programs to expand viral hepatitis screening, prevention, vaccination, and linkage to care.

A randomized trial of a hepatitis care coordination model in methadone maintenance treatment

Masson, C. L., Delucchi, K. L., McKnight, C., Hettema, J., Khalili, M., Min, A., Jordan, A. E., Pepper, N., Hall, J., Hengl, N. S., Young, C., Shopshire, M. S., Manuel, J. K., Coffin, L., Hammer, H., Shapiro, B., Seewald, R. M., Bodenheimer, H. C., Sorensen, J. L., … Perlman, D. C. (n.d.).

Publication year

2013

Journal title

American journal of public health

Volume

103

Issue

10

Page(s)

e81-e88
Abstract
Abstract
Objectives. We evaluated the efficacy of a hepatitis care coordination intervention to improve linkage to hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination and clinical evaluation of hepatitis C virus (HCV) infection among methadone maintenance patients. Methods. We conducted a randomized controlled trial of 489 participants from methadone maintenance treatment programs in San Francisco, California, and New York City from February 2008 through June 2011. We randomized participants to a control arm (n = 245) and an intervention arm (n = 244), which included on-site screening, motivational-enhanced education and counseling, on-site vaccination, and case management services. Results. Compared with the control group, intervention group participants were significantly more likely (odds ratio [OR] = 41.8; 95% confidence interval [CI] = 19.4, 90.0) to receive their first vaccine dose within 30 days and to receive an HCV evaluation within 6 months (OR = 4.10; 95% CI = 2.35, 7.17). A combined intervention adherence outcome that measured adherence to HAV-HBV vaccination, HCV evaluation, or both strongly favored the intervention group (OR = 8.70; 95% CI = 5.56, 13.61). Conclusions. Hepatitis care coordination was efficacious in increasing adherence to HAV-HBV vaccination and HCV clinical evaluation among methadone patients.

Epidemiology of pain among outpatients in methadone maintenance treatment programs

Dhingra, L., Masson, C., Perlman, D. C., Seewald, R. M., Katz, J., McKnight, C., Homel, P., Wald, E., Jordan, A. E., Young, C., & Portenoy, R. K. (n.d.).

Publication year

2013

Journal title

Drug and alcohol dependence

Volume

128

Issue

1

Page(s)

161-165
Abstract
Abstract
Background: This analysis explored the prevalence and correlates of pain in patients enrolled in methadone maintenance treatment (MMT). Methods: Patients in two MMT programs starting a hepatitis care coordination randomized controlled trial completed the Brief Pain Inventory Short-Form and other questionnaires. Associations between clinically significant pain (average daily pain. ≥. 5 or mean pain interference. ≥. 5 during the past week) and sociodemographic data, medical status, depressive symptoms, and health-related quality of life, and current substance use were evaluated in multivariate analyses. Results: The 489 patients included 31.8% women; 30.3% Hispanics, 29.4% non-Hispanic Blacks, and 36.0% non-Hispanic Whites; 60.1% had hepatitis C, 10.6% had HIV, and 46.8% had moderate or severe depressive symptomatology. Mean methadone dose was 95.7. mg (SD 48.9) and urine drug screening (UDS) was positive for opiates, cocaine, and amphetamines in 32.9%, 40.1%, and 2.9%, respectively. Overall, 237 (48.5%) reported clinically significant pain. Pain treatments included prescribed opioids (38.8%) and non-opioids (48.9%), and self-management approaches (60.8%), including prayer (33.8%), vitamins (29.5%), and distraction (12.7%). Pain was associated with higher methadone dose, more medical comorbidities, prescribed opioid therapy, and more severe depressive symptomatology; it was not associated with UDS or self-reported substance use. Conclusions: Clinically significant pain was reported by almost half of the patients in MMT programs and was associated with medical and psychological comorbidity. Pain was often treated with opioids and was not associated with measures of drug use. Studies are needed to further clarify these associations and determine their importance for pain treatment strategies.

HSV-2 Infection as a Cause of Female/Male and Racial/Ethnic Disparities in HIV Infection

Des Jarlais, D. C., Arasteh, K., McKnight, C., Perlman, D. C., Cooper, H. L., & Hagan, H. (n.d.).

Publication year

2013

Journal title

PloS one

Volume

8

Issue

6
Abstract
Abstract
Objectives:To examine the potential contribution of herpes simplex virus 2 (HSV-2) infection to female/male and racial/ethnic disparities in HIV among non-injecting heroin and cocaine drug users. HSV-2 infection increases susceptibility to HIV infection by a factor of two to three.Methods:Subjects were recruited from entrants to the Beth Israel drug detoxification program in New York City 2005-11. All subjects reported current use of heroin and/or cocaine and no lifetime injection drug use. A structured questionnaire was administered and serum samples collected for HIV and HSV-2 testing. Population-attributable risk percentages (PAR%s) were calculated for associations between HSV-2 infection and increased susceptibility to HIV.Results:1745 subjects were recruited from 2005-11. Overall HIV prevalence was 14%. Females had higher prevalence than males (22% vs. 12%) (p<0.001), African-Americans had the highest prevalence (15%), Hispanics an intermediate prevalence (12%), and Whites the lowest prevalence (3%) (p<.001). There were parallel variations in HSV-2 prevalence (females 86%, males 51%, African-Americans 66%, Hispanics 47%, Whites 36%), HSV-2 prevalence was strongly associated with HIV prevalence (OR = 3.12 95% CI 2.24 to 4.32). PAR%s for HSV-2 as a cause of HIV ranged from 21% for Whites to 50% for females. Adjusting for the effect of increased susceptibility to HIV due to HSV-2 infection greatly reduced all disparities (adjusted prevalence = males 8%, females 11%; Whites 3%, African-Americans 10%, Hispanics 9%).Conclusions:Female/male and racial/ethnic variations in HSV-2 infection provide a biological mechanism that may generate female/male and racial/ethnic disparities in HIV infection among non-injecting heroin and cocaine users in New York City. HSV-2 infection should be assessed as a potential contributing factor to disparities in sexually transmitted HIV throughout the US.

Perceptions of drug users regarding Hepatitis C screening and care: A qualitative study

Jordan, A. E., Masson, C. L., Mateu-Gelabert, P., McKnight, C., Pepper, N., Bouche, K., Guzman, L., Kletter, E., Seewald, R. M., Des-Jarlais, D. C., Sorensen, J. L., & Perlman, D. C. (n.d.).

Publication year

2013

Journal title

Harm Reduction Journal

Volume

10

Issue

1
Abstract
Abstract
Background: Illicit drug users have a high prevalence of HCV and represent the majority of newly infected persons in the U.S. Despite the availability of effective HCV treatment, few drug users have been evaluated or treated for HCV. Racial and ethnic minorities have a higher incidence and prevalence of HCV and higher HCV-related mortality. Factors contributing to poor engagement in care are incompletely understood.Methods: Fourteen mixed-gender focus groups of either African American or Latino/a drug users (N = 95) discussed barriers to HCV testing and treatment. Themes were identified through content analysis of focus group discussions.Results: Many drug users were tested for HCV in settings where they were receiving care. Outside of these settings, most were unaware of voluntary test sites. After testing HCV positive, drug users reported not receiving clear messages regarding the meaning of a positive HCV test, the impact of HCV infection, or appropriate next steps including HCV clinical evaluations. Many drug users perceived treatment as unimportant because they lacked symptoms, healthcare providers minimized the severity of the diagnosis, or providers did not recommend treatment. Mistrust of the motivations of healthcare providers was cited as a barrier to pursuing treatment. Social networks or social interactions were a source of HCV-related information and were influential in shaping drug users perceptions of treatment and its utility.Conclusion: Drug users perceived a paucity of settings for self-initiated HCV testing and poor provider-patient communication at test sites and during medical encounters. Notably, drug users reported having an unclear understanding about the meaning of a positive HCV test, the health implications of HCV infection, the importance of clinical evaluations and monitoring, and of treatment options for HCV. Efforts to improve the delivery of clinical messages about HCV infection for drug users at test settings and clinical encounters are needed.

Associations between herpes simplex virus type 2 and HCV with HIV among injecting drug users in New York City: The current importance of sexual transmission of HIV

Des Jarlais, D. C., Arasteh, K., McKnight, C., Hagan, H., Perlman, D. C., & Semaan, S. (n.d.).

Publication year

2011

Journal title

American journal of public health

Volume

101

Issue

7

Page(s)

1277-1283
Abstract
Abstract
Objectives: We examined relationships between herpes simplex virus type 2 (HSV-2), a biomarker for sexual risk, and HCV, a biomarker for injecting risk, with HIV among injecting drug users (IDUs) who began injecting after large-scale expansion of syringe exchange programs in New York City. Methods: We recruited 337 heroin and cocaine users who began injecting in 1995 or later from persons entering drug detoxification. We administered a structured interview covering drug use and HIV risk behavior and collected serum samples for HIV, HCV, and HSV-2 testing. Results: HIV prevalence was 8%, HSV-2 39%, and HCV 55%. We found a significant association between HSV-2 and HIV (odds ratio [OR]=7.9; 95% confidence interval [CI]=2.9, 21.4) and no association between HCV and HIV (OR=1.14; 95% CI=0.5, 2.6). Black IDUs had the highest prevalence of HSV-2 (76%) and HIV (24%) but the lowest prevalence of HCV (34%). Conclusions: Most HIV infections among these IDUs occurred through sexual transmission. The relative importance of injecting versus sexual transmission of HIV may be critical for understanding racial/ethnic disparities in HIV infection.

Gender and age patterns in HSV-2 and HIV infection among non-injecting drug users in New York City

Des Jarlais, D. C., Arasteh, K., McKnight, C., Perlman, D., Hagan, H., Semaan, S., & Friedman, S. R. (n.d.).

Publication year

2010

Journal title

Sexually Transmitted Diseases

Volume

37

Issue

10

Page(s)

637-643
Abstract
Abstract
Objective: To examine prevalence of and associations between herpes simplex virus type 2 (HSV-2) infection and HIV infection among never-injecting heroin and cocaine drug users (NIDUs) in New York City. METHODS:: Subjects were recruited from patients entering the Beth Israel drug detoxification program. Informed consent was obtained, a structured questionnaire including demographics, drug use history, and sexual risk behavior was administered, and a blood sample was collected for HIV and HSV-2 antibody testing. Results: A total of 1418 subjects who had never (lifetime) injected drugs (NIDUs) were recruited between July 2005 through June 2009. Subjects were primarily male (76%), and black (67%) or Hispanic (25%), reported recent crack cocaine use (74%), and had a mean age of 42 years. Eleven percent of males reported male-with-male sexual (MSM) behavior. The prevalence of both viruses was high: for HSV-2, 61% among the total sample, 50% among non-MSM males, 85% among females, and 72% among MSM; for HIV, 16% among the total sample, 12% among non-MSM males, 20% among females, and 46% among MSM. HSV-2 was associated with HIV (OR = 3.2, 95% CI: 2.3-4.5; PR = 2.7, 95% CI: 2.0-3.7). Analyses by gender and age groups indicated different patterns in mono- and coinfection for the 2 viruses. Discussion: HSV-2 and HIV rates among these NIDUs are comparable with rates in sub-Saharan Africa. Additional prevention programs, tailored to gender and age groups, are urgently needed. New platforms for providing services to NIDUs are also needed.

HIV infection during limited versus combined HIV prevention programs for IDUs in New York City: The importance of transmission behaviors

Des Jarlais, D. C., Arasteh, K., McKnight, C., Hagan, H., Perlman, D. C., Torian, L. V., Beatice, S., Semaan, S., & Friedman, S. R. (n.d.).

Publication year

2010

Journal title

Drug and alcohol dependence

Volume

109

Issue

1

Page(s)

154-160
Abstract
Abstract
Objectives: As no single HIV prevention program has eliminated HIV transmission, there is growing interest in the effectiveness of " combined" prevention programming. To compare HIV infection among persons injecting in the initial programs environment (IPE) in New York City (self-initiated risk reduction, methadone, education/outreach, and HIV testing) to HIV infection among persons injecting in a combined programs environment (CPE) (above programs plus large-scale syringe exchange). To identify potential behavioral mechanisms through which combined programs are effective. Methods: Subjects were recruited from the Beth Israel drug detoxification program. A risk behavior questionnaire was administered and HIV testing conducted. Subjects who injected only between 1984 and 1994 (IPE) were compared to subjects who injected only between 1995 and 2008 (CPE). Results: 261 IPE subjects and 1153 CPE subjects were recruited. HIV infection was significantly lower among the CPE subjects compared to IPE subjects: prevalence 6% versus 21%, estimated incidence 0.3/100 person-years versus 4/100 person-years (both p<0.001). The percentage of subjects at risk of acquiring HIV through receptive syringe sharing was similar across CPE and IPE subjects (30% versus 33%). The percentage of subjects at risk of transmitting HIV through injection-related behaviors (who were both HIV seropositive and reported passing on used needles/syringes), was much lower among the CPE subjects than among the IPE subjects (1% versus 10%, p<0.001). Conclusions: Combined prevention programs can greatly reduce HIV transmission. Reducing distributive sharing by HIV seropositive injecting drug users (IDUs) may be a critical component in reducing HIV transmission in high seroprevalence settings.

Syringe exchange, injecting and intranasal drug use

Des Jarlais, D. C., Arasteh, K., McKnight, C., Ringer, M., & Friedman, S. R. (n.d.).

Publication year

2010

Journal title

Addiction

Volume

105

Issue

1

Page(s)

155-158
Abstract
Abstract
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 < 0.001). Conclusion While assessing the possible effects of syringe exchange on trends in injecting drug use is inherently difficult, these may be the strongest data collected to date showing a lack of increase in drug injecting following implementation of syringe exchange.

Doing harm reduction better: Syringe exchange in the United States

Des Jarlais, D. C., McKnight, C., Goldblatt, C., & Purchase, D. (n.d.).

Publication year

2009

Journal title

Addiction

Volume

104

Issue

9

Page(s)

1441-1446
Abstract
Abstract
Objective To trace the growth of syringe exchange programs (SEPs) in the United States since 1994-95 and assess the current state of SEPs. Methods Annual surveys of US SEPs known to North American Syringe Exchange Network (NASEN). Surveys mailed to executive directors with follow-up interviews by telephone and/or e-mail. Response rates have varied between 70% and 88% since surveys were initiated in 1996. Results The numbers of programs known to NASEN have increased from 68 in 1994-95 to 186 in 2007. Among programs participating in the survey, numbers of syringes exchanged have increased from 8.0 million per year to 29.5 million per year, total annual budgets have increased from $6.3 to $19.6 million and public funding (from state and local governments) has increased from $3.9 to $14.4 million. In 2007, 89% of programs permitted secondary exchange and 76% encouraged it. Condoms, referrals to substance abuse treatment, human immunodeficiency virus (HIV), hepatitis C virus (HCV), hepatitis B virus (HBV) counseling and testing and naloxone for overdose were among the most commonly provided services in addition to basic syringe exchange. Each of these services was provided by 40% or more of SEPs in 2007. Conclusions While syringe exchange has remained controversial in the United States, there has been very substantial growth in numbers of programs, syringes exchange and program budgets. Utilizing secondary exchange to reach large numbers of injecting drug users and utilizing SEPs as a new platform for providing health and social services beyond basic syringe exchange have been the two major organizational strategies in the growth of SEPs in the United States.

Persistence and change in disparities in HIV infection among injection drug users in New York City after large-scale syringe exchange programs

Des Jarlais, D. C., Arasteh, K., Hagan, H., McKnight, C., Perlman, D. C., & Friedman, S. R. (n.d.).

Publication year

2009

Journal title

American journal of public health

Volume

99

Page(s)

S445-S451
Abstract
Abstract
Objectives. We examined racial/ethnic disparities in HIV infection among injection drug users (IDUs) before and after implementation of large-scale syringe exchange programs in New York City. Methods. Participants were recruited from IDUs entering the Beth Israel drug detoxification program in New York City. Participants (n=1203) recruited from 1990 through 1994, prior to large-scale syringe exchange programs (pre-exchange), were compared with 1109 participants who began injecting in 1995 or later and were interviewed in 1995 through 2008 (post-exchange). Results. There were large differences in HIV prevalence among pre-exchange vs post-exchange participants (African Americans, 57% vs 15%; Hispanics, 53% vs 5%; Whites, 27% vs 3%). Pre- and post-exchange relative disparities of HIV prevalence were similar for African Americans vs Whites (adjusted odds ratio [AOR]=3.46, 95% confidence interval [CI]=2.41, 4.96 and AOR=4.02, 95% CI=1.67, 9.69, respectively) and Hispanics vs Whites (AOR=1.76, 95% CI=1.49, 2.09 and AOR=1.49, 95% CI=1.02, 2.17). Racial/ethnic group differences in risk behavior did not explain differences in HIV prevalence. Conclusions. New interventions are needed to address continuing disparities in HIV infection among IDUs, but self-reported risk behaviors by themselves may not be adequate outcome measures for evaluating interventions to reduce racial/ethnic disparities in HIV infection.

Using hepatitis C virus and herpes simplex virus-2 to track HIV among injecting drug users in New York City

Des Jarlais, D. C., Arasteh, K., McKnight, C., Hagan, H., Perlman, D., & Friedman, S. R. (n.d.).

Publication year

2009

Journal title

Drug and alcohol dependence

Volume

101

Issue

1

Page(s)

88-91
Abstract
Abstract
Objective: To explore the potential utility of hepatitis C virus (HCV) seroprevalence as a biomarker for injection risk, and herpes simplex virus-2 (HSV-2) as a biomarker for sexual risk among injecting drug users (IDUs). We examined the relationships between HCV and HIV and between HSV-2 and HIV among injecting drug users in New York City relative to the large-scale implementation of syringe exchange in the mid-1990s. Methods: 397 injecting drug users were recruited from a drug detoxification program in New York from 2005 to 2007. Informed consent was obtained, a questionnaire covering demographics, drug use and HIV risk was administered. Blood samples were tested for antibody to HIV, HCV and HSV-2. Results: Among all subjects, HIV prevalence was 17%, HCV prevalence 72% and HSV-2 prevalence 48%. Among IDUs who began injecting before 1995, HIV was 28%, HCV serostatus was strongly associated with HIV serostatus (AOR = 8.96, 95% CI 1.16-69.04) and HSV-2 serostatus was not associated with HIV serostatus (AOR = 1.31, 95% CI 0.64-2.67). Among subjects who began injecting in 1995 or later, HIV was 6%, HCV was not associated with HIV (AOR = 1.04, 95% CI 0.27-4.08) and HSV-2 serostatus was strongly related to HIV serostatus (AOR = 10.71, 95% CI 1.18-97.57). Conclusions: HCV and HSV-2 HCV and HSV-2 may provide important new tools for monitoring evolving HIV epidemics among IDUs. Reconsideration of the current CDC hierarchical transmission risk classification system may also be warranted.

Contact

courtney.mcknight@nyu.edu 708 Broadway New York, NY, 10003