Clinical Assistant Professor of Epidemiology
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.
BA, Women's Studies, Rutgers University, New Brunswick, NJMPH, Community Health Education, Hunter College, New York, NYDrPH, The City University of New York, New York, NY
Behavioral ScienceDrug addictionEpidemiologyHIV/AIDSOpioid
Alternative kinship structures, resilience and social support among immigrant trans Latinas in the USAHwahng, S. J., Allen, B., Zadoretzky, C., Barber, H., Mcknight, C., & Des Jarlais, D.
Journal titleCulture, Health and Sexuality
Page(s)1-15Latinas comprise the largest racial/ethnic group of trans women (male-to-female transgender people) in New York City, where HIV seroprevalence among trans Latinas has been found to be as high as 49%. Despite this population’s high risk of HIV, little is known about resilience among trans Latinas that may provide protective health factors. Six focus groups and one in-depth interview were conducted with 34 low-income trans/gender-variant people of colour who attended transgender support groups at harm reduction programmes in New York City. This paper reports on data from 13 participants who identified as immigrant trans Latinas. Focus groups were coded and analysed using thematic qualitative methods. The majority of immigrants were undocumented but reported having robust social support. Unique characteristics of immigrant trans Latinas included alternative kinship structures and sources of income. Social creativity was used to develop achievable ways in which to improve their health outcomes. Resilience was evident in informal kinship dynamics, formal support groups, gender-transition, educational access and skills training and substance use reduction. Individual-level resilience increased as a result of strong community-level resilience.
Being “hooked up” during a sharp increase in the availability of illicitly manufactured fentanyl: Adaptations of drug using practices among people who use drugs (PWUD) in New York CityMcknight, C., & Des Jarlais, D.
Journal titleInternational Journal of Drug Policy
Page(s)82-88Illicitly manufactured fentanyl (IMF), a category of synthetic opioids 50–100 times more potent than morphine, is increasingly being added to heroin and other drugs in the United States (US). Persons who use drugs (PWUD) are frequently unaware of the presence of fentanyl in drugs. Use of heroin and other drugs containing fentanyl has been linked to sharp increases in opioid mortality. In New York City (NYC), opioid-related mortality increased from 8.2 per 100,000 residents in 2010 to 19.9 per 100,000 residents in 2016; and, in 2016, fentanyl accounted for 44% of NYC overdose deaths. Little is known about how PWUD are adapting to the increase in fentanyl and overdose mortality. This study explores PWUDs’ adaptations to drug using practices due to fentanyl. In-depth qualitative interviews were conducted with 55 PWUD at three NYC syringe services programs (SSP) about perceptions of fentanyl, overdose experiences and adaptations of drug using practices. PWUD utilized test shots, a consistent drug dealer, fentanyl test strips, naloxone, getting high with or near others and reducing drug use to protect from overdose. Consistent application of these methods was often negated by structural level factors such as stigma, poverty and homelessness. To address these, multi-level overdose prevention approaches should be implemented in order to reduce the continuing increase in opioid mortality.
Heterosexual male and female disparities in HIV infection at the end of an epidemic: HIV infection among persons who inject drugs in New York City, 2001–2005 and 2011–2015Des Jarlais, D., Mcknight, C., Feelemyer, J., Arasteh, K., Tross, S., Campbell, A. N., Cooper, H. L., & Perlman, D. C.
Journal titleDrug and Alcohol Dependence
Page(s)391-397Background: We examined whether sex disparities (heterosexual male:female) in HIV infection continue to persist at the “end of the HIV epidemic” among persons who inject drugs (PWID) in New York City (NYC). An “end of the epidemic” was operationally defined as 1) prevalence of untreated HIV infection <5%, and 2) estimated HIV incidence <0.5/100 person-years. Methods: PWID were recruited from persons entering substance use treatment programs at Mount Sinai Beth Israel in 2001–2005 and 2011–2015. A structured interview was administered, and HIV and HSV-2 testing was conducted. Incidence was estimated using newly diagnosed cases of HIV. Disparity analyses compared prevalence of HIV, of untreated HIV, HIV risk behaviors, and estimated HIV incidence. Results: By 2011–2015, both heterosexual male and female PWID met the two criteria for an “end of the epidemic,” and there were no significant differences in the prevalence of untreated HIV infection. A large sex difference remained in estimated HIV incidence. In 2013–2015, estimated HIV incidence was 2.8/10,000 PY for males and 7.1/10,000 PY for females. Females had greater risk for HIV on several factors. Conclusion: While NYC has reached an “end of the epidemic” for both heterosexual male and female PWID, sex disparities persist, particularly differences in HIV incidence. Eliminating the sex disparities may require a greater focus on factors associated with sexual transmission.
Potential geographic "hotspots" for drug-injection related transmission of HIV and HCV and for initiation into injecting drug use in New York city, 2011-2015, with implications for the current opioid epidemic in the USDes Jarlais, D., Cooper, H. L., Arasteh, K., Feelemyer, J., Mcknight, C., & Ross, Z.
Journal titlePLoS One
Issue3Objective We identified potential geographic “hotspots” for drug-injecting transmission of HIV and hepatitis C virus (HCV) among persons who inject drugs (PWID) in New York City. The HIV epidemic among PWID is currently in an “end of the epidemic” stage, while HCV is in a continuing, high prevalence (> 50%) stage. Methods We recruited 910 PWID entering Mount Sinai Beth Israel substance use treatment programs from 2011–2015. Structured interviews and HIV/ HCV testing were conducted. Residential ZIP codes were used as geographic units of analysis. Potential “hotspots” for HIV and HCV transmission were defined as 1) having relatively large numbers of PWID 2) having 2 or more HIV (or HCV) seropositive PWID reporting transmission risk—passing on used syringes to others, and 3) having 2 or more HIV (or HCV) seronegative PWID reporting acquisition risk—injecting with previously used needles/syringes. Hotspots for injecting drug use initiation were defined as ZIP codes with 5 or more persons who began injecting within the previous 6 years. Results Among PWID, 96% injected heroin, 81% male, 34% White, 15% African-American, 47% Latinx, mean age 40 (SD = 10), 7% HIV seropositive, 62% HCV seropositive. Participants resided in 234 ZIP codes. No ZIP codes were identified as potential hotspots due to small numbers of HIV seropositive PWID reporting transmission risk. Four ZIP codes were identified as potential hotspots for HCV transmission. 12 ZIP codes identified as hotspots for injecting drug use initiation. Discussion For HIV, the lack of potential hotspots is further validation of widespread effectiveness of efforts to reduce injecting-related HIV transmission. Injecting-related HIV transmission is likely to be a rare, random event. HCV prevention efforts should include focus on potential hotspots for transmission and on hotspots for initiation into injecting drug use. We consider application of methods for the current opioid epidemic in the US.
Decline in herpes simplex virus type 2 among non-injecting heroin and cocaine users in New York City, 2005 to 2014: Prospects for avoiding a resurgence of human immunodeficiency virusDes Jarlais, D., Arasteh, K., Feelemyer, J., Mcknight, C., Tross, S., Perlman, D. C., Campbell, A. N. C., Hagan, H., & Cooper, H. L. F.
Journal titleSexually Transmitted Diseases
Page(s)85-90Background: Herpes simplex virus type 2 (HSV-2) infection increases both susceptibility to and transmissibility of human immunodeficiency virus (HIV), and HSV-2 and HIV are often strongly associated in HIV epidemics. We assessed trends in HSV-2 prevalence among non-injecting drug users (NIDUs) when HIV prevalence declined from 16% to 8% among NIDUs in New York City. Methods: Subjects were current non-injecting users of heroin and/or cocaine and who had never injected illicit drugs. Three thousand one hundred fifty-seven NIDU subjects were recruited between 2005 and 2014 among persons entering Mount Sinai Beth Israel substance use treatment programs. Structured interviews, HIV, and HSV-2 testing were administered. Change over time was assessed by comparing 2005 to 2010 with 2011 to 2014 periods. Herpes simplex virus type 2 incidence was estimated among persons who participated in multiple years. Results: Herpes simplex virus type 2 prevalence was strongly associated with HIV prevalence (odds ratio, 3.9; 95% confidence interval, 2.9-5.1) from 2005 to 2014. Herpes simplex virus type 2 prevalence declined from 60% to 56% (P = 0.01). The percentage of NIDUs with neither HSV-2 nor HIVinfection increased from37% to 43%, (P < 0.001); the percentagewith HSV-2/HIV coinfection declined from 13% to 6% (P < 0.001). Estimated HSV-2 incidence was 1 to 2/100 person-years at risk. Conclusions: There were parallel declines in HIV and HSV-2 among NIDUs in New York City from 2005 to 2014. The increase in the percentage of NIDUs with neither HSV-2 nor HIV infection, the decrease in the percentage with HSV-2/HIV coinfection, and the low to moderate HSV-2 incidence suggest some population-level protection against resurgence of HIV. Prevention efforts should be strengthened to end the combined HIV/HSV-2 epidemic among NIDUs in New York City.
Perceived discrimination among racial and ethnic minority drug users and the association with health care utilizationMcknight, C., Shumway, M., Masson, C. L., Pouget, E. R., Jordan, A. E., Des Jarlais, D., Sorensen, J. L., & Perlman, D. C.
Journal titleJournal of Ethnicity in Substance Abuse
Page(s)404-419People who use drugs (PWUDs) are at increased risk for several medical conditions, yet they delay seeking medical care and utilize emergency departments (EDs) as their primary source of care. Limited research regarding perceived discrimination and PWUDs’ use of health care services exists. This study explores the association between interpersonal and institutional racial/ethnic and drug use discrimination in health care settings and health care utilization among respondents (N = 192) recruited from methadone maintenance treatment programs (36%), HIV primary care clinics (35%), and syringe exchange programs (29%) in New York City (n = 88) and San Francisco (n = 104). The Kaiser Family Foundation Survey of Race, Ethnicity, and Medical Care questionnaire was utilized to assess perceived institutional racial/ethnic and drug use discrimination. Perceived institutional discrimination was examined across race/ethnicity and by regular use of ERs, having a regular doctor, and consistent health insurance. Perceived interpersonal discrimination was examined by race/ethnicity. Perceived interpersonal drug use discrimination was the most common type of discrimination experienced in health care settings. Perceptions of institutional discrimination related to race/ethnicity and drug use among non-Hispanic Whites did not significantly differ from those among non-Hispanic Blacks or Hispanics. A perception of less frequent institutional racial/ethnic and drug use discrimination in health care settings was associated with increased odds of having a regular doctor. Awareness of perceived interpersonal and institutional discrimination in certain populations and the effect on health care service utilization should inform future intervention development to help reduce discrimination and improve health care utilization among PWUDs.
The New York 911 Good Samaritan Law and Opioid Overdose Prevention Among People Who Inject DrugsZadoretzky, C., Mcknight, C., Bramson, H., Des Jarlais, D., Phillips, M., Hammer, M., & Cala, M. E.
Journal titleWorld Medical and Health Policy
Page(s)318-340This 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., Arasteh, K., Mcknight, C., Feelemyer, J., Campbell, A. N. C., Tross, S., Cooper, H. L. F., Hagan, H., & Perlman, D. C.
Page(s)290-298Background 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, 2005-2014Des Jarlais, D., Arasteh, K., Mcknight, C., Feelemyer, J., Campbell, A. N. C., Tross, S., Smith, L., Cooper, H. L. F., Hagan, H., & Perlman, D.
Journal titleAmerican Journal of Public Health
Page(s)503-508Objectives. 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 HabitsDes Jarlais, D., Arasteh, K., Feelemyer, J., Mcknight, C., Barnes, D., Tross, S., Perlman, D. C., Campbell, A. N. C., Cooper, H. L. F., & Hagan, H.
Journal titleJournal of Substance Abuse Treatment
Page(s)48-53Objectives 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”Des Jarlais, D., Arasteh, K., Mcknight, C., Feelemyer, J., Hagan, H., Cooper, H. L. F., Campbell, A. N. C., Tross, S., & Perlman, D. C.
Journal titleAIDS and Behavior
Page(s)353-362New 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.
Longitudinal analysis of pain and illicit drug use behaviors in outpatients on methadone maintenanceDhingra, L., Perlman, D. C., Masson, C., Chen, J., Mcknight, C., Jordan, A. E., Wasser, T., Portenoy, R. K., & Cheatle, M. D.
Journal titleDrug and Alcohol Dependence
Page(s)285-289Background: 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?Des Jarlais, D., Arasteh, K., Mcknight, C., Feelemyer, J., Hagan, H., Cooper, H., Campbell, A., Tross, S., & Perlman, D.
Journal titlePLoS One
Issue5It 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 CityDes Jarlais, D., Mcknight, C., Arasteh, K., Feelemyer, J., Perlman, D. C., Hagan, H., Dauria, E. F., & Cooper, H. L. F.
Journal titleSubstance Use and Misuse
Page(s)783-792Prevalence 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 CityDes Jarlais, D., Arasteh, K., Mcknight, C., Feelemyer, J., Hagan, H., Cooper, H. L. F., & Perlman, D. C.
Journal titleAIDS and Behavior
Page(s)443-451Examine 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.
HSV-2 co-infection as a driver of HIV transmission among heterosexual non-injecting drug users in New York CityDes Jarlais, D., Arasteh, K., Mcknight, C., Perlman, D. C., Feelemyer, J., Hagan, H., & Cooper, H. L. F.
Journal titlePLoS One
Issue1Objective: 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 infectionDes Jarlais, D., Mcknight, C., Arasteh, K., Feelemyer, J., Perlman, D. C., Hagan, H., & Cooper, H. L. F.
Journal titleJournal of Substance Abuse Treatment
Page(s)325-331Transitions 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 interventionsPerlman, D. C., Jordan, A. E., Mcknight, C., Young, C., Delucchi, K. L., Sorensen, J. L., Des Jarlais, D., & Masson, C. L.
Journal titleJournal of Addictive Diseases
Page(s)322-331Drug 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 treatmentMasson, 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., Des Jarlais, D., & Perlman, D. C.
Journal titleAmerican Journal of Public Health
Issue10Objectives. 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 programsDhingra, 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.
Journal titleDrug and Alcohol Dependence
Page(s)161-165Background: 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 InfectionDes Jarlais, D., Arasteh, K., Mcknight, C., Perlman, D. C., Cooper, H. L. F., & Hagan, H.
Journal titlePLoS One
Issue6Objectives: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.
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 HIVDes Jarlais, D., Arasteh, K., Mcknight, C., Hagan, H., Perlman, D. C., & Semaan, S.
Journal titleAmerican Journal of Public Health
Page(s)1277-1283Objectives: 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 CityDes Jarlais, D., Arasteh, K., Mcknight, C., Perlman, D., Hagan, H., Semaan, S., & Friedman, S. R.
Journal titleSexually Transmitted Diseases
Page(s)637-643Objective: 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 behaviorsDes Jarlais, D., Arasteh, K., Mcknight, C., Hagan, H., Perlman, D. C., Torian, L. V., Beatice, S., Semaan, S., & Friedman, S. R.
Journal titleDrug and Alcohol Dependence
Page(s)154-160Objectives: 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 useDes Jarlais, D., Arasteh, K., Mcknight, C., Ringer, M., & Friedman, S. R.
Page(s)155-158Objective 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.