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Author Notes:

Corresponding Author: Samuel R. Friedman Email: friedman@ndri.org

Reviewed, contributed ideas, and helped edit the manuscript: ERP HIH JC BT SC XH HLFC SG DCDJ.

Conceived and designed the experiments: SRF BSW ERP BT HLFC SG DCDJ.

Analyzed the data: JC SC BSW.

Wrote the paper: SRF BSW ERP HIH.

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The findings and conclusions in this paper are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.


Research Funding:

This work was supported by National Institute of Drug Abuse grants # R01 DA013336 (Community Vulnerability and Responses to Drug-User-Related HIV/AIDS), R01 DA 003574 (Risk Factors for AIDS among Intravenous Drug Users), and 5T32 DA007233 (Behavioral Sciences Training in Drug Abuse Research program sponsored by Public Health Solutions and National Development and Research Institutes).


  • Science & Technology
  • Multidisciplinary Sciences
  • Science & Technology - Other Topics
  • US
  • RISK

Metropolitan Social Environments and Pre-HAART/HAART Era Changes in Mortality Rates (per 10,000 Adult Residents) among Injection Drug Users Living with AIDS

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Journal Title:



Volume 8, Number 2


, Pages e57201-e57201

Type of Work:

Article | Final Publisher PDF


Background: Among the largest US metropolitan areas, trends in mortality rates for injection drug users (IDUs) with AIDS vary substantially. Ecosocial, risk environment and dialectical theories suggest many metropolitan areas characteristics that might drive this variation. We assess metropolitan area characteristics associated with decline in mortality rates among IDUs living with AIDS (per 10,000 adult MSA residents) after highly active antiretroviral therapy (HAART) was developed. Methods: This is an ecological cohort study of 86 large US metropolitan areas from 1993-2006. The proportional rate of decline in mortality among IDUs diagnosed with AIDS (as a proportion of adult residents) from 1993-1995 to 2004-2006 was the outcome of interest. This rate of decline was modeled as a function of MSA-level variables suggested by ecosocial, risk environment and dialectical theories. In multiple regression analyses, we used 1993-1995 mortality rates to (partially) control for pre-HAART epidemic history and study how other independent variables affected the outcomes. Results: In multivariable models, pre-HAART to HAART era increases in 'hard drug' arrest rates and higher pre-HAART income inequality were associated with lower relative declines in mortality rates. Pre-HAART per capita health expenditure and drug abuse treatment rates, and pre- to HAART-era increases in HIV counseling and testing rates, were weakly associated with greater decline in AIDS mortality. Conclusions: Mortality among IDUs living with AIDS might be decreased by reducing metropolitan income inequality, increasing public health expenditures, and perhaps increasing drug abuse treatment and HIV testing services. Given prior evidence that drug-related arrest rates are associated with higher HIV prevalence rates among IDUs and do not seem to decrease IDU population prevalence, changes in laws and policing practices to reduce such arrests while still protecting public order should be considered.

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This is an Open Access work distributed under the terms of the Creative Commons Universal : Public Domain Dedication License (http://creativecommons.org/publicdomain/zero/1.0/).

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