Download Qual Health Res

Abstracts for the Field: February 11, 2010
HIV PREVENTION BRANCH
Abstracts for the Field
FEBRUARY 11, 2010
March 2009
GUIDANCE ON TESTING AND COUNSELLING FOR HIV IN SETTINGS
ATTENDED BY PEOPLE WHO INJECT DRUGS: IMPROVING ACCESS TO
TREATMENT, CARE AND PREVENTION
WHO & UNODC
This document offers basic operational guidance on HIV testing and counselling in settings
attended by people who inject drugs (PWID). It is intended for a wide audience, including
policy-makers, HIV/AIDS programme planners and coordinators, care providers,
nongovernmental organizations (NGOs) providing services for HIV-related conditions, and civil
society groups.
Surveys in the Asia–Pacific region have found that, on average, less than 20% of PWID have
been tested for HIV in the previous 12 months and received the results. Greater knowledge of
HIV status is critical to expanding access to HIV treatment, care and support in a timely
manner, and offers people living with HIV an opportunity to receive information and the tools to
prevent them from transmitting HIV to others.
Available at: http://www.who.int/hiv/topics/idu/care/GuidanceTC_IDUsettings.pdf
ANTIRETROVIRAL THERAPY
AIDS Patient Care STDS. 2009 Aug;23(8):631-8.
ADAPTATIONS ACROSS CLINICAL SITES OF AN INTEGRATED TREATMENT
MODEL FOR PERSONS WITH HIV AND SUBSTANCE ABUSE
Lombard F, Proescholdbell RJ, Cooper K, Musselwhite L, Quinlivan EB.
Substance use disorders are common among people living with HIV (PLWHA), and PLWHA
with untreated substance use are less likely to receive antiretroviral therapy (ART) or achieve
viral suppression when ART is prescribed. Integrated behavioral and medical interventions are
one approach used to treat complex chronic illnesses, including HIV and substance abuse
(SA). As the potential benefit for integrated HIV-substance abuse treatment is recognized, the
number of providers attempting to integrate care is growing. Integrated care models can range
from coordinated to colocated to fully integrated models. Providers need a better
understanding of these implementation options for HIV-substance abuse treatment and how
1
Abstracts for the Field: February 11, 2010
they impact providers of different disciplines. Between April and November 2006, interviews
exploring the process of implementing an integrated HIV-substance abuse intervention were
completed with clinic staff at three diverse HIV clinics in North Carolina. Key differences in
implementation between sites were found. The degree of integrated care between sites ranged
from colocated to integrated, and clinic staff perceived each integrated model to have
advantages and disadvantages. Recommendations for implementing HIV-SA integrated care
are made.
BEHAVIORAL INTERVENTIONS
Drug and Alcohol Dependence, Jan. 2010, Vol. 106, Iss. 1, p. 7-15
BRIEF COUNSELING FOR REDUCING SEXUAL RISK AND BACTERIAL STIS
AMONG DRUG USERS—RESULTS FROM PROJECT RESPECT
S Semaan, MS Neumann, K Hutchins, LH D’Anna, ML Kamb
Objective: Project RESPECT’s brief risk reduction counseling (BRRC) reduced sexual risk and
bacterial STIs among at-risk heterosexuals and has been packaged for use with this
population. We assessed BRRC’s efficacy with RESPECT participants who used drugs and
examined BRRC’s applicability to present-day users of heroin, cocaine, speedball, or crack.
Methods: We compared baseline demographic and economic variables, risk behaviors, and
prevalence and correlates of bacterial STIs for ever-injectors ([EIs], N= 335) and neverinjectors ([NIs], N= 3963). We assessed changes in risk behaviors and bacterial STIs for EIs
and NIs at 12 months. We compared prevalence of HSV-2, hepatitis B core antigen virus
(HBV), hepatitis C virus (HCV), and trichomonas among EIs with recently reported rates
among drug users. Results: At baseline, 19% of EIs and 29% of NIs had bacterial STIs. Both
groups had similar baseline STI correlates. At 12 months, 4% of EIs and 7% of NIs had
bacterial STIs. Twelve-month cumulative incidence of bacterial STIs in BRRC was 21% lower
among EIs and 18% lower among NIs compared to the informational condition. At 12 months,
EIs reported fewer sexual risk behaviors than at baseline. Baseline positivity rates of
trichomoniasis in EIs (female: 15%) and in male and female EIs of HSV-2 (39%, 68%), HBV
(41%, 37%), and HCV (60%, 58%) were similar to rates in present-day drug users. Conclusion:
Efficacy of BRRC in reducing sexual risk and bacterial STIs in EIs, and similar profiles for EIs
and present-day drug users suggest evaluating BRRC with present-day drug users.
Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007192.
PSYCHOSOCIAL INTERVENTIONS FOR REDUCING INJECTION AND SEXUAL
RISK BEHAVIOUR FOR PREVENTING HIV IN DRUG USERS
Meader N, Li R, Des Jarlais DC, Pilling S.
2
Abstracts for the Field: February 11, 2010
BACKGROUND: Drug users (including both injection drug users and crack cocaine users), are
at high levels of risk for contracting HIV. Therefore it is important to reduce the injection and/or
sexual risk behaviours of these groups both for the benefit of themselves and for society as a
whole. OBJECTIVES: To assess the efficacy of multi-session psychosocial interventions in
comparison with standard education and minimal intervention controls for the reduction of
injection and sexual risk behaviour. SEARCH STRATEGY: Electronic searches were
conducted of a number of bibliographic databases (including Cochrane Library, CINAHL,
MEDLINE, PsycINFO). In addition, other methods of locating papers were employed including
contacting various authors working in the field of HIV risk reduction and examining reference
lists of applicable papers identified in the electronic search. SELECTION CRITERIA: The
inclusion criteria consisted of randomised and quazi-randomised trials assessing the efficacy
of psychosocial interventions in the reduction of injection and sexual risk behaviour for people
who misused opiates, cocaine, or a combination of these drugs. DATA COLLECTION AND
ANALYSIS: Two authors independently assessed the eligibility of studies identified by the
search strategy, quality assessed these studies and extracted the data. A total of 35 trials met
the eligibility criteria of the review providing data on 11,867 participants. MAIN RESULTS:
There were minimal differences identified between multi-session psychosocial interventions
and standard educational interventions for both injection and sexual risk behaviour. Although it
should be noted there were large pre-post changes for both groups suggesting both were
effective in reducing risk behaviours. In addition, there was some evidence of benefit for multisession psychosocial interventions when compared with minimal controls. Subgroup analyses
suggest that people in formal treatment are likely to respond to multi-session psychosocial
interventions. It also appears single-gender groups may be associated with greater benefit.
AUTHORS' CONCLUSIONS: There is limited support for the widespread use of formal multisession psychosocial interventions for reducing injection and sexual risk behaviour. Brief
standard education interventions appear to be a more cost-effective option. Further research is
required to assess if there are particular groups of drug users more likely to respond to such
interventions.
AIDS Behav. 2009 Dec 23. [Epub ahead of print]
A RANDOMIZED TRIAL TO EVALUATE THE EFFICACY OF A COMPUTERTAILORED INTERVENTION TO PROMOTE SAFER INJECTION PRACTICES
AMONG DRUG USERS
Gagnon H, Godin G, Alary M, Bruneau J, Otis J.
The aim of this study was to evaluate the efficacy of a theory-based intervention to increase
the use of a new syringe for each injection among injection drug users (IDUs). Users of two
needle exchange programs (NEPs) were involved. At both sites, participants were assigned at
random to either the experimental or the control group. Once a week for four weeks, users
reported to the NEPs where they logged onto a computer and received an audiovisual
message. A total of 260 IDUs were recruited. At baseline, 52.3% of participants reported that
they had not always used new syringes in the previous week. The results indicate that it is
3
Abstracts for the Field: February 11, 2010
possible for IDUs to adopt safer injection practices. One month after the intervention began,
participants in the experimental group were using fewer dirty syringes compared to the control
group (RR: 0.47 CI(95%) 0.28-0.79; P = .004). This short-term effect was no longer present 3
months later.
Harm Reduct J. 2009 Dec 15;6:36.
GETTING THE MESSAGE STRAIGHT: EFFECTS OF A BRIEF HEPATITIS
PREVENTION INTERVENTION AMONG INJECTION DRUG USERS
Grau LE, Green TC, Singer M, Bluthenthal RN, Marshall PA, Heimer R.
To redress gaps in injection drug users' (IDUs) knowledge about hepatitis risk and prevention,
we developed a brief intervention to be delivered to IDUs at syringe exchange programs
(SEPs) in three US cities. Following a month-long campaign in which intervention packets
containing novel injection hygiene supplies and written materials were distributed to every
client at each visit, intervention effectiveness was evaluated by comparing exposed and
unexposed participants' self-reported injection practices. Over one-quarter of the exposed
group began using the novel hygiene supplies which included an absorbent pad ("Safety
Square") to stanch blood flow post-injection. Compared to those unexposed to the intervention,
a smaller but still substantial number of exposed participants continued to inappropriately use
alcohol pads post-injection despite exposure to written messages to the contrary (22.8% vs.
30.0%). It should also be noted that for those exposed to the intervention, 8% may have
misused Safety Squares as part of pre-injection preparation of their injection site; attention
should be paid to providing explicit and accurate instruction on the use of any health promotion
materials being distributed. While this study indicates that passive introduction of risk reduction
materials in injection drug users through syringe exchange programs can be an economical
and relatively simple method of changing behaviors, discussions with SEP clients regarding
explicit instructions about injection hygiene and appropriate use of novel risk reduction
materials is also needed in order to optimize the potential for adoption of health promotion
behaviors. The study results suggest that SEP staff should provide their clients with brief,
frequent verbal reminders about the appropriate use when distributing risk reduction materials.
Issues related to format and language of written materials are discussed.
AIDS Behav. 2009 Sep 11. [Epub ahead of print]
REDUCING HIV RISKS AMONG ACTIVE INJECTION DRUG AND CRACK
USERS: THE SAFETY COUNTS PROGRAM.
Rotheram-Borus MJ, Rhodes F, Desmond K, Weiss RE
The efficacy of Safety Counts, a CDC-diffused intervention, was reanalyzed. In a quasi
experimental, cross-over design, injection drug users (IDU) and crack users in two
4
Abstracts for the Field: February 11, 2010
neighborhoods were assigned by neighborhood to receive individual Voluntary HIV Counseling
and Testing or Safety Counts and 78% were reassessed at 5-9 months. Drug users in the
Safety Counts program reported significantly greater reductions in risky sex, crack and hard
drug use, and risky drug injection. The more sessions of Safety Counts attended, the greater
were the reductions in risky acts. Different analytic decisions result in very different findings for
the same intervention. Safety Counts is an effective intervention for IDU and crack users.
Analytic decision of intervention outcomes is highly related to evaluations of an intervention's
efficacy.
CORRECTIONS
Addiction. 2010 Feb;105(2):216-223.
DOES OPIOID SUBSTITUTION TREATMENT IN PRISONS REDUCE INJECTINGRELATED HIV RISK BEHAVIOURS? A SYSTEMATIC REVIEW
Larney S.
Objectives To review systematically the evidence on opioid substitution treatment (OST) in
prisons in reducing injecting-related human immunodeficiency virus (HIV) risk behaviours.
Methods Systematic review in accordance with guidelines of the Cochrane Collaboration.
Electronic databases were searched to identify studies of prison-based opioid substitution
treatment programmes that included assessment of effects of prison OST on injecting drug
use, sharing of needles and syringes and HIV incidence. Published data were used to
calculate risk ratios for outcomes of interest. Risk ratios were not pooled due to the low
number of studies and differences in study designs. Results Five studies were included in the
review. Poor follow-up rates were reported in two studies, and representativeness of the
sample was uncertain in the remaining three studies. Compared to inmates in control
conditions, for treated inmates the risk of injecting drug use was reduced by 55-75% and risk
of needle and syringe sharing was reduced by 47-73%. No study reported a direct effect of
prison OST on HIV incidence. Conclusions There may be a role for OST in preventing HIV
transmission in prisons, but methodologically rigorous research addressing this question
specifically is required. OST should be implemented in prisons as part of comprehensive HIV
prevention programmes that also provide condoms and sterile injecting and tattooing
equipment.
AIDS Care. 2009 Jun;21(6):708-14.
THE IMPACT OF INCARCERATION UPON ADHERENCE TO HIV TREATMENT
AMONG HIV-POSITIVE INJECTION DRUG USERS: A QUALITATIVE STUDY
Small W, Wood E, Betteridge G, Montaner J, Kerr T.
5
Abstracts for the Field: February 11, 2010
INTRODUCTION: HIV-positive injection drug users (IDU) often do not derive the full benefits of
highly active antiretroviral therapy (HAART). Among IDU, recent incarceration has been
associated with discontinuation of HAART for non-clinical reasons. We sought to qualitatively
evaluate experiences with HAART among HIV-positive IDU who had been recently
incarcerated within provincial prisons in British Columbia in order to identify factors influencing
adherence to treatment. METHODS: Twelve in-depth qualitative interviews were conducted
with males recruited from a cohort study (ACCESS) involving over 450 HIV-positive IDU. All
participants had been incarcerated after initiating HAART. Audio-recorded interviews were
conducted to examine experiences of taking HAART in prison, with particular attention to
adherence and experiences of treatment discontinuation. FINDINGS: Participant accounts
described situations where adherence to HIV treatment was compromised in custody. A small
number of participants reported treatment interruptions that lasted over a week when they
were unable to obtain HIV medications through institutional healthcare. Short-term
interruptions in treatment were said to be common during intake into the correctional system
and at the point of release from custody. High levels of HIV discrimination motivate prisoners
to hide the fact that they are HIV-positive by making efforts to take medications discreetly,
which may result in missed doses. CONCLUSIONS: The current study identified contextual
factors within correctional environments that hinder individuals' ability to adhere to HAART.
These findings also indicate that improved health services and coordination with community
care providers are needed to enhance the quality of HIV treatment within correctional
environments.
DRUG TREATMENT
AIDS. 2010 Jan 28;24(3):331-40.
MEDICATION-ASSISTED TREATMENT AND HIV/AIDS: ASPECTS IN TREATING
HIV-INFECTED DRUG USERS
Bruce RD, Kresina TF, McCance-Katz EF.
Drug use and HIV/AIDS remain serious public health issues in the US. The intersection of the
twin epidemics of HIV and drug/alcohol use, results in difficult medical management issues for
the healthcare providers who work in the HIV prevention and treatment fields. Access to care
and treatment, medication adherence to multiple therapeutic regimens and concomitant drugdrug interactions of prescribed treatments are difficult barriers for drug users to overcome
without directed interventions. Injection drug users are frequently disenfranchised from medical
care and suffer stigma and discrimination creating additional barriers to care and treatment for
their substance use disorders as well as HIV infection. Controlling the transmission of HIV will
require access to care and treatment of individuals who abuse illicit drugs and alcohol.
Improving health outcomes (e.g. access to and adherence to antiretroviral therapy) among
HIV-infected substance users will also require access to evidenced-based pharmacological
therapies for the treatment of drug abuse and dependence. The current review presents an
overview of issues regarding the use of medication-assisted treatments for substance abuse
6
Abstracts for the Field: February 11, 2010
and dependence among HIV-infected individuals, providing medical management paradigms
for their care and treatment.
J Public Health (Oxf). 2009 Sep 23. [Epub ahead of print]
INABILITY TO ACCESS ADDICTION TREATMENT AND RISK OF HIV INFECTION
AMONG INJECTION DRUG USERS RECRUITED FROM A SUPERVISED
INJECTION FACILITY
Milloy MJ, Kerr T, Zhang R, Tyndall M, Montaner J, Wood E.
BACKGROUND: Treatment for drug addiction is effective in reducing the harms of injection
drug use, including infection with HIV and/or hepatitis C. We sought to examine the prevalence
and correlates of being unable to access addiction treatment in a representative sample of
injection drug users randomly recruited from a supervised injection facility. METHODS: Using
generalized estimating equations, we determined the prevalence and factors associated with
being unable to access addiction treatment. RESULTS: Between 1 July 2004 and 30 June
2006, 889 individuals completed at least one interview and were included in this analysis. At
each interview, approximately 20% of respondents reported trying but being unable to access
any type of drug or alcohol treatment in the previous 6 months. Being unable to access
treatment was independently associated with recent incarceration, daily use of heroin and
borrowing used syringes. In a secondary question, the majority of individuals reported waiting
lists were the reason for being unable to access treatment. CONCLUSION: Given the
independent association between inability to access addiction treatment and elevated HIV risk
behavior, these results suggest expanding addiction treatment may contribute significantly to
HIV prevention efforts in this population.
AIDS Patient Care and STDs. Online Ahead of Print: January 24, 2010
INTEGRATED OPIOID USE DISORDER AND HIV TREATMENT: RATIONALE,
CLINICAL GUIDELINES FOR ADDICTION TREATMENT AND REVIEW OF
INTERACTIONS OF ANTIRETROVIRAL AGENTS AND OPIOID AGONIST
THERAPIES
Marcelo F. Batkis, Glenn J. Treisman, Andrew F. Angelino.
Injection drug use (IDU) is an important vector of HIV infection in the United States. Many
patients with HIV infection have comorbid substance use disorders. Integrated treatment for
HIV and substance use disorders has been shown to improve HIV and other health outcomes,
but significant barriers to integrated treatment exist. For individuals who are dependent on
injection opioid drugs, agonist therapies of methadone or buprenorphine maintenance are
available as part of a treatment program. Patients who are infected with HIV and require
7
Abstracts for the Field: February 11, 2010
antiretroviral therapy (ART) are at risk for drug–drug interaction between ART and methadone
or buprenorphine. We present a programmatic approach to the evaluation and treatment of
opioid use disorders for HIV care providers, as well as a summary of the available knowledge
of interactions of methadone and buprenorphine with ART, along with the level of evidence for
each actual or potential interaction. Based on the available information of practice and the level
of clinical significance of drug-drug interactions, we conclude that buprenorphine-based
maintenance treatment for opioid dependent patients is the preferred maintenance therapy for
integrated treatment systems.
Clin Infect Dis. 2009 Nov 1;49(9):1433-40.
RETENTION IN OPIOID SUBSTITUTION TREATMENT: A MAJOR PREDICTOR OF
LONG-TERM VIROLOGICAL SUCCESS FOR HIV-INFECTED INJECTION DRUG
USERS RECEIVING ANTIRETROVIRAL TREATMENT
Roux P, Carrieri MP, Cohen J, Ravaux I, Poizot-Martin I, Dellamonica P, Spire B.
BACKGROUND: The positive impact of opioid substitution treatment (OST) on opioiddependent individuals with human immunodeficiency virus (HIV) infection is well documented,
especially with regard to adherence to highly active antiretroviral therapy (HAART). We used
the data from a 5-year longitudinal study of the MANIF 2000 cohort of individuals infected with
HIV (as a result of injection drug use) and receiving HAART to investigate the predictors of
long-term virological success. Design. Data were collected every 6 months from outpatient
hospital services delivering HIV care in France. We selected all patients who were receiving
HAART for at least 6 months (baseline visit) and who had indications for OST (ie, still
dependent on opioids). We selected a total of 113 patients, accounting for a total of 562 visits
for all the analyses. METHODS: Long-term virological success was defined as an undetectable
viral load after at least 6 months on HAART. Retention in OST was defined as the time interval
between the last initiation or reinitiation of OST during HAART follow-up and any given visit on
OST. A mixed logistic model was used to identify predictors of long-term virological success.
RESULTS: At baseline, 53 patients were receiving buprenorphine, 28 patients were receiving
methadone, and 32 patients were not on OST. The median duration of OST was 25 months
(range, 3-42 months). In the multivariate analysis, after adjustment for significant predictors of
long-term virological success such as adherence to HAART and early virological response,
retention in OST was associated with long-term virological success (odds ratio, 1.20 per 6month increase; 95% confidence interval, 1.09-1.32). CONCLUSIONS: Our study presents
important evidence of the positive impact of retention in OST on HIV outcomes. Increasing
access to OST based on a comprehensive model of care for HIV-infected patients who have
indications for OST may foster adherence and ensure long-term response to HAART.
EPIDEMIOLOGY/RISK FACTORS
MMWR Morb Mortal Wkly Rep. 2009 Nov 27;58(46):1291-5.
8
Abstracts for the Field: February 11, 2010
HIV INFECTION AMONG INJECTION-DRUG USERS - 34 STATES, 2004-2007
Centers for Disease Control and Prevention (CDC).
Injection-drug users (IDUs) acquire human immunodeficiency virus (HIV) infection by sharing
drug equipment with HIV-infected persons and by engaging in risky sexual behavior. In 2007,
injection-drug use was the third most frequently reported risk factor for HIV infection in the
United States, after male-to-male sexual contact and high-risk heterosexual contact. To
characterize HIV-infected IDUs aged >or=13 years in the United States, CDC analyzed data
from the national notifiable disease reporting system for 2004-2007 from the 34 states that had
conducted confidential, name-based HIV surveillance since at least 2003. The results of that
analysis indicated that, during 2004-2007, 62.2% of IDUs with a new diagnosis of HIV infection
were males, 57.5% were blacks or African Americans, and 74.8% lived in urban areas at the
time of their HIV diagnosis. In addition, during 2004-2006, approximately 40% of HIV-infected
IDUs received late HIV diagnoses (i.e., diagnosis of acquired immunodeficiency syndrome
[AIDS] <12 months after the date of HIV diagnosis). To reduce the prevalence of HIV infection
and late HIV diagnosis among IDUs, HIV prevention programs serving IDUs should have
comprehensive approaches that incorporate access to HIV testing as part of community-based
outreach, drug abuse treatment, and syringe exchange programs.
AIDS and Behavior, Dec. 2009, Vol 13, 6, p. 1106-1118
BINGE USE OF CRACK COCAINE AND SEXUAL RISK BEHAVIORS AMONG
AFRICAN-AMERICAN, HIV-POSITIVE USERS
Amy Jo Harzke, Mark L. Williams and Anne M. Bowen
This study describes binge use of crack cocaine, binge users, and their sexual risk behaviors
in a sample of 303 African-American, HIV-positive users. Recent binge use was defined as,
“using as much crack cocaine as you can, until you run out of crack or are unable to use any
more” in the last 30 days. Fifty-one percent reported a recent crack binge. The typical crack
binge lasted 3.7 days and involved smoking 40 rocks on average. Nearly two-thirds reported
their last binge was in their own or another’s home. Seventy-two percent had sex during the
last binge, with an average of 3.1 partners. In multivariable logistic regression analyses, recent
bingers were more likely than non-bingers to consider themselves homeless, to have any
income source, to have used crack longer, and to score higher on risk-taking and need for help
with their drug problem. In multivariable ordinal and logistic regression analyses, recent
bingers had more sex partners in the last six months and 30 days and were more likely to have
never used a condom in the last 30 days. Among male users, recent bingers were more likely
to report lifetime and recent exchange of money for sex and drugs for sex. Among both male
and female users, recent bingers were more likely to report lifetime trading of sex for drugs.
African-American, HIV-positive binge users of crack cocaine appear to be at increased risk for
HIV transmission. Further investigations of binge crack use and sexual risk behaviors and
interventions targeting and tailored to this group should be considered.
9
Abstracts for the Field: February 11, 2010
AIDS Behav. 2010 Feb;14(1):92-102.
IS SEXUAL SEROSORTING OCCURRING AMONG HIV-POSITIVE INJECTION
DRUG USERS? COMPARISON BETWEEN THOSE WITH HIV-POSITIVE
PARTNERS ONLY, HIV-NEGATIVE PARTNERS ONLY, AND THOSE WITH ANY
PARTNERS OF UNKNOWN STATUS
Y Mizuno, DW Purcell, MH. Latka, LR Metsch, H Ding, CA Gomez and AR Knowlton
Using baseline data from a multi-site, randomized controlled study (INSPIRE), we categorized
999 HIV-positive IDUs into three groups based on serostatus of their sex partners. Our data
provide some evidence for serosorting occurring in our sample; about 40% of the sample had
sex exclusively with HIV-positive partners, and about half of them reported having unprotected
sex with these partners. Twenty per cent had sex exclusively with HIV-negative partners; their
sexual behaviors tended to be least risky with about two-thirds reporting their sex was
protected. However, we also found that another 40% had at least one partner of unknown HIV
status and sexual and drug risk was the highest among them. They were also least
empowered, showing attributes that may undermine HIV prevention. Some of these findings
are consistent with findings from MSM studies, suggesting that partner selection practices are
similar between primarily heterosexual IDUs and MSM.
J Womens Health (Larchmt). 2010 Feb 7. [Epub ahead of print]
TRENDS IN INJECTION DRUG USE AMONG PREGNANT WOMEN ADMITTED
INTO DRUG TREATMENT: 1994-2006
Terplan M, Smith EJ, Glavin SH.
Objective: To describe trends in the regional and demographic characteristics of injection drug
use (IDU) during pregnancy. Methods: Data were obtained from the Treatment Episode Data
Set (TEDS), an administrative data set that captures admissions to federally funded treatment
centers in the United States. Demographic and treatment-related measures were examined
and compared between injection drug and noninjection drug admissions. The results were
stratified by year of admission to assess trends over time. Results: From 1994 to 2006, there
were 239,511 admissions of pregnant women, of whom 34,717 (14.4%) reported IDU. There
was little change in the proportion of injecting from year to year. Compared with admissions of
noninjecting pregnant women, a greater proportion of injection drug users were white (68.5 vs.
48.6%), reported heroin use (70.0% vs. 13.2%), and had no health insurance (48.2% vs.
40.2%). Over the time period, the proportion of injection drug users was seen to spread from
the West to the South and Northeast for heroin and to the Midwest for amphetamines.
10
Abstracts for the Field: February 11, 2010
Conclusions: IDU among pregnant women in drug treatment remains a significant public health
issue, especially among white women.
FEMALE DRUG USERS
Journal of Urban Health, Nov. 2009, Vol. 86, 6, p. 951 - 964
RELATIONSHIP POWER AND SEXUAL RISK AMONG WOMEN IN COMMUNITYBASED SUBSTANCE ABUSE TREATMENT
ANC Campbell, S Tross, SL Dworkin, MC Hu, J Manuel, M Pavlicova & EV Nunes
Relationship power has been highlighted as a major factor influencing women’s safer sex
practices. Little research, however, has specifically examined relationship power in druginvolved women, a population with increased risk for HIV transmission. Using baseline data
from a National Institute on Drug Abuse Clinical Trials Network multisite trial of a women’s HIV
prevention intervention in community-based drug treatment programs, this paper examined the
association between sexual relationship power and unprotected vaginal or anal sex. The
Sexual Relationship Power Scale, a measure of relationship control and decision-making
dominance, was used to assess the association between power and unprotected sex in
relationships with primary male partners. It was hypothesized that increased relationship power
would be associated with decreased unprotected sexual occasions, after controlling for
relevant empirical and theoretical covariates. Findings show a more complex picture of the
association between power and sexual risk in this population, with a main effect in the
hypothesized direction for decision-making dominance but not for relationship control. Possible
explanations for these findings are discussed, and future research directions for examining
power constructs and developing interventions targeting relationship power among druginvolved women are suggested.
AIDS Behav. 2010 Jan 27. [Epub ahead of print]
NUMBER OF SEXUAL PARTNERS AND ASSOCIATIONS WITH INITIATION AND
INTENSITY OF SUBSTANCE USE
Cavazos-Rehg PA, Krauss MJ, Spitznagel EL, Schootman M, Cottler LB, Bierut LJ.
We dissected associations between initiation and intensity of substance use and number of
sexual partners using pooled data from high school seniors (weighted n = 13,580) who
participated in the 1999-2007 Youth Risk Behavior Surveillance System (YRBS), a crosssectional, nationally representative survey. In multinomial multivariable logistic regressions,
number of sexual partners steadily increased as substance use intensified from never use to
experimental/new user to heavy use across all substances for both male and females. Severity
of substance use is more closely related to, and thus a better indicator of, higher number of
sexual partners than age of substance use onset.
11
Abstracts for the Field: February 11, 2010
Int J STD AIDS, Feb 2010; 21: 141 - 142.
SEXUALLY TRANSMITTED INFECTIONS AMONG PREGNANT HEROIN- OR
COCAINE-ADDICTED WOMEN IN TREATMENT: THE SIGNIFICANCE OF
PSYCHIATRIC CO-MORBIDITY AND SEX TRADE
C E Cavanaugh, S L Hedden, and W W Latimer
Psychiatric co-morbidity and sex trade were tested as correlates of sexually transmitted
infections (STIs) among 76 pregnant heroin- or cocaine-dependent women. Participants were
recruited from a drug treatment programme and attended a clinician-administered assessment
including the Structured Clinical Interview for DSM-IV (SCID-IV-TR) and self-report
questionnaires about lifetime histories of sex trade and STIs (i.e. gonorrhoea, syphilis,
chlamydia, herpes, genital warts or trichomonas). Lifetime and six month rates of STIs were
53.9% and 18.4%, respectively. The majority of women also had lifetime histories of
psychiatric co-morbidity (61.8%) and/or sex trade (60.5%). Participants with psychiatric comorbidity (adjusted odds ratio [AOR] 3.9; 95% confidence interval [CI] 1.3–11.6) and/or sex
trade (AOR 3.2; 95% CI 1.1–9.5) were more likely to report STIs during their lifetime compared
with those without such histories while controlling for age, education and race/ethnicity.
Results suggest that as many as one-in-five pregnant heroin- or cocaine-dependent women in
treatment have one or more STIs that are concurrent with their pregnancy and may contribute
to risk for contracting HIV and pregnancy complications; psychiatric co-morbidity and/or sex
trade were associated with greater STI risk. Findings underscore the importance of identifying
and addressing co-morbid psychiatric disorders and sex trade behaviour in this population.
HEPATITIS
Addiction. 2010 Feb;105(2):311-8. Epub 2009 Nov 16.
CAN HEPATITIS C VIRUS PREVALENCE BE USED AS A MEASURE OF
INJECTION-RELATED HUMAN IMMUNODEFICIENCY VIRUS RISK IN
POPULATIONS OF INJECTING DRUG USERS? AN ECOLOGICAL ANALYSIS
Vickerman P, Hickman M, May M, Kretzschmar M, Wiessing L.
BACKGROUND: Human immunodeficiency virus (HIV) outbreaks occur among injecting drug
users (IDUs), but where HIV is low insight is required into the future risk of increased
transmission. The relationship between hepatitis C virus (HCV) and HIV prevalence among
IDUs is explored to determine whether HCV prevalence could indicate HIV risk. METHODS:
Systematic review of IDU HIV/HCV prevalence data and regression analysis using weighted
prevalence estimates and time-series data. RESULTS: HIV/HCV prevalence estimates were
obtained for 343 regions. In regions other than South America/sub-Saharan Africa (SAm/SSA),
12
Abstracts for the Field: February 11, 2010
mean IDU HIV prevalence is likely to be negligible if HCV prevalence is <30% (95%
confidence interval 22-38%) but increases progressively with HCV prevalence thereafter
[linearly (beta = 0.39 and R(2) = 0.67) or in proportion to cubed HCV prevalence (beta = 0.40
and R(2) = 0.67)]. In SAm/SSA, limited data suggest that mean HIV prevalence is proportional
to HCV prevalence (beta = 0.84, R(2) = 0.99), but will be much greater than in non-SAm/SSA
settings with no threshold HCV prevalence that corresponds to low HIV risk. At low HCV
prevalences (<50%), time-series data suggest that any change in HIV prevalence over time is
likely to be much smaller (<25%) than the change in HCV prevalence over the same timeperiod, but that this difference diminishes at higher HCV prevalences. CONCLUSIONS: HCV
prevalence could be an indicator of HIV risk among IDUs. In most settings, reducing HCV
prevalence below a threshold (30%) would reduce substantially any HIV risk, and could
provide a target for HIV prevention.
J Infect Dis. 2010 Feb 1;201(3):378-85.
ATTRIBUTION OF HEPATITIS C VIRUS SEROCONVERSION RISK IN YOUNG
INJECTION DRUG USERS IN 5 US CITIES
Hagan H, Pouget ER, Williams IT, Garfein RL, Strathdee SA, Hudson SM, Latka MH, Ouellet
LJ
BACKGROUND. In studies of hepatitis C virus (HCV) seroconversion in injection drug users
(IDUs), some have questioned whether underreporting of syringe sharing, a stigmatized
behavior, has led to misattribution of HCV risk to other injection-related behaviors. METHODS.
IDUs aged 15-30 years who were seronegative for human immunodeficiency virus and HCV
antibodies were recruited into a prospective study in 5 US cities. Behavioral data were
collected via computer-assisted self-interviewing to reduce socially desirable reporting. Hazard
ratios (HRs) were estimated to assess associations between behavior and HCV
seroconversion. Because the shared use of cookers, cottons, and rinse water was highly
correlated, a summary variable was created to represent drug preparation equipment sharing.
RESULTS. Among 483 IDUs who injected during the period covered by the follow-up
assessments, the incidence of HCV infection was 17.2 cases per 100 person years; no HIV
seroconversions occurred. Adjusting for confounders, the shared use of drug preparation
equipment was significantly associated with HCV seroconversion (adjusted HR, 2.66; 95%
confidence interval, 1.03-23.92), but syringe sharing was not (adjusted HR, 0.91). We
estimated that 37% of HCV seroconversions in IDUs were due to the sharing of drug
preparation equipment. CONCLUSIONS. Associations between sharing drug preparation
equipment and HCV seroconversion are not attributable to underascertainment of syringe
sharing. Avoiding HCV infection will require substantial reductions in exposure to all sources of
contaminated blood.
13
Abstracts for the Field: February 11, 2010
Addiction. 2009 Dec;104(12):2033-8.
DETERMINANTS OF SUCCESSFUL CHRONIC HEPATITIS C CASE FINDING
AMONG PATIENTS RECEIVING OPIOID MAINTENANCE TREATMENT IN A
PRIMARY CARE SETTING
Senn O, Seidenberg A, Rosemann T.
AIMS: Injection drug users are at high risk for chronic hepatitis C virus infection (CHC). Opioid
maintenance treatment (OMT) offers a unique opportunity to screen for CHC. This study
proposed the hypothesis that a general practitioner (GP) with special interest in addiction
medicine can achieve CHC screening rates comparable to specialized centres and aimed to
investigate determinants for a successful CHC case finding in a primary care setting. DESIGN
AND PARTICIPANTS: Retrospective medical record analysis of 387 patients who received
opioid maintenance therapy between 1 January 2002 and 31 May 2008 in a general practice in
Zurich, Switzerland. MEASUREMENTS: Successful CHC assessment was defined as
performance of hepatitis C virus (HCV) serology with consecutive polymerase chain reactionbased RNA and genotype recordings. The association between screening success and patient
characteristics was assessed using multiple logistic regression. findings: Median (interquartile
range) age and duration of OMT of the 387 (268 males) patients was 38.5 (33.6-44.5) years
and 34 (11.3-68.0) months, respectively. Fourteen patients (3.6%) denied HCV testing and
informed consent about screening was missing in 13 patients (3.4%). In 327 of 360 patients
(90.8%) with informed consent a successful CHC assessment has been performed. Screening
for HCV antibodies was positive in 136 cases (41.6%) and in 86 of them (63.2%) a CHC was
present. The duration of OMT was an independent determinant of a successful CHC
assessment. CONCLUSIONS: In addicted patients a high CHC assessment rate in a primary
care setting in Switzerland is feasible and opioid substitution provides an optimal framework.
Drug Alcohol Depend. 2009 Nov 16. [Epub ahead of print]
FACTORS ASSOCIATED WITH UPTAKE OF TREATMENT FOR RECENT
HEPATITIS C VIRUS INFECTION IN A PREDOMINANTLY INJECTING DRUG USER
COHORT: THE ATAHC STUDY
Grebely J, Petoumenos K, Matthews GV, Haber P, Marks P, Lloyd AR, Kaldor JM, Dore GJ,
Hellard M; for the ATAHC Study Group
Despite that the majority of hepatitis C virus (HCV) infection occurs among injection drug users
(IDUs), little is known about HCV treatment uptake in this group, particularly during recent
infection. We evaluated uptake of treatment for recent HCV infection, including associated
factors, within a population predominantly made up of IDUs. The Australian Trial in Acute
Hepatitis C was a study of the natural history and treatment of recent HCV infection. All
participants with detectable HCV RNA at screening were offered HCV treatment, assessed for
14
Abstracts for the Field: February 11, 2010
eligibility and those initiating treatment were identified. Logistic regression analyses were used
to identify predictors of HCV treatment uptake. Between June 2004 and February 2008, 163
were enrolled, with 146 positive for HCV RNA at enrolment. The mean age was 35 years, 77%
(n=113) participants had ever injected illicit drugs and 23% (n=34) reported having ever
received methadone or buprenorphine treatment. The uptake of HCV treatment was 76% (111
of 146) among those who were eligible on the basis of positive HCV RNA. Estimated duration
of HCV infection (OR=1.03 per week, 95% CI=1.00-1.06, P=0.035) and log(10) HCV RNA
(OR=1.92 per log(10) increase, 95% CI=1.36-2.73, P<0.001) were independently associated
with treatment uptake whereas injection drug use was not. This study demonstrates that a high
uptake of HCV treatment can be achieved among participants with recently acquired HCV
infection. Decisions about whether to initiate treatment for recently acquired HCV were mainly
driven by clinical factors, rather than factors related to sociodemographics or injecting
behaviors.
J Infect Dis. 2009 Oct 15;200(8):1216-26.
ACUTE HEPATITIS C VIRUS INFECTION IN YOUNG ADULT INJECTION DRUG
USERS: A PROSPECTIVE STUDY OF INCIDENT INFECTION, RESOLUTION, AND
REINFECTION
Page K, Hahn JA, Evans J, Shiboski S, Lum P, Delwart E, Tobler L, Andrews W, Avanesyan L,
Cooper S, Busch MP.
BACKGROUND: Hepatitis C virus (HCV) infection, clearance, and reinfection are best studied
in injection drug users (IDUs), who have the highest incidence of HCV and are likely to
represent most infections. METHODS: A prospective cohort of HCV-negative young IDUs was
followed up from January 2000 to September 2007, to identify acute and incident HCV and
prospectively study infection outcomes. RESULTS: Among 1,191 young IDUs screened, 731
(61.4%) were HCV negative, and 520 (71.1%) of the 731 were enrolled into follow-up.
Cumulative HCV incidence was 26.7/100 person-years of observation (95% confidence
interval [CI], 21.5-31.6). Of 135 acute/incident HCV infections, 95 (70.4%) were followed; 20
(21.1%) of the 95 infections cleared. Women had a significantly higher incidence of viral
clearance than did men (age-adjusted hazard ratio, 2.91 [95% CI, 1.68-5.03]) and also showed
a faster rate of early HCV viremia decline (P < .01). The estimated reinfection rate was
24.6/100 person-years of observation (95% CI, 11.7-51.6). Among 7 individuals, multiple
episodes of HCV reinfection and reclearance were observed. CONCLUSIONS: In this large
sample of young IDUs, females show demonstrative differences in their rates of viral clearance
and kinetics of early viral decline. Recurring reinfection and reclearance suggest possible
protection against persistent infection. These results should inform HCV clinical care and
vaccine development.
15
Abstracts for the Field: February 11, 2010
MEN WHO HAVE SEX WITH MEN
Addictive Behaviors, Vol, 35, 4, April 2010, Pages 312-317
PREVALENCE AND PREDICTORS OF NON-MEDICAL PRESCRIPTION DRUG USE
AMONG MEN WHO HAVE SEX WITH MEN
Brian C. Kelly and Jeffrey T. Parsons
Although non-medical prescription drug use has dramatically increased in many populations
during the past decade, this phenomenon remains understudied among men who have sex
with men (MSM). Using a community-based sample of MSM, we provide data on the high
prevalence of lifetime and recent non-medical prescription drug use among MSM for a range of
prescription drug classes such as pain killers, sedatives, sleep aids, stimulants, and erectile
dysfunction medications. The paper also highlights differences in rates of recent non-medical
prescription drug use within this population, noting that White MSM, HIV-positive MSM, gayidentified MSM, and MSM over 40 were typically more likely to have recently used a range of
prescription drugs than their counterparts. After controlling for various factors, the findings
demonstrate that age, HIV-positive status, gay identity, low educational level, and White race
are significant correlates of both lifetime and recent non-medical prescription drug use among
MSM. The data suggest that prevention and treatment efforts for this population are likely to
require some tailoring, particularly for HIV-positive MSM who may have different needs than
other MSM given their health concerns and medication regimens.
METHAMPHETAMINE USE
J Urban Health. 2010 Jan 26. [Epub ahead of print]
CRYSTAL METHAMPHETAMINE USE AND SEXUAL RISK BEHAVIORS AMONG
HIV-POSITIVE AND HIV-NEGATIVE MEN WHO HAVE SEX WITH MEN IN
SOUTH FLORIDA
Forrest DW, Metsch LR, Lalota M, Cardenas G, Beck DW, Jeanty Y.
Using data collected through venue-based sampling in South Florida from 2004 to 2005 as
part of the Centers for Disease Control and Prevention-funded National HIV Behavioral
Surveillance Among Men Who Have Sex with Men, we estimate the prevalence of crystal
methamphetamine use and its association with high-risk sexual behaviors among a large and
diverse sample of men who have sex with men (MSM) residing in South Florida. We also
examine how these associations differ between HIV-positive and HIV-negative men. Bivariate
analyses were used to assess the characteristics of study participants and their sexual risk
behaviors by drug use and self-reported HIV status group. Of 946 MSM participants in South
Florida, 18% reported crystal methamphetamine use in the past 12 months. Regardless of selfreported HIV status, crystal methamphetamine users were more likely to report high-risk
16
Abstracts for the Field: February 11, 2010
sexual behaviors, an increased number of non-main sex partners, and being high on drugs
and/or alcohol at last sex act with a non-main partner. Our findings indicate that crystal
methamphetamine use is prevalent among the MSM population in South Florida, and this
prevalence rate is similar, if not higher, than that found in US cities that have been long
recognized for having a high rate of crystal methamphetamine use among their MSM
populations. Notably, the use of crystal methamphetamine among both HIV-positive and HIVnegative MSM is associated with increased HIV-related risk behaviors.
J Neuroimmune Pharmacol. 2009 Mar;4(1):129-39. Epub 2008 Oct 29.
METHAMPHETAMINE ENHANCES HIV-1 INFECTIVITY IN MONOCYTE DERIVED
DENDRITIC CELLS
MPN Nair, ZM Saiyed, N Nair, N Gandhi, JW Rodriguez, N Boukli, E Provencio-Vasquez,
RM Malow & MJ Miguez-Burbano
The US is currently experiencing an epidemic of methamphetamine (Meth) use as a
recreational drug. Recent studies also show a high prevalence of HIV-1 infection among Meth
users. We report that Meth enhances HIV-1 infectivity of dendritic cells as measured by
multinuclear activation of a galactosidase indicator (MAGI) cell assay, p24 assay, and LTRRU5 amplification. Meth induces increased HIV-1 infection in association with an increase in
the HIV-1 coreceptors, CXCR4 and CCR5, and infection is mediated by downregulation of
extracellular-regulated kinase (ERK2) and the upregulation of p38 mitogen-activated protein
kinase (MAPK). A p38 inhibitor (SB203580) specifically reversed the Meth-induced
upregulation of the CCR5 HIV-1 coreceptor. The dopamine D2 receptor antagonist RS +/sulpiride significantly reversed the Meth-induced upregulation of CCR5, demonstrating that the
Meth-induced effect is mediated via the D2 receptor. These studies report for the first time that
Meth fosters HIV-1 infection, potentially via upregulating coreceptor gene expression. Further,
Meth mediates its regulatory effects via dopamine receptors and via downregulating ERK2 with
a reciprocal upregulation of p38 MAPK. Elucidation of the role of Meth in HIV-1 disease
susceptibility and the mechanism through which Meth mediates its effects on HIV-1 infection
may help to devise novel therapeutic strategies against HIV-1 infection in high-risk Meth-using
HIV-1-infected subjects.
International Journal of Drug Policy, In Press
METH/AMPHETAMINE USE AND ASSOCIATED HIV: IMPLICATIONS FOR
GLOBAL POLICY AND PUBLIC HEALTH
L Degenhardt, B Mathers, M Guarinieri, S Panda, B Phillips, SA Strathdee, M Tyndall, L
Wiessing, A Wodak, J Howard and the Reference Group to the United Nations on HIV and
injecting drug use
17
Abstracts for the Field: February 11, 2010
Amphetamine type stimulants (ATS) have become the focus of increasing attention worldwide.
There are understandable concerns over potential harms including the transmission of HIV.
However, there have been no previous global reviews of the extent to which these drugs are
injected or levels of HIV among users. A comprehensive search of the international peerreviewed and grey literature was undertaken. Multiple electronic databases were searched and
documents and datasets were provided by UN agencies and key experts from around the
world in response to requests for information on the epidemiology of use. Amphetamine or
methamphetamine (meth/amphetamine, M/A) use was documented in 110 countries, and
injection in 60 of those. Use may be more prevalent in East and South East Asia, North
America, South Africa, New Zealand, Australia and a number of European countries. In
countries where the crystalline form is available, evidence suggests users are more likely to
smoke or inject the drug; in such countries, higher levels of dependence may be occurring.
Equivocal evidence exists as to whether people who inject M/A are at differing risk of HIV
infection than other drug injectors; few countries document HIV prevalence/incidence among
M/A injectors. High risk sexual behaviour among M/A users may contribute to increased risk of
HIV infection, but available evidence is not sufficient to determine if the association is causal. A
range of possible responses to M/A use and harm are discussed, ranging from supply and
precursor control, to demand and harm reduction. Evidence suggests that complex issues
surround M/A, requiring novel and sophisticated approaches, which have not yet been met
with sufficient investment of time or resources to address them. Significant levels of M/A in
many countries require a response to reduce harms that in many cases remain poorly
understood. More active models of engagement with M/A users and provision of services that
meet their specific needs are required.
NON-INJECTION DRUG USE
Current Opinion in HIV & AIDS. 4(4):314-318, July 2009.
HIV, ALCOHOL, AND NON-INJECTION DRUG USE
Van Tieu H & Koblin BA
Purpose of review: Alcohol and noninjection drug use has been shown to be associated with
increased risk of HIV infection in select populations. In this review, we discuss recent data on
the prevalence of alcohol and noninjection drug use and the relationship to HIV acquisition and
transmission risk.
Recent findings: A strong association between alcohol use and HIV-infection risk has been
demonstrated in multiple studies conducted in sub-Saharan Africa. Among men who have sex
with men in the USA as well as other countries, substance use is highly prevalent and has
been associated with high-risk sexual behavior. Substance use, mental health problems, and
sexual risk behaviors conjoin in what is known as a syndemic to increase HIV risk among
young men who have sex with men. Only a limited number of intervention studies provide
promising results in reducing HIV-infection risk among substance users.
Summary: Alcohol and noninjection drug use is prevalent in certain populations. There is a
strong association between use of alcohol and noninjecting substances, including
methamphetamines, amyl nitrates, cocaine, and other drugs, and HIV-infection risk. This
18
Abstracts for the Field: February 11, 2010
underscores the need for a comprehensive HIV prevention strategy that addresses substance
use, including screening and behavioral intervention, among those at risk.
RISK REDUCTION
Int J Drug Policy. 2009 Dec 15. [Epub ahead of print]
LEARNING FROM HIV EPIDEMICS AMONG INJECTING DRUG USERS
Des Jarlais Don, C.
HIV/AIDS was the defining issue for international harm reduction during its first twenty years.
This issue was marked by strong contrasts: rapid HIV transmission in some populations of
injecting drug users, and close to elimination of HIV in other populations; a formidable research
base for designing effective HIV programmes and persistent political problems in implementing
evidence-based programmes on a public health scale. Elevated rates of HIV infection among
ethnic minority drug users have occurred in many different countries. We do not yet have
systematic knowledge of how to reduce stigmatization of AIDS or people who use drugs.
Nevertheless, international harm reduction for people who use drugs has moved beyond
HIV/AIDS to a variety of other health and social problems, while retaining firm bases in science
and human rights.
J Acquir Immune Defic Syndr. 2009 Dec;52 Suppl 2:S132-42.
ESTIMATING THE LEVEL OF HIV PREVENTION COVERAGE, KNOWLEDGE AND
PROTECTIVE BEHAVIOR AMONG INJECTING DRUG USERS: WHAT DOES THE
2008 UNGASS REPORTING ROUND TELL US?
Mathers BM, Degenhardt L, Adam P, Toskin I, Nashkhoev M, Lyerla R, Rugg D.
OBJECTIVES: The 2001 Declaration of Commitment from the United Nations General
Assembly Special Session on HIV/AIDS (UNGASS) set the prevention of HIV infection among
injecting drug users (IDUs) as an important priority in the global fight against HIV/AIDS. This
article examines data gathered to monitor the fulfillment of this commitment in low-income and
middle-income countries (LMICs) where resources to develop an effective response to HIV are
limited and where injecting drug use is reported to occur in 99 (of 147) countries, home to 75%
of the estimated 15.9 million global IDU population. METHODS: Data relating to injecting drug
use submitted by LMICs to the Joint United Nations Programme on HIV/AIDS (UNAIDS) in the
2008 reporting round for monitoring the Declaration of Commitment on HIV/AIDS were
reviewed. The quality of the data reported was assessed and country data were aggregated
and compared to determine progress in HIV prevention efforts. For each indicator, the mean
value weighted for the size of each country's IDU population was determined; regional
estimates were also made. RESULTS: Reporting was inconsistent between countries. Forty
percent of LMIC (40/99), where injecting occurs, reported data for 1 or more of the 5 indicators
19
Abstracts for the Field: February 11, 2010
pertinent to HIV prevention among IDUs. Many of the data reported were excluded from this
analysis because the indicators used by countries were not consistent with those defined by
UNAIDS Monitoring and Evaluation Reference Group and could not be compared. Data from
32 of 99 countries met our inclusion criteria. These 32 countries account for approximately
two-thirds (68%) of the total estimated IDU population in all LMICs.The IDU population
weighted means are as follows: 36% of IDUs tested for HIV in the last year; 26% of IDUs
reached with HIV prevention programs in the last year; 45% of IDUs with correct HIV
prevention knowledge; 37% of IDUs used a condom at last sexual intercourse; and 63% of
IDUs used a clean syringe at last injection. Marked variance was observed in the data reported
between different regions. CONCLUSIONS: Data from the 2008 United Nations General
Assembly Special Session reporting round provide a baseline against which future progress
might be measured. The data indicate a wide variation in HIV service coverage for IDUs and a
wide divergence in HIV knowledge and risk behaviors among IDUs in different countries.
Countries should be encouraged and assisted in monitoring and reporting on HIV prevention
for IDUs.
AIDS Behav. 2010 Jan 23. [Epub ahead of print]
SOCIAL-LEVEL CORRELATES OF SHOOTING GALLERY ATTENDANCE: A
FOCUS ON NETWORKS AND NORMS
Tobin KE, Davey-Rothwell M, Latkin CA.
The purpose of this study was to examine the association between social network
characteristics and peer norms related to sharing needles and shooting gallery use.
Multivariate logistic regression modeling was used to identify factors that were independently
associated with shooting gallery use among a sample of injection drug users recruited in
Baltimore, Maryland. Of 842 study participants, 35% reported attending a shooting gallery in
the past 6 months. Social networks of shooting gallery users were larger, had a greater
number of injectors and crack smokers, were younger and less dense with fewer kin members
compared to networks of non-gallery attenders. A greater proportion of those who used a
gallery perceived that their peers shared needles and that peers would not disapprove if they
used a dirty needle. Future research is needed to understand how social networks and peer
norms are specific to behavioral settings and how this may impede adoption of preventive
behaviors.
SYRINGE ACCESS
Med Sci Monit. 2010 Jan;16(1):PH1-13.
FEDERAL FUNDING FOR NEEDLE EXCHANGE PROGRAMS
Clark PA, Fadus M.
20
Abstracts for the Field: February 11, 2010
The HIV/AIDS pandemic has affected millions across the globe. The sharing of needles, for
reasons of economy or social relations, has become the most common mode of HIV
transmission among injection drug users. Needle exchange programs, which provide many
services in addition to the exchange of clean needles for contaminated needles, have proven
effective in reducing HIV rates among injection drug users in their communities. Although
these programs have proven to be one of the most effective strategies in the efforts to reduce
HIV rates, there has been a federal ban on the use of federal money for needle exchange
programs since 1989. This ban was introduced by Congress in accordance with the drug war
ideology, a narrow and elusive plan to completely eradicate drug use in the United States.
Although there are a significant number of government reports supporting needle exchange
programs, including support from the CDC, American Medical Association, the National
Institutes of Health, it appears as If public health and the lives of others have become a
secondary concern to strong federal policy on eradicating drug use. Lifting the federal ban
would save the country millions of lives and billions of dollars in healthcare costs. Needle
exchange programs should be an integral part of HIV prevention strategy, and are ethically
imperative as well, restoring human dignity to the clients that so often need it.<
Journal of Urban Health, Nov. 2009, Vol. 86, 6, p. 929 - 945
TEMPORAL TRENDS IN SPATIAL ACCESS TO PHARMACIES THAT SELL
OVER-THE-COUNTER SYRINGES IN NEW YORK CITY HEALTH DISTRICTS:
RELATIONSHIP TO LOCAL RACIAL/ETHNIC COMPOSITION AND NEED
HLF Cooper, BH Bossak, B Tempalski, SR Friedman & DC Des Jarlais
Pharmacies that sell over-the-counter (OTC) syringes are a major source of sterile syringes for
injection drug users in cities and states where such sales are legal. In these cities and states,
however, black injectors are markedly less likely to acquire syringes from pharmacies than
white injectors. The present analysis documents spatial and temporal trends in OTC pharmacy
access in New York City health districts over time (2001–2006) and investigates whether these
trends are related to district racial/ethnic composition and to local need for OTC pharmacies.
For each year of the study period, we used kernel density estimation methods to characterize
spatial access to OTC pharmacies within each health district. Higher values on this measure
indicate better access to these pharmacies. “Need” was operationalized using two different
measures: the number of newly diagnosed injection-related AIDS cases per 10,000 residents
(averaged across 1999–2001), and the number of drug-related hospital discharges per 10,000
residents (averaged across 1999–2001). District sociodemographic characteristics were
assessed using 2000 US decennial census data. We used hierarchical linear models (HLM) for
descriptive and inferential analyses and investigated whether the relationship between need
and temporal trajectories in the Expanded Syringe Access Demonstration Program access
varied by district racial/ethnic composition, controlling for district poverty rates. HLM analyses
indicate that the mean spatial access to OTC pharmacies across New York City health districts
was 12.71 in 2001 and increased linearly by 1.32 units annually thereafter. Temporal
trajectories in spatial access to OTC pharmacies depended on both need and racial/ethnic
21
Abstracts for the Field: February 11, 2010
composition. Within high-need districts, OTC pharmacy access was twice as high in 2001 and
increased three times faster annually, in districts with higher proportions of non-Hispanic white
residents than in districts with low proportions of these residents. In low-need districts, “whiter”
districts had substantially greater baseline access to OTC pharmacies than districts with low
proportions of non-Hispanic white residents. Access remained stable thereafter in low-need
districts, regardless of racial/ethnic composition. Conclusions were consistent across both
measures of “need” and persisted after controlling for local poverty rates. In both high- and
low-need districts, spatial access to OTC pharmacies was greater in “Whiter” districts in 2001;
in high-need districts, access also increased more rapidly over time in “whiter” districts.
Ensuring equitable spatial access to OTC pharmacies may reduce injection-related HIV
transmission overall and reduce racial/ethnic disparities in HIV incidence among injectors.
Journal of Urban Health, Nov. 2009, Vol. 86, 6, p. 946 - 950
WHO PURCHASES NONPRESCRIPTION SYRINGES? CHARACTERIZING
CUSTOMERS OF THE EXPANDED SYRINGE ACCESS PROGRAM (ESAP)
HB Battles, KA Rowe, C Ortega-Peluso, SJ Klein
This study represents the first attempt in the USA to survey pharmacy nonprescription syringe
customers at their point of purchase. We surveyed 62 individuals purchasing nonprescription
syringes in seven pharmacies located in NYC and Albany, NY, USA. Three quarters of
respondents purchased for illicit use, and 36% purchased for medical use, with differences
found by race and gender. Half got their syringes from pharmacies “most of the time.” Half had
ever been refused a syringe purchase in a NYS pharmacy, with men, Blacks, and Hispanics
reporting higher levels of refusals than women or whites. Two thirds reported syringe reuse but
very few reported sharing. While approximately one quarter safely obtained and disposed of
syringes “most of the time,” two thirds used both safe and unsafe methods. Pharmacy-based
syringe access programs are essential in areas not served by syringe exchanges.
Int J Drug Policy. 2010 Jan 21. [Epub ahead of print]
RACIAL DIFFERENCES IN ACQUISITION OF SYRINGES FROM PHARMACIES
UNDER CONDITIONS OF LEGAL BUT RESTRICTED SALES
Costenbader EC, Zule WA, Coomes CC.
BACKGROUND: Injecting drug users (IDUs) are at increased risk of acquiring and transmitting
HIV and other bloodborne pathogens through the multi-person use of syringes. Although
research has shown that increased access to syringes through syringe exchange programs
(SEPs) is an effective strategy to reduce risky injection practices many areas of the United
States still do not have SEPs. In the absence of SEPs, legislation allowing pharmacies overthe-counter sales of syringes has also been shown to reduce syringe sharing. The success of
22
Abstracts for the Field: February 11, 2010
pharmacy sales however is limited by other legal stipulations, such as drug paraphernalia
laws, which in turn may contribute to fear among IDUs about being caught purchasing and
carrying syringes. METHODS: Between 2003 and 2006, 851 out-of-treatment IDUs were
recruited using street outreach in the Raleigh-Durham (North Carolina) area. Data were
collected using audio-computer assisted interview (ACASI) technology. Multiple logistic
regression analyses were performed to assess factors associated with purchasing syringes
from pharmacies. RESULTS: In our study sample, African-American IDUs were one-fifth as
likely as white IDUs to report pharmacies as their primary source of syringes. CONCLUSIONS:
Given the absence of syringe exchange programs and the relatively high prevalence of HCV
and HIV among IDUs in the Raleigh-Durham area, the limited use of pharmacies as a source
of syringes among African-American IDUs in this study sample is problematic. The study
findings support the need for effective multilevel interventions to increase access to clean
needles in this population, as well as for policy interventions, such as legalization of SEPs and
elimination of penalties for carrying syringes, to reduce harm and eliminate the health threats
posed by receptive syringe sharing.
AFRICA
Int J Drug Policy. 2009 Dec 24. [Epub ahead of print]
OPPORTUNITIES FOR ENHANCING AND INTEGRATING HIV AND DRUG
SERVICES FOR DRUG USING VULNERABLE POPULATIONS IN SOUTH AFRICA
Parry CD, Petersen P, Carney T, Needle R
BACKGROUND: Little has been done to improve the integration of drug use and HIV services
in sub-Saharan Africa where substance use and HIV epidemics often co-exist. METHODS:
Data were collected using rapid assessment methods in two phases in Cape Town, Durban
and Pretoria, South Africa. Phase I (2005) comprised 140 key informant and focus group drug
using interviewees and 19 service providers (SPs), and Phase 2 (2007) comprised 69 drug
using focus group interviewees and 11 SPs. RESULTS: Drug users put themselves at risk for
HIV transmission through various drug-related sexual practices as well as through needle
sharing. Drug users in both phases had limited knowledge of the availability of drug treatment
services, and those that had accessed treatment identified a number of barriers, including
affordability, stigma and a lack of aftercare and reintegration services. SPs identified similar
barriers. Drug users displayed a general awareness of both HIV transmission routes and
prevention strategies, but the findings also indicated a number of misperceptions, and
problematic access to materials such as condoms and safe injection equipment. Knowledge
around HIV treatment was low, and VCT experiences were mixed. SPs recognized the
importance of integrating HIV and substance use services, but barriers such as funding issues,
networking/referral gaps and additional burden on staff were reported in Phase 2.
CONCLUSION: A comprehensive, accessible, multi-component intervention strategy to
prevent HIV risk in drug users needs to be developed including community outreach, risk
reduction counselling, VCT and substance use treatment.
23
Abstracts for the Field: February 11, 2010
AIDS Educ Prev. 2009 Oct;21(5):474-83.
HIV SEROPREVALENCE IN A SAMPLE OF TANZANIAN INTRAVENOUS DRUG
USERS
Williams ML, McCurdy SA, Bowen AM, Kilonzo GP, Atkinson JS, Ross MW, Leshabari MT
Injection drug use has recently emerged in sub-Saharan Africa. The purpose of this study was
to assess the factors associated with increased risk of testing HIV-positive in a sample of
injection drug users (IDUs) in Dar es Salaam, Tanzania. Participants were recruited by a
trained outreach worker or were referred by IDUs who had completed the study. Blood
specimens and self-reported socioeconomic and behavioral data were collected from 315 male
and 219 female IDUs. Data were analyzed using univariate odds ratios and multivariate logistic
regression modeling. Forty-two percent of the sample tested HIV-positive. Several
socioeconomic, injection, and sexual factors were found to be associated with increased odds
of testing HIV-positive. Multivariate analysis showed that having had sex more than 81 times in
past 30 days, earning less than 100,000 shillings (US$76) in the past month, residency in Dar
es Salaam for less than 5 years, and injecting for 3 years were independently associated with
the greatest risk of infection. The rate of HIV infection in this sample of IDUs was found to be
very high, suggesting that injection drug use may be a factor in the continuing epidemic in subSaharan Africa. The factors associated with increased risk of HIV infection suggest further
research is needed on the needle use and sexual networks of IDUs.
CHINA
AIDS Care. 2009 Jul;21(7):909-17.
COMPARING PREVALENCE OF HIV-RELATED BEHAVIORS AMONG FEMALE
INJECTING DRUG USERS (IDU) WHOSE REGULAR SEXUAL PARTNER WAS OR
WAS NOT IDU IN SICHUAN AND YUNNAN PROVINCES, CHINA
Lau JT, Gu J, Zhang L, Cheng F, Zhang Y, Zhang J, Wang N, Lan Y.
Injecting drug users made up a high percentage of HIV cases in China; partners of IDU are
hence, at very high risk of HIV transmission. The goal of this study is to compare
characteristics and prevalence of injecting drug use and sex-related risk behaviors among
female IDU who were or were not having a regular sex partner (RSP) with concordant IDU
status. Data were obtained from all female IDU respondents (n=1414) surveyed in the
behavioral surveillance surveys as conducted during 2003 through 2006 in Sichuan and
Yunnan, China. The findings from this research reveal that about half of the female IDU
respondents belonged to the concordant group (50.4%). As compared to members of the
discordant group, such concordant respondents were significantly more likely to have practiced
different types of studied syringe sharing behaviors (adjusted odds ratios AOR=1.34-2.23,
24
Abstracts for the Field: February 11, 2010
p<0.05), to have served as female sex workers in the last month (AOR=1.24, p<0.05), or to
have used some particular types of HIV-related prevention services (AOR=1.36-1.60, p<0.05)
but were less likely to be always using new needles for drug injection in the last month
(AOR=0.54, p<0.05) or to have used a condom in the last episode of sex with their RSP
(AOR=0.64, p<0.01). The findings suggest that concordant IDU status is very common among
RSP of IDU. The risk for HIV transmission between concordant RSP seems to be very high
and the prevention services seem unable to alleviate the risk. Specific programs targeting
concordant IDU couples are greatly warranted.
AIDS Patient Care STDS. 2009 Oct;23(10):877-84.
CONSEQUENCES OF DRUG ABUSE AND HIV/AIDS IN CHINA:
RECOMMENDATIONS FOR INTEGRATED CARE OF HIV-INFECTED DRUG
USERS
Li X, He G, Wang H, Williams AB
Drug abuse is a complicated social phenomenon rather than a neural disease. It especially
fuels the HIV/AIDS epidemic. Researchers have shown interest in HIV-infected drug users as
the socially and medically marginalized population, but they did not provide good enough care.
Based on published English and Chinese journal articles and official reports, this integrated
literature review summarizes the epidemic of drug abuse and HIV/AIDS, and comments on the
clinical and psychosocial consequences, and harm reduction measures in China. Officially
registered drug users have reached more than 1 million recently. A little under half of the
people living with HIV/AIDS are injection drug users, as they transmit the disease through
needle sharing and unprotected sexual behavior. The main consequences of drug abuse and
HIV/AIDS included high prevalence of hepatitis viruses and tuberculosis co-infections, severe
mental problems and extreme poverty. Even health professionals hold discriminative attitude
toward drug users because of condemnation of drug abuse behavior and fear of HIV infection.
Although interventions for drug addiction and harm reduction have been scaled up quickly,
such as methadone maintenance treatment and needle syringe programs, the measures
should be further revised, and the effectiveness needs to be evaluated appropriately. To
enhance HIV-infected drug users' quality of life and the utility of medical services, improving
health care providers' attitude is the first step. Then securing good quality of integrated medical
care services with multidisciplinary cooperation will be essential.
ESTONIA
Journal of Urban Health, Nov. 2009, Vol. 86, 6, p. 918 – 928
SHOULD PHARMACISTS HAVE A ROLE IN HARM REDUCTION SERVICES FOR
IDUS? A QUALITATIVE STUDY IN TALLINN, ESTONIA
25
Abstracts for the Field: February 11, 2010
Sigrid Vorobjov, Anneli Uusküla, Katri Abel-Ollo, Ave Talu & Don Des Jarlais
Despite the high number of injecting drug users (IDUs) in Estonia, little is known about
involving pharmacies into human immunodeficiency virus (HIV) prevention activities and
potential barriers. Similarly, in other Eastern European countries, there is a need for additional
sources for clean syringes besides syringe exchange programmes (SEPs), but data on current
practices relating to pharmacists’ role in harm reduction strategies is scant. Involving
pharmacies is especially important for several reasons: they have extended hours of operation
and convenient locations compared to SEPs, may provide access for IDUs who have avoided
SEPs, and are a trusted health resource in the community. We conducted a series of focus
groups with pharmacists and IDUs in Tallinn, Estonia, to explore their attitudes toward the role
of pharmacists in HIV prevention activities for IDUs. Many, but not all, pharmacists reported a
readiness to sell syringes to IDUs to help prevent HIV transmission. However, negative
attitudes toward IDUs in general and syringe sales to them specifically were identified as
important factors restricting such sales. The idea of free distribution of clean syringes or other
injecting equipment and disposal of used syringes in pharmacies elicited strong resistance.
IDUs stated that pharmacies were convenient for acquiring syringes due to their extended
opening hours and local distribution. IDUs were positive toward pharmacies, although they
were aware of stigma from pharmacists and other customers. They also emphasized the need
for distilled water and other injection paraphernalia. In conclusion, there are no formal or
legislative obstacles for providing HIV prevention services for IDUs at pharmacies. Addressing
negative attitudes through educational courses and involving pharmacists willing to be public
health educators in high drug use areas would improve access for HIV prevention services for
IDUs.
J Urban Health. 2010 Feb 4. [Epub ahead of print]
EVALUATING RECRUITMENT AMONG FEMALE SEX WORKERS AND
INJECTING DRUG USERS AT RISK FOR HIV USING RESPONDENT-DRIVEN
SAMPLING IN ESTONIA
Uusküla A, Johnston LG, Raag M, Trummal A, Talu A, Des Jarlais DC.
Few recent publications have highlighted theoretical and methodological challenges using
respondent-driven sampling (RDS). To explore why recruitment with RDS may work in some
populations and not in others, we assess the implementation of RDS to recruit female sex
workers (FSWs) and injection drug users (IDUs) into a human immunodeficiency virus
biological and risk behavior survey in Tallinn, Estonia. Recruitment of FSWs was slower and
more challenging than that of IDUs. The IDU study recruited 350 participants within 7 weeks,
while the FSW study recruited 227 participants over 28 weeks. Implementation modifications
that did not negatively impact key RDS theoretical and methodological requirements were
used to improve recruitment during the FSW study. We recommend that all RDS studies
include a formative research process to involve the participation of target populations and key
persons associated with these populations in the study planning and throughout the
26
Abstracts for the Field: February 11, 2010
implementation processes to improve recruitment from the outset and to respond to poor
recruitment during data collection.
Ann Epidemiol. 2010 Feb;20(2):159-167.
EVALUATING RESPONDENT-DRIVEN SAMPLING IN A MAJOR
METROPOLITAN AREA: COMPARING INJECTION DRUG USERS IN THE 2005
SEATTLE AREA NATIONAL HIV BEHAVIORAL SURVEILLANCE SYSTEM
SURVEY WITH PARTICIPANTS IN THE RAVEN AND KIWI STUDIES
Burt RD, Hagan H, Sabin K, Thiede H.
PURPOSE: To empirically evaluate respondent-driven sampling (RDS) recruitment methods,
which have been proposed as an advantageous means of surveying hidden populations.
METHODS: The National HIV Behavioral Surveillance system used RDS to recruit 370
injection drug users (IDU) in the Seattle area in 2005 (NHBS-IDU1). We compared the NHBSIDU1 estimates of participants' area of residence, age, race, sex, and drug most frequently
injected to corresponding data from two previous surveys, the RAVEN and Kiwi Studies, and to
persons newly diagnosed with HIV/AIDS and reported from 2001 through 2005. RESULTS:
The NHBS-IDU1 population was estimated to be more likely to reside in downtown Seattle
(52%) than participants in the other data sources (22%-25%), be older than 50 years of age
(29% vs. 5%-10%), and report multiple races (12% vs. 3%-5%). The NHBS-IDU1 population
resembled persons using the downtown needle exchange in age and race distribution. An
examination of cross-group recruitment frequencies in NHBS-IDU1 suggested barriers to
recruitment across different areas of residence, races, and drugs most frequently injected.
CONCLUSIONS: The substantial differences in age and area of residence between NHBSIDU1 and the other data sources suggest that RDS may not have accessed the full universe of
Seattle area injection networks. Further empirical data are needed to guide the evaluation of
RDS-generated samples.
AIDS Care. 2009 Jul;21(7):851-7.
KNOWLEDGE OF HIV SEROSTATUS AND RISK BEHAVIOUR AMONG
INJECTING DRUG USERS IN ESTONIA
Abel-Ollo K, Rahu M, Rajaleid K, Talu A, Ruutel K, Platt L, Bobrova N, Rhodes T, Uuskula A.
We used the findings from two, cross-sectional studies of HIV serostatus and risk behaviours
to assess the effects of knowledge of HIV serostatus and risk behaviours (relating to sex and
injection drug use) among injecting drug users (IDUs). Respondent-driven sampling was used
simultaneously at two sites in Estonia (the capital Tallinn, and the second-largest city of IdaVirumaa County, Kohtla-Jarve). The research tool was an interviewer-administered survey.
27
Abstracts for the Field: February 11, 2010
Biological samples were collected for HIV testing. Participants were categorised into three
groups based on HIV testing results and self-report on HIV serostatus: HIV-negative (n=133);
HIV-positive unaware of their serostatus (n=75); and HIV-positive aware of their serostatus
(n=168). In total, 65% of the participants tested positive for HIV. Of those 69% were aware of
their positive serostatus. HIV-positive IDUs aware of their serostatus exhibited more risk
behaviours than their HIV-positive counterparts unaware of their serostatus or HIV-negative
IDUs. Effective prevention of HIV among IDUs should therefore, include programmes to
reduce high-risk sexual and drug use behaviours at the public health scale and enhanced
prevention efforts focusing on HIV-infected individuals.
J Urban Health. 2009 Nov;86(6):918-28. Epub 2009 Nov 18.
SHOULD PHARMACISTS HAVE A ROLE IN HARM REDUCTION SERVICES FOR
IDUS? A QUALITATIVE STUDY IN TALLINN, ESTONIA
Vorobjov S, Uusküla A, Abel-Ollo K, Talu A, Jarlais DD.
Despite the high number of injecting drug users (IDUs) in Estonia, little is known about
involving pharmacies into human immunodeficiency virus (HIV) prevention activities and
potential barriers. Similarly, in other Eastern European countries, there is a need for additional
sources for clean syringes besides syringe exchange programmes (SEPs), but data on current
practices relating to pharmacists' role in harm reduction strategies is scant. Involving
pharmacies is especially important for several reasons: they have extended hours of operation
and convenient locations compared to SEPs, may provide access for IDUs who have avoided
SEPs, and are a trusted health resource in the community. We conducted a series of focus
groups with pharmacists and IDUs in Tallinn, Estonia, to explore their attitudes toward the role
of pharmacists in HIV prevention activities for IDUs. Many, but not all, pharmacists reported a
readiness to sell syringes to IDUs to help prevent HIV transmission. However, negative
attitudes toward IDUs in general and syringe sales to them specifically were identified as
important factors restricting such sales. The idea of free distribution of clean syringes or other
injecting equipment and disposal of used syringes in pharmacies elicited strong resistance.
IDUs stated that pharmacies were convenient for acquiring syringes due to their extended
opening hours and local distribution. IDUs were positive toward pharmacies, although they
were aware of stigma from pharmacists and other customers. They also emphasized the need
for distilled water and other injection paraphernalia. In conclusion, there are no formal or
legislative obstacles for providing HIV prevention services for IDUs at pharmacies. Addressing
negative attitudes through educational courses and involving pharmacists willing to be public
health educators in high drug use areas would improve access for HIV prevention services for
IDUs.
28
Abstracts for the Field: February 11, 2010
INDIA
AIDS Care. 2009 Nov;21(11):1420-4.
THE RISK OF HIV AND HCV INFECTIONS AMONG INJECTION DRUG USERS IN
NORTHEAST INDIA
Mahanta J, Borkakoty B, Das HK, Chelleng PK.
Injection drug users (IDUs) and their associated risk behavior are responsible for driving the
human immunodeficiency virus (HIV) epidemic in northeast India. So a group of IDUs from two
northeastern states (Mizoram and Nagaland) of India were studied to find the prevalence of
HIV, co-infection with hepatitis C virus (HCV), hepatitis B virus (HBV), and associated risk
behaviors. Out of the 400 IDUs enrolled, 398 consented for HIV, HCV, and hepatitis B surface
antigen (HbsAg) test. Of them, 10.8% were HIV-1 antibody positive, 47.8% had HCV antibody,
and 3.8% had detectable HBsAg. Among the HIV infected subjects, 79.1% were co-infected
with HCV and 6.9% had triple infection. Heroin users showed a higher association with HIV
(OR = 7.3, 95% CI: 2.5-21.5, p=0.0003) and HCV infection (OR = 7.6, 95% CI: 3.5-16.6,
p<0.0001) than Spasmo-proxyvon (dextropropoxyphene, a synthetic opiod analgesic). In
summary, apart from the known risk variables among IDUs, type of injecting drugs also
influences the HIV/HCV transmission pattern among the IDUs.
IRAN
Journal of Urban Health, Nov. 2009, Vol. 86, 6, p. 902 - 908
PREVALENCE AND CORRELATES OF HEPATITIS C INFECTION AMONG MALE
INJECTION DRUG USERS IN DETENTION, TEHRAN, IRAN
P Kheirandish, S Ahmad, S Alinaghi, MR Jahani, H Shirzad, M Reza, S Ahmadian, A Majidi,
AH Sharifi, M Hosseini, M Mohraz & W McFarland
For the benefit of planning for the future care and treatment of people infected with hepatitis C
virus (HCV) and to help guide prevention and control programs, data are needed on HCV
seroprevalence and associated risk factors. We conducted a cross-sectional sero-behavioral
survey of injection drug users (IDU) detained for mandatory rehabilitation during a police
sweep of Tehran, Iran, in early 2006. During the study period, a consecutive sample
comprising 454 of 499 (91.0%) men arrested and determined to be IDU by urine test and
physical examination consented to a face-to-face interview and blood collection for HCV
antibody testing. Overall, HCV prevalence was 80.0% (95% confidence interval (CI) 76.2–
83.6). Factors independently associated with HCV infection included history of incarceration
(adjusted OR 4.35, 95% CI 1.88–10.08), age of first injection ≤25 years (OR 2.72, 95% CI
1.09–6.82), and history of tattooing (OR 2.33, 95% CI 1.05–5.17). HCV prevalence in this
population of IDU upon intake to jail was extremely high and possibly approaching saturation.
29
Abstracts for the Field: February 11, 2010
Findings support that incarceration is contributing to the increased spread of HCV infection in
Iran and calls for urgent increased availability of HCV treatment, long-term preparation for the
care of complications of chronic infection, and rapid scale-up of programs for the primary
prevention of parenterally transmitted infections among drug users.
PAKISTAN
World J Gastroenterol. 2009 Dec 7;15(45):5647-53.
HEPATITIS C VIRUS IN PAKISTAN: A SYSTEMATIC REVIEW OF PREVALENCE,
GENOTYPES AND RISK FACTORS
Waheed Y, Shafi T, Safi SZ, Qadri I.
In Pakistan more than 10 million people are living with Hepatitis C virus (HCV), with high
morbidity and mortality. This article reviews the prevalence, genotypes and factors associated
with HCV infection in the Pakistani population. A literature search was performed by using the
keywords; HCV prevalence, genotypes and risk factors in a Pakistani population, in Pubmed,
PakMediNet and Google scholar. Ninety-one different studies dating from 1994 to May 2009
were included in this study, and weighted mean and standard error of each population group
was calculated. Percentage prevalence of HCV was 4.95% +/- 0.53% in the general adult
population, 1.72% +/- 0.24% in the pediatric population and 3.64% +/- 0.31% in a young
population applying for recruitment, whereas a very high 57% +/- 17.7% prevalence was
observed in injecting drug users and 48.67% +/- 1.75% in a multi-transfused population. Most
prevalent genotype of HCV was 3a. HCV prevalence was moderate in the general population
but very high in injecting drug users and multi-transfused populations. This data suggests that
the major contributing factors towards increased HCV prevalence include unchecked blood
transfusions and reuse of injection syringes. Awareness programs are required to decrease
the future burden of HCV in the Pakistani population.
BMC Infect Dis. 2010 Jan 12;10(1):7. [Epub ahead of print]
EVIDENCE FOR A "FOUNDER EFFECT" AMONG HIV-INFECTED INJECTION
DRUG USERS (IDUS) IN PAKISTAN
Rai MA, Nerurkar VR, Khoja S, Khan S, Yanagihara R, Rehman A, Kazmi SU, Ali SH.
BACKGROUND: We have previously reported a HIV-1 subtype A infection in a community of
injection drug users (IDUs) in Karachi, Pakistan. We now show that this infection among the
IDUs may have originated from a single source. METHOD: S: Phylogenetic analysis was
performed of partial gag sequences, generated using PCR, from 26 HIV-positive IDU samples.
RESULTS: : Our results showed formation of a tight monophyletic group with an intrasequence identity of < 98% indicating a "founder effect". Our data indicate that the HIV-1
epidemic in this community of IDUs may have been transmitted by an HIV positive overseas
30
Abstracts for the Field: February 11, 2010
contract worker who admitted to having contact with commercial sex workers during stay
abroad. CONCLUSION: Specific measures need to implemented to control transmission of
HIV infection in Pakistan through infected migrant workers.
RUSSIA
AIDS and Behavior. 2010, Vol. 14, 1, p. 141-51
INJECTING EQUIPMENT SHARING IN RUSSIAN DRUG INJECTING DYADS
Gyarmathy VA, Li N, Tobin KE, Hoffman IF, Sokolov N, Levchenko J, Batluk J, Kozlov AA,
Kozlov AP, Latkin CA.
In this study, we investigated how individual attributes, dyad characteristics and social network
characteristics may influence engaging in receptive syringe sharing, distributive syringe
sharing and sharing cookers in injecting partnerships of IDUs in St Petersburg, Russia. We
found that all three levels were associated with injecting equipment sharing, and that dyad
characteristics were modified by characteristics of the social network. Self-reported HIV
discordance and male gender concordance played a role in the risk of equipment sharing.
Dyad interventions may not be sufficient to reduce injecting risk in IDU partnerships, but a
combination of dyad and network interventions that target both IDU partnerships and the entire
IDU population may be more appropriate to address injecting risk among IDUs.
Drug Alcohol Depend. 2010 Jan 6. [Epub ahead of print]
ESTIMATION OF THE NUMBER OF INJECTION DRUG USERS IN ST.
PETERSBURG, RUSSIA
Heimer R, White E.
The conjoined epidemics of HIV and injection drug abuse have progressed rapidly in many
parts of the Russian Federation, including the City of St. Petersburg, which now has more
cases of HIV than any other region in the country. Official estimates of the number of injection
drug users (IDUs), which rely on official registration of IDUs, greatly underestimate their
number. We have combined official statistics that register HIV cases and attribute risk to
causes including injection drug use with data from a study that collected data from IDUs about
their HIV serostatus and their history of HIV testing to estimate the number of IDUs in the city.
We conclude that there are 83,118+/-5799 total IDUs. Since many IDUs have not been tested
and even some who have been officially tested do not know their serostatus, a first step in
countering the growing HIV epidemic among IDUs in St. Petersburg must be expanded access
to HIV testing, prevention, and treatment that is targeted to IDUs.
31
Abstracts for the Field: February 11, 2010
THAILAND
Int J Drug Policy. 2010 Jan 13. [Epub ahead of print]
Drug use and the risk of HIV infection amongst injection drug users participating in an HIV
vaccine trial in Bangkok, 1999-2003
Martin M, Vanichseni S, Suntharasamai P, Mock PA, van Griensven F, Pitisuttithum P,
Tappero JW, Chiamwongpaet S, Sangkum U, Kitayaporn D, Gurwith M, Choopanya K; for the
Bangkok Vaccine Evaluation Group
BACKGROUND: HIV spread rapidly amongst injecting drug users (IDUs) in Bangkok in the
late 1980s. In recent years, changes in the drugs injected by IDUs have been observed. We
examined data from an HIV vaccine trial conducted amongst IDUs in Bangkok during 19992003 to describe drug injection practices, drugs injected, and determine if drug use choices
altered the risk of incident HIV infection. METHODS: The AIDSVAX B/E HIV vaccine trial was
a randomized, double-blind, placebo-controlled trial. At enrolment and every 6 months
thereafter, HIV status and risk behaviour were assessed. A proportional hazards model was
used to evaluate demographic characteristics, incarceration, drug injection practices, sexual
activity, and drugs injected during follow-up as independent predictors of HIV infection.
RESULTS: The proportion of participants injecting drugs, sharing needles, and injecting daily
declined from baseline to month 36. Amongst participants who injected, the proportion injecting
heroin declined (98.6-91.9%), whilst the proportions injecting methamphetamine (16.2-19.6%)
and midazolam (9.9-31.9%) increased. HIV incidence was highest amongst participants
injecting methamphetamine, 7.1 (95% CI, 5.4-9.2) per 100 person years. Injecting heroin and
injecting methamphetamine were independently associated with incident HIV infection.
CONCLUSIONS: Amongst AIDSVAX B/E vaccine trial participants who injected drugs during
follow-up, the proportion injecting heroin declined whilst the proportion injecting
methamphetamine, midazolam, or combinations of these drugs increased. Controlling for
heroin use and other risk factors, participants injecting methamphetamine were more likely to
become HIV-infected than participants not injecting methamphetamine. Additional HIV
prevention tools are urgently needed including tools that address methamphetamine use.
VIETNAM
J Urban Health. 2009 Dec 30. [Epub ahead of print]
PREVALENCE AND INCIDENCE OF HCV INFECTION AMONG VIETNAM
HEROIN USERS WITH RECENT ONSET OF INJECTION
Clatts MC, Colón-López V, Giang LM, Goldsamt LA.
HCV infection continues to spread at an alarming rate among IDU populations. The available
evidence suggests that HCV is acquired relatively quickly following onset of injection.
However, there are few prospective studies of HCV acquisition, particularly among IDU
32
Abstracts for the Field: February 11, 2010
populations in resource-poor settings. A sample of young male heroin injectors with recent
onset of injection (<4 years) was recruited in Hanoi, Vietnam for a prospective assessment of
the early course of injection (n = 179). Both behavioral and biological assessments (including
detailed retrospective assessment of injection initiation) were conducted at baseline and
repeated at 6-month intervals for a period of 16 months. Variables associated with HCV
infection (p value < 0.05) in bivariate analyses were considered for inclusion in logistic
regression models to identify risk factors independently associated with HCV infection. HCV
incidence was calculated by using the incidence density approach and was expressed in terms
of person-years of observation. The baseline of prevalence of HCV was 46%. HCV
significantly increased in relation to time since first injection, from 30% in subjects with </=10
months of injection risk to 70% in subjects with >/=30 months injection risk (p value = 0.0005).
In multivariate logistic regression analysis, increasing age, incarceration in a drug detention
facility (OR = 2.54; 95%CI 1.05, 6.15), and time since first injection remained significantly
associated with HCV infection. Use of injection as primary mode of administration (OR = 2.56;
95%CI 0.98, 6.69) achieved marginal significance. After 16 months of follow-up, the incidence
rate of HCV was 23.35 per 100 person-years and the mean time between first injection and
first positive HCV test was 1.2 years. HCV is acquired much more rapidly among new injector
populations than previously recognized, demonstrating the need for early behavioral
intervention among new heroin-user populations. Particularly critical are interventions that
target new heroin user populations, including interventions that improve understanding of viral
transmission dynamics, that promote alternative strategies for drug sharing, and that delay
initiation of injection.
NEWS TO THE FIELD
US ENDS FUNDING BAN FOR NEEDLE EXCHANGES
San Francisco Chronicle
(12.18.09):: Bob Egelko
A 21-year ban on federal funding for needle-exchange programs (NEPs) came to an end with
the signing of an appropriations bill on Wednesday.
The repeal, part of a $163.5 billion labor, health, and education appropriations measure, does
not allocate federal funding for needle-exchange initiatives. However, it does make such
programs eligible for federal money for NEPs, subject to approval by local police and health
officials.
"Hundreds of thousands of Americans will not get HIV/AIDS or hepatitis C, thanks to Congress
repealing the federal syringe funding ban," said Bill Piper, spokesperson for the Drug Policy
Alliance.
The federal funding ban was sponsored by the late Sen. Jesse Helms (R-N.C.). Robert
Martinez, former Florida governor and drug czar under President George H.W. Bush, said
government funding of NEPs "undercuts the credibility of society's message that drug use is
illegal and morally wrong."
33
Abstracts for the Field: February 11, 2010
The campaign to free up federal funding for the programs argued that NEPs were effective in
reducing disease without increasing drug use itself. Twenty-nine cities with such programs saw
HIV infection rates drop by 5.8 percent, while 52 cities without them saw a 5.9 percent
increase, according to a 1997 international analysis.
During consideration of the bill, a House-Senate conference committee successfully removed
a provision that would have barred federal funding to any program operating within 1,000 feet
of a school, park, or day care center, effectively removing much if not all of large urban areas
from eligibility.
34