Challenges posed by COVID-19 to people who inject drugs and lessons from other outbreaks

INTRODUCTION

In light of the COVID-19 pandemic, considerable effort is going into identifying and protecting those at risk. Criminalization, stigmatization and the psychological, physical, behavioural and economic consequences of substance use make people who inject drugs (PWID) extremely vulnerable to many infectious diseases. While relationships between drug use and blood-borne and sexually transmitted infections are well studied, less attention has been paid to other infectious disease outbreaks among PWID.

DISCUSSION

COVID-19 is likely to disproportionally affect PWID due to a high prevalence of comorbidities that make the disease more severe, unsanitary and overcrowded living conditions, stigmatization, common incarceration, homelessness and difficulties in adhering to quarantine, social distancing or self-isolation mandates. The COVID-19 pandemic also jeopardizes essential for PWID services, such as needle exchange or substitution therapy programmes, which can be affected both in a short- and a long-term perspective. Importantly, there is substantial evidence of other infectious disease outbreaks in PWID that were associated with factors that enable COVID-19 transmission, such as poor hygiene, overcrowded living conditions and communal ways of using drugs.

CONCLUSIONS

The COVID-19 crisis might increase risks of homelessnes, overdoses and unsafe injecting and sexual practices for PWID. In order to address existing inequalities, consultations with PWID advocacy groups are vital when designing inclusive health response to the COVID-19 pandemic.

Phylodynamics Helps to Evaluate the Impact of an HIV Prevention Intervention

Assessment of the long-term population-level effects of HIV interventions is an ongoing public health challenge. Following the implementation of a Transmission Reduction Intervention Project (TRIP) in Odessa, Ukraine, in 2013-2016, we obtained HIV pol gene sequences and used phylogenetics to identify HIV transmission clusters. We further applied the birth-death skyline model to the sequences from Odessa (n = 275) and Kyiv (n = 92) in order to estimate changes in the epidemic's effective reproductive number (Re) and rate of becoming uninfectious (δ). We identified 12 transmission clusters in Odessa; phylogenetic clustering was correlated with younger age and higher average viral load at the time of sampling. Estimated Re were similar in Odessa and Kyiv before the initiation of TRIP; Re started to decline in 2013 and is now below Re = 1 in Odessa (Re = 0.4, 95%HPD 0.06-0.75), but not in Kyiv (Re = 2.3, 95%HPD 0.2-5.4). Similarly, estimates of δ increased in Odessa after the initiation of TRIP. Given that both cities shared the same HIV prevention programs in 2013-2019, apart from TRIP, the observed changes in transmission parameters are likely attributable to the TRIP intervention. We propose that molecular epidemiology analysis can be used as a post-intervention effectiveness assessment tool.

Social network approaches to locating people recently infected with HIV in Odessa, Ukraine

Introduction

This paper examines the extent to which an intervention succeeded in locating people who had recently become infected with HIV in the context of the large‐scale Ukrainian epidemic. Locating and intervening with people who recently became infected with HIV (people with recent infection, or PwRI) can reduce forward HIV transmission and help PwRI remain healthy.

Methods

The Transmission Reduction Intervention Project (TRIP) recruited recently‐infected and longer‐term infected seeds in Odessa, Ukraine, in 2013 to 2016, and asked them to help recruit their extended risk network members. The proportions of network members who were PwRI were compared between TRIP arms (i.e. networks of recently‐infected seeds vs. networks of longer‐term infected seeds) and to the proportion of participants who were PwRI in an RDS‐based Integrated Biobehavioral Surveillance of people who inject drugs in 2013.

Results

The networks of PwRI seeds and those of longer‐term infected seeds had similar (2%) proportions who were themselves PwRI. This was higher than the 0.25% proportion in IBBS (OR = 7.80; p = 0.016). The odds ratio among the subset of participants who injected drugs was 11.17 (p = 0.003). Cost comparison analyses using simplified ingredients‐based methods found that TRIP spent no more than US $4513 per PwRI located whereas IBBS spent $11,924.

Conclusions

Further research is needed to confirm these results and improve TRIP further, but our findings suggest that interventions that trace the networks of people who test HIV‐positive are a cost‐effective way to locate PwRI and reduce HIV transmission and should therefore be implemented.

Trends over time in HIV prevalence among people who inject drugs in 89 large US metropolitan statistical areas, 1992-2013

PURPOSE

After years of stable or declining HIV prevalence and declining incidence among people who inject drugs (PWID) in the United States, some rapidly emerging outbreaks have recently occurred in new areas (e.g., Scott County, Indiana). However, to our knowledge, trends over time in HIV prevalence among PWID in US metropolitan statistical areas (MSAs) across all major regions of the country have not been systematically estimated beyond 2002, and the extent to which HIV prevalence may be increasing in other areas is largely unknown. This article estimates HIV prevalence among PWID in 89 of the most populated US MSAs, both overall and by geographic region, using more recent surveillance and HIV testing data.

METHODS

We computed MSA-specific annual estimates of HIV prevalence (both diagnosed and undiagnosed infections) among PWID for these 89 MSAs, for 1992-2013, using several data series from the Centers for Disease Control and Prevention's (CDC) National HIV Surveillance System and National HIV Prevention Monitoring and Evaluation data; Holmberg's (1997) estimates of 1992 PWID population size and of HIV prevalence and incidence among PWID; and research estimates from published literature using 1992-2013 data. A mixed effects model, with time nested within MSAs, was used to regress the literature review estimates on all of the other data series. Multiple imputation was used to address missing data. Resulting estimates were validated using previous 1992-2002 estimates of HIV prevalence and data on antiretroviral (ARV) prescription volumes and examined for patterns based on geographic region, numbers of people tested for HIV, and baseline HIV prevalence.

RESULTS

Mean (across all MSAs) trends over time suggested decreases through 2002 (from approximately 11.4% in 1992 to 9.2% in 2002), followed by a period of stability, and steep increases after 2010 (to 10.6% in 2013). Validation analyses found a moderate positive correlation between our estimates and ARV prescription volumes (r = 0.45), and a very strong positive correlation (r = 0.94) between our estimates and previous estimates by Tempalski et al. (2009) for 1992-2002 (which used different methods). Analysis by region and baseline prevalence suggested that mean increases in later years were largely driven by MSAs in the Western United States and by MSAs in the Midwest that had low baseline prevalence. Our estimates suggest that prevalence decreased across all years in the Eastern United States. These trends were particularly clear when MSAs with very low numbers of people tested for HIV were removed from analyses to reduce unexplained variability in mean trajectories.

CONCLUSIONS

Our estimates suggest a fairly large degree of variation in 1992-2013 trajectories of PWID HIV prevalence among 89 US MSAs, particularly by geographic region. They suggest that public health responses in many MSAs (particularly those with larger HIV prevalence among PWID in the early 1990s) were sufficient to decrease or maintain HIV prevalence over time. However, future research should investigate potential factors driving the estimated increase in prevalence after 2002 MSAs in the West and Midwest. These findings have potentially important implications for program and/or policy decisions, but estimates for MSAs with low HIV testing denominators should be interpreted with caution and verified locally before planning action.

Prescription opioid injection among young people who inject drugs in New York City: a mixed-methods description and associations with hepatitis C virus infection and overdose

Aim

Evidence is emerging that prescription opioid (PO) injection is associated with increased health risks. This mixed-methods study compares the mechanics of PO and heroin injection and examines the demographic and drug-related correlates of lifetime PO injection in a sample of young people who inject drugs (PWID) in New York City (NYC).

Methods

Qualitative analysis of 46 semi-structured interviews with young adult opioid users ages 18–32. Interview segments describing PO injection were analyzed for common themes. Quantitative analysis of structured interviews with 539 young adult opioid users ages 18–29 recruited via respondent-driven sampling (RDS). Analyses are based on the subsample of 353 participants (65%) who reported having ever injected drugs. All variables were assessed via self-report, except hepatitis C virus status, which was established via rapid antibody testing.

Results

Participants described injecting POs and reported that preparing abuse-deterrent pills for injection is especially cumbersome, requiring extended manipulation and large amounts of water. Injecting POs, in contrast to injecting heroin, requires repeated injections per injection episode. Among RDS-recruited participants, the majority of injectors reported injecting POs, sporadically (33%) or regularly (26%), but often infrequently (≤ 7 days/month). In separate multivariable analyses controlling for syringe- and cooker-sharing, ever injecting POs was a significant predictor of testing HCV antibody-positive (AOR = 2.97) and lifetime experience of non-fatal overdose (AOR = 2.51). Ever injecting POs was independently associated with lifetime homelessness (AOR = 2.93) and having grown up in a middle-income ($51,000–100,000/year vs. ≤ $50,000/year; AOR = 1.86) or a high-income household (> $100,000/year vs. ≤ $50,000/year; AOR = 2.54).

Conclusions

Even in an urban environment like NYC with widespread heroin access, most young PWID have injected POs, although less frequently than heroin. PO injection involves practices that are known to increase risk for blood-borne viral infection (e.g., repeated injections) and predicted testing HCV-positive, as well as overdose. PO injection may also serve as a marker for a subgroup of PWID at elevated risk for multiple drug use-related comorbidities. Programs that provide prevention services to PWID need to tailor harm reduction measures and messaging to the specific practices and harms associated with the injection of POs.

People with high HIV viral load within risk networks: who are these people and who refers them best?

Introduction:

Viral load is one of the most important determinants for HIV transmission. Identification of people with high viral load (PHVL) can be effective in limiting onward HIV transmission. In order to improve the identification of these individuals within risk networks, we determined a) the number of PHVL recruited through risk networks b) their socio-demographic, behavioural and clinical characteristics and c) the characteristics of individuals who referred these PHVL to the study.

Methodology:

From November 2013 to March 2016, in Odessa, Ukraine, Transmission Reduction Intervention Project (TRIP) was implemented to identify people recently infected with HIV within the risk networks of “seeds” and “venues” where they engaged in risk behaviour.

Results:

TRIP identified 53 PHVL, of whom 32 (60%) injected drugs; 42 (79%) were unaware of their HIV status; 25 (47%) had more than one sex partner, and only 14 (26%) were using condoms. There were 164 people who referred individuals into the study; 33 of them (20%) referred PHVL. In terms of referrers, those with lower than secondary level of education, not living with a sex partner, and reporting regular condom use were significantly more likely (p < 0.05) to refer PHVL. Most PHVL (38, 72%) and their referrers (27, 82%) were found through venues.

Conclusions:

In Odessa city, PHVL are at high risk of transmitting HIV as the majority inject drugs, do not know their HIV status, and have unprotected sex and/or multiple partners. Targeting these individuals for HIV prevention, harm reduction and initiation of antiretroviral treatment (ART) is urgent.

Mortgage Discrimination and Racial/Ethnic Concentration Are Associated with Same-Race/Ethnicity Partnering among People Who Inject Drugs in 19 US Cities

Racial/ethnic homophily in sexual partnerships (partners share the same race/ethnicity) has been associated with racial/ethnic disparities in HIV. Structural racism may partly determine racial/ethnic homophily in sexual partnerships. This study estimated associations of racial/ethnic concentration and mortgage discrimination against Black and Latino residents with racial/ethnic homophily in sexual partnerships among 7847 people who inject drugs (PWID) recruited from 19 US cities to participate in CDC's National HIV Behavioral Surveillance. Racial/ethnic concentration was defined by two measures that respectively compared ZIP code-level concentrations of Black residents to White residents and Latino residents to White residents, using the Index of Concentration at the Extremes. Mortgage discrimination was defined by two measures that respectively compared county-level mortgage loan denial among Black applicants to White applicants and mortgage loan denial among Latino applicants to White applicants, with similar characteristics (e.g., income, loan amount). Multilevel logistic regression models were used to estimate associations. Interactions of race/ethnicity with measures of racial/ethnic concentration and mortgage discrimination were added to the final multivariable model and decomposed into race/ethnicity-specific estimates. In the final multivariable model, among Black PWID, living in ZIP codes with higher concentrations of Black vs. White residents and counties with higher mortgage discrimination against Black residents was associated with higher odds of homophily. Living in counties with higher mortgage discrimination against Latino residents was associated with lower odds of homophily among Black PWID. Among Latino PWID, living in ZIP codes with higher concentrations of Latino vs. White residents and counties with higher mortgage discrimination against Latino residents was associated with higher odds of homophily. Living in counties with higher mortgage discrimination against Black residents was associated with lower odds of homophily among Latino PWID. Among White PWID, living in ZIP codes with higher concentrations of Black or Latino residents vs. White residents was associated with lower odds of homophily, but living in counties with higher mortgage discrimination against Black residents was associated with higher odds of homophily. Racial/ethnic segregation may partly drive same race/ethnicity sexual partnering among PWID. Future empirical evidence linking these associations directly or indirectly (via place-level mediators) to HIV/STI transmission will determine how eliminating discriminatory housing policies impact HIV/STI transmission.

Predictors of historical change in drug treatment coverage among people who inject drugs in 90 large metropolitan areas in the USA, 1993-2007

Background

Adequate access to effective treatment and medication assisted therapies for opioid dependence has led to improved antiretroviral therapy adherence and decreases in morbidity among people who inject drugs (PWID), and can also address a broad range of social and public health problems. However, even with the success of syringe service programs and opioid substitution programs in European countries (and others) the US remains historically low in terms of coverage and access with regard to these programs. This manuscript investigates predictors of historical change in drug treatment coverage for PWID in 90 US metropolitan statistical areas (MSAs) during 1993–2007, a period in which, overall coverage did not change.

Methods

Drug treatment coverage was measured as the number of PWID in drug treatment, as calculated by treatment entry and census data, divided by numbers of PWID in each MSA. Variables suggested by the Theory of Community Action (i.e., need, resource availability, institutional opposition, organized support, and service symbiosis) were analyzed using mixed-effects multivariate models within dependent variables lagged in time to study predictors of later change in coverage.

Results

Mean coverage was low in 1993 (6.7%; SD 3.7), and did not increase by 2007 (6.4%; SD 4.5). Multivariate results indicate that increases in baseline unemployment rate (β = 0.312; pseudo-p < 0.0002) predict significantly higher treatment coverage; baseline poverty rate (β = − 0.486; pseudo-p < 0.0001), and baseline size of public health and social work workforce (β = 0.425; pseudo-p < 0.0001) were predictors of later mean coverage levels, and baseline HIV prevalence among PWID predicted variation in treatment coverage trajectories over time (baseline HIV * Time: β = 0.039; pseudo-p < 0.001). Finally, increases in black/white poverty disparity from baseline predicted significantly higher treatment coverage in MSAs (β = 1.269; pseudo-p < 0.0001).

Conclusions

While harm reduction programs have historically been contested and difficult to implement in many US communities, and despite efforts to increase treatment coverage for PWID, coverage has not increased. Contrary to our hypothesis, epidemiologic need, seems not to be associated with change in treatment coverage over time. Resource availability and institutional opposition are important predictors of change over time in coverage. These findings suggest that new ways have to be found to increase drug treatment coverage in spite of economic changes and belt-tightening policy changes that will make this difficult.

New Measures for Research on Men Who Have Sex with Men and for At-Risk Heterosexuals: Tools to Study Links Between Structural Interventions or Large-Scale Social Change and HIV Risk Behaviors, Service Use, and Infection

Large-scale structural interventions and "Big Events" like revolutions, wars and major disasters can affect HIV transmission by changing the sizes of at-risk populations, making high-risk behaviors more or less likely, or changing contexts in which risk occurs. This paper describes new measures to investigate hypothesized pathways that could connect macro-social changes to subsequent HIV transmission. We developed a "menu" of novel scales and indexes on topics including norms about sex and drug injecting under different conditions, experiencing denial of dignity, agreement with cultural themes about what actions are needed for survival or resistance, solidarity and other issues. We interviewed 298 at-risk heterosexuals and 256 men who have sex with men in New York City about these measures and possible validators for them. Most measures showed evidence of criterion validity (absolute magnitude of Pearson's r ≥ 0.20) and reliability (Cronbach's alpha ≥ 0.70). These measures can be (cautiously) used to understand how macro-changes affect HIV and other risk. Many can also be used to understand risk contexts and dynamics in more normal situations. Additional efforts to improve and to replicate the validation of these measures should be conducted.

Relationship of Racial Residential Segregation to Newly Diagnosed Cases of HIV among Black Heterosexuals in US Metropolitan Areas, 2008-2015

Social science and public health literature has framed residential segregation as a potent structural determinant of the higher HIV burden among black heterosexuals, but empirical evidence has been limited. The purpose of this study is to test, for the first time, the association between racial segregation and newly diagnosed heterosexually acquired HIV cases among black adults and adolescents in 95 large US metropolitan statistical areas (MSAs) in 2008-2015. We operationalized racial segregation (the main exposure) using Massey and Denton's isolation index for black residents; the outcome was the rate of newly diagnosed HIV cases per 10,000 black adult heterosexuals. We tested the relationship of segregation to this outcome using multilevel multivariate models of longitudinal (2008-2015) MSA-level data, controlling for potential confounders and time. All covariates were lagged by 1 year and centered on baseline values. We preliminarily explored mediation of the focal relationship by inequalities in education, employment, and poverty rates. Segregation was positively associated with the outcome: a one standard deviation decrease in baseline isolation was associated with a 16.2% reduction in the rate of new HIV diagnoses; one standard deviation reduction in isolation over time was associated with 4.6% decrease in the outcome. Exploratory mediation analyses suggest that black/white socioeconomic inequality may mediate the relationship between segregation and HIV. Our study suggests that residential segregation may be a distal determinant of HIV among black heterosexuals. The findings further emphasize the need to address segregation as part of a comprehensive strategy to reduce racial inequities in HIV.

A New Generation of Drug Users in St. Petersburg, Russia? HIV, HCV, and Overdose Risks in a Mixed-Methods Pilot Study of Young Hard Drug Users

Russia has a widespread injection drug use epidemic with high prevalence of HIV and HCV among people who inject drugs (PWID). We conducted a mixed methods study of young (age 18-26) hard drug users in St. Petersburg. Thirty-nine structured and 10 semi-structured interviews were conducted. No HIV cases and two HCV cases were detected among the PWID subsample (n = 29). Amphetamine and other stimulants were common (70%), opioid use was rare and episodic. Consistent condom use was 10%. No PWID reported syringe-sharing, 51% reported other drug paraphernalia sharing. Most (89%) never or rarely communicated with older (30 +) opiate users. A new cohort of drug users in St. Petersburg may have emerged, which is much safer in its injection practices compared to previous cohorts. However, risky sexual practices among this new cohort may expose them to the possibility of sexual transmission of HIV and widespread drug paraphernalia sharing to the HCV epidemic.

States with higher minimum wages have lower STI rates among women: Results of an ecological study of 66 US metropolitan areas, 2003-2015

Prior research has found that places and people that are more economically disadvantaged have higher rates and risks, respectively, of sexually transmitted infections (STIs). Economic disadvantages at the level of places and people, however, are themselves influenced by economic policies. To enhance the policy relevance of STI research, we explore, for the first time, the relationship between state-level minimum wage policies and STI rates among women in a cohort of 66 large metropolitan statistical areas (MSAs) in the US spanning 2003-2015. Our annual state-level minimum wage measure was adjusted for inflation and cost of living. STI outcomes (rates of primary and secondary syphilis, gonorrhea and chlamydia per 100,000 women) were obtained from the CDC. We used multivariable hierarchical linear models to test the hypothesis that higher minimum wages would be associated with lower STI rates. We preliminarily explored possible socioeconomic mediators of the minimum wage/STI relationship (e.g., MSA-level rates of poverty, employment, and incarceration). We found that a $1 increase in the price-adjusted minimum wage over time was associated with a 19.7% decrease in syphilis rates among women and with an 8.5% drop in gonorrhea rates among women. The association between minimum wage and chlamydia rates did not meet our cutpoint for substantive significance. Preliminary mediation analyses suggest that MSA-level employment among women may mediate the relationship between minimum wage and gonorrhea. Consistent with an emerging body of research on minimum wage and health, our findings suggest that increasing the minimum wage may have a protective effect on STI rates among women. If other studies support this finding, public health strategies to reduce STIs among women should include advocating for a higher minimum wage.

Police killings of Black people and rates of sexually transmitted infections: a cross-sectional analysis of 75 large US metropolitan areas, 2016

OBJECTIVES

Emerging literature shows that racialised police brutality, a form of structural racism, significantly affects health and well-being of racial/ethnic minorities in the USA. While public health research suggests that structural racism is a distal determinant of sexually transmitted infections (STIs) among Black people, no studies have empirically linked police violence to STIs. To address this gap, our study measures associations between police killings and rates of STIs among Black residents of US metropolitan statistical areas (MSAs).

METHODS

This cross-sectional ecological analysis assessed associations between the number of Black people killed by police in 2015 and rates of primary and secondary syphilis, gonorrhoea and chlamydia per 100 000 Black residents of all ages in 2016 in 75 large MSAs. Multivariable models controlled for MSA-level demographic and socioeconomic characteristics, police expenditures, violent crime, arrest and incarceration rates, insurance rates and healthcare funding.

RESULTS

In 2015, the median number of Black people killed by police per MSA was 1.0. In multivariable models, police killings were positively and significantly associated with syphilis and gonorrhoea rates among Black residents. Each additional police killing in 2015 was associated with syphilis rates that were 7.5% higher and gonorrhoea rates that were 4.0% higher in 2016.

CONCLUSIONS

Police killings of Black people may increase MSA-level risk of STI infections among Black residents. If future longitudinal analyses support these findings, efforts to reduce STIs among Black people should include reducing police brutality and addressing mechanisms linking this violence to STIs.

Near Full-length Genomic Sequencing and Molecular Analysis of HIV-Infected Individuals in a Network-based Intervention (TRIP) in Athens, Greece: Evidence that Transmissions Occur More Frequently from those with High HIV-RNA

Background:

TRIP (Transmission Reduction Intervention Project) was a network-based, contact tracing approach to locate and link to care, mostly people who inject drugs (PWID) with recent HIV infection.

Objective:

We investigated whether sequences from HIV-infected participants with high viral load cluster together more frequently than what is expected by chance.

Methods:

Paired end reads were generated for 104 samples using Illumina MiSeq next-generation se-quencing.

Results:

63 sequences belonged to previously identified local transmission networks of PWID (LTNs) of an HIV outbreak in Athens, Greece. For two HIV-RNA cut-offs (105 and 106 IU/mL), HIV transmissions were more likely between PWID with similar levels of HIV-RNA (p<0.001). 10 of the 14 sequences (71.4%) from PWID with HIV-RNA >106 IU/mL were clustered in 5 pairs. For 4 of these clusters (80%), there was in each one of them at least one sequence from a recently HIV-infected PWID.

Conclusion:

We showed that transmissions are more likely among PWID with high viremia.

Decreasing HIV transmissions to African American women through interventions for men living with HIV post-incarceration: An agent-based modeling study

Background

Incarceration and HIV disproportionately impact African American communities. The mass incarceration of African American men is hypothesized to increase HIV acquisition risk for African American women. Interventions optimizing HIV care engagement and minimizing sexual risk behaviors for men living with HIV post-incarceration may decrease HIV incidence.

Methods

Using an agent-based model, we simulated a sexual and injection drug using network representing the African American population of Philadelphia. We compared intervention strategies for men living with HIV post-incarceration by the number of averted HIV transmissions to women within the community. Three interventions were evaluated: a 90-90-90 scenario scaling up HIV testing, ART provision, and ART adherence; a behavioral intervention decreasing sexual risk behaviors; and a combination intervention involving both.

Results

The status quo scenario projected 2,836 HIV transmissions to women over twenty years. HIV transmissions to women decreased by 29% with the 90-90-90 intervention, 23% with the behavioral intervention, and 37% with both. The number of men living with HIV receiving the intervention needed in order to prevent a single HIV transmission ranged between 6 and 10.

Conclusion

Interventions to improve care engagement and decrease sexual risk behaviors post-incarceration for men living with HIV have the potential to decrease HIV incidence within African American heterosexual networks.

Risk network approaches to locating undiagnosed HIV cases in Odessa, Ukraine

INTRODUCTION

Providing HIV healthcare and Treatment as Prevention both depend on diagnosing HIV cases, preferably soon after initial infection. We hypothesized that tracing risk networks recruits higher proportions of undiagnosed positives than outreach-based testing or respondent-driven sampling (RDS) in Odessa, Ukraine.

METHODS

The Transmission Reduction Intervention Project (TRIP) used risk network tracing to recruit sexual and injection networks of recently-infected and longer-term infected (LTs) seeds (2013 to 2016). Integrated Biobehavioural Surveillance (IBBS) (2013) used RDS to recruit people who inject drugs (PWID). Outreach Testing tested PWID for HIV at community outreach sites (2013 to 2016). Proportions of undiagnosed positives among those tested were compared TRIP versus IBBS; TRIP versus Outreach Testing and between TRIP arms. Costs were compared across the projects.

RESULTS

TRIP tested 1252 people (21% women) in seeds' risk networks; IBBS tested 400 (18% women); Outreach Testing 13,936 (31% women). TRIP networks included a higher proportion of undiagnosed positives (14.6%) than IBBS (5.0%) or Outreach Testing (2.4%); odds ratio (OR) 3.25 (95% CI 2.07, 5.12) versus IBBS and 7.03 (CI 5.95, 8.31) versus Outreach Testing respectively. Findings remained significant in analyses stratified by sex and when PWID in TRIP networks were compared with Outreach Testing and IBBS. Within TRIP, recently-infected participants' networks contained higher proportions of undiagnosed positives (16.3%) than LTs' networks (12.2%); OR 1.41 (CI 1.01, 1.95). TRIP located undiagnosed positives less expensively than did RDS or Outreach Testing.

CONCLUSIONS

TRIP's recruiting techniques, including prioritizing networks of the recently infected, find undiagnosed HIV-positive people efficiently. They should be integrated with standard practice to improve case-finding. Research should test these techniques in other socio-epidemiologic contexts.

CLINICAL TRIAL REGISTRY

Registered ClinicalTrials.gov: NCT01827228.

Experiences of Stigma and Support Reported by Participants in a Network Intervention to Reduce HIV Transmission in Athens, Greece; Odessa, Ukraine; and Chicago, Illinois

A growing body of evidence suggests that network-based interventions to reduce HIV transmission and/or improve HIV-related health outcomes have an important place in public health efforts to move towards 90-90-90 goals. However, the social processes involved in network-based recruitment may pose a risk to participants of increasing HIV-related stigma if network recruitment causes HIV status to be assumed, inferred, or disclosed. On the other hand, the social processes involved in network-based recruitment to HIV testing may also encourage HIV-related social support. Yet despite the relevance of these processes to both network-based interventions and to other more common interventions (e.g., partner services), there is a dearth of literature that directly examines them among participants of such interventions. Furthermore, both HIV-related stigma and social support may influence participants' willingness and ability to recruit their network members to the study. This paper examines (1) the extent to which stigma and support were experienced by participants in the Transmission Reduction Intervention Project (TRIP), a risk network-tracing intervention aimed at locating recently HIV-infected and/or undiagnosed HIV-infected people and linking them to care in Athens, Greece; Odessa, Ukraine; and Chicago, Illinois; and (2) whether stigma and support predicted participant engagement in the intervention. Overall, experiences of stigma were infrequent and experiences of support frequent, with significant variation between study sites. Experiences and perceptions of HIV-related stigma did not change significantly between baseline and six-month follow-up for the full TRIP sample, and significantly decreased during the course of the study at the Chicago site. Experiences of HIV-related support significantly increased among recently-HIV-infected participants at all sites, and among all participants at the Odessa site. Both stigma and support were found to predict participants' recruitment of network members to the study at the Athens site, and to predict participants' interviewer-rated enthusiasm for naming and recruiting their network members at both the Athens and Odessa sites. These findings suggest that network-based interventions like TRIP which aim to reduce HIV transmission likely do not increase stigma-related risks to participants, and may even encourage increased social support among network members. However, the present study is limited by its associational design and by some variation in implementation by study site. Future research should directly assess contextual differences to improve understanding of the implications of site-level variation in stigma and support for the implementation of network-based interventions, given the finding that these constructs predict participants' recruitment of network members and engagement in the intervention, and thereby could limit network-based interventions' abilities to reach those most in need of HIV testing and care.

Detailed Molecular Surveillance of the HIV-1 Outbreak Among People who Inject Drugs (PWID) in Athens During a Period of Four Years

BACKGROUND

New diagnoses of HIV-1 infection among people who inject drugs (PWID) increased significantly during 2011 in Athens.

OBJECTIVE

Our aim was to investigate the patterns of HIV epidemic spread among PWID and to estimate the transmission dynamics for the major local transmission networks (LTNs).

METHODS

We analyzed sequences from 2,274 HIV-infected subjects sampled in Greece during 01/01/2011-31/10/2014. Of specimens in our sample, 874 sequences were isolated from HIV-infected PWID. Phylodynamic analysis was performed using birth-death serial skyline models.

RESULTS

Phylogenetic analysis revealed that the majority of sequences from PWID (N=746, 85.4%) fell within four LTNs: CRF14_BG (N=456, 58.3%), CRF35_AD (N=149, 19.1%), subtype B (N=118, 15.1%) and A1 (N=59, 7.5%). In addition to PWID, we also found that sequences from 36 non-PWID belonged to the LTNs corresponding to cross-group transmissions. Based on the estimated plots of the effective reproductive number (Re) over time, subtype A1 and CRF35_AD LTNs showed a sharp increase before and during 2011 (maximum value of Re=3.0 and Re=4.6, respectively). For subtype B and CRF14_BG LTNs, the Re was increasing until the end of 2012 (maximum value of Re=3.2 and Re=3.0, respectively).

CONCLUSION

HIV transmissions within subtype A1 and CRF35_AD LTNs increased sharply during the early stage of the outbreak, in contrast to subtype B and CRF14_BG. A significant reduction in the number of infections was estimated on all transmission networks from the beginning of 2013 onwards. Prevention measures that took place in the Athens metropolitan area at the end of 2012 including also the ARISTOTLE program may explain this decrease.

Knowledge, Normative Beliefs and Attitudes Related to Recent HIV Infection among People who Inject Drugs in Athens, Greece

BACKGROUND

Despite great improvements in prevention over the last years, much has to be done to reduce new human immunodeficiency virus (HIV) infections. Substantial evidence shows that the six-month period of recent HIV infection contributes disproportionately to HIV transmission.

OBJECTIVE

This study aims to investigate knowledge, normative beliefs, and attitudes of people who inject drugs (PWID) regarding recent HIV infection.

METHODS

People who inject drugs in Athens, Greece were recruited in the fifth round of a respondent- driven sampling program (ARISTOTLE). The participants were tested for HIV and answered a structured questionnaire, which also included items on knowledge, normative beliefs, and attitudes regarding recent infection to address needs of the social network-based Transmission Reduction Intervention Project. The multivariable analyses included logistic regression models, which produced odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

In total, 1,407 people (mean age: 36.3 ± 7.9 years old; males: 81.9%) took part in the fifth round of ARISTOTLE. Of these, 61.5% knew that HIV-infected people who are not on treatment are more likely to transmit HIV during the first six months of their infection and 58.4% reported that people in their network would react positively towards a recently HIV-infected person. People who inject drugs who were knowledgeable of recent HIV infection were more likely to disagree with statements such as that one should avoid all contact with a person recently infected by HIV (adjusted OR: 1.510, 95% CI: 1.090, 2.091) or more likely to agree with statements such as that an HIV+ person is much less likely to transmit HIV when h/she is on combination antiretroviral treatment (adjusted OR: 2.083, 95% CI: 1.231, 3.523).

CONCLUSION

A considerable proportion of PWID in Athens, Greece, were aware of the high HIV transmission risk of recent HIV infection, although improvement is needed for some population segments. People who inject drugs who were knowledgeable of the role of recent HIV infection were more likely to have normative beliefs and attitudes that favor behaviors that could help rather than harm or stigmatize people who have recently been infected with HIV. Interventions that are based on the role of recent HIV infection in HIV transmission could be important to HIV prevention.

Identifying, linking, and treating people who inject drugs and were recently infected with HIV in the context of a network-based intervention

Identifying and linking people to care soon after HIV infection could limit viral transmission and protect their health. This work aims at describing the continuum of care among recently HIV-infected people who inject drugs (PWID) and participated in an intervention in the context of an HIV outbreak in Athens, Greece. The Transmission Reduction Intervention Project (TRIP) conducted risk network-based contact tracing and screened people for recent HIV infection. A comprehensive approach with a case management component that aimed to remove barriers to accessing care was adopted. Follow-up data on antiretroviral treatment (ART) and HIV-RNA levels were obtained from HIV clinics. TRIP enrolled 45 recently HIV-infected PWID (80% male) with a median viral load at recruitment of 5.43 log₁₀ copies/mL. Of the recently infected persons in TRIP, 87% were linked to care; of these, 77% started ART; and of those on ART, 89% achieved viral load <200 copies/mL. TRIP and its public health allies managed to get most of the recently HIV-infected PWID who were identified by the program into care and many of them onto ART. This resulted in very low HIV-RNA levels. Treatment as prevention can work if individuals are aided in overcoming difficulties in entry to, or attrition from care.

State minimum wage laws and newly diagnosed cases of HIV among heterosexual black residents of US metropolitan areas

This ecologic cohort study explores the relationship between state minimum wage laws and rates of HIV diagnoses among heterosexual black residents of U.S metropolitan areas over an 8-year span. Specifically, we applied hierarchical linear modeling to investigate whether state-level variations in minimum wage laws, adjusted for cost-of-living and inflation, were associated with rates of new HIV diagnoses among heterosexual black residents of metropolitan statistical areas (MSAs; n=73), between 2008 and 2015. Findings suggest that an inverse relationship exists between baseline state minimum wages and initial rates of newly diagnosed HIV cases among heterosexual black individuals, after adjusting for potential confounders. MSAs with a minimum wage that was $1 higher at baseline had a 27.12% lower rate of newly diagnosed HIV cases. Exploratory analyses suggest that income inequality may mediate this relationship. If subsequent research establishes a causal relationship between minimum wage and this outcome, efforts to increase minimum wages should be incorporated into HIV prevention strategies for this vulnerable population.

Identifying Which Place Characteristics are Associated with the Odds of Recent HIV Testing in a Large Sample of People Who Inject Drugs in 19 US Metropolitan Areas

This exploratory analysis investigates relationships of place characteristics to HIV testing among people who inject drugs (PWID). We used CDC's 2012 National HIV Behavioral Surveillance (NHBS) data among PWID from 19 US metropolitan statistical areas (MSAs); we restricted the analytic sample to PWID self-reporting being HIV negative (N = 7477). Administrative data were analyzed to describe the 1. Sociodemographic Composition; 2. Economic disadvantage; 3. Healthcare Service/Law enforcement; and 4. HIV burden of the ZIP codes, counties, and MSAs where PWID lived. Multilevel models tested associations of place characteristics with HIV testing. Fifty-eight percent of PWID reported past-year testing. MSA-level per capita correctional expenditures were positively associated with recent HIV testing among black PWID, but not white PWID. Higher MSA-level household income and imbalanced sex ratios (more women than men) in the MSA were associated with higher odds of testing. HIV screening for PWID is suboptimal (58%) and needs improvement. Identifying place characteristics associated with testing among PWID can strengthen service allocation and interventions in areas of need to increase access to HIV testing.

Potential drivers of HIV acquisition in African-American women related to mass incarceration: an agent-based modelling study

Background

The United States has the highest incarceration rate in the world. Incarceration can increase HIV risk behaviors for individuals involved with the criminal justice system and may be a driver of HIV acquisition within the community.

Methods

We used an agent-based model to simulate HIV transmission in a sexual-contact network representing heterosexual African American men and women in Philadelphia to identify factors influencing the impact of male mass incarceration on HIV acquisition in women. The model was calibrated using surveillance data and assumed incarceration increased the number of sexual contacts and decreased HIV care engagement for men post-release. Incarceration of a partner increased the number of sexual contacts for women. We compared a counterfactual scenario with no incarceration to scenarios varying key parameters to determine what factors drove HIV acquisition in women.

Results

Setting the duration of male high-risk sexual behavior to two years post-release increased the number of HIV transmissions to women by more than 20%. Decreasing post-release HIV care engagement and increasing HIV acquisition risk attributable to sexually transmitted infections (STIs) also increased the number of HIV transmissions to women. Changing the duration of risk behavior for women, the proportion of women engaging in higher risk behavior, and the relative risk of incarceration for HIV-infected men had minimal impact.

Conclusion

The mass incarceration of African American men can increase HIV acquisition in African American women on a population-level through factors including post-release high-risk behaviors, disruption of HIV care engagement among formerly incarcerated men, and increased STI prevalence. These findings suggest that the most influential points of intervention may be programs seeking to reduce male risk behaviors and promote HIV care engagement post-release, as well as STI testing and treatment programs for recently incarcerated men, as well as women with incarcerated partners.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6304-x) contains supplementary material, which is available to authorized users.

An Innovative Study Design to Assess the Community Effect of Interventions to Mitigate HIV Epidemics Using Transmission-Chain Phylodynamics

Given globalization and other social phenomena, controlling the spread of infectious diseases has become an imperative public health priority. A plethora of interventions that in theory can mitigate the spread of pathogens have been proposed and applied. Evaluating the effectiveness of such interventions is costly and in many circumstances unrealistic. Most important, the community effect (i.e., the ability of the intervention to minimize the spread of the pathogen from people who received the intervention to other community members) can rarely be evaluated. Here we propose a study design that can build and evaluate evidence in support of the community effect of an intervention. The approach exploits molecular evolutionary dynamics of pathogens in order to track new infections as having arisen from either a control or an intervention group. It enables us to evaluate whether an intervention reduces the number and length of new transmission chains in comparison with a control condition, and thus lets us estimate the relative decrease in new infections in the community due to the intervention. We provide as an example one working scenario of a way the approach can be applied with a simulation study and associated power calculations.