Current trends of seroprevalence of transfusion transmitted infections in Pakistani β-thalassaemic patients

BACKGROUND

Though regular blood transfusion improves the survival, it carries the unavoidable risk of transfusion transmitted infections (TTI) in β-thalassaemic patients. Owing to the lack of uniformity in blood screening practices in Pakistan, TTI is still a major challenge.

OBJECTIVES

To study the current trends of TTI in regularly transfused β-thalassaemics and their correlation with age, number of transfusions, hematological and biochemical markers.

METHODS

We carried out a prospective case-control study. 100 β-thalassemic patients and 200 healthy donors were recruited from June 2011 to June 2014. HCV antibodies, Hepatitis B surface antigen and human immunodeficiency virus antibodies (I & II) were evaluated. Complete blood counts, LFTs and serum ferritin were tested on all patients.

RESULTS

Mean age of patients and controls was 11.18±5.07 and 20.5±1.87 years respectively. In patients, 54% and 46% were males and females respectively. Anti-HCV antibody and HbsAg were positive in 27% versus 3% and 3% versus 2% in patients and controls respectively. None of the patients and controls was HIV reactive. Seropositivity of Anti-HCV was significantly higher in patients than that of controls (P<0.001). Anti-HCV positively correlated with age above 10 years, numbers of transfusions (≥150 units), high serum ferritin, elevated ALT and alkaline phosphatase (P<0.001).

CONCLUSIONS

Over the decade, TTI magnitude has significantly reduced, but hepatitis C is still a main hazard. Further preventive measures including nucleic acid testing, voluntary donation and stringent donor selection will be required for reducing TTI in β-thalassaemics.

Characterization and Role of Lentivirus-Associated Host Proteins

Enveloped viruses obtain their envelopes during the process of budding from infected cells. During this process, however, these viruses acquire parts of the host cell membranes and host cell-derived proteins as integral parts of their mature envelopes. These host-derived components of viral envelopes may subsequently exhibit various effects on the life cycle of the virus; virus cell interactions, especially host response to virus-incorporated self-proteins; and the pathogenesis of the disease induced by these viruses. Although it was known for some time that various viruses incorporate host cell-derived proteins, the issue of the role of these proteins has received increased attention, specifically in connection with human immunodeficiency virus (HIV) infection and development of acquired immunodeficiency syndrome (AIDS) in humans. The aim of this review is to summarize our current knowledge of the analysis and role of host-derived proteins associated with enveloped viruses, with emphasis on the potential role of these proteins in the pathogenesis of AIDS. Clearly, differences in the clinical outcome of those nonhuman primates infected with simian immunodeficiency virus (SIV) that are disease resistant compared with SIV-infected species that are disease susceptible provide a unique opportunity to determine whether differences in the incorporation of distinct sets of host proteins play a role with distinct clinical outcomes.

Endocarditis as a Marker for New Epidemics of Injection Drug Use

BACKGROUND

We examined discharges for infective endocarditis (IE) at an academic teaching hospital for over 10 years to evaluate if an increase in hospitalizations for IE and increase in hepatitis C virus (HCV) in patients with IE could predict a new epidemic of injection drug use (IDU).

MATERIALS AND METHODS

Retrospective medical record review of discharged patients with the diagnosis of IE as defined by the modified Duke criteria. Student's t test, chi-squared test and Fisher's exact test were used to calculate P values.

RESULTS

There were 542 discharges among 392 unique patients with IE and 104 patients were readmitted 2-7 times. Of the total discharges, 367 (67.7%) were not screened for HCV, and of those tested, 86 (49.1%) were HCV+; 404 (74.5%) were not screened for HIV and of those tested, 28 (20.3%) were HIV+. Patients who self-identify as a person who injects drugs were more likely to be tested for HCV, 75 (69.4%) versus 12 (31.5%, P < 0.0001), and for HIV, 72 (66.6%) versus 13 (34.2%, P < 0.0001) compared with those who self-report no IDU. Those with a positive result for opiate or heroin toxicology test were more likely to be screened for HCV, 70 (66%) versus 22 (44.8%, P < 0.0001), and for HIV, 66 (62.2%) versus 25 (51%, P < 0.0001) than those with negative result for toxicology test. Over this period, there was a 2-fold increase in IE cases, a 3-fold increase in HCV antibody prevalence and a 6-fold increase in opiate toxicology screens showing positive result, but no increase in HIV.

CONCLUSIONS

Although IDU is a known risk factor for IE, the observation of a sharp increase in IE cases may signal a new epidemic of IDU and HCV.

Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees

The prison setting presents not only challenges, but also opportunities, for the prevention and treatment of HIV, viral hepatitis, and tuberculosis. We did a comprehensive literature search of data published between 2005 and 2015 to understand the global epidemiology of HIV, hepatitis C virus (HCV), hepatitis B virus (HBV), and tuberculosis in prisoners. We further modelled the contribution of imprisonment and the potential impact of prevention interventions on HIV transmission in this population. Of the estimated 10·2 million people incarcerated worldwide on any given day in 2014, we estimated that 3·8% have HIV (389 000 living with HIV), 15·1% have HCV (1 546 500), 4·8% have chronic HBV (491 500), and 2·8% have active tuberculosis (286 000). The few studies on incidence suggest that intraprison transmission is generally low, except for large-scale outbreaks. Our model indicates that decreasing the incarceration rate in people who inject drugs and providing opioid agonist therapy could reduce the burden of HIV in this population. The prevalence of HIV, HCV, HBV, and tuberculosis is higher in prison populations than in the general population, mainly because of the criminalisation of drug use and the detention of people who use drugs. The most effective way of controlling these infections in prisoners and the broader community is to reduce the incarceration of people who inject drugs.

The Incidence Patterns Model to Estimate the Distribution of New HIV Infections in Sub-Saharan Africa: Development and Validation of a Mathematical Model

BACKGROUND

Programmatic planning in HIV requires estimates of the distribution of new HIV infections according to identifiable characteristics of individuals. In sub-Saharan Africa, robust routine data sources and historical epidemiological observations are available to inform and validate such estimates.

METHODS AND FINDINGS

We developed a predictive model, the Incidence Patterns Model (IPM), representing populations according to factors that have been demonstrated to be strongly associated with HIV acquisition risk: gender, marital/sexual activity status, geographic location, "key populations" based on risk behaviours (sex work, injecting drug use, and male-to-male sex), HIV and ART status within married or cohabiting unions, and circumcision status. The IPM estimates the distribution of new infections acquired by group based on these factors within a Bayesian framework accounting for regional prior information on demographic and epidemiological characteristics from trials or observational studies. We validated and trained the model against direct observations of HIV incidence by group in seven rounds of cohort data from four studies ("sites") conducted in Manicaland, Zimbabwe; Rakai, Uganda; Karonga, Malawi; and Kisesa, Tanzania. The IPM performed well, with the projections' credible intervals for the proportion of new infections per group overlapping the data's confidence intervals for all groups in all rounds of data. In terms of geographical distribution, the projections' credible intervals overlapped the confidence intervals for four out of seven rounds, which were used as proxies for administrative divisions in a country. We assessed model performance after internal training (within one site) and external training (between sites) by comparing mean posterior log-likelihoods and used the best model to estimate the distribution of HIV incidence in six countries (Gabon, Kenya, Malawi, Rwanda, Swaziland, and Zambia) in the region. We subsequently inferred the potential contribution of each group to transmission using a simple model that builds on the results from the IPM and makes further assumptions about sexual mixing patterns and transmission rates. In all countries except Swaziland, individuals in unions were the single group contributing to the largest proportion of new infections acquired (39%-77%), followed by never married women and men. Female sex workers accounted for a large proportion of new infections (5%-16%) compared to their population size. Individuals in unions were also the single largest contributor to the proportion of infections transmitted (35%-62%), followed by key populations and previously married men and women. Swaziland exhibited different incidence patterns, with never married men and women accounting for over 65% of new infections acquired and also contributing to a large proportion of infections transmitted (up to 56%). Between- and within-country variations indicated different incidence patterns in specific settings.

CONCLUSIONS

It is possible to reliably predict the distribution of new HIV infections acquired using data routinely available in many countries in the sub-Saharan African region with a single relatively simple mathematical model. This tool would complement more specific analyses to guide resource allocation, data collection, and programme planning.

Fulminant bilateral acute retinal necrosis after chickenpox - a case report

We present the case of a 34-year-old male, admitted for progressive bilateral loss of vision after a recent episode of chickenpox. Ophthalmological exam revealed bilateral acute retinal necrosis. As the patient was following a drug detoxification program, he was tested for HIV, HVB, HVC, and results highly positive. Immediate intravenous therapy with high doses of acyclovir and methylprednisolone was initiated, but the evolution was extremely severe resulting in necrotic retinal detachment. Surgery was performed in right eye, but no improvement of visual acuity was observed.

CONCLUSIONS

The fulminant evolution of bilateral acute retinal necrosis and the lack of response to maximal intravenous therapy were clinical elements indicating coexistent immunosuppressive disease. Very severe acute retinal necrosis may occur in immunosuppressed patients, leading to blindness.

Prevalence of sexually transmitted diseases and human immunodeficiency virus among women attending prenatal services in Apia, Samoa

There is no routine prenatal screening for sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV) in pregnancy in Samoa. Testing for chlamydial infection is not available. To gather information on pregnant women, a prevalence survey was conducted in Apia, Samoa, utilizing two prenatal hospital clinics. Pregnant ( n = 427) women were tested for Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis using polymerase chain reaction (PCR), and for syphilis ( n = 441) by rapid plasmid reagin (RPR) and HIV ( n = 441) by enzyme-linked immunosorbent assay (ELISA). Results were: chlamydia 30.9% (132); trichomoniasis 20.8%; gonorrhoea 3.3%; syphilis 0.5%; and HIV 0%. Overall 42.7% had at least 1 STD. Young women aged <25 years were three times more likely to have a STD than older women (odds ratio = 3.0, 95% confidence intervals 2.0, 4.5). The lack of inexpensive, reliable field diagnostics remain a barrier to sustainable STD control programmes for pregnant women living in developing countries.

The global burden of disease attributable to contaminated injections given in health care settings

As part of the 2000 Global Burden of Disease study, we quantified the death and disability from injection-associated infections with hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). We modelled the fraction of incident infections attributable to health care injections in the year 2000 on the basis of the annual number of injections, the proportion of injections administered with reused equipment, the probability of transmission following percutaneous exposure, the prevalence of active infection, the prevalence of immunity and the total incidence. Infections in 2000 were converted into disability-adjusted life years (DALYs) in 2000–2030 using natural history parameters, background mortality, duration of disease, disability weights, age weights and a 3% discount rate. Four Global Burden of Disease regions where reuse of injection equipment in the absence of sterilization was negligible were excluded from the analysis. In the remaining 10 regions, in 2000, persons received an average of 3.4 injections per year, 39.3% of which were given with reused equipment. In 2000, contaminated injections caused an estimated 21 million HBV infections, two million HCV infections and 260,000 HIV infections, accounting for 32%, 40% and 5%, respectively, of new infections for a burden of 9,177,679 DALYs between 2000 and 2030. Injection overuse and unsafe practices account for a substantial burden of death and disability worldwide. There is a need for policies and plans for the safe and appropriate use of injections in countries where practices are poor.

Spatio-Temporal History of HIV-1 CRF35_AD in Afghanistan and Iran

HIV-1 Circulating Recombinant Form 35_AD (CRF35_AD) has an important position in the epidemiological profile of Afghanistan and Iran. Despite the presence of this clade in Afghanistan and Iran for over a decade, our understanding of its origin and dissemination patterns is limited. In this study, we performed a Bayesian phylogeographic analysis to reconstruct the spatio-temporal dispersion pattern of this clade using eligible CRF35_AD gag and pol sequences available in the Los Alamos HIV database (432 sequences available from Iran, 16 sequences available from Afghanistan, and a single CRF35_AD-like pol sequence available from USA). Bayesian Markov Chain Monte Carlo algorithm was implemented in BEAST v1.8.1. Between-country dispersion rates were tested with Bayesian stochastic search variable selection method and were considered significant where Bayes factor values were greater than three. The findings suggested that CRF35_AD sequences were genetically similar to parental sequences from Kenya and Uganda, and to a set of subtype A1 sequences available from Afghan refugees living in Pakistan. Our results also showed that across all phylogenies, Afghan and Iranian CRF35_AD sequences formed a monophyletic cluster (posterior clade credibility> 0.7). The divergence date of this cluster was estimated to be between 1990 and 1992. Within this cluster, a bidirectional dispersion of the virus was observed across Afghanistan and Iran. We could not clearly identify if Afghanistan or Iran first established or received this epidemic, as the root location of this cluster could not be robustly estimated. Three CRF35_AD sequences from Afghan refugees living in Pakistan nested among Afghan and Iranian CRF35_AD branches. However, the CRF35_AD-like sequence available from USA diverged independently from Kenyan subtype A1 sequences, suggesting it not to be a true CRF35_AD lineage. Potential factors contributing to viral exchange between Afghanistan and Iran could be injection drug networks and mass migration of Afghan refugees and labours to Iran, which calls for extensive preventive efforts.

Mujeres que Consumen Sustancias y su Vulnerabilidad frente al VIH en Santiago de Chile (Women Who Consume Substances and Their Vulnerability to HIV in Santiago of Chile)

INTRODUCTION

Women represent 15% of the people living with HIV in Chile. Risk behaviors for HIV are: multiple partners, unsafe sex, and exchange of sex for drugs/money.

METHODOLOGY

A correlational design was used. A sample of 203 women who were sexually active and consumed substances within the last 3-months were selected for this study.

RESULTS

The average age of the participants was 32.4 years (SD = 9.2) and 68.1% were housewives. The substance most commonly used was alcohol (95.1%) and marijuana (49.8%); 23.7% of the women were drunk or drugged before having sex; 74.4% had multiple sexual partners and 95.6% had unprotected sex. There is a significant correlation (p < 0.05) between substance abuse and HIV risk behaviors.

CONCLUSION

It is necessary to develop more research to understand in depth the relationship between substance use and HIV risk among Chilean women. It is important to consider the use of substances to develop and implement HIV prevention programs in the Chilean community.

HIV risk perception and behavior among medically and traditionally circumcised males in South Africa

BACKGROUND

In South Africa, voluntary medical male circumcision (VMMC) has recently been implemented as a strategy for reducing the risk of heterosexual HIV acquisition among men. However, there is some concern that VMMC may lead to low risk perception and more risky sexual behavior. This study investigated HIV risk perception and risk behaviors among men who have undergone either VMMC or traditional male circumcision (TMC) compared to those that had not been circumcised.

METHODS

Data collected from the 2012 South African national population-based household survey for males aged 15 years and older were analyzed using bivariate and multivariate multinomial logistic regression, and relative risk ratios (RRRs) with 95 % confidence interval (CI) were used to assess factors associated with each type of circumcision relative no circumcision.

RESULTS

Of the 11,086 males that indicated that they were circumcised or not, 19.5 % (95 % CI: 17.9-21.4) were medically circumcised, 27.2 % (95 % CI: 24.7-29.8) were traditionally circumcised and 53.3 % (95 % CI: 50.9-55.6) were not circumcised. In the final multivariate models, relative to uncircumcised males, males who reported VMMC were significantly more likely to have had more than two sexual partners (RRR = 1.67, p = 0.009), and males who reported TMC were significantly less likely to be low risk alcohol users (RRR = 0.72, p < 0.001).

CONCLUSION

There is a need to strengthen and improve the quality of the counselling component of VMMC with the focus on education about the real and present risk for HIV infection associated with multiple sexual partners and alcohol abuse following circumcision.

Quantity Versus Quality: A Survey Experiment to Improve the Network Scale-up Method

The network scale-up method is a promising technique that uses sampled social network data to estimate the sizes of epidemiologically important hidden populations, such as sex workers and people who inject illicit drugs. Although previous scale-up research has focused exclusively on networks of acquaintances, we show that the type of personal network about which survey respondents are asked to report is a potentially crucial parameter that researchers are free to vary. This generalization leads to a method that is more flexible and potentially more accurate. In 2011, we conducted a large, nationally representative survey experiment in Rwanda that randomized respondents to report about one of 2 different personal networks. Our results showed that asking respondents for less information can, somewhat surprisingly, produce more accurate size estimates. We also estimated the sizes of 4 key populations at risk for human immunodeficiency virus infection in Rwanda. Our estimates were higher than earlier estimates from Rwanda but lower than international benchmarks. Finally, in this article we develop a new sensitivity analysis framework and use it to assess the possible biases in our estimates. Our design can be customized and extended for other settings, enabling researchers to continue to improve the network scale-up method.

Risk of HIV and Hepatitis B and C Over Time Among Men Who Inject Image and Performance Enhancing Drugs in England and Wales: Results From Cross-Sectional Prevalence Surveys, 1992-2013

BACKGROUND

Infection risks among people who inject drugs (PWID) are widely recognized, but few studies have focused on image and performance enhancing drugs (IPEDs). Globally, concern about IPED injection has increased and, in the United Kingdom, IPED injectors have become the largest group using Needle and Syringe Programmes. Blood-borne virus prevalence trends among IPED injectors are explored.

METHOD

Data from 2 surveys of IPED injectors (2010-2011; 2012-2013) and the national bio-behavioral surveillance system for PWID (1992-1997; 1998-2003; 2004-2009) were merged. Psychoactive drug injectors and women were excluded. Logistic regression analyses explored temporal changes.

RESULTS

Between 1992 and 2009, median age increased from 25 to 29 years (N = 1296), years injecting from 2 to 4. There were 53 men who had sex with men (MSM). Overall, 0.93% had HIV, 4.4% ever had hepatitis B (HBV), and 3.9% hepatitis C (HCV, from 1998, N = 1083). In multivariable analyses, HIV increased in 2004-2009 [adjusted odds ratio (AOR) = 10 (95% confidence interval (CI): 0.94 to 106) vs. 1992-2003], and remained elevated (AOR = 4.12, 95% CI: 0.31 to 54, 2012-2013); HBV also increased in 2004-2009 (AOR = 3.98, 95% CI: 1.59 to 9.97). HCV prevalence increase was only borderline significant (AOR = 2.47, 95% CI: 0.90 to 6.77, 2010-2011). HIV and HBV were associated with MSM and HCV with sharing needles/syringes. Uptake of diagnostic testing for HIV and HCV, and HBV vaccination increased (to 43%, 32% and 44% respectively). Condom use was consistently poor; needle/syringe sharing occurred.

CONCLUSION

Blood-borne virus prevalences among IPED injectors have increased and for HIV, is now similar to that among psychoactive drug injectors. Targeted interventions to reduce risks are indicated.

HIV-1 gp120 impairs the differentiation and survival of cord blood CD34+ HPCs induced to the erythroid lineage

Anemia is the most common hematological abnormality in human immunodeficiency virus (HIV)-infected patients. Besides chronic disease, opportunistic infections, nutritional deficiencies and antiretroviral drug toxicity, the direct role of HIV in the development of anemia has not yet been fully investigated. To explore the HIV-related mechanisms involved in the genesis of anemia, we used two experimental designs. In the first, HPCs purified from cord blood were challenged with HIV-1IIIb or recombinant gp120 (rgp120) and then committed to erythrocyte differentiation (EPO-post-treated HPCs). In the second, HPCs were first committed to differentiate towards the erythroid lineage and only afterwards challenged with HIV-1IIIb or rgp120 (EPO-pre-treated HPCs). Our results showed that HPCs and EPO-induced HPCs were not susceptible to HIV-1 infection. In addition, the two experimental designs (EPO post or pre-treated HPCs) independently showed that HIV-1IIIb or rgp120 were able to induce the impairment of survival, proliferation, and differentiation albeit differing in kinetics and extent. Interestingly, the gp120 interaction with CD4 and CXCR4 played a pivotal role in the impairment of erythrocyte differentiation by inducing TGF-b1 expression. These observations reveal an important additional mechanism involved in the genesis of anemia suggesting a complex competition between EPO-positive regulation and HIV-negative priming regarding erythrocyte survival, proliferation and maturation.

Feasibility of Identifying a Female Sex Worker Cohort at High Risk of HIV Infection in the Caribbean for HIV Vaccine Efficacy Trials: Longitudinal Results of HVTN 907

BACKGROUND

Identifying cohorts of Caribbean women with HIV infection rates sufficient for inclusion in HIV vaccine efficacy trials has been challenging. HVTN 907 determined the feasibility of identifying and retaining a cohort of women at high risk for HIV acquisition by focusing recruitment on female sex workers (FSWs).

METHODS

HIV uninfected FSWs, residing in Haiti, Dominican Republic, and Puerto Rico, who reported unprotected sex and met previously described more stringent site-specific eligibility criteria, were eligible. Behavioral risk assessment, HIV counseling and testing, and pregnancy testing were performed at baseline, 6, 12, and 18 months.

RESULTS

Among 799 FSWs (264 from Dominican Republic, 334 from Haiti, and 201 from Puerto Rico), the median age was 26 years, with 54% having less than a high school education and 45% having a monthly household income of less than $US 100. Median number of male partners 6 months before screening was 200. Retention at 18 months was 93%. Twelve women became HIV infected, 9 from Haiti. The annualized HIV incidence was 1.07% (95% confidence interval: 0.55% to 1.87%). Pregnancy incidence was 22.5% (95% confidence interval: 21.9% to 29.5%). Statistically significant declines in risk behaviors occurred between screening and the 18-month visit assessment.

DISCUSSION

The HVTN 907 study identified a high-risk cohort of women with excellent retention for all 3 sites, despite major challenges especially in Haiti. These results show that a bridging study of a vaccine shown to be efficacious in other clade settings would be possible among FSWs in the region, particularly in Haiti.

Sexual Behavior and Network Characteristics and Their Association with Bacterial Sexually Transmitted Infections among Black Men Who Have Sex with Men in the United States

Background

Black men who have sex with men (MSM) have a high prevalence of bacterial sexually transmitted infections (STIs), and individual risk behavior does not fully explain the higher prevalence when compared with other MSM. Using the social-ecological framework, we evaluated individual, social and sexual network, and structural factors and their association with prevalent STIs among Black MSM.

Methods

The HIV Prevention Trials Network 061 was a multi-site cohort study designed to determine the feasibility and acceptability of a multi-component intervention for Black MSM in six US cities. Baseline assessments included demographics, risk behavior, and social and sexual network questions collected information about the size, nature and connectedness of their sexual network. Logistic regression was used to estimate the odds of having any prevalent sexually transmitted infection (gonorrhea, chlamydia, or syphilis).

Results

A total of 1,553 Black MSM were enrolled in this study. In multivariate analysis, older age (aOR = 0.57; 95% CI 0.49–0.66, p<0.001) was associated with a lower odds of having a prevalent STI. Compared with reporting one male sexual partner, having 2–3 partners (aOR = 1.74; 95% CI 1.08–2.81, p<0.024) or more than 4 partners (aOR = 2.29; 95% CI 1.43–3.66, p<0.001) was associated with prevalent STIs. Having both Black and non-Black sexual partners (aOR = 0.67; 95% CI 0.45–0.99, p = 0.042) was the only sexual network factor associated with prevalent STIs.

Conclusions

Age and the number and racial composition of sexual partners were associated with prevalent STIs among Black MSM, while other sexual network factors were not. Further studies are needed to evaluate the effects of the individual, network, and structural factors on prevalent STIs among Black MSM to inform combination interventions to reduce STIs among these men.

Mortality, Causes of Death and Associated Factors Relate to a Large HIV Population-Based Cohort

INTRODUCTION

Antiretroviral therapy has led to a decrease in HIV-related mortality and to the emergence of non-AIDS defining diseases as competing causes of death. This study estimates the HIV mortality rate and their risk factors with regard to different causes in a large city from January 2001 to June 2013.

MATERIALS AND METHODS

We followed-up 3137 newly diagnosed HIV non-AIDS cases. Causes of death were classified as HIV-related, non-HIV-related and external. We examined the effect of risk factors on survival using mortality rates, Kaplan-Meier plots and Cox models. Finally, we estimated survival for each main cause of death groups through Fine and Gray models.

MORTALITY RESULTS

182 deaths were found [14.0/1000 person-years of follow-up (py); 95% confidence interval (CI):12.0-16.1/1000 py], 81.3% of them had a known cause of death. Mortality rate by HIV-related causes and non-HIV-related causes was the same (4.9/1000 py; CI:3.7-6.1/1000 py), external was lower [1.7/1000 py; (1.0-2.4/1000 py)].

SURVIVAL RESULTS

Kaplan-Meier estimate showed worse survival in intravenous drug user (IDU) and heterosexuals than in men having sex with men (MSM). Factors associated with HIV-related causes of death include: IDU male (subHazard Ratio (sHR):3.2; CI:1.5-7.0) and <200 CD4 at diagnosis (sHR:2.7; CI:1.3-5.7) versus ≥500 CD4. Factors associated with non-HIV-related causes of death include: ageing (sHR:1.5; CI:1.4-1.7) and heterosexual female (sHR:2.8; CI:1.1-7.3) versus MSM. Factors associated with external causes of death were IDU male (sHR:28.7; CI:6.7-123.2) and heterosexual male (sHR:11.8; CI:2.5-56.4) versus MSM.

CONCLUSION AND RECOMMENDATION

There are important differences in survival among transmission groups. Improved treatment is especially necessary in IDUs and heterosexual males.

Epidemiology of Drug Use and HIV-Related Risk Behaviors among People Who Inject Drugs in Mwanza, Tanzania

Heroin trafficking and consumption has increased steadily over the past decade in Tanzania, but limited information regarding HIV and drug use exists for the city of Mwanza. Our study investigates the epidemiology of drug use, and HIV risk behaviors among drug users in the northwestern city of Mwanza. Using a combination of targeted sampling and participant referral, we recruited 480 participants in Mwanza between June and August 2014. The sample was 92% male. Seventy-nine (16.4%) participants reported injecting heroin, while 434 (90.4%) reported smoking heroin. Unstable housing and cohabitation status were the only socioeconomic characteristics significantly associated with heroin injection. More than half of heroin injectors left syringes in common locations, and half reported sharing needles and syringes. Other risk behaviors such as lack of condom use during sex, and the use of illicit drugs during sex was widely reported as well. Among the study sample, there was poor awareness of health risks posed by needle/syringe sharing and drug use. Our results show that heroin use and HIV risk related behaviors are pressing problems that should not be ignored in Mwanza. Harm reduction programs are urgently needed in this population.

Exploring Contextual Factors of Youth Homelessness And Sexual Risk Behaviors: A Qualitative Study

CONTEXT

HIV disproportionately affects homeless youth, and interventions to date have had minimal success in reducing sexual risk behaviors in this population. Few qualitative studies have been conducted to provide insight into the influence of homelessness-related factors on sexual risk behaviors.

METHODS

A qualitative study with a quantitative component was conducted with a nonprobability sample of 64 homeless youth aged 14-24; participants were recruited from a variety of venues in Houston between October 2013 and March 2014. Thirteen focus group discussions were conducted; thematic analysis was used to identify themes related to HIV risk.

RESULTS

Participants were predominantly black (75%), sheltered (67%) and aged 18 or older (77%). Youth discussed how the circumstances of their homelessness and the struggle to meet their immediate needs led to behaviors and experiences that put them at risk for HIV. Three themes emerged: Homeless youth frequently engage in risky sexual behavior, sometimes as a way to cope with stress; they often trade sex, either voluntarily or involuntarily, for such necessities as money or a place to sleep; and many experienced childhood sexual victimization or have been victimized since becoming homeless. Youth also described how stress, stigma and self-reliance contributed to their involvement in HIV risk behaviors.

CONCLUSIONS

HIV prevention methods that target stress and stigma while respecting youths' self-reliance may help reduce sexual risk behaviors. Further research is needed to determine suitable behavioral change techniques to address these potentially modifiable factors.