Maintaining low HIV seroprevalence in populations of injecting drug users

Attitudes toward pharmacy-based HCV/HIV testing among people who use drugs in rural Kentucky

PURPOSE

Rural areas of the United States have experienced outbreaks of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections among people who use drugs (PWUD). Pharmacy-based interventions may play a crucial role in prevention and entry into care, especially when traditional health care access is limited. The willingness of rural PWUD to use pharmacies for HIV/HCV-related services remains unknown. The purpose of this study was to describe the factors associated with the perceived likelihood of participating in free pharmacy-based HIV and HCV testing among PWUD living in rural Kentucky.

METHODS

Baseline data from the CARE2HOPE study in five Appalachian counties in eastern Kentucky were used. Participants were recruited using respondent-driven sampling and completed interviewer-administered surveys. Guided by the Andersen and Newman Framework of Health Services Utilization, we examined distributions and correlates of items regarding willingness to participate in free pharmacy-based HIV/HCV testing using logistic regression. Analyses included individuals who reported being HIV (N = 304) or HCV (N = 185) negative.

FINDINGS

Seventy-five percent of PWUD reported being "very likely" to participate in free pharmacy-based HIV testing and 80% for HCV testing. Two factors were associated with being less willing to participate in free HIV testing: PWUD who previously tested for HIV (OR: 0.47, CI: 0.25-0.88) and PWUD who obtained a high school diploma or equivalent compared to those who completed less (OR: 0.50, CI: 0.26-0.99).

CONCLUSION

Free pharmacy-based HIV and HCV testing was invariably acceptable among most of the rural PWUD in our sample, suggesting that pharmacies might be acceptable testing venues for this population.

Principles of Harm Reduction for Young People Who Use Drugs

In summarizing the proceedings of a longitudinal meeting of experts on substance use disorders among adolescents and young adults, we review 2 principles of care related to harm reduction for young adults with substance use disorders. The first is that harm reduction services are critical to keeping young adults alive and healthy and can offer opportunities for future engagement in treatment. Such services therefore should be offered at every opportunity, regardless of an individual's interest or ability to minimize use of substances. The second is that all evidence-based harm reduction strategies available to older adults should be available to young adults and that whenever possible, harm reduction programs should be tailored to young adults and be developmentally appropriate.

Peer-to-peer injection: Demographic, drug use, and injection-related risk factors

BACKGROUND

Peer-to-peer injection (either providing or receiving an injection to/from a person who injects drugs [PWID]) is common (19%-50%) among PWID. Most studies of peer-to-peer injection have focused on receiving injection assistance, with fewer examining providing injection assistance and none considering characteristics of PWID who do both. We examined characteristics of PWID by peer-to-peer injection categories (receiving, providing, both, and neither) and determined if these behaviors were associated with receptive and distributive syringe sharing.

METHODS

Los Angeles and San Francisco PWID (N = 777) were recruited using targeted sampling methods and interviewed during 2011-2013. Multinomial logistic regression was used to determine characteristics associated with peer-to-peer injection categories and logistic regression was used to examine if peer-to-peer categories were independently associated with distributive and receptive syringe sharing.

RESULTS

Recent peer-to-peer injection was reported by 42% of PWID (18% provider; 14% recipient; 10% both). In multinomial regression analysis, PWID reporting any peer-to-peer injection were more likely to inject with others than those who did neither. Injection providers and those who did both were associated with more frequent injection, illegal income source, and methamphetamine injection while injection recipients were associated with fewer years of injection. Injection providers were younger, had more years of injecting, and were more likely to inject heroin than PWID who did neither. In multivariate analyses, we found that providers and PWID who did both were significantly more likely to report receptive and distributive syringe sharing than PWID who did neither.

CONCLUSION

Peer-to-peer injection is associated with HIV/HCV risk. Current prevention strategies may not sufficiently address these behaviors. Modification of existing interventions and development of new interventions to better respond to peer-to-peer injection is urgently needed.

Young Drug Users: a Vulnerable Population and an Underutilized Resource in HIV/HCV Prevention

PURPOSE OF REVIEW

The social networks of people who inject drugs (PWID) have long been studied to understand disease transmission dynamics and social influences on risky practices. We illustrate how PWID can be active agents promoting HIV, HCV, and overdose prevention.

RECENT FINDINGS

We assessed drug users' connections and interactions with others at risk for HIV/HCV in three cities: New York City (NYC), USA (n = 539); Pereira, Colombia (n = 50); and St. Petersburg, Russia (n = 49). In all three cities, the majority of participants' network members were of a similar age as themselves, yet connections across age groups were also present. In NYC, knowing any opioid user(s) older than 29 was associated with testing HCV-positive. In NYC and St. Petersburg, a large proportion of PWID engaged in intravention activities to support safer injection and overdose prevention; in Pereira, PWID injected, had sex, and interacted with other key groups at risk. People who use drugs can be active players in HIV/HCV and overdose risk- reduction; their networks provide them with ample opportunities to disseminate harm reduction knowledge, strategies, and norms to others at risk. Local communities could augment prevention programming by empowering drug users to be allies in the fight against HIV and facilitating their pre-existing health-protective actions.

Heterosexual male and female disparities in HIV infection at the end of an epidemic: HIV infection among persons who inject drugs in New York City, 2001-2005 and 2011-2015

BACKGROUND

We examined whether sex disparities (heterosexual male:female) in HIV infection continue to persist at the "end of the HIV epidemic" among persons who inject drugs (PWID) in New York City (NYC). An "end of the epidemic" was operationally defined as 1) prevalence of untreated HIV infection <5%, and 2) estimated HIV incidence <0.5/100 person-years.

METHODS

PWID were recruited from persons entering substance use treatment programs at Mount Sinai Beth Israel in 2001-2005 and 2011-2015. A structured interview was administered, and HIV and HSV-2 testing was conducted. Incidence was estimated using newly diagnosed cases of HIV. Disparity analyses compared prevalence of HIV, of untreated HIV, HIV risk behaviors, and estimated HIV incidence.

RESULTS

By 2011-2015, both heterosexual male and female PWID met the two criteria for an "end of the epidemic," and there were no significant differences in the prevalence of untreated HIV infection. A large sex difference remained in estimated HIV incidence. In 2013-2015, estimated HIV incidence was 2.8/10,000 PY for males and 7.1/10,000 PY for females. Females had greater risk for HIV on several factors.

CONCLUSION

While NYC has reached an "end of the epidemic" for both heterosexual male and female PWID, sex disparities persist, particularly differences in HIV incidence. Eliminating the sex disparities may require a greater focus on factors associated with sexual transmission.

Racial/Ethnic Disparities at the End of an HIV Epidemic: Persons Who Inject Drugs in New York City, 2011-2015

OBJECTIVES

To examine whether racial/ethnic disparities persist at the "end of the HIV epidemic" (prevalence of untreated HIV infection < 5%; HIV incidence < 0.5 per 100 person-years) among persons who inject drugs (PWID) in New York City.

METHODS

We recruited 2404 PWID entering New York City substance use treatment in 2001 to 2005 and 2011 to 2015. We conducted a structured interview, and testing for HIV and herpes simplex virus 2 (HSV-2; a biomarker for high sexual risk). We estimated incidence by using newly diagnosed cases of HIV. Disparity analyses compared HIV, untreated HIV, HIV-HSV-2 coinfection, HIV monoinfection, and estimated HIV incidence among Whites, African Americans, and Latinos.

RESULTS

By 2011 to 2015, Whites, African Americans, and Latino/as met both criteria of our operational "end-of-the-epidemic" definition. All comparisons that included HIV-HSV-2-coinfected persons had statistically significant higher rates of HIV among racial/ethnic minorities. No comparisons limited to HIV monoinfected persons were significant.

CONCLUSIONS

"End-of-the-epidemic" criteria were met among White, African American, and Latino/a PWID in New York City, but elimination of disparities may require a greater focus on PWID with high sexual risk.

Challenges in initiating antiretroviral therapy for all HIV-infected people regardless of CD4 cell count

Introduction

Recently published large randomized controlled trials, START, TEMPRANO and HPTN 052 show the clinical benefit of early initiation of antiretroviral treatment (ART) in HIV-infected persons and in reducing HIV transmission. The trials influenced the World Health Organization (WHO) decision to issue updated recommendations to prescribe ART to all individuals living with HIV, irrespective of age and CD4 cell count.

Discussion

It is clear that the new 2015 WHO recommendations if followed, will change the face of the HIV epidemic and probably curb its burden over time. Implementation however, requires that health systems, especially those in low and middle-income settings, be ready to face this challenge on a large scale. HIV prevention and treatment are easy in theory yet hard in practice. The new WHO guidelines for initiation of ART regardless of CD4 cell count will lead to upfront increases in the costs of healthcare delivery as the goal is to treat all those now newly eligible for ART. Around 22 million people living with HIV qualify and will therefore require ART. Related challenges immediately follow: firstly, that everyone must be tested for HIV; secondly, that anyone who has had an HIV test should know their result and understand its significance; and, thirdly, that every person identified as HIV-positive should receive and remain on ART. The emergence of HIV drug resistant strains when treatment is started at higher CD4 cell count thresholds is a further concern as persons on HIV treatment for longer periods of time are at increased risk of intermittent medication adherence.

Conclusions

The new WHO recommendations for ART are welcome, but lacking as they fail to consider meaningful solutions to the challenges inherent to implementation. They fail to incorporate actual strategies on how to disseminate and adopt these far-reaching guidelines, especially in sub-Saharan Africa, an area with weak healthcare infrastructures. Well-designed, high-quality research is needed to assess the feasibility, safety, acceptability, impact, and cost of innovations such as the universal voluntary testing and immediate treatment approaches, and broad consultation must address community, human rights, ethical, and political concerns.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0179-9) contains supplementary material, which is available to authorized users.

HCV/HIV coinfection among people who inject drugs and enter opioid substitution treatment in Greece: prevalence and correlates

Background

HCV/HIV coinfection in people who inject drugs is a public health issue, which presents a variety of challenges to healthcare providers. The determinants of HCV/HIV coinfection in this population are nonetheless not well known. The aim of the present study is to identify the factors associated with HCV/HIV coinfection in people who inject drugs and enter drug-related treatment.

Methods

Linked serological and behavioral data were collected from people who entered 38 opioid substitution treatment clinics in central and southern Greece between January and December 2013. Three mutually exclusive groups were defined based on the presence of HCV and HIV antibodies. Group 1 clients had neither infection, Group 2 had HCV but not HIV, and Group 3 had HCV/HIV coinfection. Multinomial logistic regression analyses identified differences between groups according to socio-demographic, drug use and higher-risk behavioral characteristics.

Results

Our study population consisted of 580 people who injected drugs in the past 12 months (79.8 % males, with median age 36 years).79.4 % were HCV and 15.7 % HIV infected. Of those with complete serological data in both HCV and HIV indicators, 20.4 % were uninfected, 64.0 % HCV monoinfected, and 14.9 % HCV/HIV coinfected. HCV infection with or without HIV coinfection was positively associated with living alone or with a spouse/partner without children, prior incarceration, drug injecting histories of ≥10 years, and syringe sharing in the past 12 months, and negatively associated with never having previously been tested for HCV. HCV/HIV coinfection, but not HCV infection alone, was positively associated with residence in urban areas (relative risk ratio [RRR] = 4.8, 95 % confidence interval [CI]: 1.7–13.7, p = 0.004) and averaging >3 injections a day in the past 30 days (RRR = 4.5, 95 % CI: 1.6–12.8, p = 0.005), and negatively associated with using a condom in the last sexual intercourse.

Conclusions

People who inject drugs and live in urban areas and inject frequently have higher risk of coinfection. Findings highlight the need for scaling-up needle and syringe programs in inner city areas and promoting access of this population to screening and treatment, especially in prisons. The protective role of living with parents and children could inform the implementation of indicated interventions.

Risk Environments, Race/Ethnicity, and HIV Status in a Large Sample of People Who Inject Drugs in the United States

INTRODUCTION

We analyzed relationships between place characteristics and being HIV-negative among black, Latino, and white people who inject drugs (PWID) in the US.

METHODS

Data on PWID (N = 9077) were from the Centers for Disease Control and Prevention's 2009 National HIV Behavioral Surveillance. Administrative data were analyzed to describe the 968 ZIP codes, 51 counties, and 19 metropolitan statistical areas (MSAs) where they lived. Multilevel multivariable models examined relationships between place characteristics and HIV status. Exploratory population attributable risk percents (e-PAR%s) were estimated.

RESULTS

Black and Latino PWID were more likely to be HIV-negative if they lived in less economically disadvantaged counties, or in MSAs with less criminal-justice activity (i.e., lower drug-related arrest rates, lower policing/corrections expenditures). Latino PWID were more likely to be HIV-negative in MSAs with more Latino isolation, less black isolation, and less violent crime. E-PAR%s attributed 8-19% of HIV cases among black PWID and 1-15% of cases among Latino PWID to place characteristics.

DISCUSSION

Evaluations of structural interventions to improve economic conditions and reduce drug-related criminal justice activity may show evidence that they protect black and Latino PWID from HIV infection.

Heroin Use and Injection Risk Behaviors in Colombia: Implications for HIV/AIDS Prevention

BACKGROUND

Heroin production in Colombia has increased dramatically in recent decades, and some studies point to an increase in local heroin use since the mid-1990s. Despite this rapid increase, little is known about the effects of these activities on heroin injection within Colombia. One of the biggest concerns surrounding heroin injection is the potential spread of HIV through drug user networks.

OBJECTIVES

This article examines injection risk behaviors among heroin injectors in the Colombian cities of Medellín and Pereira to explore the implications for possible increased HIV transmission within this group.

METHODS

A cross-sectional study used respondent-driving sampling to recruit a sample of 540 people who inject drugs (PWID) over 18 years of age (Medellín: n = 242, Pereira: n = 298). Structured interviews with each participant were conducted using the World Health Organization Drug Injection Study Phase II Survey. An HIV test was also administered.

RESULTS

Information regarding the socio-demographics, injection drug use, HIV risk and transmission behaviors, injection risk management, and HIV knowledge and prevalence of participants are reported. The study identified many young, newly initiated injectors who engage in risky injection practices. The study also found that HIV prevalence is fairly low among participants (2.7%).

CONCLUSIONS/IMPORTANCE

Findings indicate a potential risk for the spread of HIV among PWID in Colombia given their widespread sharing practices, high rate of new injector initiation, and unsafe syringe cleaning practices. Colombia has a possibly time-limited opportunity to prevent an HIV epidemic by implementing harm reduction interventions among young, newly initiated PWID.

Injecting Drug Users Retention in Needle-Exchange Program and its Determinants in Iran Prisons

BACKGROUND

Participation and to stay in a health program depends on many factors. One of these programs is Needle Exchange Program (NEP) in prisons.

OBJECTIVES

The current study aimed to evaluate the retention of injecting drug prisoners and find the related factors in Iran.

PATIENTS AND METHODS

This cohort study analyzed data about injecting drug male prisoners who were participated in NEP in three Iranian prisons. Data was collected from October 2009 to June 2010. A proper approach of survival analyses including Kaplan-Meier method, Log-Rank test, and Cox Proportional Hazard Model were used to evaluate Injecting Drug Users (IDUs) retention in NEP and its determinants.

RESULTS

Out of 320 prisoners, 167 were from Isfahan Central Prison, 82 from Tehran-Ghezel-Hesar Prison, and 71 from Hamadan Central Prison. Two-hundred and fifty prisoners (78.4%) had history of drug injection; and drug injection was the most common choice for 115 persons (35.9%). Participants were followed up for 29 weeks, the mean (SD) time of retention in the program was 24.1 (0.6) weeks. There was a significant relationship between age, number of used needles per week, duration of addiction, age of addiction onset, as well as imprisonment age, main method of drug use, type of main using drug, Hepatitis B Virus (HBV) infection, job status, reason of arrestment, history of involvement in harm reduction programs, and the length of retention (P < 0.05). There was also significant relationship between the history of using harm reduction services (P = 0.007), tattooing (P = 0.01), longer durations of addiction (P = 0.048), and retention.

CONCLUSIONS

Tattooing and longer duration of addiction were two important factors that significantly increased retention in the program. In contrast, history of using harm reduction services was the factor that decreased persistence. The risk of quitting the program may decrease about 68% in those who did not involve in harm reduction programs.

Labor migration, externalities and ethics: theorizing the meso-level determinants of HIV vulnerability

This paper discusses labor migration as an example of how focusing on the meso-level highlights the social processes through which structural factors produce HIV risk. Situating that argument in relation to existing work on economic organization and HIV risk as well as research on labor migration and HIV vulnerabilities, the paper demonstrates how analyzing the processes through which labor migration creates vulnerability can shift attention away from the proximate behavioral determinants of HIV risk and toward the community and policy levels. Further, it presents the concepts of externalities and the ethics of consumption, which underline how both producers and consumers benefit from low-waged migrant labor, and thus are responsible for the externalization of HIV risk characteristic of supply chains that rely on migrant labor. These concepts point to strategies through which researchers and advocates could press the public and private sectors to improve the conditions in which migrants live and work, with implications for HIV as well as other health outcomes.

30 Years on Selected Issues in the Prevention of HIV among Persons Who Inject Drugs

After 30 years of extensive research on human immunodeficiency virus (HIV) among persons who inject drugs (PWID), we now have a good understanding of the critical issues involved. Following the discovery of HIV in 1981, epidemics among PWID were noted in many countries, and consensus recommendations for interventions for reducing injection related HIV transmission have been developed. While high-income countries have continued to develop and implement new Harm Reduction programs, most low-/middle-income countries have implemented Harm Reduction at very low levels. Modeling of combined prevention programming including needle exchange (NSP) and antiretroviral therapy (ARV) suggests that NSP be given the highest priority. Future HIV prevention programming should continue to provide Harm Reduction programs for PWID coupled with interventions aimed at reducing sexual transmission. As HIV continues to spread in low- and middle-income countries, it is important to achieve and maintain high coverage of Harm Reduction programs in these locations. As PWID almost always experience multiple health problems, it will be important to address these multiple problems within a comprehensive approach grounded in a human rights perspective.

Transitions from injection-drug-use-concentrated to self-sustaining heterosexual HIV epidemics: patterns in the international data

BACKGROUND

Injecting drug use continues to be a primary driver of HIV epidemics in many parts of the world. Many people who inject drugs (PWID) are sexually active, so it is possible that high-seroprevalence HIV epidemics among PWID may initiate self-sustaining heterosexual transmission epidemics.

METHODS

Fourteen countries that had experienced high seroprevalence (<20%) HIV epidemics among PWID and had reliable data for injection drug use (IDU) and heterosexual cases of HIV or AIDS were identified. Graphs of newly reported HIV or AIDS cases among PWID and heterosexuals were constructed to identify temporal relationships between the two types of epidemics. The year in which newly reported cases among heterosexuals surpassed newly reported cases among PWID, aspects of the epidemic curves, and epidemic case histories were analyzed to assess whether it was "plausible" or "highly unlikely" that the HIV epidemic among PWID might have initiated the heterosexual epidemic in each country.

RESULTS

Transitions have occurred in 11 of the 14 countries. Two types of temporal relationships between IDU and heterosexual HIV epidemics were identified, rapid high incidence transitions vs. delayed, low incidence transitions. In six countries it appears "plausible" that the IDU epidemic initiated a heterosexual epidemic, and in five countries it appears "highly unlikely" that the IDU epidemic initiated a heterosexual epidemic. A rapid decline in incidence among PWID after the peak year of new cases and national income were the best predictors of the "highly unlikely" initiation of a heterosexual epidemic.

DISCUSSION

Transitions from IDU concentrated epidemics to heterosexual epidemics are common in countries with high seroprevalence among PWID though there are distinct types of transitions. Interventions to immediately reduce HIV incidence among PWID may reduce the likelihood that an IDU epidemic may initiate a heterosexual epidemic.

Toward a comprehensive approach to HIV prevention for people who use drugs

Comprehensive HIV prevention interventions are increasingly recognized as critical in the global effort to reduce HIV transmission among people who use injection drugs. Scientific evidence clearly shows that a variety of biomedical, behavioral, and structural interventions can prevent and reduce injection drug user-driven HIV epidemics, yet social and structural barriers to their implementation remain. This review discusses the scientific evidence on the effectiveness of individual programs for reducing HIV incidence among people who use injection drugs and how, by integrating individual programs as complements within a comprehensive HIV prevention approach, it is possible to achieve, and to sustain, greater results than those of individual programs alone. The article concludes with a discussion of a critical research priority; namely, to improve the implementation of comprehensive HIV prevention interventions in settings of prevalent injection drug use and to overcome the often complex barriers that impede them. Such an effort will require more than research alone, however. It will also require the ongoing commitment of policymakers, public health officials, and the affected communities themselves to use comprehensive HIV treatment and prevention as the most effective strategy to reduce new HIV infections.

Spatial access to syringe exchange programs and pharmacies selling over-the-counter syringes as predictors of drug injectors' use of sterile syringes

OBJECTIVES

We examined relationships of spatial access to syringe exchange programs (SEPs) and pharmacies selling over-the-counter (OTC) syringes with New York City drug injectors' harm reduction practices.

METHODS

Each year from 1995 to 2006, we measured the percentage of 42 city health districts' surface area that was within 1 mile of an SEP or OTC pharmacy. We applied hierarchical generalized linear models to investigate relationships between these exposures and the odds that injectors (n = 4003) used a sterile syringe for at least 75% of injections in the past 6 months.

RESULTS

A 1-unit increase in the natural log of the percentage of a district's surface area within a mile of an SEP in 1995 was associated with a 26% increase in the odds of injecting with a sterile syringe; a 1-unit increase in this exposure over time increased these odds 23%. A 1-unit increase in the natural log of OTC pharmacy access improved these odds 15%.

CONCLUSIONS

Greater spatial access to SEPs and OTC pharmacies improved injectors' capacity to engage in harm reduction practices that reduce HIV and HCV transmission.

HIV infection during limited versus combined HIV prevention programs for IDUs in New York City: the importance of transmission behaviors

OBJECTIVES

As no single HIV prevention program has eliminated HIV transmission, there is growing interest in the effectiveness of "combined" prevention programming. To compare HIV infection among persons injecting in the initial programs environment (IPE) in New York City (self-initiated risk reduction, methadone, education/outreach, and HIV testing) to HIV infection among persons injecting in a combined programs environment (CPE) (above programs plus large-scale syringe exchange). To identify potential behavioral mechanisms through which combined programs are effective.

METHODS

Subjects were recruited from the Beth Israel drug detoxification program. A risk behavior questionnaire was administered and HIV testing conducted. Subjects who injected only between 1984 and 1994 (IPE) were compared to subjects who injected only between 1995 and 2008 (CPE).

RESULTS

261 IPE subjects and 1153 CPE subjects were recruited. HIV infection was significantly lower among the CPE subjects compared to IPE subjects: prevalence 6% versus 21%, estimated incidence 0.3/100 person-years versus 4/100 person-years (both p<0.001). The percentage of subjects at risk of acquiring HIV through receptive syringe sharing was similar across CPE and IPE subjects (30% versus 33%). The percentage of subjects at risk of transmitting HIV through injection-related behaviors (who were both HIV seropositive and reported passing on used needles/syringes), was much lower among the CPE subjects than among the IPE subjects (1% versus 10%, p<0.001).

CONCLUSIONS

Combined prevention programs can greatly reduce HIV transmission. Reducing distributive sharing by HIV seropositive injecting drug users (IDUs) may be a critical component in reducing HIV transmission in high seroprevalence settings.

Learning from HIV epidemics among injecting drug users

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.

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

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 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.

From research to community-based practice--working with Latino researchers to translate and diffuse a culturally relevant evidence-based intervention: the Modelo de Intervención Psicomédica (MIP) experience

Efforts to translate, package, and diffuse HIV/AIDS research into practice have gained momentum with the Centers for Disease Control and Prevention's (CDC's) launch of three projects: the Prevention Research Synthesis Project, which identifies evidence-based interventions studies; the Replicating Effective Programs Project, which supports the translation of evidence-based interventions into materials suitable for use in local prevention programs; and the Diffusion of Effective Behavioral Interventions Project, which moves behavioral interventions into full-scale practice across the United States. This article describes the CDC's fast-track process of translation, packaging, and diffusion of an HIV intervention for Hispanic/Latino injection drug users, the Modelo de Intervención Psicomédica conducted by the Diffusion of Effective Behavioral Interventions Project in collaboration with a CBA organization and the original researchers.

HIV seroprevalence in a sample of Tanzanian intravenous drug users

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 sub-Saharan Africa. The factors associated with increased risk of HIV infection suggest further research is needed on the needle use and sexual networks of IDUs.

Harm reduction policies in Argentina: a critical view

The concept of 'harm' underpinning current drug harm reduction policies is most often limited to viral infections and other health consequences for drug users. This paper analyses harm reduction policies in Argentina, with the purpose of challenging and extending this narrow conception of harm to encompass all harms inflicted on drug users, in a context of criminalization of drug use and poverty. Faced with a steep rise in poverty, rapid changes in drug use practices, the quality and prices of drugs, and patterns of morbidity and mortality, Argentina has implemented harm reduction policies specifically for drug users who mostly live in the Greater Buenos Aires impoverished areas. These changes, as well as the Latin American tradition of social and health policies that focus on the collective, subjective, and political-economic aspects of harm, highlight some tensions between the individualistic, public health model structured in the North and its application in Argentina.

The epidemic history of hepatitis C among injecting drug users in Flanders, Belgium

We employed recently developed statistical methods to explore the epidemic behaviour of hepatitis C subtype 1a and subtype 3a among injecting drug users (IDUs) in Flanders, Belgium, using new gene sequence data sampled among two geographically distinct populations of IDUs. First the extent of hepatitis C transmission across regions/countries was studied through calculation of association indices. It was shown that viral exchange had occurred between both populations in Flanders as well as across international borders. Furthermore, evidence was found suggestive of subtypes 1a and 3a predominantly circulating in subpopulations of Flemish IDUs, exhibiting different degrees of travelling/migration behaviour. Secondly, through coalescent-based analysis the viral epidemic history of the hepatitis C subtype 1a and 3a epidemics was inferred. Evidence was found for different dynamic forces driving both epidemics. Moreover, results suggested that the hepatitis C subtype 3a epidemic has reached a steady state, while the hepatitis C 1a epidemic has not, which therefore might become the predominant subtype among IDUs.

HIV, hepatitis C, and hepatitis B infections and associated risk behavior in injection drug users, Kabul, Afghanistan

Behavior of injection drug users increases the risk for an HIV epidemic.

Limited prevalence data for HIV, hepatitis B surface antigen (HBsAg), and hepatitis C virus (HCV) exist for Afghanistan. We studied a cross-sectional sample of adult injection drug users (IDUs) in Kabul, Afghanistan, from June 2005 through June 2006. Study participants completed interviewer-administered questionnaires and underwent testing for HIV, antibody to HCV, and HBsAg. Overall prevalences of HIV, HCV, and HBsAg were 3.0% (95% confidence interval [CI] 1.7%–5.1%), 36.6% (95% CI 32.2%–41.0%), and 6.5% (95% CI 4.2%–8.7%), respectively (N = 464). Among male IDUs (n = 463), risky behavior, including sharing syringes (50.4%), paying women for sex (76.2%), and having sex with men or boys (28.3%), were common. Needle sharing, injecting for >3 years, and receiving injections from nonmedical providers were independently associated with increased risk for HCV infection. The high prevalence of risky behavior indicate that Kabul is at risk for an HIV epidemic. Scale-up of harm-reducing interventions is urgently needed.

Burden of HIV infection among aboriginal injection drug users in Vancouver, British Columbia

OBJECTIVES

We sought to examine whether there were differential rates of HIV incidence among Aboriginal and non-Aboriginal injection drug users in a Canadian setting.

METHODS

Data were derived from 2 prospective cohort studies of injection drug users in Vancouver, British Columbia. Using the Kaplan-Meier method and Cox proportional hazards regression, we compared HIV incidence among Aboriginal and non-Aboriginal participants.

RESULTS

Overall, 2496 individuals were recruited between May 1996 and December 2005. Compared with that of non-Aboriginal persons, the baseline HIV prevalence was higher among Aboriginal persons (16.0% vs 25.1%; P<.001). Among participants who were HIV negative at baseline, the cumulative HIV incidence at 48 months was higher among Aboriginal persons (18.5% vs 9.5%; P<.001). In multivariate analyses, Aboriginal ethnicity was independently associated with elevated HIV incidence (relative hazard=1.59; 95% confidence interval=1.12, 2.26; P=.009).

CONCLUSIONS

Aboriginal persons in Vancouver had a significantly elevated burden of HIV infection, which calls for a culturally sensitive and evidence-based response. Policymakers in other settings with at-risk Aboriginal populations should seek to avert similar public health emergencies by being proactive with evidence-based HIV-prevention programs.

Residual injection risk behavior, HIV infection, and the evaluation of syringe exchange programs

This study assessed relationships between residual risk behavior (risk behavior among persons participating in effective HIV prevention programs) and HIV infection. Structured interviews and HIV tests were obtained from participants in six large U.S. syringe exchange programs. Program characteristics were obtained through interviews with the directors. Findings indicated that injection risk behaviors varied significantly across the six programs--from 10% to 27% of the participants at each program reported receptive sharing of needles and syringes in the 30 days prior to the interview. HIV prevalence ranged from 2.5% to 22.2% across the six programs. HIV prevalence among new injectors was strongly related to HIV prevalence among long-term injectors across the programs (r = .869). There was a consistent pattern of negative relationships between injection risk behaviors and HIV infection across the six programs (higher rates of risk behavior at a program associated with lower HIV infection). As a result, appropriate evaluation of HIV prevention programs may require not only information on continuing risk behavior and HIV infection among program participants but also historical information on the epidemiology of HIV in the local community.

Lower injection-related HIV-1 risk associated with participation in a harm reduction program in Kazan, Russia

This study was carried out to investigate the extent of unsafe practices associated with participation in a harm reduction program in Kazan, Russian Federation. In this cross-sectional study a convenience sample of active drug injectors encountered by the field outreach teams was interviewed. Demographic data and information on injection drug use were obtained using a structured survey instrument. Comparisons between program clients and newly encountered individuals not yet engaged by the program were made. Clients were divided into four groups based on the duration and intensity of their interaction with the program. Clients were found to be less likely than newly encountered injectors to give away or use previously used syringes, more likely to have used a new syringe the last time they injected with others, and more likely to be able to anticipate their need to acquire new syringes. However, the sharing of nonsyringe injection paraphernalia was no different between clients and newly encountered injectors. Despite the limitations of a cross-sectional study, it appears that engagement with the harm reduction program in Kazan was associated with reduction in many aspects of unsafe injecting.

Summary of findings from the evaluation of a pilot medically supervised safer injecting facility

In many cities, infectious disease and overdose epidemics are occurring among illicit injection drug users (IDUs). To reduce these concerns, Vancouver opened a supervised safer injecting facility in September 2003. Within the facility, people inject pre-obtained illicit drugs under the supervision of medical staff. The program was granted a legal exemption by the Canadian government on the condition that a 3-year scientific evaluation of its impacts be conducted. In this review, we summarize the findings from evaluations in those 3 years, including characteristics of IDUs at the facility, public injection drug use and publicly discarded syringes, HIV risk behaviour, use of addiction treatment services and other community resources, and drug-related crime rates. Vancouver's safer injecting facility has been associated with an array of community and public health benefits without evidence of adverse impacts. These findings should be useful to other cities considering supervised injecting facilities and to governments considering regulating their use.

Psychiatric barriers to readiness for treatment for hepatitis C Virus (HCV) infection among injection drug users: clinical experience of an addiction psychiatrist in the HIV-HCV coinfection clinic of a public health hospital

Among injection drug users, psychological and psychiatric barriers to readiness for treatment for hepatitis C virus (HCV) infection include mood and anxiety disorders, cognitive deficits, temperament disorders, and personality vulnerabilities, as well as ongoing drug use. Many aspects of these barriers can be overcome with direct treatment or social support. To establish effective treatment for HCV infection in this population of patients, it is essential that the patient and providers develop a rapport that allows for active communication. It is also important that the patient make an effort to adhere to the treatment requirements and that the patient receive the appropriate evaluation and management of treatable barriers.

Outpatient substance abuse treatment and HIV prevention: an update

Testing and counseling, along with community outreach, have been identified as valuable in the prevention of human immunodeficiency virus (HIV) and other blood-borne diseases. This article assesses the extent to which outpatient substance abuse treatment (OSAT) programs provide such services. Longitudinal data for 1988-2000 were analyzed from the National Drug Abuse Treatment System Survey (NDATSS). Random-effects regression was used to examine factors associated with the provision of prevention services. HIV testing, which had became more common between 1990 and 1995, continued to proliferate between 1995 and 2000. The proportion of units that provide HIV testing and counseling increased from 66% to 86%. The proportion of units that provide HIV community outreach increased significantly before 1995 but then slightly decreased from 77% to 73% between 1995 and 2000. In conclusion, HIV testing and counseling widely proliferated in OSAT care. However, OSAT units remain less likely to offer HIV community outreach services.

Evidence for a substantial role of sharing of injecting paraphernalia other than syringes/needles to the spread of hepatitis C among injecting drug users

In industrialized countries, transmission of hepatitis C occurs primarily through injecting drug use. Transmission of hepatitis C in injecting drug users is mainly associated with the sharing of contaminated syringes/needles, although evidence for risk of hepatitis C infection through sharing of other injecting paraphernalia is increasing. In this paper, the independent effects of sharing paraphernalia other than syringes/needles have been estimated. The prevalence and force of infection were modelled using three serological data sets from drug users in three centres in Belgium as a function of the sharing behaviour. It was found that sharing of materials other than syringes/needles indeed seemed to contribute substantially to the spread of hepatitis C among injecting drug users.

Diffusion of the D.A.R.E and syringe exchange programs

We examined the diffusion of the D.A.R.E program to reduce use of illicit drugs among school-aged children and youths and the diffusion of syringe exchange programs to reduce HIV transmission among injection drug users. The D.A.R.E program was diffused widely in the United States despite a lack of evidence for its effectiveness; there has been limited diffusion of syringe exchange in the United States, despite extensive scientific evidence for its effectiveness. Multiple possible associations between diffusion and evidence of effectiveness exist, from widespread diffusion without evidence of effectiveness to limited diffusion with strong evidence of effectiveness. The decision theory concepts of framing and loss aversion may be useful for further research on the diffusion of public health innovations.

Neighborhood and HIV infection among IDU: place of residence independently predicts HIV infection among a cohort of injection drug users

This study was undertaken to investigate geographic residence in Vancouver's Downtown Eastside (DTES), Canada's poorest urban neighborhood, as an environmental risk factor for HIV infection among a cohort of injection drug users. HIV incidence rates were examined using Kaplan-Meier methods, and Cox proportional hazards regression was used to determine independent risk factors for HIV seroconversion. After intensive multivariate adjustment, DTES residence remained an independent predictor of HIV seroconversion (relative hazard=2.0, 95% CI: 1.4-3.0, p<0.001). These findings indicate the need for a greater recognition among policy-makers of geographic location as a risk factor for HIV incidence in urban settings and the need for further research to determine why place contributes so greatly to HIV risk. The findings also mark a need for prevention interventions to be appropriately targeted towards high-risk neighborhoods.

Service uptake and characteristics of injection drug users utilizing North America's first medically supervised safer injecting facility

In 2003, the city of Vancouver, British Columbia, opened North America's first government-sanctioned safer injecting facility, where injection drug users (IDUs) can inject preobtained illicit drugs under the supervision of nurses. Use of the service by IDUs was followed by measurable reductions in public drug use and syringe sharing. IDUs who are frequently using the program tend to be high-intensity cocaine and heroin injectors and homeless individuals. The facility has provided high-risk IDUs a hygienic space where syringe sharing can be eliminated and the risk of fatal overdose reduced. Ongoing evaluation will be required to assess its impact on overdose rates and HIV infection levels, as well as its ability to improve IDU contact with medical care and addiction treatment.

Using standardized methods for research on HIV and injecting drug use in developing/transitional countries: case study from the WHO Drug Injection Study Phase II

BACKGROUND

Successful cross-national research requires methods that are both standardized across sites and adaptable to local conditions. We report on the development and implementation of the methodology underlying the survey component of the WHO Drug Injection Study Phase II--a multi-site study of risk behavior and HIV seroprevalence among Injecting Drug Users (IDUs).

METHODS

Standardized operational guidelines were developed by the Survey Coordinating Center in collaboration with the WHO Project Officer and participating site Investigators. Throughout the duration of the study, survey implementation at the local level was monitored by the Coordinating Center. Surveys were conducted in 12 different cities. Prior rapid assessment conducted in 10 cities provided insight into local context and guided survey implementation. Where possible, subjects were recruited both from drug abuse treatment centers and via street outreach. While emphasis was on IDUs, non-injectors were also recruited in cities with substantial non-injecting use of injectable drugs. A structured interview and HIV counseling/testing were administered.

RESULTS

Over 5,000 subjects were recruited. Subjects were recruited from both drug treatment and street outreach in 10 cities. Non-injectors were recruited in nine cities. Prior rapid assessment identified suitable recruitment areas, reduced drug users' distrust of survey staff, and revealed site-specific risk behaviors. Centralized survey coordination facilitated local questionnaire modification within a core structure, standardized data collection protocols, uniform database structure, and cross-site analyses. Major site-specific problems included: questionnaire translation difficulties; locating affordable HIV-testing facilities; recruitment from drug treatment due to limited/selective treatment infrastructure; access to specific sub-groups of drug users in the community, particularly females or higher income groups; security problems for users and interviewers, hostility from local drug dealers; and interference by local service providers.

CONCLUSION

Rapid assessment proved invaluable in paving the way for the survey. Central coordination of data collection is crucial. While fully standardized methods may be a research ideal, local circumstances may require substantial adaptation of the methods to achieve meaningful local representation. Allowance for understanding of local context may increase rather than decrease the generalizability of the data.

Impact of a medically supervised safer injection facility on community drug use patterns: a before and after study

PROBLEM

Illicit use of injected drugs is linked with high rates of HIV infection and fatal overdose, as well as community concerns about public drug use. Supervised injecting facilities have been proposed as a potential solution, but fears have been raised that they might encourage drug use.

DESIGN

A before and after study. Participants and setting 871 injecting drug users recruited from the community in Vancouver, Canada.

KEY MEASURES FOR IMPROVEMENT

Rates of relapse into injected drug use among former users and of stopping drug use among current users.

STRATEGIES FOR CHANGE

Local health authorities established the Vancouver supervised injecting facility to provide injecting drug users with sterile injecting equipment, intervention in the event of overdose, primary health care, and referral to external health and social services.

EFFECTS OF CHANGE

Analysis of periods before and after the facility's opening showed no substantial increase in the rate of relapse into injected drug use (17% v 20%) and no substantial decrease in the rate of stopping injected drug use (17% v 15%).

LESSONS LEARNT

Recently reported benefits of supervised injecting facilities on drug users' high risk behaviours and on public order do not seem to have been offset by negative community impacts.

Patterns of drug use among a sample of drug users and injecting drug users attending a General Practice in Iran

AIM

This study aimed to examine drug use, drug treatment history and risk behaviour among a sample of Iranian drug users seeking treatment through a general practice clinic in Iran.

METHODS

Review of medical records and an intake questionnaire at a large general practice in Marvdasht, Iran, with a special interest in drug dependence treatment. Records from a random sample of injecting drug users (IDU), non-injecting drug users (DU) and non-drug using patients were examined.

RESULTS

292 records were reviewed (34% IDU, 31% DU and 35% non-drug users). Eighty-three percent were males; all females were non-drug users. The mean age of the sample was 30 years. Of the IDU sample, 67% reported sharing a needle or syringe, 19% of these had done so in prison. Of those who had ever used drugs, being 'tired' of drug use was the most common reason for seeking help (34%). Mean age of first drug use was 20 years. The first drugs most commonly used were opium (72%), heroin (13%) and hashish/ other cannabinoids (13%). Three quarters reported having previously attempted to cease their drug use. IDU were more likely than DU to report having ever been imprisoned (41% vs 7%) and 41% to have used drugs in prison.

CONCLUSION

This study has shown that there is a need for general practice clinics in Iran to treat drug users including those who inject and that a substantial proportion of those who inject have shared needles and syringes, placing them at risk of BBVI such as HIV and hepatitis C. The expansion of services for drug users in Iran such as needle and syringe programs and pharmacotherapies are likely to be effective in reducing the harms associated with opium use and heroin injection.

Behavior change and health-related interventions for heterosexual risk reduction among drug users

Prevention of heterosexual transmission of HIV between and from drug users is important for controlling the local and global HIV heterosexual epidemic. Sex risk reduction interventions and health-related interventions are important for reducing the sex risk behaviors of drug users. Sex risk reduction interventions address individual-level, peer-level, and structural-level determinants of risk reduction. Health-related interventions include HIV counseling and testing, prevention and treatment of sexually transmitted diseases, and delivery of highly active antiretroviral therapy. It is important to adapt effective interventions implemented in resource-rich countries to the realities of the resource-constrained settings and to address relevant contextual factors.

"Vivo para consumirla y la consumo para vivir" ["I live to inject and inject to live"]: high-risk injection behaviors in Tijuana, Mexico

Injection drug use is a growing problem on the US-Mexico border, where Tijuana is situated. We studied the context of injection drug use among injection drug users (IDUs) in Tijuana to help guide future research and interventions. Guided in-depth interviews were conducted with 10 male and 10 female current IDUs in Tijuana. Topics included types of drug used, injection settings, access to sterile needles, and environmental influences. Interviews were taped, transcribed verbatim, and translated. Content analysis was conducted to identify themes. Of the 20 IDUs, median age and age at first injection were 30 and 18. Most reported injecting at least daily: heroin ("carga", "chiva", "negra"), methamphetamine ("crico", "cri-cri"), or both drugs combined. In sharp contrast to Western US cities, almost all regularly attended shooting galleries ("yongos" or "picaderos") because of the difficulties obtaining syringes and police oppression. Almost all shared needles/paraphernalia ["cuete" (syringe), "cacharros" (cookers), cotton from sweaters/socks (filters)]. Some reported obtaining syringes from the United States. Key themes included (1) pharmacies refusing to sell or charging higher prices to IDUs, (2) ample availability of used/rented syringes from "picaderos" (e.g., charging approximately 5 pesos or "10 drops" of drug), and (3) poor HIV/AIDS knowledge, such as beliefs that exposing syringes to air "kills germs." This qualitative study suggests that IDUs in Tijuana are at high risk of HIV and other blood-borne infections. Interventions are urgently needed to expand access to sterile injection equipment and offset the potential for a widespread HIV epidemic.

The impact of changes to heroin supply on blood-borne virus notifications and injecting related harms in New South Wales, Australia

Background

In early 2001 Australia experienced a sudden and unexpected disruption to heroin availability, know as the 'heroin shortage'. This 'shortage has been linked to a decrease in needle and syringe output and therefore possibly a reduction in injecting drug use. We aimed to examine changes, if any, in blood-borne viral infections and presentations for injecting related problems related to injecting drug use following the reduction heroin availability in Australia, in the context of widespread harm reduction measures.

Methods

Time series analysis of State level databases on HIV, hepatitis B, hepatitis C notifications and hospital and emergency department data. Examination of changes in HIV, hepatitis B, hepatitis C notifications and hospital and emergency department admissions for injection-related problems following the onset of the heroin shortage; non-parametric curve-fitting of number of hepatitis C notifications among those aged 15–19 years.

Results

There were no changes observed in hospital visits for injection-related problems. There was no change related to the onset heroin shortage in the number of hepatitis C notifications among persons aged 15–19 years, but HCV notifications have subsequently decreased in this group. No change occurred in HIV and hepatitis B notifications.

Conclusion

A marked reduction in heroin supply resulted in no increase in injection-related harm at the community level. However, a delayed decrease in HCV notifications among young people may be related. These changes occurred in a setting with widespread, publicly funded harm reduction initiatives.

A description of a peer-run supervised injection site for injection drug users

Owing to the ongoing health crisis among injection drug users in Vancouver, Canada, there have been repeated calls for the establishment of supervised injection sites (SIS) since the early 1990s. In April 2003, a group of advocates and drug users opened an unsanctioned SIS in Vancouver's Downtown Eastside. The "327 SIS" operated for 184 days. During the operation of the SIS, volunteers supervised over 3,000 injections by a high-risk injection drug using population. The SIS provided a sterile environment for injection drug use without measured negative consequences and demonstrated the feasibility of a peer-driven low-threshold SIS.

Changes in HIV and AIDS in the United States: Entering the third decade

The epidemiology of the HIV transmission in the United States has changed considerably since the epidemic began. Our increased understanding of the virus has fostered development of new treatments to prolong life, and vaccine research has increased hope for those at risk in both developed and less developed countries. In this review, we provide information about current trends in HIV and AIDS among those in the United States most affected by the epidemic.

Changes in HIV and AID in the United States: Entering the third decade

The epidemiology of the HIV transmission in the United States has changed considerably since the epidemic began. Our increased understanding of the virus has fostered development of new treatments to prolong life, and vaccine research has increased hope for those at risk in both developed and less developed countries. In this review, we provide information about current trends in HIV and AIDS among those in the United States most affected by the epidemic.