Young injectors: a comparative analysis of risk behaviour

A cross-sectional study describing factors associated with utilisation of GP services by a cohort of people who inject drugs

Background

People who inject drugs (PWID) use healthcare services, including primary care, at a disproportionately high rate. We investigated key correlates of general practitioner (GP) related service utilisation within a cohort of PWID.

Methods

Using baseline data from a cohort of 645 community-recruited PWID based in Melbourne, Victoria, we conducted a secondary analysis of associations between past month use of GP services unrelated to opioid substitution therapy (OST) and socio-demographic and drug use characteristics and self-reported health using multivariate logistic regression.

Results

Just under one-third (29%) of PWID had accessed GP services in the month prior to being surveyed. Participants who reported living with children (adjusted odds ratio, AOR 1.97, 95% CI 1.04 - 3.73) or having had contact with a social worker in the past month (AOR 1.92, 95% CI 1.24 - 2.98) were more likely to have seen a GP in the past month. Participants who were injecting daily or more frequently (AOR 0.50, 95% CI 0.30 - 0.83) or had a weekly income of less than $400 (AOR 0.59, 95% CI 0.38 - 0.91) were less likely to report having seen a GP in the past month.

Conclusions

Our sample frequently attended GP services for health needs unrelated to OST. Findings highlight both the characteristics of PWID accessing GP services and also those potentially missing out on primary care and preventive services.

Prevalence of HIV infection and risk behaviors among younger and older injecting drug users in the United States, 2009

This study compared HIV sero-prevalence and risk behaviors between younger and older injecting drug users (IDUs). IDUs aged ≥18 years were interviewed for the 2009 National HIV Behavioral Surveillance System. Using GEE regression, we assessed characteristics of younger (18-29 years) and older (≥30 years) IDUs, and factors associated with past 12-month receptive syringe sharing and unprotected sex (vaginal/anal). Of 10,090 participants, 10 % were younger. HIV sero-prevalence was lower among younger than older IDUs (4 vs. 10 %, p = 0.001). Younger IDUs were more likely (p ≤ 0.002) to be non-black race/ethnicity, report higher household income, homelessness, being arrested and to engage in receptive syringe sharing and unprotected sex. In multivariable models, age remained associated (p < 0.001) with receptive syringe sharing (aPR = 1.14, 95 % CI1.07-1.22) and unprotected sex (aPR = 1.10, 95 % CI1.06-1.14). Although younger IDUs had lower HIV prevalence, their behaviors place them at increased risk of HIV infection and could lead to a rapid spread in this susceptible population.

Modelling the prevalence of HCV amongst people who inject drugs: an investigation into the risks associated with injecting paraphernalia sharing

BACKGROUND

In order to prevent the spread of the hepatitis C virus (HCV) amongst people who inject drugs (PWID), it is imperative that any injecting risk behaviour which may contribute to the transmission of disease has its role quantified. To inform public health organisations, mathematical modelling techniques were used to explore the risk of HCV infection through the sharing of injecting paraphernalia (including filters, cookers and water).

METHODS

A mathematical model was developed for the spread of HCV based on the injecting behaviour of PWID in Scotland, with transmission occurring through the sharing of needles/syringes and other injecting paraphernalia. Numerical simulations were used to estimate the transmission probability for HCV through the sharing of injecting paraphernalia such that the modelled endemic HCV prevalence fitted with that observed amongst PWID in Scotland.

RESULTS

The transmission probability of HCV through injecting paraphernalia was modelled to be over 8 times lower than that through needles/syringes (approximately 0.19-0.30% and 2.5%, respectively), assuming transmission occurs through a combination of at least filters and cookers. In the context of reported needle/syringe and paraphernalia sharing rates in Scotland, it is estimated that 38% and 62% of HCV infections are contributed by these practices, respectively. If needle/syringe sharing rates were to be twice those reported, the contributions would be 70% and 30%, respectively.

CONCLUSION

Given that the sharing of injecting paraphernalia among PWID is common, HCV transmission through this route could be contributing to the growing healthcare burden associated with this chronic disease. Every effort should therefore be made to establish (a) the contribution that paraphernalia sharing is making to the spread of HCV, and (b) the effectiveness of services providing sterile paraphernalia in preventing infection.

Analysis of duration of risk behaviour for key populations: a literature review

Background

The objective of this paper is to review literature in order to calculate regional estimates of the average duration of time individuals maintain a specific high-risk behaviour.

Methods

The review targeted the key populations of female sex workers (FSW), male clients of female sex workers (MCFSW), people who inject drugs (injecting drug users (IDU)) and high-risk men who have sex with men (MSM). To be included in the review the study had to provide information on (1) the time a person spent at risk until death or cessation of the risk behaviour, (2) the percentage of the sample who initiated the risk behaviour in less than a year or (3) the mean or median duration of the behaviour from a representative sample.

Results

49 papers were found for the FSW population describing the period of time FSW stay in sex work to be between 2.9 years (Asia) and 12 years (Latin America). Eight papers were found for MCFSW showing the duration of the risk behaviour in this category varying from 4.6 years in Africa to 32 years in Asia. 86 papers were reviewed for the population of IDU showing that the average time a person injects illegal drugs varies from 5.6 years (Africa) to 21 years (South America). No information was found for duration of high-risk behaviour among MSM; instead, the definitions found in the literature for high- and low-risk behaviour among MSM were described.

Conclusions

There is high variability of estimates of duration of high-risk behaviours at regional level. More research is needed to inform models and prevention programmes on the average duration of time individuals maintain a specific high-risk behaviour.

Utilization patterns and correlates of retention among clients of the needle exchange program in Baltimore, Maryland

NEP effectiveness at a population level depends on several factors, including the number of injection drug users (IDUs) retained, or consistently accessing services. Patterns of retention in the Baltimore Needle Exchange Program (BNEP) from 1994 to 2006 were calculated using enrollment surveys and client records. We used Andersen's Behavioral Model of Health Services Use to frame our examination of factors associated with retention. Client retention was measured in two ways: whether a client returned to the exchange within 12 months of enrollment and how many times a client returned within these 12 months. BNEP clients (N=12,388) were predominantly male (69%), African-American (73%), and >or=age 30 (86%). Nearly two-thirds (64%) of clients returned within 12 months of their first BNEP visit. The median number of return visits per client within 12 months was one (IQR: 0-5). Young age (<30), being married, having an injection drug use history of less than 20 years, and living farther from the BNEP site were characteristics independently associated with both measures of low retention in multivariate analysis. Among younger injectors, geographical proximity was a particularly important predictor of retention. Further insight into the influence of these factors may help in developing programmatic changes that will be effective in increasing retention.

Changes in HIV prevalence and risk among new injecting drug users in a Russian city of high HIV prevalence

OBJECTIVE

To measure HIV prevalence and associated risk factors among recent initiates into drug injecting in 2001 and 2004 in Togliatti City, Russian Federation.

DESIGN

Two unlinked, anonymous, cross-sectional, community-recruited surveys of injecting drug users (IDUs) with oral fluid samples for anti-HIV testing.

METHODS

IDUs completed an interviewer-administered questionnaire, and oral fluid samples were tested for antibodies to HIV. Demographic characteristics and injecting risk behaviors were compared between subsamples of IDUs who reported injecting for 3 years or less in each of the survey years, 2001 (n = 138) and 2004 (n = 96). Univariable and multivariable analyses explored risk factors with anti-HIV among these new injectors.

RESULTS

Among IDUs overall, although HIV prevalence was high, a lower prevalence was found in 2004 (38.5%, 95% confidence interval [CI]: 34.1 to 42.9) than in 2001 (56%, 95% CI: 51.2 to 60.8). A significantly lower prevalence of HIV was found among new injectors in 2004 (11.5%, 95% CI: 5.0 to 17.9) than in 2001 (55.2%, 95% CI: 46.7 to 63.8). Proportionally, fewer new injectors reported injecting daily, injecting with used needles/syringes, and frontloading in 2004 compared with 2001. Decreased odds of anti-HIV were associated with being recruited in 2004 and with a history of drug treatment. Increased odds of HIV were associated with exchanging sex, duration of injection, and frontloading.

CONCLUSIONS

Findings indicate a decrease in HIV prevalence among new injectors between 2001 and 2004 and emphasize the role of provision of needle/syringes through pharmacies and providing access to voluntary HIV testing. These findings have implications for other cities in which explosive HIV outbreaks have occurred.

Transition to injection drug use among street youth--a qualitative analysis

OBJECTIVES

To examine social contexts and processes influencing transition to drug injection among street youth.

METHODS

42 street youth participated in in-depth interviews. A typology of experiences was built founded on youth's street life and drug use trajectories. The transition to drug injection was examined through these experiences.

RESULTS

We identified five types of mutually exclusive experiences. The "downtowner's" experience is characterised by early street life and drug consumption trajectories, and a strong identification with the downtown milieu. These youth progress from one drug to another and, in a milieu where drug injection is omnipresent, this escalation culminates in transition to injection. The "tripper" street life and substance use trajectories begin later and are less intense. Most "tripper" youth are already chronic hallucinogens users when they arrive in downtown Montréal. Although they judge "junkies" severely, they show some ambivalence towards injection. The "on the go" experience is characterised by trajectories of drug use and street life that are intermingled, leading to a loss of control. These youth, who often have serious delinquent behaviours, come to downtown Montréal to party and consume drugs, mostly stimulants. Their drug use pattern and network make them at high risk of starting cocaine injection. The "hard-luck's" experience is characterised by a lack of identification with the downtown milieu. These youth who use drugs recreationally, end up in the streets accidentally, often because of unemployment. The "alcoholic' experience is related to alcohol misuse. These youth usually end up in the streets due to this dependence. Their street involvement is mostly an experience of solitude. The risk of transitioning to injection for both these types is low.

CONCLUSIONS

Some combinations of street life and drug use trajectories seem to contribute to injection among street youth. Some important factors interact and increase the risk of street youth transitioning to injection: poor personal assets; early rupture with primary social institutions; social integration into subcultures where both street life and "drug trips" are fashionable, drug preferences and the local drug market.

Perceived risk, peer influences, and injection partner type predict receptive syringe sharing among young adult injection drug users in five U.S. cities

OBJECTIVES

This study examined risk factors for receptive syringe sharing (RSS) during illicit drug injection by persons 15-30 years old in five U.S. cities.

METHODS

Participants were recruited through street outreach and respondent-driven referrals in Baltimore, Chicago, Los Angeles, New York, and Seattle between May 2002 and January 2004. Surveys of drug use, sexual behaviors, and correlates were administered through audio computer-assisted self-interviews at baseline and, for the subset of participants who enrolled in an HIV/HCV prevention intervention trial, at 3-months and 6-months post-baseline. The proportions of injections involving RSS at baseline and at follow-up were used as outcomes in multivariate models that adjusted for intervention effects.

RESULTS

At baseline, 54% of 3128 participants reported RSS in the past 3 months. RSS decreased to 21% at 6-months post-baseline for the combined trial arms. Participants were more likely to report RSS if they perceived that their peers were not against RSS and if they injected with sex partners. Lower levels of perceived risk of infection with HIV (baseline, p<.001) or HCV (follow-up, p<.001) through RSS were also significant predictors of greater RSS.

CONCLUSIONS

Perceived risks, peer influences, and type of injection partner were robust predictors of RSS. Perceived risks and peer influences are particularly amenable to intervention efforts that may prevent RSS in this age group.

Cessation of injecting drug use among street-based youth

Young injecting drug users (IDUs) are at high risk for a number of negative health outcomes such as hepatitis B, hepatitis C, and human immunodeficiency virus (HIV) infection. However, very little is known about injecting drug-use patterns among this population, particularly with respect to cessation of injection. We sought to identify the factors associated with cessation of injection in a population of young street-based IDUs. A prospective cohort study design was used to assess long-term (> or = 1 year) cessation of drug injection. Data was collected between January 1995 and September 2000 in Montreal, Québec, Canada. Subjects were originally recruited from various street-based outreach programs in Montreal and, for this study, had to have reported injecting drugs within the prior 6 months at baseline or during follow-up and had to have completed at least two semiannual follow-up questionnaires. Cessation incidence rates stratified by duration of injection and adjusted hazard ratios (AdjHRs) were calculated. A Cox proportional hazards regression model was used to identify risk factors independently associated with cessation of drug injection. Of 502 young IDUs, 305 subjects met the inclusion criteria. Cessation of injection for approximately 1 year or more occurred in 119 (39%) of the young IDUs. The incidence of cessation was 32.6/100 person-years but consistently declined as duration of time spent injecting increased. Independent predictors of cessation of injection were currently injecting on a less than monthly or less than weekly basis (HR = 6.4; 95% confidence interval (CI): 3.0-13.6 and HR = 2.4; 95% CI = 1.1-5.3, respectively); currently injecting two or fewer different types of drug (HR = 2.1; 95% CI = 1.1-4.0); currently employed (HR = 1.7; 95% CI = 1.1-2.7); and having at least one parent born outside of Canada (HR = 1.4; 95% CI = 1.1-1.7). Independent predictors of not ceasing injection were currently attending a needle-exchange program (HR = 0.5; 95% CI = 0.3-0.8); and current homelessness (HR = 0.6; 95% CI = 0.4-1.0). The early sharp decline in cessation of drug injection followed by a consistent decrease in this rate suggest difficulties in breaking the habit later on in the drug injecting career. Intensity of drug use and factors which may help to stabilize the social environment of the young IDU may also influence the ability to stop injecting.

Le « partage » des matériels d’injection chez les jeunes usagers de drogues injectables de Montréal

Cette étude visait à déterminer dans quels contextes les jeunes de la rue qui s’injectent des drogues « partagent » des matériels d’injection. Nous avons mené des entrevues en profondeur auprès de 24 jeunes (15 à 22 ans) recrutés avec l’aide d’organismes communautaires et par la technique de « snowballing ». Au moment de la première injection, ces jeunes sont peu préoccupés par les risques d’infection et s’inquiètent davantage du risque de développer une dépendance. Cependant, ceux qui persistent sont conscients des risques associés au « partage » de seringues et considèrent qu’il s’agit d’une pratique à éviter dans une ville où les programmes de prévention fournissent l’accès gratuit aux seringues. Ce n’est toutefois pas le cas pour les autres matériels d’injection. Les contextes de vulnérabilité par rapport au « partage » se constituent au carrefour de plusieurs facteurs qui sont à la fois d’ordre individuel et social. Certains moments critiques dans la trajectoire de vie des jeunes par rapport à la consommation de drogues et à la vie dans la rue ainsi qu’un degré élevé d’intimité entre partenaires d’injection les fragilisent pour ce qui est des pratiques non sécuritaires.

Interventions de prévention efficaces contre le VIH et l’hépatite C chez les jeunes utilisateurs de drogues par injection (UDI)

La dernière décennie a été marquée par une augmentation importante du nombre de pays rapportant que l’injection de drogues est présente dans leur population. Et, dans plusieurs pays, particulièrement dans ceux en voie de développement, la plupart des nouveaux injecteurs ont entre 15 et 24 ans. De nombreuses conséquences sociales et sanitaires sont associées à l’injection de drogues, les principales conséquences de type infectieux étant l’hépatite C et l’infection par le virus de l’immunodéficience humaine (VIH). Nous présenterons dans cet article les comportements d’injection et les comportements sexuels des injecteurs adolescents et jeunes adultes qui en font des personnes à risque pour ces deux infections. Nous y décrirons également des caractéristiques de ces jeunes injecteurs, qui sont liées à leur âge, dont il faut tenir compte dans l’élaboration de programmes de prévention : besoins liés au développement cognitif, physique et psychologique et aux contraintes d’ordre légal. Finalement, nous exposerons les résultats d’une vaste recherche que nous avons menée dans la littérature en vue de trouver des projets de prévention de l’infection par le VIH et de l’hépatite C qui ont répondu aux besoins spécifiques des jeunes injecteurs et qui ont fait l’objet d’une évaluation. Cette recherche a démontré qu’il existe très peu d’interventions satisfaisantes dans ce domaine. Selon nous, il est urgent que de telles interventions soient développées, évaluées et diffusées afin de contrer les épidémies de VIH et d’hépatite C qui sévissent chez les jeunes injecteurs.

Between-city variation in frequency of injection among Puerto Rican injection drug users: East Harlem, New York, and Bayamon, Puerto Rico

Frequency of injection has been consistently found to be higher among Puerto Rican Injection drug users (IDUs) than among other groups of IDUs. Several explanations have been suggested, but an empirical explanation has yet to be presented. This study compares the frequency of injection of Puerto Rican IDUs in East Harlem, New York, with that of IDUs in Bayamon, Puerto Rico. Study subjects comprised 521 Puerto Rican IDUs from East Harlem and 303 IDUs from Bayamon. The mean frequency of injection among IDUs in East Harlem was 2.8, the corresponding mean in Bayamon was 5.4. Younger IDUs reported a higher number of daily injection episodes than older IDUs, and the IDU group in Bayamon was 5 years younger than the group in East Harlem. The drug use variables accounted for a greater portion of the between-city difference than the demographic and psychosocial variables. Use of noninjected drugs, as well as the use of prescribed methadone, were found to be associated with a lower number of daily injections. Conversely, injection of cocaine, injection of cocaine mixed with heroin ("speedball"), and injection of larger amounts of drug solution were found to be associated with a higher number of daily injections.

Blood-borne infections in Dublin's opiate users

BACKGROUND

Injecting drug users are at high risk of acquiring blood-borne infections. Ireland has had a harm reduction policy of methadone maintenance and needle exchange since 1992.

AIM

To estimate prevalence of hepatitis B, hepatitis C and HIV infection and appropriate uptake of hepatitis B vaccine in methadone attendees and to make recommendations for a simple record-based surveillance system.

METHOD

Retrospective study of 138 client records for evidence of laboratory tests or test results for blood-borne viruses and appropriate immunisation against hepatitis B.

RESULTS

A total of 60% of clients had evidence of one or more laboratory tests in their notes. Of those tested for individual viruses, 5.1% were positive for hepatitis B surface antigen, 78.8% had antibodies to hepatitis C and 16.7% were HIV positive. Nearly two-thirds of clients had no evidence of vaccination or information on prior immunity in their records.

CONCLUSIONS

A standardised written protocol for screening for blood-borne viruses and for immunisation against hepatitis B in methadone service attendees was clearly needed, and was subsequently introduced by the Eastern Region Health Authority.

Characteristics and utilization patterns of needle-exchange attendees in Chicago: 1994-1998

The objectives of this study were to describe characteristics and utilization patterns of participants attending a needle-exchange program (NEP) in Chicago, Illinois. Since 1994, demographics of NEP attendees and program utilization data were collected systematically at 22 sites operated by the Chicago Recovery Alliance (CRA). Descriptive statistics were used to assess time trends, site variations, and characteristics of attendees in day sites versus evening sites. A total of 11,855 injection drug users (IDUs) visited the NEP at least once from 1994 to 1998. Median age was 41 years, and 74% were male. Overall race distribution was African-American 50%, Caucasian 38%, Puerto Rican 10%, other 2%. Over time, there was a proportional decrease in African-American users (55.4% to 39.9%, P < .001), a significant increase in Puerto Rican users (1.4% to 14.1%, P < .001), and a stable proportion of Caucasian users (42%). Each year, 15-20% of all clients were first-time attenders. Overall, participants attending evening versus day sites were younger (median age 39 years vs. 42 years, P < .001) and more ethnically diverse. Over a 4-year period, this NEP reached a diverse population of IDUs and recruited a stable proportion of first-time users. Compared to daytime NEP venues, evening NEP sites attracted younger clients and those who were more diverse ethnically. To maximize coverage of sterile syringes, NEPs should strive for diversification in terms of hours of operation and location.

Sex- and drug-related risk among populations of younger and older injection drug users in adjacent neighborhoods in San Francisco

The objective of this study was to compare drug injection- and sex-related risk behaviors of younger and older injection drug users (IDUs) in two adjacent neighborhoods. IDUs were recruited from street settings in two adjacent neighborhoods in San Francisco in April, 1997. All participants were interviewed using a standardized questionnaire and were tested for HIV antibodies. Drug injection- and sex-related risk behaviors were compared between younger IDUs (< 30 years; n = 56) and older IDUs (> or = 30 years; n = 116). Younger IDUs were more likely to be white, be homeless, have injected amphetamines, and have been arrested in the past year. Older IDUs were more likely to be African American and smoke crack cocaine; they had injected a mean of 18 years longer. Younger IDUs were more likely to have shared syringes in the past month (52% versus 10%; p < .05), report drug overdose in the past 15 months (39% versus 7%; p < .05), and to have had unprotected vaginal intercourse in the past 6 months (77% versus 53%; p < .05). After controlling for confounding factors using logistic regression analysis, all these associations remained significant. There is an urgent need for innovative prevention programs that target younger, homeless IDUs.