Change in HIV-HCV risk-taking behavior and seroprevalence among opiate users seeking treatment over an 11-year period and harm reduction policy

Cost-effectiveness of drug consumption rooms in France: a modelling study

BACKGROUND

People who inject drugs (PWID) experience many health problems which result in a heavy economic and public health burden. To tackle this issue, France opened two drug consumption rooms (DCRs) in Paris and Strasbourg in 2016. This study assessed their long-term health benefits, costs and cost-effectiveness.

METHODS

We developed a model to simulate two fictive cohorts for each city (n=2,997 in Paris and n=2,971 in Strasbourg) i) PWID attending a DCR over the period 2016-2026, ii) PWID attending no DCR. The model accounted for HIV and HCV infections, skin abscesses and related infective endocarditis, drug overdoses and emergency department visits. We estimated the number of health events and associated costs over 2016-2026, the lifetime number of quality-adjusted life-years (QALYs) and costs, and the incremental cost-effectiveness ratio (ICER).

RESULTS

The numbers of abscesses and associated infective endocarditis, drug overdoses, and emergency department visits decreased significantly in PWID attending DCRs (-77%, -69%, and -65%, respectively) but the impact on HIV and HCV infections was modest (-11% and -6%, respectively). This resulted in savings of €6.6 (Paris) and €5.8 (Strasbourg) millions of medical costs. The ICER of DRCs was €30,600/QALY (Paris) and €9,200/QALY (Strasbourg). In scenario analysis where drug consumption spaces are implemented inside existing harm reduction structures, these ICERs decreased to €21,400/QALY and €2,500/QALY, respectively.

CONCLUSIONS

Our findings show that DCRs are highly effective and efficient to prevent harms in PWID in France, and advocate extending this intervention to other cities by adding drug consumption spaces inside existing harm reduction centers.

[Drug Consumption Rooms : Opinion and willingness among people who inject drugs in Marseille, France]

BACKGROUND

In France, people who inject drugs (PWID) are still one of the most at risk population for contracting hepatitis C virus (HCV). Drug consumption rooms (DCR) have shown their effectiveness on HCV risk behaviors abroad and in France, where they have been recently evaluated with the COSINUS study. In France, two DCRs opened in 2016, one in Paris and another in Strasbourg. The objective of this sub-analysis was to explore the willingness to use a DCR in PWID living in Marseille, where no DCR is opened.

METHODS

The COSINUS study is a prospective multicenter cohort that included 665 PWID recruited in Bordeaux, Marseille, Paris and Strasbourg between 2016 and 2019. Investigators administered questionnaires face-to-face at regular intervals at baseline, 3 months, 6 months and 12 months. In Marseille, 199 PWID were recruited. A multivariable logistic regression model was performed to assess factors associated with willingness to use DCR among this population.

RESULTS

Among 545 observations corresponding to 195 distinct participants selected for analyses, 57% declared they were willing to attend a DCR. The main reason given was "to consume more cleanly". Receiving allowances (OR = 2.38; 95% confidence interval (CI) (95% CI) = 1.17-4.81), not having health insurance (OR = 3.61; 95% CI = 1.49-8.75), injecting daily (OR = 1.97; 95% CI = 1.05-3.70) and in a public space (OR = 2.66; 95% CI = 1.29-5.47) were all positively associated with willingness to use a DCR.

CONCLUSIONS

DCR are devices that target PWID exposed to high sanitary or social risks, i.e. people living in precarious conditions, who have to inject in public spaces, in deleterious sanitary environments and with rapid gestures in order not to be seen. These analyzes highlight that the people who most want to attend a DCR are aware of the harms associated with their practices and show a desire to seek protection from street-based drug scenes.

Interventions to prevent HIV and Hepatitis C among people who inject drugs: Latest evidence of effectiveness from a systematic review (2011 to 2020)

BACKGROUND

Hepatitis C virus (HCV) and HIV remain prevalent among people who inject drugs (PWID) and transmission is usually associated with injecting risk behaviour (IRB). We update a 2011 review of reviews (RoR) to assess the latest evidence on the effectiveness of harm reduction interventions - drug treatment (including opioid agonist therapy [OAT]), needle and syringe programmes (NSP) and other interventions - in the prevention of HCV and HIV transmission, and related measures of infection risk (IRB and injecting frequency [IF]), among PWID.

METHODS

We undertook an initial search for systematic reviews (i.e. an Overview of Reviews [OoR]) and subsequent systematic searches for primary studies where required. Where there was sufficient evidence based on synthesis of multiple robust studies for an intervention effect in the 2011 RoR, new evidence was not sought. Medline, CINAHL, The Cochrane Library, EMBASE, PsycINFO and Web of Science were searched (2011-2020). Two reviewers screened papers, extracted data, and graded reviews/studies. We classified evidence as 'sufficient', 'tentative', 'insufficient', or 'no evidence'.

RESULTS

We screened 8513 reviews and 7133 studies, with 27 and 61 identified as relevant, respectively. The level of evidence increased since the 2011 RoR and is now 'sufficient' for OAT (regarding all outcomes), NSP (for reducing HIV transmission and IRB), and combination OAT/NSP (for reducing HCV transmission). There is also now sufficient evidence for in-prison OAT, psychosocial interventions, pharmacy-based NSP and provision of sterile drug preparation equipment for reducing IRB.

CONCLUSION

There is now a strong body of empirical evidence for the effectiveness of OAT and NSP, alone and in combination, in reducing IRB, and HCV and HIV transmission. However, there is still a relative lack of evidence for other interventions, including heroin-assisted treatment, pharmacological treatment for stimulant dependence, contingency management, technology-based interventions, low dead space syringes and drug consumption rooms on HCV or HIV risk.

Opportunities to Offer Harm Reduction to People who Inject Drugs During Infectious Disease Encounters: Narrative Review

Increased rates of overdose (OD) and blood-borne infections have been associated with injection drug use (IDU). This increasing overlap between IDU-related infectious diseases (ID) is a byproduct of the opioid OD crisis, especially with the transition to synthetic opioids with faster onset and shorter duration leading to potentially more frequent injections. ID specialists are uniquely positioned to positively impact the opioid OD crisis by capitalizing on opportunistic moments of engagement during clinical encounters with people who inject drugs (PWID). Harm reduction services should therefore be expanded and offered to PWID in ID settings to reduce rates of OD, infection, and hospitalization. Major target areas include (1) teaching and distribution of materials related to safer injection practice such as sterile injection supplies, fentanyl test strips, and naloxone; (2) increased screening and access to pre-exposure prophylaxis and postexposure prophylaxis; and (3) initiation of medications for opioid use disorder. Incorporating these strategies in various treatment settings can expand treatment access, improve patient outcomes, and reduce stigma associated with IDU.

Impact of drug consumption rooms on risk practices and access to care in people who inject drugs in France: the COSINUS prospective cohort study protocol

INTRODUCTION

The high prevalence of hepatitis C and the persistence of HIV and hepatitis C virus (HCV) risk practices in people who inject drugs (PWID) in France underlines the need for innovative prevention interventions. The main objective of this article is to describe the design of the COSINUS cohort study and outline the issues it will explore to evaluate the impact of drug consumption rooms (DCR) on PWID outcomes. Secondary objectives are to assess how DCR (a) influence other drug-related practices, such as the transition from intravenous to less risky modes of use, (b) reduce drug use frequency/quantity, (c) increase access to treatment for addiction and comorbidities (infectious, psychiatric and other), (d) improve social conditions and (e) reduce levels of violence experienced and drug-related offences. COSINUS will also give us the opportunity to investigate the impact of other harm reduction tools in France and their combined effect with DCR on reducing HIV-HCV risk practices. Furthermore, we will be better able to identify PWID needs.

METHODS AND ANALYSIS

Enrollment in this prospective multi-site cohort study started in June 2016. Overall, 680 PWID in four different cities (Bordeaux, Marseilles, Paris and Strasbourg) will be enrolled and followed up for 12 months through face-to-face structured interviews administered by trained staff to all eligible participants at baseline (M0), 3 month (M3), 6 month (M6) and 12 month (M12) follow-up visits. These interviews gather data on socio-demographic characteristics, past and current drug and alcohol consumption, drug-use related practices, access to care and social services, experience of violence (as victims), offences, other psychosocial issues and perception and needs about harm reduction interventions and services. Longitudinal data analysis will use a mixed logistic model to assess the impact of individual and structural factors, including DCR attendance and exposure to other harm reduction services, on the main outcome (HIV-HCV risk practices).

ETHICS AND DISSEMINATION

This study was reviewed and approved by the institutional review board of the French Institute of Medical Research and Health (opinion number: 14-166). The findings of this cohort study will help to assess the impact of DCR on HIV-HCV risk practices and other psycho-social outcomes and trajectories. Moreover, they will enable health authorities to shape health and harm reduction policies according to PWID needs. Finally, they will also help to improve current harm reduction and therapeutic interventions and to create novel ones.

Street-involved youth engaged in sex work at increased risk of syringe sharing

Syringe sharing places street-involved young people at risk of acquiring HIV and hepatitis C. While markers of economic marginalization, such as homelessness, have been linked with syringe sharing and have led to targeted interventions, the relationship between syringe sharing and other markers of economic vulnerability, such as sex work, are not well documented among young people. This study examines whether those engaged in sex work are at increased risk of syringe borrowing and syringe lending among street-involved youth who use injection drugs in Vancouver, Canada. Between September 2005 and May 2014, data was collected from the At-Risk Youth Study (ARYS), a prospective cohort of street involved youth aged 14-26. Generalized estimating equations with a confounding model building approach was used to examine the relationship between sex work and syringe borrowing and lending. 498 youth reported injecting drugs at some point during the study period and were therefore included in the analysis. In multivariable analysis, youth who engaged in sex work were at an elevated risk of both syringe borrowing (Adjusted Odds Ratio (AOR) = 2.17, 95% Confidence Interval [CI] = 1.40-3.36) and syringe lending (AOR = 1.66, 95% CI = 1.07-2.59). Our study found that youth engaged in street-based sex work were at a significantly higher risk of both syringe borrowing and lending among youth who use injection drugs in Vancouver. Ready access to clean syringes, safer working conditions for sex workers to enable risk reduction measures, and increased access to addiction treatment are identified as promising opportunities for reducing syringe sharing in this setting.

Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs

BACKGROUND

Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugsNeedle syringe programmes (NSP) and opioid substitution therapy (OST) are the primary interventions to reduce hepatitis C (HCV) transmission in people who inject drugs. There is good evidence for the effectiveness of NSP and OST in reducing injecting risk behaviour and increasing evidence for the effectiveness of OST and NSP in reducing HIV acquisition risk, but the evidence on the effectiveness of NSP and OST for preventing HCV acquisition is weak.

OBJECTIVES

To assess the effects of needle syringe programmes and opioid substitution therapy, alone or in combination, for preventing acquisition of HCV in people who inject drugs.

SEARCH METHODS

We searched the Cochrane Drug and Alcohol Register, CENTRAL, the Cochrane Database of Systematic Reviews (CDSR), the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment Database (HTA), the NHS Economic Evaluation Database (NHSEED), MEDLINE, Embase, PsycINFO, Global Health, CINAHL, and the Web of Science up to 16 November 2015. We updated this search in March 2017, but we have not incorporated these results into the review yet. Where observational studies did not report any outcome measure, we asked authors to provide unpublished data. We searched publications of key international agencies and conference abstracts. We reviewed reference lists of all included articles and topic-related systematic reviews for eligible papers.

SELECTION CRITERIA

We included prospective and retrospective cohort studies, cross-sectional surveys, case-control studies and randomised controlled trials that measured exposure to NSP and/or OST against no intervention or a reduced exposure and reported HCV incidence as an outcome in people who inject drugs. We defined interventions as current OST (within previous 6 months), lifetime use of OST and high NSP coverage (regular attendance at an NSP or all injections covered by a new needle/syringe) or low NSP coverage (irregular attendance at an NSP or less than 100% of injections covered by a new needle/syringe) compared with no intervention or reduced exposure.

DATA COLLECTION AND ANALYSIS

We followed the standard Cochrane methodological procedures incorporating new methods for classifying risk of bias for observational studies. We described study methods against the following 'Risk of bias' domains: confounding, selection bias, measurement of interventions, departures from intervention, missing data, measurement of outcomes, selection of reported results; and we assigned a judgment (low, moderate, serious, critical, unclear) for each criterion.

MAIN RESULTS

We identified 28 studies (21 published, 7 unpublished): 13 from North America, 5 from the UK, 4 from continental Europe, 5 from Australia and 1 from China, comprising 1817 incident HCV infections and 8806.95 person-years of follow-up. HCV incidence ranged from 0.09 cases to 42 cases per 100 person-years across the studies. We judged only two studies to be at moderate overall risk of bias, while 17 were at serious risk and 7 were at critical risk; for two unpublished datasets there was insufficient information to assess bias. As none of the intervention effects were generated from RCT evidence, we typically categorised quality as low. We found evidence that current OST reduces the risk of HCV acquisition by 50% (risk ratio (RR) 0.50, 95% confidence interval (CI) 0.40 to 0.63, I2 = 0%, 12 studies across all regions, N = 6361), but the quality of the evidence was low. The intervention effect remained significant in sensitivity analyses that excluded unpublished datasets and papers judged to be at critical risk of bias. We found evidence of differential impact by proportion of female participants in the sample, but not geographical region of study, the main drug used, or history of homelessness or imprisonment among study samples.Overall, we found very low-quality evidence that high NSP coverage did not reduce risk of HCV acquisition (RR 0.79, 95% CI 0.39 to 1.61) with high heterogeneity (I2 = 77%) based on five studies from North America and Europe involving 3530 participants. After stratification by region, high NSP coverage in Europe was associated with a 76% reduction in HCV acquisition risk (RR 0.24, 95% CI 0.09 to 0.62) with less heterogeneity (I2 =0%). We found low-quality evidence of the impact of combined high coverage of NSP and OST, from three studies involving 3241 participants, resulting in a 74% reduction in the risk of HCV acquisition (RR 0.26 95% CI 0.07 to 0.89).

AUTHORS' CONCLUSIONS

OST is associated with a reduction in the risk of HCV acquisition, which is strengthened in studies that assess the combination of OST and NSP. There was greater heterogeneity between studies and weaker evidence for the impact of NSP on HCV acquisition. High NSP coverage was associated with a reduction in the risk of HCV acquisition in studies in Europe.

Syringe Sharing Among a Prospective Cohort of Street-Involved Youth: Implications for Needle Distribution Programs

The sharing of previously used syringes is associated with the transmission of Hepatitis C and HIV. This longitudinal study examines syringe borrowing and syringe lending within a prospective cohort of street-involved youth in Vancouver, Canada. From September 2005 to May 2014, data were collected from the At-Risk Youth Study, a cohort of street-involved youth age 14-26 at enrollment, and analyzed using generalized estimating equations. Among 505 participants, 142 (28.1%) reported syringe borrowing and 132 (26.1%) reported syringe lending during the study period. In separate multivariable analyses, having difficulty finding clean needles and homelessness were significantly associated with syringe borrowing (Adjusted Odds Ratio (AOR) = 2.28, 95% CI 1.66-3.12 and AOR = 1.52, CI 1.05-2.21, respectively) and syringe lending (AOR = 1.89, 95% CI 1.32-2.71 and AOR = 1.65, 95% CI 1.11-2.44, respectively) (all p values < 0.05). Findings highlight gaps in syringe access for vulnerable young injectors and suggest that service delivery for youth may be suboptimal. Further examination of how needle distribution efforts might be improved to better meet the needs of young people is warranted.

HIV and the criminalisation of drug use among people who inject drugs: a systematic review

BACKGROUND

Mounting evidence suggests that laws and policies prohibiting illegal drug use could have a central role in shaping health outcomes among people who inject drugs (PWID). To date, no systematic review has characterised the influence of laws and legal frameworks prohibiting drug use on HIV prevention and treatment.

METHODS

Consistent with PRISMA guidelines, we did a systematic review of peer-reviewed scientific evidence describing the association between criminalisation of drug use and HIV prevention and treatment-related outcomes among PWID. We searched MEDLINE, Embase, SCOPUS, PsycINFO, Sociological Abstracts, CINAHL, Web of Science, and other sources. To be included in our review, a study had to meet the following eligibility criteria: be published in a peer-reviewed journal or presented as a peer-reviewed abstract at a scientific conference; examine, through any study design, the association between an a-priori set of indicators related to the criminalisation of drugs and HIV prevention or treatment among PWID; provide sufficient details on the methods followed to allow critical assessment of quality; be published or presented between Jan 1, 2006, and Dec 31, 2014; and be published in the English language.

FINDINGS

We identified 106 eligible studies comprising 29 longitudinal, 49 cross-sectional, 22 qualitative, two mixed methods, four mathematical modelling studies, and no randomised controlled trials. 120 criminalisation indicators were identified (range 1-3 per study) and 150 HIV indicators were identified (1-5 per study). The most common criminalisation indicators were incarceration (n=38) and street-level policing (n=39), while the most frequent HIV prevention and treatment indicators were syringe sharing (n=35) and prevalence of HIV infection among PWID (n=28). Among the 106 studies included in this review, 85 (80%) suggested that drug criminalisation has a negative effect on HIV prevention and treatment, 10 (9%) suggested no association, five (5%) suggested a beneficial effect, one (1%) suggested both beneficial and negative effects, and five (5%) suggested both null and negative effects.

INTERPRETATION

These data confirm that criminalisation of drug use has a negative effect on HIV prevention and treatment. Our results provide an objective evidence base to support numerous international policy initiatives to reform legal and policy frameworks criminalising drug use.

FUNDING

Canadian Institutes of Health Research and US National Institutes of Health.

HCV epidemiology in high-risk groups and the risk of reinfection

Injecting risk behaviours among people who inject drugs (PWID) and high-risk sexual practices among men who have sex with men (MSM) are important routes of hepatitis C virus (HCV) transmission. Current direct-acting antiviral treatment offers unique opportunities for reductions in HCV-related liver disease burden and epidemic control in high-risk groups, but these prospects could be counteracted by HCV reinfection due to on-going risk behaviours after successful treatment. Based on existing data from small and heterogeneous studies of interferon-based treatment, the incidence of reinfection after sustained virological response range from 2-6/100 person years among PWID to 10-15/100 person years among human immunodeficiency virus-infected MSM. These differences mainly reflect heterogeneity in study populations with regards to risk behaviours, but also reflect variations in study designs and applied virological methods. Increasing levels of reinfection are to be expected as we enter the interferon-free treatment era. Individual- and population-level efforts to address and prevent reinfection should therefore be undertaken when providing HCV care for people with on-going risk behaviour. Constructive strategies include acknowledgement, education and counselling, harm reduction optimization, scaled-up treatment including treatment of injecting networks, post-treatment screening, and rapid retreatment of reinfections.

A socio-structural approach to preventing injection drug use initiation: rationale for the PRIMER study

BACKGROUND

Injection drug use remains a primary driver of HIV and HCV-related harms globally. However, there is a gap in efforts to prevent individuals from transitioning into injecting. People who inject drugs (PWID) play a key role in the transition of others into injecting, and while behavioral interventions have been developed to address this phenomenon, socio-structural approaches remain unexplored. To that end, we hypothesize that certain interventions designed to reduce injecting-related risk behaviors may also reduce the risk that PWID expose and introduce others into injecting. Identifying the preventive potential of existing interventions will inform broader efforts to prevent injecting and related harms.

METHODS

The Preventing Injecting by Modifying Existing Responses (PRIMER) study is a multi-country mixed methods study with an aim to investigate whether specific interventions (e.g., opioid substitution therapy, supervised injection facilities, stable housing, incarceration environments) and related factors (e.g., public injecting and gender) influence the likelihood that PWID initiate others into injecting. This study will (1) investigate the PWID participation in injection initiation; (2) identify factors influencing the risk that PWID expose others to or facilitate injection initiation; (3) describe drug scene roles that increase the risk of PWID facilitating injection initiation; and (4) evaluate the impact of structural, social, or biomedical interventions on the risk that PWID facilitate injection initiation. It does so by pooling observational data from cohort studies of PWID in six cities: Vancouver, Canada; San Diego, USA; Tijuana, Mexico; Paris, Marseille, and Bordeaux, France.

RESULTS

Team members are conducting a prospective, multi-site study of PWID (n = 3050) in North America and France that includes quantitative and qualitative data collection through four separate cohort studies of PWID (San Diego, STAHR II; Tijuana, El Cuete IV; Vancouver, V-DUS; Bordeaux, Marseille, Paris and Strasbourg, COSINUS).

CONCLUSIONS

PRIMER is the largest study of injection initiation to date and the first to investigate structural approaches to preventing injection drug use initiation. Findings have the potential to inform the development and scale up of new and existing interventions to prevent transitions into injecting.

TRIAL REGISTRATION

Preventing Injecting by Modifying Existing Responses (PRIMER), NIDA DP2-DA040256-01 .

Developing a Brief Scale to Measure HIV Transmission Risk Among Injecting Drug Users

Background:

One of the main concerns of policymakers is to measure the impact of harm reduction programs and different interventions on the risk of HIV transmission among Injecting Drug Users (IDUs). Looking simultaneously at multiple factors and conditions that affect the risk of HIV transmission may provide policymakers a better insight into the mixed nature of HIV transmission.

Objectives:

The present study aimed to design a simple, brief, and multi-dimensional scale for measuring HIV transmission risk among IDUs.

Patients and Methods:

From October 2013 to March 2014, we conducted face-to-face interviews with 147 IDUs. Eligible participants were individuals 18 years or older who had injected drugs at least once during the last year and had not participated in similar studies within the 2 months before the interview. To design a scale for measuring HIV transmission risk, we specified 11 items, which address different dimensions of HIV risk taking behaviors/situations based on experts’ opinion. We applied exploratory factor analysis (EFA) with principal component extraction to develop scales. Eigen values greater than 1 were used as a criterion for factor extraction.

Results:

We extracted 7 items based on first factor, which were accounted for 21% of the variations. The final scale contained 7 items: 4 items were related to injecting practice and 3 items related to sexual behaviors. The Cronbach’s α coefficient was 0.66, acceptable for such a brief scale.

Conclusions:

Applying a simple and brief scale that incorporates the different dimensions of HIV transmission risk may provide policymakers and harm reductionists with a better understanding of HIV transmission in this key group and may be advantageous for evaluating intervention programs.

Hepatitis C Virus Testing and Treatment Among Persons Receiving Buprenorphine in an Office-Based Program for Opioid Use Disorders

AIMS

In the United States, hepatitis C virus (HCV) infection is primarily spread through injection drug use. There is an urgent need to improve access to care for HCV among persons with opioid use disorders who inject drugs. The purpose of our study was to determine the prevalence of HCV, patient characteristics, and receipt of appropriate care in a sample of patients treated with buprenorphine for their opioid use disorders in a primary care setting.

METHODS

This study used retrospective clinical data from the electronic medical record. The study population included patients receiving buprenorphine in the Office Based Opioid Treatment (OBOT) clinic within the adult primary medicine clinic at Boston Medical Center between October 2003 and August 2013 who received a conclusive HCV antibody (Ab) test within a year of clinic entry. We compared characteristics by HCV serostatus using Pearson's chi-square and provided numbers/percentages receiving appropriate care.

RESULTS

The sample comprised 700 patients. Slightly less than half of all patients (n=334, 47.7%) were HCV Ab positive, and were significantly more likely to be older, Hispanic or African American, have diagnoses of post-traumatic stress disorder (PTSD) or bipolar disorder, have prior heroin or cocaine use, and be HIV-infected. Among the 334 HCV Ab positive patients, 226 (67.7%) had detectable HCV ribonucleic acid (RNA) indicating chronic HCV infection; only 5 patients (2.21%) with chronic HCV infection ever initiated treatment.

CONCLUSIONS

Nearly half of patients (47.7%) receiving office-based treatment with buprenorphine for their opioid use disorder had a positive hepatitis C virus antibody screening test although initiation of HCV treatment was nearly non-existent (2.21%).