Needle and Syringe Programs and HIV-Related Risk Behaviors Among Men Who Inject Drugs: A Multilevel Analysis of Two Cities in Iran

The Impact of Needle and Syringe Exchange Programs on HIV-Related Risk Behaviors in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis Examining Individual- Versus Community-Level Effects

We conducted a systematic review and meta-analysis of the impact of needle and syringe exchange programs (NSP) on both individual- and community-level needle-sharing behaviors and other HIV-related outcomes in low- and middle-income countries (LMIC). A search of five databases for peer-reviewed trial or quasi-experimental studies reported through July 2021 identified 42 interventions delivered in 35 studies, with a total of 56,751 participants meeting inclusion criteria. Random-effects meta-analysis showed a significant protective association between NSP exposure and needle-sharing behaviors at the individual-level (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.16-0.39, 8 trials, n = 3947) and community-level (OR 0.39, CI 0.22-0.69, 12 trials, n = 6850), although with significant heterogeneity. When stratified by needle-sharing directionality, NSP exposure remained associated with reduced receptive sharing, but not distributive sharing. NSP exposure was also associated with reduced HIV incidence and increased HIV testing but there were no consistent associations with prevalence of bloodborne infections. Current evidence suggests positive impacts of NSPs in LMICs.

Prevalence and associates of non-fatal overdose among people who inject drugs in Saveh, Iran

Background

As a public health issue, non-fatal overdose (NFOD) is highly prevalent among people who inject drugs (PWID). This can lead to an elevated risk of future overdose, causing various harms including possible death. It is essential to improve knowledge concerning this problem and its associated risk factors to inform overdose prevention and assistance programs. The primary aim of the present study was to determine the prevalence of NFOD and associated risk factors among PWID in Saveh, Iran.

Methods

In the present cross-sectional study, 272 PWID living in Saveh, Iran were interviewed face-to-face using a structured survey. Data concerning socio-demographics, substance use, risky behaviors, and services utilization data were collected. The outcome variable (i.e., NFOD) was assessed by answering “Yes” to the question: “In the past three months, have you ever overdosed (at least once) by accident?”

Results

The prevalence of NFOD among PWID in the past three months was 54%. The characteristics and behaviors that were associated with an increased risk of experiencing NFOD in the past three months were being of older age (AOR = 5.2, p < 0.05), drug use initiation under the age of 22 years (AOR = 7.8, p < 0.05), being an alcohol user (AOR = 3.0, p < 0.05), and being a simultaneous multiple drug user (AOR = 5.8, p < 0.05). Also, more recent initiates to injecting (< 2 years) had an increased risk of experiencing a non-fatal overdose in the past three months. Findings also indicated that those who (i) attended a needle and syringe program (AOR: 0.3, p < 0.05), (ii) were visited by a general practitioner (AOR: 0.03, p < 0.05), and (iii) received a psychosocial intervention (AOR: 0.1, p < 0.05) were 0.3, 0.03 and 0.1 times less likely to report non-fatal overdosing than other participants, respectively.

Conclusions

The results indicate that intervention and prevention initiatives seeking to reduce NFOD among PWID should not only be focused on the primary drug used but also the use of alcohol and polysubstance use. Specific and tailored psychological interventions combined with pharmacotherapy may be highly beneficial for PWID who experience more severe types of substance use, including alcohol use disorders and/or polysubstance abuse.

Non -fatal overdose among people who inject drugs in Tehran, Iran

BACKGROUND

With increasing frequencies of non-fatal overdose in people who inject drugs (PWID), it is essential to improve our knowledge about associated risk factors for overdose to inform overdose prevention and assistance programs. The aim of present study was to determine the prevalence of non-fatal overdose and the associated risk factors among PWID in Tehran, Iran.

METHODS

Snowball sampling was used to collect data from 465 participants in Tehran using a cross-sectional survey. Consenting participants who reported drug injecting in the past month and were able to speak and comprehend Farsi enough to respond to survey questions were interviewed. The endpoint of interest was non-fatal overdose in the previous 6 months, or answering "Yes" to the question: "In the last six months, have you ever overdosed by accident? (at least once)". We used STATA v. 14 for this analysis. Statistical significance was defined as p < 0.05 for all analyses.

RESULTS

Of 465 PWIDs who participated in this study, all were male, and about half had less than a high school education. The prevalence of self-reported non-fatal overdose in the past 6 months was 38% (CI95%: 34, 43%). Our findings indicate that characteristics and behaviors that were associated with an increased risk of experiencing an overdose in the past 6 months were drug use initiation under 22 years (AOR =2.2, P < 0.05), using methamphetamine (AOR =2.8, P < 0.05), and using multiple drugs at the same time (AOR =2.1, P < 0.05). Also, more recent initiates to injecting (< 2 years) had an increased risk of experiencing an overdose in the past 6 months. The odds of experiencing a non-fatal overdose among PWIDs who regularly attended NSP were 0.6 times less than for those who did not attend regularly (OR = 0.6,95% CI: 0.2-0.9).

CONCLUSION

Methamphetamine and alcohol use were the most significant association for non-fatal overdose among PWIDs. Our results indicate that intervention and prevention initiatives seeking to reduce overdoses among PWIDs should not only be focused on the primary drug used but also the use of alcohol and poly-drug use.

Methamphetamine use and HIV risk behavior among men who inject drugs: causal inference using coarsened exact matching

BACKGROUND

Understanding the association between methamphetamine (MA) use and HIV risk behavior among people who inject drugs (PWID) will assist policy-makers and program managers to sharpen the focus of HIV prevention interventions. This study examines the relationship between MA use and HIV risk behavior among men who inject drugs (MWID) in Tehran, Iran, using coarsened exact matching (CEM).

METHODS

Data for these analyses were derived from a cross-sectional study conducted between June and July 2016. We assessed three outcomes of interest-all treated as binary variables, including distributive and receptive needle and syringe (NS) sharing and condomless sex during the month before interview. Our primary exposure of interest was whether study participants reported any MA use in the month prior to the interview. Firstly, we report the descriptive statistics for the pooled samples and matched sub-samples using CEM. The pooled and matched estimates of the associations and their 95% CI were estimated using a logistic regression model.

RESULTS

Overall, 500 MWID aged between 18 and 63 years (mean = 28.44, SD = 7.22) were recruited. Imbalances in the measured demographic characteristics and risk behaviors between MA users and non-users were attenuated using matching. In the matched samples, the regression models showed participants who reported MA use were 1.82 times more likely to report condomless sex (OR = 1.82 95% CI 1.51, 4.10; P = 0.031), and 1.35 times more likely to report distributive NS sharing in the past 30 days, as compared to MA non-users (OR = 1.35 95% CI 1.15-1.81). Finally, there was a statistically significant relationship between MA use and receptive NS sharing in the past month. People who use MA in the last month had higher odds of receptive NS sharing when compared to MA non-users (OR = 4.2 95% CI 2.7, 7.5; P = 0.013).

CONCLUSIONS

Our results show a significant relationship between MA use and HIV risk behavior among MWID in Tehran, Iran. MA use was related with increased NS sharing, which is associated with higher risk for HIV exposure and transmission.

Dental caries and periodontal disease among people who use drugs: a systematic review and meta-analysis

BACKGROUND

The aim of our study was to perform a systematic review of the literature and meta-analysis in order to investigate relationship between drug use and oral health.

METHODS

We searched for studies in English published before July 1, 2019 on PsycINFO, PubMed, SciELO, Scopus, and Web of Science. We assessed the relationship between drug use (methamphetamines, heroin; opiates; crack, cocaine and cannabis as dependent variables) and reported tooth loss, periodontal disease, or decayed, missing, and filled teeth index as an independent variable. The data were analyzed using Stata 12.0 software.

RESULTS

We initially identified 1836 potential articles (with 1100 duplicates) and screened the remaining 736 titles and abstracts, comprising 54 studies. In the next step, we evaluated the full-texts; 44 studies were excluded, accordingly. In total, we included 10 publications in the meta-analysis. Drug type was associated with periodontal disease (OR 1.44; 95% CI 0.8-2.6) and pooled estimates showed that type of drug used increased the odds of the number of decayed, missed and filled teeth (DMFT) (OR 4.11; 95% CI 2.07-8.15) respectively.

CONCLUSIONS

The analytical challenges of segregating the impact of individual drug types on oral health diseases mean that investigations on the direct relationship between oral health status and drug use are limited. Developing programs to improve potential confounding with various substances and addressing the dental health needs of people who use drugs is vital if we are to improve their overall quality of life.

Accessibility of Needle and Syringe Programs and Injecting and Sharing Risk Behaviors in High Hepatitis C Virus Prevalence Settings

Background: Access to healthcare services is a basic human right. Objective: The main purpose of this study is to assess the association between accessibility of needle and syringe programs (NSP) and injecting and sharing risk behaviors. Methods: A cross-sectional study employed respondent-driving sampling (RDS) to recruit a sample of 634 people who inject drugs (PWID) from three provinces, Golestan, Ardabil, and Sistan and Baluchestan, in Iran between November 2018 and February 2019. Participants completed a questionnaire based on the WHO Drug Injecting Study Phase II survey. Results: Participants reported their accessibility of NSP services as low (6%), middle (19%), and high (75%) in the past 2 months at the time of the survey. PWID who had increased access to NSP services were less likely to report utilization of used cooker (aOR = 1.40; CI 95% 0.99-1.82), cotton (aOR = 1.30; CI 95% 0.79-1.81), and water (aOR = 1.07; CI 95% 0.89-1.26), receptive needle/syringe sharing (aOR= 1.86, 95% CI 1.69-2.03), and distributive needle/syringe sharing (aOR= 1.09, 95% CI 0.81-1.37). Conclusions/Importance: There is evidence of inequality in PWID's access to health care as they relate to the prevention of HCV transmission. An understanding of both the social determinants and prevention of injecting and sharing risk behaviors seeks to connect HCV risk reduction within the context of human rights and vulnerability.

Substance Use Disorder, Intravenous Injection, and HIV Infection: A Review

DSM-V-defined substance use disorder comprises four groups of symptoms: impaired control, social impairment, risky use, and pharmacological reactions. Behavioral patterns of impaired control, including impulsivity and risk taking, are associated with HIV risk behaviors. Substance users with stronger craving symptoms are more likely to use drugs via intravenous injection than other routes because of the faster drug effect and the higher bioavailability; thus, they are at high risk of HIV infection. HIV risk behaviors such as unprotected sex and intravenous injection facilitate HIV disease spread. Public health policies such as Needle and Syringe Exchange Programs and medication-assisted treatment are proven to reduce HIV risk behaviors such as the frequency of intravenous injection and even the incidence of HIV infection, but both of them have limitations. While intravenous injection is a frequently discussed issue in public policies and the HIV-related literature, it is a much less frequent topic in the addiction literature. We believed that understanding the mental substrate behind impulsivity/risk taking and the possible biological mechanism of intravenous injection may help in creating more effective strategies to slow down HIV infection.