Injecting and sexual risk correlates of HBV and HCV seroprevalence among new drug injectors

Impact of the Universal Implementation of Adolescent Hepatitis B Vaccination in Spain

The aim of this study was to analyse the impact of the introduction of universal adolescent HBV vaccination on the incidence of acute hepatitis B virus (HBV) infections. Acute HBV cases reported to the Spanish National Epidemiological Surveillance Network between 2005 and 2021 were included. For regions starting adolescent vaccination in 1991-1993 and in 1994-1996, HBV incidence rates were compared by calculating the incidence rate ratio (IRR) and 95% confidence interval (CI). We also analysed the 2017 Spanish national seroprevalence survey data. The overall acute HBV incidence per 100,000 persons was 1.54 in 2005 and 0.64 in 2021 (p < 0.001). The incidence in 2014-2021 was lower for regions that started adolescent vaccination in 1991-1993 rather than in 1994-1996 (IRR 0.76; 95% CI 0.72-0.83; p < 0.001). In the 20-29 age group, incidence in regions that started adolescent vaccination in 1991-1993 was also lower (IRR 0.87; 95% CI 0.77-0.98; p = 0.02 in 2005-2013 and IRR 0.71; 95% CI 0.56-0·90; p < 0.001 in 2014-2021). Anti-HBc prevalence in the 35-39 age group was lower in the regions that started vaccination earlier, although the difference was not statistically significant (p = 0.09). Acute HBV incidence decreased more in the young adult population in regions that began adolescent vaccination earlier. Maintaining high universal vaccination coverage in the first year of life and in at-risk groups is necessary to achieve HBV elimination by 2030.

Progress and Unfinished Business: Hepatitis B in the United States, 1980-2019

During 1990-2019, universal infant and childhood vaccination for hepatitis B resulted in a 99% decline in reported cases of acute hepatitis B among children, adolescents, and young adults aged <19 years in the United States; however, during 2010-2019, cases of acute hepatitis B plateaued or increased among adults aged ≥40 years. We conducted a topical review of surveillance strategies that will be critical to support the elimination of hepatitis B as a public health threat in the United States. In 2019, notifiable disease surveillance for acute hepatitis B showed continued transmission, especially among people who inject drugs and people with multiple sexual partners; rates were highest among people who were aged 30-59 years, non-Hispanic White, and living in rural areas. In contrast, newly reported cases of chronic hepatitis B (CHB) were highest among people who were aged 30-49 years, Asian or Pacific Islander, and living in urban areas. The National Health and Nutrition Examination Survey documented the highest CHB prevalence among non-US-born, non-Hispanic Asian people during 2013-2018; only one-third of people with CHB were aware of their infection. In the context of universal adult vaccination (2022) and screening (2023) recommendations for hepatitis B, better data are needed to support programmatic strategies to improve (1) vaccination rates among people with behaviors that put them at risk for transmission and (2) screening and linkage to care among non-US-born people. Surveillance for hepatitis B needs to be strengthened throughout the health care and public health systems.

Hepatitis C virus screening of high-risk patients in a community hospital emergency department: Retrospective review of patient characteristics and future implications

Background

Chronic hepatitis C virus infection (HCV) is a common infectious disease that affects more than 2.7 million people in the US. Because the emergency department (ED) can present an ideal opportunity to screen patients who may not otherwise get routine screening, we implemented a risk-based screening program for ED patients and established a system to facilitate linkage to care.

Methods and findings

A risk-based screening algorithm for HCV was programmed to trigger an alert in Epic electronic medical record system. Patients identified between August 2018 and April 2020 in the ED were tested for HCV antibody reflex to HCV RNA. Patients with a positive screening test were contacted for the confirmatory test result and to establish medical care for HCV treatment. Patient characteristics including age, sex, self-awareness of HCV infection, history of previous HCV treatment, history of opioids use, history of tobacco use, and types of insurance were obtained.

A total of 4,525 patients underwent a screening test, of whom 131 patients (2.90%) were HCV antibody positive and 43 patients (0.95%) were HCV RNA positive, indicating that only 33% of patients with positive screening test had chronic HCV infection. The rate of chronic infection was higher in males as compared to females (1.34% vs 0.60%, p = 0.01). Patients with history of opioid use or history of tobacco use were found to have a lower rate of spontaneous clearance than patients without each history (opioids: 48.6% vs 72.0%, p = 0.02; tobacco: 56.6% vs 80.5%, p = 0.01). Among 43 patients who were diagnosed with chronic hepatitis C, 26 were linked to a clinical setting that can address chronic HCV infection, with linkage to care rate of 60.5%. The most common barrier to this was inability to contact patients after discharge from the ED.

Conclusions

A streamlined EMR system for HCV screening and subsequent linkage to care from the ED can be successfully implemented. A retrospective review suggests that male sex is related to chronic HCV infection, and history of opioid use or history of tobacco use is related to lower HCV spontaneous clearance.

Risk behaviours and viral infections among drug injecting migrants from the former Soviet Union in Germany: Results from the DRUCK-study

BACKGROUND

High prevalence of drug use and injection-related risk behaviours have been reported among former Soviet Union (FSU)-migrants. To investigate hepatitis C (HCV) and HIV seroprevalence and related risk behaviours in this subgroup in Germany, we compared first generation FSU-migrants and native Germans using data from a sero-behavioural survey of people who inject drugs (PWID).

METHODS

Current injectors were recruited using respondent-driven sampling in eight German cities in 2011-2014. Questionnaire-based interviews were conducted and dried blood spots collected and tested for anti-HCV, HCV-RNA, and anti-HIV1/2. Descriptive and multivariable analyses (MVA) were performed.

RESULTS

A total of 208 FSU-born and 1318 native German PWID were included in the analysis. FSU-migrants were younger than Germans (median age: 33 vs. 39 years), and more often male (83.1% vs. 75.9%, p = 0.022). HCV seroprevalence was 74.5% in FSU-migrants vs. 64.6% in Germans (p = 0.006), HIV seroprevalence was 5.8% and 4.6%, respectively (p = 0.443). The proportion of FSU-migrants reporting injecting-related risk behaviours was higher than among Germans: injecting daily (39.4% vs. 30.2%, p = 0.015), with friends (39.2% vs. 31.2%, p = 0.038), cocaine (32.7% vs. 23.8%, p = 0.044), more than one drug (18.2% vs. 9.6%, p = 0.006), and sharing filters/cookers (35.5% vs. 28.0%, p = 0.045). No statistically significant differences were observed in HIV/HCV testing rates (range: 50.7%-65.6%), opioid substitution treatment (43.9% vs. 50.5%), and access to clean needles/syringes (89.8% vs. 90.3%). In MVA, risk for HCV-infection was increased in male FSU-migrants compared to German males (OR 3.32, p = 0.006), no difference was identified between female FSU-migrants and German females (OR: 0.83, p = 0.633).

CONCLUSION

Male FSU-migrants were at highest risk of being HCV infected. Therefore, targeted actions are needed to ensure access and acceptance of harm reduction measures, including HCV-testing and -treatment for this subpopulation of PWID.

Trends in HIV and HCV Risk Behaviors and Prevalent Infection Among People Who Inject Drugs in New York City, 2005-2012

BACKGROUND

We assess trends in HIV and hepatitis C virus (HCV) risk behaviors and prevalent infection among people who inject drugs (PWID) in New York City (NYC).

METHODS

PWID in NYC were sampled using respondent-driven sampling in 2005, 2009, and 2012 (serial cross sections) for the Centers for Disease Control and Prevention-sponsored National HIV Behavioral Surveillance study. Participants were interviewed about their current (≤12 months) risk behaviors and tested for HIV and HCV. The crude and adjusted risk ratio (RR) and 95% confidence interval (95% CI) for linear time trends were estimated using generalized estimating equations regression with a modified Poisson model.

RESULTS

The sample comprised 500, 514, and 525 participants in 2005, 2009, and 2012, respectively. Significant (P < 0.05) linear trends in risk behaviors included a decline in unsafe syringe sources (60.8%, 31.3%, 46.7%; RR = 0.86, 95% CI: 0.81 to 0.92), an increase in all syringes from syringe exchanges or pharmacies (35.4%, 67.5%, 50.3%; RR = 1.15, 95% CI: 1.09 to 1.22), and an increase in condomless vaginal or anal sex (53.6%, 71.2%, 70.3%; RR = 1.14, 95% CI: 1.09 to 1.19). Receptive syringe sharing (21.4%, 27.0%, 25.1%), sharing drug preparation equipment (45.4%, 43.4%, 46.7%), and having ≥2 sex partners (51.2%, 44.0%, 50.7%) were stable. Although HIV seroprevalence declined (18.1%, 12.5%, 12.2%), HCV seroprevalence was high (68.2%, 75.8%, 67.1%). In multivariate analysis, adjusting for sample characteristics significantly associated with time, linear time trends remained significant, and the decline in HIV seroprevalence gained significance (adjusted RR = 0.76, 95% CI: 0.64 to 0.91, P = 0.003).

CONCLUSIONS

This trend analysis suggests declining HIV prevalence among NYC PWID. However, HCV seroprevalence was high and risk behaviors were considerable. Longitudinal surveillance of HIV and HCV risk behaviors and infections is needed to monitor trends and for ongoing data-informed prevention among PWID.

Risk Factors Associated with HCV Among Opioid-Dependent Patients in a Multisite Study

We examined risk factors associated with hepatitis C virus (HCV) infection among opioid-dependent patients enrolled into medication-assisted therapy (buprenorphine or methadone) to determine factors affecting chronic infection. Patients (N = 1039) were randomized as part of a larger, multisite clinical trial sponsored by the National Drug Abuse Treatment Clinical Trials Network assessing liver function. HCV status was first assessed with an antibody screen; if positive, then current infection was determined with an antigen screen testing for detectable virus. Patients were classified as HCV negative, HCV positive but have cleared the virus, or as having chronic HCV. Logistic regression analysis was used to examine demographic and behavioral correlates of the three groups. Thirty-four percent of patients were classified with chronic infection and 14% had evidence of prior infection with apparent clearing of the virus. Chronic infection was associated with recent injection drug use and cocaine use. Chronic HCV infection was also associated with being older and Hispanic. Age, ethnicity, and current drug use increase the likelihood of being chronically infected with HCV. Strategies targeting high risk subgroups can aid in preventing further disease escalation.

High Prevalence and Incidence of HIV and HCV Among New Injecting Drug Users With a Large Proportion of Migrants--Is Prevention Failing?

OBJECTIVES

The aim of this study was to assess differences in the prevalence of HIV and HCV infection and associated risk factors between new (injecting for ≤5 years) and long-term injectors and to estimate HIV/HCV incidence among new injectors.

METHODS

Cross-sectional study among people who inject drugs (PWID) who attended harm reduction centers in Catalonia in 2010-11. Anonymous questionnaires and oral fluid samples were collected. Poisson regression models were applied to determine the association between HIV/HCV infection and risk factors.

RESULTS

Of the 761 participants, 21.4% were new injectors. New injectors were younger than long-term injectors (mean age = 31.6 vs. 37.8) and were more likely to be immigrants (59.0% vs. 33.4%). HIV and HCV prevalence was 20.6% and 59.4% among new injectors, and estimated HIV and HCV incidence 8.7 and 25.1 /100 person-years, respectively. Among new injectors, HIV infection was associated with homelessness (PR = 3.10) and reporting a previous sexually transmitted infection (PR = 1.79). Reporting front/backloading (PR = 1.33) and daily injection (PR = 1.35) were risk-factors for HCV infection. For long-term injectors, HIV risk factors were: having shared syringes (PR = 1.85), having injected cocaine (PR = 1.38), reporting front/backloading (PR = 1.30) and ever having been in prison (PR = 2.03).

CONCLUSION

A large proportion of PWID in Catalonia are new injectors, a subgroup with a high level of both sexual and parenteral exposure and a high incidence rate of HIV/ HCV infections. It is important to improve early diagnosis of these infections among this group, in particular among migrants. To identify and address risk factors for homelessness PWID should be a priority.

HIV and STI prevalence and injection behaviors among people who inject drugs in Nairobi: results from a 2011 bio-behavioral study using respondent-driven sampling

There is a dearth of evidence on injection drug use and associated HIV infections in Kenya. To generate population-based estimates of characteristics and HIV/STI prevalence among people who inject drugs (PWID) in Nairobi, a cross-sectional study was conducted with 269 PWID using respondent-driven sampling. PWID were predominantly male (92.5 %). An estimated 67.3 % engaged in at least one risky injection practice in a typical month. HIV prevalence was 18.7 % (95 % CI 12.3–26.7), while STI prevalence was lower [syphilis: 1.7 % (95 % CI 0.2–6.0); gonorrhea: 1.5 % (95 % CI 0.1–4.9); and Chlamydia: 4.2 % (95 % CI 1.2–7.8)]. HIV infection was associated with being female (aOR, 3.5; p = 0.048), having first injected drugs 5 or more years ago (aOR, 4.3; p = 0.002), and ever having practiced receptive syringe sharing (aOR, 6.2; p = 0.001). Comprehensive harm reduction programs tailored toward PWID and their sex partners must be fully implemented as part of Kenya’s national HIV prevention strategy.

Human immunodeficiency virus and hepatitis C virus coinfection in Nepal

OBJECTIVES

The study aimed at finding prevalence, mode of transmission, and pattern of CD4 cell count among hepatitis C virus (HCV) coinfected human immunodeficiency virus (HIV)-positive individuals in Nepal.

METHODS

This was a descriptive cross-sectional study carried out in three Volunteer Counseling and Testing clinics, one from Dharan and two from Kathmandu, Nepal. Three hundred and thirteen individuals were recruited.

RESULTS

Forty-two percent of HIV-infected persons had HCV coinfection. Significant associations with HIV and HCV coinfection were male gender (p <0.001) and injection drug use (IDU) (p <0.001). The mean CD4 cell count was significantly lower in HCV coinfected individuals, compared to those without coinfection, after 1.5 years (p =0.017), 2 years (p =0.0457), 3 years (p =0.011), and 3.5 years (p <0.001) of antiretroviral therapy.

CONCLUSION

HCV coinfection was common in HIV-infected individuals in Nepal and was associated with male gender, IDU, and lower CD4 counts.

Gender differences in circumstances surrounding first injection experience of rural injection drug users in the United States

BACKGROUND

Research has demonstrated that there can be substantial gender differences in circumstances surrounding initiation of injection drug use; however, little is known about the gendered dynamics of first injection in rural areas where syringe exchange is inaccessible or among those who predominantly inject prescription medications. The present study examines gender differences in first injection experience among rural residents who predominantly inject prescription opioids.

METHODS

Interview-administered questionnaires collected data from a sample of injection drug users (n=394) recruited from Appalachian Kentucky using respondent-driven sampling.

RESULTS

Women were more likely to have initiated injection due to social-pressure (p=0.001), received the drugs as a gift (p=0.011), initiated in their partner's home (p=0.004) and in their partner's presence (p<0.001), been injected by their partner (p<0.001), used an unclean syringe (p=0.026), and received the syringe from their partner (p<0.001). Women were also more likely to report having engaged in sexual intercourse before or after initiation (p<0.001). Men were more likely to have personally purchased the drugs (p=0.002), to have acquired the syringe from a pharmacy/clinic (p=0.004), and to have injected with a friend (p=0.001) or family member (p=0.020). Men were also more likely to have a friend administer the first injection (p=0.007).

CONCLUSIONS

In this population of rural drug users, notable gender differences in injection initiation were observed. Social pressure played a more substantial role in women's first injection experience, and male partners had an integral role in women's initiation.

The relationship between age and risky injecting behaviours among a sample of Australian people who inject drugs

BACKGROUND

Limited evidence suggests that younger people who inject drugs (PWID) engage in high-risk injecting behaviours. This study aims to better understand the relationships between age and risky injecting behaviours.

METHODS

Data were taken from 11 years of a repeat cross-sectional study of sentinel samples of regular PWID (The Australian Illicit Drug Reporting System, 2001-2011). Multivariable Poisson regression was used to explore the relationship between age and four outcomes of interest: last drug injection occurred in public, receptive needle sharing (past month), experiencing injecting-related problems (e.g. abscess, dirty hit; past month), and non-fatal heroin overdose (past six months).

RESULTS

Data from 6795 first-time study participants were analysed (median age: 33 years, interquartile range [IQR]: 27-40; median duration of injecting: 13 years [IQR: 7-20]). After adjusting for factors including duration of injecting, each five year increase in age was associated with significant reductions in public injecting (adjusted incidence rate ratio [AIRR]: 0.90, 95% confidence interval [CI]: 0.88-0.92), needle sharing (AIRR: 0.84, 95% CI: 0.79-0.89) and injecting-related problems (AIRR: 0.96, 95% CI: 0.95-0.97). Among those who had injected heroin in the six months preceding interview, each five year increase in age was associated with an average 10% reduction in the risk of heroin overdose (AIRR: 0.90, 95% CI: 0.85-0.96).

CONCLUSIONS

Older PWID report significantly lower levels of high-risk injecting practices than younger PWID. Although they make up a small proportion of the current PWID population, younger PWID remain an important group for prevention and harm reduction.

Sexual risk behavior associated with transition to injection among young non-injecting heroin users

The aim of this study was to investigate the effects of transitioning from non-injection heroin use to injection drug use on sexual risk behavior. Non-injecting heroin users age 16-30 were enrolled from 2002 to 2005, and were re-interviewed at 6-month intervals for up to three years; 561 participants completed at least one follow-up interview. The majority of participants were non-Hispanic (NH) Black (54 %), 23 % were Hispanic, and 21 % were NH white. During follow-up, 154 participants (27.5 %) transitioned to injecting drugs. Logistic regression analyses were conducted using generalized estimating equations (GEE) to estimate the effect of transition to injection drug use on changes in sexual risk behavior during follow-up. Transition to injection drug use during follow-up was associated with increased likelihood of sexual risk behavior, especially for men. Harm reduction efforts that focus on preventing initiation or return to injection among non-injecting drug users may also ameliorate HIV sexual risk behaviors.

Effects of HCV seropositive status on buprenorphine pharmacokinetics in opioid-dependent individuals

BACKGROUND AND OBJECTIVES

The purpose of this study was to examine the effect of hepatitis C virus (HCV) infection on buprenorphine pharmacokinetics in opioid-dependent, buprenorphine/naloxone-maintained adults.

METHODS

A retrospective analysis of buprenorphine pharmacokinetics in HCV seropositive and seronegative buprenorphine/naloxone-maintained individuals (N = 49) was undertaken.

RESULTS

Relative to HCV seronegative subjects, HCV seropositive subjects had higher buprenorphine exposure, as demonstrated by elevated buprenorphine AUC and Cmax values (p = .03 and .02, respectively) and corresponding elevations in the metabolites, buprenorphine-3-glucuronide AUC values (p = .03) and norbuprenorphine-3-glucuronide AUC and C24 values (p = .05 and .03, respectively).

DISCUSSION AND CONCLUSIONS

HCV infection was associated with higher plasma concentrations of buprenorphine and buprenorphine metabolites.

SCIENTIFIC SIGNIFICANCE AND FUTURE DIRECTIONS

Findings suggest the potential for opioid toxicity among HCV-infected patients treated with buprenorphine/naloxone, and possible hepatotoxic effects related to increased buprenorphine exposure. HCV-infected patients receiving buprenorphine may need lower doses to maintain therapeutic plasma concentrations.

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.

Are females who inject drugs at higher risk for HIV infection than males who inject drugs: an international systematic review of high seroprevalence areas

OBJECTIVE

There are multiple reasons why females who inject drugs may be more likely to become infected with HIV than males who inject drugs. Where this is the case, special HIV prevention programs for females would be needed.

DESIGN

International systematic review and meta-analysis of studies across 14 countries.

METHODS

Countries with high seroprevalence (>20%) HIV epidemics among persons who inject drugs (PWID) were identified from the Reference Group to the UN on HIV and Injecting Drug Use. Systematic literature reviews collected data on HIV prevalence by gender for these countries. Non-parametric and parametric tests along with meta-analytic techniques examined heterogeneity and differences in odds ratios (OR) across studies.

RESULTS

Data were abstracted from 117 studies in 14 countries; total sample size N = 128,745. The mean weighted OR for HIV prevalence among females to males was 1.18 [95% CI 1.10-1.26], with high heterogeneity among studies (I(2)= 70.7%). There was a Gaussian distribution of the log ORs across studies in the sample.

CONCLUSION

There was a significantly higher HIV prevalence among females compared to males who inject drugs in high seroprevalence settings, but the effect size is extremely modest. The high level of heterogeneity and the Gaussian distribution suggest multiple causes of differences in HIV prevalence between females and males, with a specific difference determined by local factors. Greater understanding of factors that may protect females from HIV infection may provide insights into more effective HIV prevention for both females and males who inject drugs.

Behavior and major barriers faced by non-injectable drug users with HBV/HCV seeking treatment for hepatitis and drug addiction in Rio de Janeiro, Brazil

Drug users (DU) are a marginalized group and at risk for viral hepatitis, who seldom access health services. A cross-sectional survey was conducted with 111 DU with chronic HBV/HCV and 15 in-depth interviews with health professionals/policymakers in Rio de Janeiro, Brazil. Most interviewees were male, non-white, with a low educational background, unemployed and/or living on less than $245 a month (minimun wage). In the last 6 months, 61.8% of interviewees snorted cocaine, 64.7% at least once a week. Half of the interviewees had a stable partner and 38.3% of those with occasional partners never/almost never using condoms. Addiction treatment seeking was found to be associated with: being white (OR:5.5), high-school degree (OR:8.7), and employment (OR:5.7). Hepatitis treatment seeking was high (80.9%), and access to low-threshold, user-friendly health services was key for treatment seeking behaviors (OR:3.6). Missed opportunities for hepatitis treatment seem to be associated with structural (uneven political/financial support to hepatitis programs) and patient-related barriers (severe addiction and non-adherence). Those most in need were less likely to access treatment, calling for renewed strategies, in order to curb hepatitis among impoverished drug users and their sexual partners.

Prevalence of HCV risk behaviors among prison inmates: tattooing and injection drug use

Hepatitis C virus (HCV) is the most common blood-borne chronic viral infection in the United States and it is over represented in incarcerated populations. This study estimates if in prison tattooing is associated with self reported HCV infection in a probabilistic sample of 1,331 sentenced inmates in Puerto Rico prisons anonymously surveyed in 2004, who had previously been tested for HCV. Analysis were carried out with the total sample and among non-injectors (n=796) to control for injection drug use (IDU) and other confounders. Nearly 60% of inmates had acquired tattoos in prison. HCV was reported by 27% of subjects in the total sample and by 12% of non-injectors who had undergone tattoos in prison. IDU was the strongest predictor of HCV in the total sample (OR=5.6, 95% CI=3.2-9.7). Among non injectors, tattooing with reused needles or sharp objects and/ or reusing ink was positively associated with HCV self-report (OR=2.6, 95% CI=1.3-5.5). Tattooing is a common occurrence in this prison setting. Findings suggest that preventive interventions are required to reduce the risk of HCV transmission through unsterile tattooing and injection practices.

The association between social marginalisation and the injecting of alcohol amongst IDUs in Budapest, Hungary

BACKGROUND

Alcohol injecting may cause intense irritation, serious vein damage, and additional risks. What little is known about alcohol injecting points to the potential role of social marginalisation.

METHODS

Injecting drug users (N=215) were recruited between October 2005 and December 2006 in Budapest, Hungary from non-treatment settings. Multivariate logistic regression models identified correlates of lifetime alcohol injecting.

RESULTS

About a quarter (23%) reported ever injecting alcohol-only 3% reported injecting alcohol in the past 30 days. In multivariate analysis, six variables were statistically significantly associated with ever injecting alcohol: male gender, being homeless, ever sharing cookers or filters and injecting mostly in public places showed a positive association, whilst Roma ethnicity and working at least part time showed a negative association.

CONCLUSIONS

Our study suggests that alcohol injecting is more of a rare event than a so far undiscovered research and prevention priority. Still, providers of harm reduction services should be aware that alcohol injecting happens, albeit rarely, especially amongst socially marginalised IDUs, who should be counselled about the risks of and discouraged from alcohol injecting.

Examining racial/ethnic disparities in sexually transmitted diseases among recent heroin-using and cocaine-using women

BACKGROUND

This study examined racial differences in the prevalence of sexual risk behaviors and their associations with sexually transmitted diseases (STDs) among recent heroin-using and cocaine-using women.

METHODS

Participants were 214 women (59% black, 41% white) who were recruited during 2002-2010 using targeted sampling to participate in a study in Baltimore, Maryland, and reported using heroin, cocaine, or crack during the previous 6 months. Participants completed self-report questionnaires about their drug use, sexual risk behaviors, and lifetime history of one of six STDs, including gonorrhea, syphilis, chlamydia, genital herpes, genital warts, or trichomoniasis.

RESULTS

More black women (50%) than white women (28%) reported a lifetime STD. Although there were no racial differences in the lifetime prevalence of sexual risk behaviors assessed, there were racial differences in the sexual behaviors associated with ever having a lifetime STD. Simple logistic regressions revealed that ever having a casual sex partner or anal sex were correlates of having a lifetime STD among black women but not among white women. Multiple logistic regression analyses revealed that ever having a casual sex partner was significantly associated with having a lifetime STD among black women, and ever trading sex for money was significantly associated with having a lifetime STD among white women.

CONCLUSIONS

Findings are consistent with national studies and elucidate racial disparities in STDs and associated sexual behaviors among recent heroin-using and cocaine-using women. Findings underscore the need to tailor STD prevention interventions differently for black and white recent heroin-using and cocaine-using women.

Risk of window period HIV infection in high infectious risk donors: systematic review and meta-analysis

The OPTN defines high risk donors (HRDs), colloquially known as 'CDC high risk donors', as those thought to carry an increased risk of HIV window period (WP) infection prior to serologic detectability. However, the true risk of such infection remains unknown. To quantify the risk of WP infection in each HRD behavior category, we performed a systematic review and meta-analysis of studies of HIV prevalence and incidence. Of 3476 abstracts reviewed, 27 eligible studies of HIV infection in HRD populations were identified. Pooled HIV incidence estimates were calculated for each category of HRD behavior and used to calculate the risk of WP HIV infection. Risks ranged from 0.09-12.1 per 10 000 donors based on WP for ELISA and 0.04-4.9 based on nucleic acid testing (NAT), with NAT reducing WP risk by over 50% in each category. Injection drug users had the greatest risk of WP infection (4.9 per 10 000 donors by NAT WP), followed by men who have sex with men (4.2:10 000), commercial sex workers (2.7:10 000), incarcerated donors (0.9:10 000), donors exposed to HIV through blood (0.6:10 000), donors engaging in high-risk sex (0.3:10 000) and hemophiliacs (0.035:10 000). These estimates can help inform patient and provider decision making regarding HRDs.

Risk of window period hepatitis-C infection in high infectious risk donors: systematic review and meta-analysis

The OPTN classifies high infectious risk donors (HRDs) based on criteria originally intended to identify people at risk for HIV infection. These donors are sometimes referred to as 'CDC high risk donors' in reference to the CDC-published guidelines adopted by the OPTN. However, these guidelines are also being used to identify deceased donors at increased risk of window period (WP) hepatitis C virus (HCV) infection, although not designed for this purpose. The actual risk of WP HCV infection in HRDs is unknown. We performed a systematic review of 3476 abstracts and identified 37 eligible estimates of HCV incidence in HRD populations in the United States/Canada. Pooled HCV incidence was derived and used to estimate the risk of WP infection for each HRD category. Risks ranged from 0.26 to 300.6 per 10,000 donors based on WP for ELISA and 0.027 to 32.4 based on nucleic acid testing (NAT). Injection drug users were at highest risk (32.4 per 10,000 donors by NAT WP), followed by commercial sex workers and donors exhibiting high risk sexual behavior (12.3 per 10,000), men who have sex with men (3.5 per 10,000), incarcerated donors (0.8 per 10,000), donors exposed to HIV infected blood (0.4 per 10,000) and hemophiliacs (0.027 per 10,000). NAT reduced WP risk by approximately 10-fold in each category.

High rates of transitions to injecting drug use among Mexican American non-injecting heroin users in San Antonio, Texas (never and former injectors)

OBJECTIVE

To assess the incidence and rate of transition to injecting among Mexican American noninjecting heroin users.

METHODS

In a prospective cohort study of street-recruited MA-NIU in San Antonio, Texas, 2002-2005, participants were administered structured interviews and tested for Human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV). The analysis sample comprised former injection drug users (last injected >6 months ago, n=47) and those who had never injected drugs and tested HCV negative (n=219). A transition to injecting was defined as the first injection of illicit drugs since baseline interview. Transition rates were based on person-years at-risk (PYAR). Proportional hazards regression was used to estimate crude and adjusted (for significant differences between former and never injectors) hazard ratios and 95% confidence intervals of injecting history on transitioning to injecting.

RESULTS

Sixty-three (24%) participants transitioned to injecting at a rate of 22.3/100 PYAR (95% CI: 17.2-28.2). Former-injectors were significantly more likely to transition than never injectors (43% or 20/47 vs. 20% or 43/219; p<0.001), and did so at a faster rate (40.4/100 PYAR, 95% CI: 24.6-60.0 vs. 18.5/100 PYAR, 95% CI: 13.4-24.4), with the crude HR=1.931 (95% CI: 1.116, 3.341) and adjusted HR=2.263 (95% CI: 1.192-4.294).

CONCLUSIONS

The rate of transitioning to injecting was high and greater among former injectors. Of particular concern is the high rate of injecting initiation among never injectors. Future analyses will examine factors associated with injecting initiation, including individual susceptibility and behaviors, social networks, and the cultural and drug market context.

HIV heterosexual sexual risk from injecting drug users among HIV-seronegative noninjecting heroin users

Noninjecting heroin users (NIUs) were recruited in New York City during 1996-2003. Cumulative logistic regression was used to analyze the correlates of HIV sexual risk from injecting drug users (IDUs) among HIV seronegative NIUs engaging in heterosexual vaginal or anal sex in the past 30 days (N = 347). Participants were 67% male and 70% African American or Latino, with a mean age of 32.6 years. Hierarchical categories of IDU partner sexual risk included (1) no unprotected sex and no IDU sex partners (21%), (2) unprotected sex but not with IDUs (55%), (3) IDU sex partners but no unprotected sex with them (6%), and (4) unprotected sex with IDUs (17%). Independent correlates (p < .05) of HIV sexual risk from IDU partners included female versus male gender (adjusted odds ratio [AOR] = 2.01), ex-IDU versus never IDU (AOR = 1.90), and lower versus higher perceived social distance from IDUs (AOR = 1.60). Interventions should target female NIUs, ex-IDUs, and NIU members of IDU social and sexual networks. The study's limitations are noted.

High risk behavior for HIV transmission among former injecting drug users: a survey from Indonesia

BACKGROUND

Injecting drug use is an increasingly important cause of HIV transmission in most countries worldwide, especially in eastern Europe, South America, and east and southeast Asia. Among people actively injecting drugs, provision of clean needles and opioid substitution reduce HIV-transmission. However, former injecting drug users (fIDUs) are often overlooked as a high risk group for HIV transmission. We compared HIV risk behavior among current and former injecting drug users (IDUs) in Indonesia, which has a rapidly growing HIV-epidemic largely driven by injecting drug use.

METHODS

Current and former IDUs were recruited by respondent driven sampling in an urban setting in Java, and interviewed regarding drug use and HIV risk behavior using the European Addiction Severity Index and the Blood Borne Virus Transmission Questionnaire. Drug use and HIV transmission risk behavior were compared between current IDUs and former IDUs, using the Mann-Whitney and Pearson Chi-square test.

RESULTS

Ninety-two out of 210 participants (44%) were self reported former IDUs. Risk behavior related to sex, tattooing or piercing was common among current as well as former IDUs, 13% of former IDUs were still exposed to contaminated injecting equipment. HIV-infection was high among former (66%) and current (60%) IDUs.

CONCLUSION

Former IDUs may contribute significantly to the HIV-epidemic in Indonesia, and HIV-prevention should therefore also target this group, addressing sexual and other risk behavior.

Circumstances, pedagogy and rationales for injection initiation among new drug injectors

Injection drug use is especially risky for new injectors. To understand the social and environmental contexts in which risks occur, we interviewed individuals who had initiated injection within the past 3 years (n = 146, 69.2% male) about the circumstances and rationales for their initial injection events. Respondents typically initiated injection due to tolerance (49.3%) and/or for experimentation (61.1%). Most (86.2%) did not possess the technical skills required to self-inject, and relied on the assistance of someone older (58.5%). While low levels of syringe sharing (5.8%) were reported, a majority of respondents (60.5%) engaged in at least one type of behavioral risk. Female injectors were more likely than male injectors to rely on another individual (95.5 vs. 82.2%), often a sex partner (40.5 vs. 7.2%), for assistance. The diversity seen in early injection practices highlights the need for tailored prevention messages to reach this population prior to the onset of injection risk.

Differences between men and women in the course of opiate dependence: is there a telescoping effect?

According to the so-called telescoping effect, there is a gender-specific course of alcohol dependence with women starting alcohol use later than men and having a faster development of harmful consequences. There are inconsistent data regarding a telescoping effect in opiate dependence. In each of six European centres, 100 opiate addicts were investigated by a structured interview (mainly the EuropASI and CIDI) at admission to various kinds of treatment (TREAT project). In a secondary analysis of the TREAT data, women and men were compared regarding age at onset of heroin use and the current severity of addiction. In addition, a comparison of female (n = 140) and male (n = 140) addicts matched for age and study centre were carried out. Eventually, multiple logistic and linear regressions were done with the interaction term of gender and time of regular consumption as predictor for the severity of dependence, besides, other sociodemographic variables. There was no difference between genders regarding the age at onset of regular heroin consumption. Up to 4 years of regular consumption, there are gender-specific differences in the course of opiate dependence, e.g. a faster progression of legal problems in men and social problems in women. There were no differences in the severity of dependence other than more economic problems for women. A telescoping effect could only partially be observed in this large sample of opiate addicts. A gender-specific course was limited to the first years of consumption, and included domains with a faster progression for men. It has to be assumed that opiate dependence is a rapidly developing disorder with early chronification. Afterwards, only individual courses with influences of the national treatment system were observed.

Prevalence rates and risk factors for hepatitis C among drug users not in treatment in Malaysia

INTRODUCTION AND AIMS

The prevalence of hepatitis C virus (HCV) among heroin dependants in treatment was estimated at 89.9%; however, virtually no information exists on the prevalence or risk behaviour among the larger population of drug users not in treatment. This study assessed the prevalence of HCV and associated risk factors among this group with a view to designing more effective intervention programs.

DESIGN AND METHODS

A cross-sectional survey of 552 not-in-treatment drug users recruited from five key urban centres across peninsular Malaysia with on-site serological testing for HCV and HIV seropositivity was conducted.

RESULTS

HCV prevalence was 65.4% for the overall sample, but higher among injecting drug users (67.1%) relative to non-injecting drug users (30.8%). Bivariate analysis suggested seven risk factors though only sharing injecting paraphernalia and lifetime homosexual/bisexual behaviour remained significant in multivariate analysis.

DISCUSSION AND CONCLUSIONS

With the majority (65.9%) sharing injecting equipment and about the same proportion (65.4%) being HCV positive, the risk of further transmission to new drug users is high. It is imperative that the nascent needle and syringe exchange and condom distribution program and its ancillary services--launched in 2005 to fight HIV--be fine tuned, as a first step, to control HCV. With its greater infectivity and non-symptomatic character, HCV is more insidious. Given the shared risk factors of HCV and HIV, routine screening of drug users for HCV--currently non-existent--should be instituted. This, with other intervention measures, will help detect and control HCV at an earlier stage while also checking the spread of HIV.

Vulnerability to drug-related infections and co-infections among injecting drug users in Budapest, Hungary

BACKGROUND

Drug-related infectious diseases are among the major health consequences of drug use, and any existing drug-related infection may predispose injecting drug users (IDUs) to other infections.

METHODS

We assessed among IDUs in Budapest, Hungary the prevalence of and vulnerability to selected drug-related infections and co-infections. The sample consisted of 186 participants recruited between October 2005 and December 2006.

RESULTS

We found 0% HIV, 37% HCV, 24% HAV, and 14% past HBV infection. Infections with Herpes 1 or 2, tuberculosis, Chlamydia, syphilis, and gonorrhoea were 79%, 12%, 7%, 4%, and 0%, respectively. Co-infection with HAV/HCV was 12%, HBV/HCV 9%, HAV/HBV 7%, and HAV/HBV/HCV 4%. Those over age 30, the ethnic Roma, and the homeless were more likely to have any hepatitis and a higher number of drug-related infections. Amphetamine injectors were more likely to have a higher number of drug-related infections and those who travelled within Hungary were more likely to have any STI. However, those who worked at least part time and those who were in treatment were less likely to have drug-related infections.

CONCLUSIONS

These results highlight the need of interventions in Hungary to reach and focus on marginalized (Roma or homeless) IDUs and address not only injecting and sex risk, but also hygienic living and injecting conditions. Furthermore, structural interventions to increase social integration (working or being in treatment) may improve welfare and decrease drug use and infection risk tied to drug use/injection among disadvantaged, marginalized, mostly minority populations.

Can abuse deterrent formulations make a difference? Expectation and speculation

It is critical that issues surrounding the abuse and misuse of prescription opioids be balanced with the need for these medications for the treatment of pain. One way to decrease the abuse of prescription opioid medications is to develop abuse deterrent formulations (or ADFs) that in some way prevent drug abusers from extracting out the active ingredient in order to employ alternate routes of administration, such as injection, snorting, and smoking. Several factors including the pharmacokinetic profile of the drug, the features of the drug formulation that make it attractive or unattractive for abuse, the type of drug abuser, the progression of one's addiction pathway, and one's social environment may all play a role in the abuse of prescription opioids and what methods are used to abuse these drugs. This paper will examine these factors in order to understand how they affect the abuse of prescription opioids and routes of administration, and how the development of ADFs may alter these patterns.

The relationship of sexual dyad and personal network characteristics and individual attributes to unprotected sex among young injecting drug users

We examine in the heterosexual partnerships (dyads) of IDUs the correlates of engaging in unprotected sex on three levels: individual attributes, social network characteristics, and dyad characteristics. Unprotected sex was significantly less likely to occur in dyads where the participant injected daily or had high safe-sex attitude scores, and in dyads where both members encouraged each other to use condoms. Unprotected sex was significantly more likely to occur in dyads that smoked crack together, shared needles with each other, and where the participant knew that the sex partner had concurrent sex partners. In the sexual dyads of IDUs there is a combined risk of unsafe injecting and unsafe sex. Both injecting and sexual risk, and their combination need to be addressed in interventions that target the sexual partnerships of IDUs. Such interventions should also aim to reduce injected and non-injected crack and other stimulant use associated with high-risk sex.

The association of syringe type and syringe cleaning with HCV infection among IDUs in Budapest, Hungary

We assessed whether syringe type, syringe cleaning and distributive syringe sharing were associated with self-reported and laboratory-confirmed HCV infection among Hungarian IDUs. Injecting drug users (N=215) were recruited from non-treatment settings in Budapest, Hungary between October 2005 and December 2006. Multivariate logistic regression models identified correlates of self-report of being HCV infected and testing positive for HCV. While 37% tested positive for HCV, 14% of the total (39% of those who tested positive) self-reported being HCV infected. Using any two-piece syringes was significantly associated with self-reported HCV infection, while distributive syringe sharing was not associated with self-report of being HCV infected. Engaging in receptive sharing of only one-piece syringes but always cleaning before reuse was not associated with testing HCV positive, while any receptive sharing of only one-piece syringes and not always cleaning before reuse was significantly associated with testing HCV positive. Sharing cookers and squirting drugs from one syringe into another syringe were not associated with testing HCV positive. The high percent of those HCV infected who did not know they were infected highlights the need to provide better access to confidential testing and counseling services. Counseling should emphasize secondary prevention of HCV among HCV infected IDUs. Our findings also indicate that syringe type and syringe cleaning practices may play a role in HCV transmission. Ethnographic research should identify the reasons why IDUs may use two-piece syringes and suggest means to reduce their use. Thorough cleaning of one-piece syringes when sterile syringes are unavailable may be an efficient way to reduce the risk of HCV infection.

Viral hepatitis and HIV-associated tuberculosis: risk factors and TB treatment outcomes in Thailand

Background

The occurrence of tuberculosis (TB), human immunodeficiency virus (HIV), and viral hepatitis infections in the same patient poses unique clinical and public health challenges, because medications to treat TB and HIV are hepatotoxic. We conducted an observational study to evaluate risk factors for HBsAg and/or anti-HCV reactivity and to assess differences in adverse events and TB treatment outcomes among HIV-infected TB patients.

Methods

Patients were evaluated at the beginning, during, and at the end of TB treatment. Blood samples were tested for aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin (BR), complete blood count, and CD4+ T lymphocyte cell count. TB treatment outcomes were assessed at the end of TB treatment according to international guidelines.

Results

Of 769 enrolled patients, 752 (98%) had serologic testing performed for viral hepatitis: 70 (9%) were reactive for HBsAg, 237 (31%) for anti-HCV, and 472 (63%) non-reactive for both markers. At the beginning of TB treatment, 18 (26%) patients with HBsAg reactivity had elevated liver function tests compared with 69 (15%) patients non-reactive to any viral marker (p = 0.02). At the end of TB treatment, 493 (64%) were successfully treated. Factors independently associated with HBsAg reactivity included being a man who had sex with men (adjusted odds ratio [AOR], 2.1; 95% confidence interval [CI], 1.1–4.3) and having low TB knowledge (AOR, 1.8; CI, 1.0–3.0). Factors most strongly associated with anti-HCV reactivity were having injection drug use history (AOR, 12.8; CI, 7.0–23.2) and living in Bangkok (AOR, 15.8; CI, 9.4–26.5). The rate of clinical hepatitis and death during TB treatment was similar in patients HBsAg reactive, anti-HCV reactive, both HBsAg and anti-HCV reactive, and non-reactive to any viral marker.

Conclusion

Among HIV-infected TB patients living in Thailand, markers of viral hepatitis infection, particularly hepatitis C virus infection, were common and strongly associated with known behavioral risk factors. Viral hepatitis infection markers were not strongly associated with death or the development of clinical hepatitis during TB treatment.

Greater drug injecting risk for HIV, HBV, and HCV infection in a city where syringe exchange and pharmacy syringe distribution are illegal

Comparing drug-injecting risk between cities that differ in the legality of sterile syringe distribution for injection drug use provides a natural experiment to assess the efficacy of legalizing sterile syringe distribution as a structural intervention to prevent human immunodeficiency virus (HIV) and other parenterally transmitted infections among injection drug users (IDUs). This study compares the parenteral risk for HIV and hepatitis B (HBV) and C (HCV) infection among IDUs in Newark, NJ, USA, where syringe distribution programs were illegal during the period when data were collected, and New York City (NYC) where they were legal. IDUs were nontreatment recruited, 2004-2006, serotested, and interviewed about syringe sources and injecting risk behaviors (prior 30 days). In multivariate logistic regression, adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) for city differences are estimated controlling for potential city confounders. IDUs in Newark (n = 214) vs. NYC (n = 312) were more likely to test seropositive for HIV (26% vs. 5%; AOR = 3.2; 95% CI = 1.6, 6.1), antibody to the HBV core antigen (70% vs. 27%; AOR = 4.4; 95% CI = 2.8, 6.9), and antibody to HCV (82% vs. 53%; AOR = 3.0; 95% CI = 1.8, 4.9), were less likely to obtain syringes from syringe exchange programs or pharmacies (AOR = 0.004; 95% CI = 0.001, 0.01), and were more likely to obtain syringes from street sellers (AOR = 74.0; 95% CI = 29.9, 183.2), to inject with another IDU's used syringe (AOR = 2.3; 95% CI = 1.1, 5.0), to reuse syringes (AOR = 2.99; 95% CI = 1.63, 5.50), and to not always inject once only with a new, sterile syringe that had been sealed in a wrapper (AOR = 5.4; 95% CI = 2.9, 10.3). In localities where sterile syringe distribution is illegal, IDUs are more likely to obtain syringes from unsafe sources and to engage in injecting risk behaviors. Legalizing and rapidly implementing sterile syringe distribution programs are critical for reducing parenterally transmitted HIV, HBV, and HCV among IDUs.