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

Substances detected in used syringes of injecting drug users across 7 cities in Europe in 2017 and 2018: The European Syringe Collection and Analysis Project Enterprise (ESCAPE)

BACKGROUND AND AIMS

Injecting drug use is a matter of public health concern, associated with risks of overdoses, addiction and increased risk of bloodborne viral transmissions. Self-reported data on substances injected can be inaccurate or subject to bias or drug users might be oblivious to their injected substances or adulterations. Gathering of robust analytical information on the actual composition of substances injected might provide better information about the drugs that are being used. Therefore, this study aimed to analyse the residual content of discarded syringes collected across 7 European cities, collectively called the European Syringe Collection and Analysis Project Enterprise (ESCAPE).

METHODS

Used syringes were collected at street automatic injection kit dispensers or at harm-reduction services in Amsterdam, Budapest, Cologne, Glasgow, Helsinki, Lausanne and Paris. Two sampling periods were executed thus far, in 2017 and 2018. Qualitative chemical analysis of the content of used syringes was performed combining gas chromatographic (GC) and ultra(high)performance liquid chromatographic ((U)HPLC) analytical techniques with detection by mass spectrometry (MS).

RESULTS

Substances detected most frequently across both campaigns were cocaine, heroin, buprenorphine, amphetamines and synthetic cathinones. In Amsterdam, Cologne, Lausanne and Glasgow heroin and cocaine were the psychoactive substances most often detected, often in conjunction with each other. Helsinki showed a high presence of buprenorphine and amphetamines. In Budapest and Paris, synthetic cathinones were frequently detected. Less synthetic cathinones and cocaine was detected in 2018, whereas buprenorphine was detected almost twice as much. Inner-city variations were found, probably reflecting the types of people who inject drugs (PWID) in different areas of the city.

CONCLUSION

Overall, laboratory-confirmed local data on injected substances showed resemblance to national surveys done among PWID. However, the ESCAPE data also showed some interesting differences, showing it can be used for local interventions and complementing existing monitoring data.

Co-design of harm reduction materials for people who inject drugs to implement research findings

Background

Equipment used by people who inject drugs (PWID) either has a needle which is fixed to the syringe or can be detached and replaced. Detachable low dead space syringes (LDSS) have been developed, with less space between the needle and plunger (referred to as dead space) than traditional detachable equipment. This equipment can help protect PWID from harm of infection as less blood is transferred if equipment is shared. Our previous research found that detachable LDSS are likely to be acceptable to PWID, and we produced recommendations for their introduction in needle and syringe programmes (NSP) in the United Kingdom (UK). We held a national stakeholder meeting to discuss how to accelerate the pace and scale of the rollout and uptake of detachable LDSS. This commentary reflects on the involvement of PWID as co-designers of harm reduction materials to implement these research findings in a way that supports the uptake of LDSS equipment by NSP and service users. We present the user-centred design process, peer reflections on the project, and lessons learnt by the team working with the peers.

Main body

Peers and stakeholders translated the research into easy to understand messages following a consultation with NSP across the UK. Working with Linnell Publications over three workshops, peers selected their preferred design style and informed the language, messages, and overall look of the designs. The peers ensured the designs avoided images and language with negative connotations, humour, and unequivocal language. Peers said that they found the process enjoyable and informative—leading to increased awareness of harm reduction practices. The facilitators took steps to ensure the views of the peers were heard throughout. They reflected on the importance of involving PWID meaningfully throughout the project. Without the peers, the designs would be less effective and engaging to their target audience.

Conclusion

We conclude that placing peers at the heart of this research implementation project was essential to ensure the materials are appropriate and engaging and do not stigmatise or alienate the intended audience unintentionally. We recommend that others planning similar work include peers within the entire project to support their meaningful contribution.

Usage of low dead space syringes and association with hepatitis C prevalence amongst people who inject drugs in the UK

INTRODUCTION

Syringes with attached needles (low dead space syringes [LDSS]) retain far less blood following injection than syringes with detachable needles (high dead space syringes [HDSS]). People who inject drugs (PWID) who share needles/syringes may be less likely to acquire Hepatitis C virus (HCV) infection using LDSS, compared with HDSS, but data are limited.

METHODS

Utilizing drug behavior and HCV antibody testing data from the UK 2014/2015 Unlinked Anonymous Monitoring Survey of PWID, we calculated the percentage of syringes used in the past month that were LDSS. We investigated which injecting characteristics and demographic factors were associated with 100% LDSS (against 0-99%) usage, and whether 100% LDSS use was associated with antibody HCV-status, after adjusting for confounders.

RESULT

Of 2174 participants, 55% always used LDSS, 27% always used HDSS, and 17% used both LDSS and HDSS. PWID that had injected into their groin during the past month were unlikely to use LDSS, adjusted odds ratio (aOR) 0.14 (95% confidence interval 0.11-0.17), compared to those not using the groin. Those injecting crack were less likely to use LDSS than those not, aOR 0.79 (0.63-0.98). Polydrug use was negatively associated with LDSS use, aOR 0.88 (0.79-0.98) per additional drug. LDSS use was associated with lower prevalent HCV among all PWID (aOR 0.77, [0.64-0.93]), which was stronger among recent initiates (aOR 0.53 [0.30-0.94]) than among experienced PWID (aOR 0.81 [0.66-0.99]).

DISCUSSION

People who inject into their groin were less likely to use LDSS. Exclusive LDSS use was associated with lower prevalence of HCV amongst PWID that started injecting recently, suggesting LDSS use is protective against HCV.

Prevalence of hepatitis C viral infection among injecting drug users in a Saudi Arabian hospital: A point cross sectional survey

Hepatitis C Virus is an important cause of preventable morbidity and mortality among Injecting Drug Users worldwide. The aim of this study is to determine the prevalence and correlations of HCV infection among IDUs in Saudi Arabia. A point cross-sectional survey was conducted between May 2012 and Nov 2012 to determine hepatitis C viral antibodies serological status using venous blood among IDUs (N=300) accessing care at Al-Amal Hospital in the Kingdom of Saudi Arabia, as well as to determine clinical correlates of hepatitis C infection among the Injecting Drug Users. There was an overall HCV prevalence of 42.7% among IDUs studied. Low level primary education, single marital status, being unemployed and commencing Injecting Drugs beyond the age of 15 years have higher specific prevalence of HCV among IDUs population. There was statistically significant association between clinical assessments of the participants who were abusing drugs generally, dependent on drugs, specifically abusing cocaine, amphetamines, opioids, cannabinoids and alcohol with HCV antibodies seropositivity. There was no statistical significant relationship between drug induced sleep/sexual disorder and psychosis/delusion with HCV seropositivity. This study demonstrated a relatively high prevalence of HCV among IDUs in KSA. Targeted public health preventive strategies are necessary to halt the spread of HCV among IDUs in KSA. The resultant benefits of these will include reduction in morbidity and mortality as well as improved socioeconomic wellbeing of the IDU's population.

Injection-related hepatitis C serosorting behaviors among people who inject drugs: An urban/rural comparison

Although previous research has focused on injection drug use behaviors in both urban and rural settings, few have drawn direct comparisons between adjacent rural and urban areas. Using data from the National HIV Behavioral Surveillance study as well as original data collected in a similar fashion, we compare the risk behaviors of people who inject drugs (PWID) in San Juan, Puerto Rico, with those of PWID in nearby rural areas. Specifically, we examine whether one's own hepatitis C (HCV) infection status can be used to predict whether one asked their most recent co-injection partner about their HCV status. Acquiring such information allows injectors to seek out co-injection partners of concordant status as a way to minimize the risk of viral transmission. Results indicate that urban PWID with a known HCV+ status were more likely to know their last co-injector partner's HCV status than were their peers with a negative or unknown HCV status. However, this relationship was not present in the rural data. These findings suggest that there are different risk norms in rural and urban PWID communities and that interventions successful in one type of community may not be so in others.

Options for reducing HIV transmission related to the dead space in needles and syringes

BACKGROUND

When shared by people who inject drugs, needles and syringes with different dead space may affect the probability of HIV and hepatitis C virus (HCV) transmission differently.

METHODS

We measured dead space in 56 needle and syringe combinations obtained from needle and syringe programs across 17 countries in Europe and Asia. We also calculated the amounts of blood and HIV that would remain in different combinations following injection and rinsing.

RESULTS

Syringe barrel capacities ranged from 0.5 to 20 mL. Needles ranged in length from 8 to 38 mm. The average dead space was 3 μL in low dead space syringes with permanently attached needles, 13 μL in high dead space syringes with low dead space needles, 45 μL in low dead space syringes with high dead space needles, and 99 μL in high dead space syringes with high dead space needles. Among low dead space designs, calculated volumes of blood and HIV viral burden were lowest for low dead space syringes with permanently attached needles and highest for low dead space syringes with high dead space needles.

CONCLUSION

The dead space in different low dead space needle and syringe combinations varied substantially. To reduce HIV transmission related to syringe sharing, needle and syringe programs need to combine this knowledge with the needs of their clients.

Correlates of anti-hepatitis C positivity and use of harm reduction services among people who inject drugs in two cities in Croatia

BACKGROUND

We assessed correlates of anti-hepatitis C (anti-HCV) positivity and utilization of needle and syringe exchange programs (NSEP) and opioid agonist treatment (OAT) among people who inject drugs (PWID) in two Croatian cities.

METHODS

We conducted a cross-sectional study using respondent-driven (RDS) sampling among PWID in Rijeka (N=255) and Split (N=399). We used RDS-weighted population estimates and multivariable logistic regression to explore correlates of anti-HCV positivity and NSEP and OAT utilization.

RESULTS

Seventy-eight percent (78.0%) of PWID in Rijeka and 61.5% in Split had been tested previously for HCV, while 21.5% and 7.0%, respectively, were tested for HCV in the past 12 months. Among PWID who report being infected with HCV, 24.9% in Rijeka and 11.3% in Split received anti-HCV treatment. In Rijeka, PWID who utilized NSEP and, in Split, those who were ever imprisoned, had higher odds of anti-HCV positivity. In Rijeka, PWID on OAT were more likely to use non-sterile injecting equipment and to inject for longer than 10 years. PWID enrolled in NSEP were more likely to inject opioid agonist medication (OAM) and less likely to use non-sterile injecting equipment. More than half of PWID reported misuse of OAM in the past month, while out of PWID enrolled in OAT, 65.4% in Rijeka and 88.7% in Split injected OAM in the month prior to the survey.

CONCLUSIONS

Key findings of the paper point to the need to scale up HCV testing and treatment, improve access to NSEP and the quality of OAT provisions in order to prevent its misuse among PWID.

Acceptability of low dead space syringes and implications for their introduction: A qualitative study in the West of England

BACKGROUND

It is recommended that needle and syringe programmes (NSP) distribute low dead space syringes (LDSS) to reduce blood-borne virus transmission. We explored the acceptability of detachable LDSS among people who inject drugs (PWID) and staff who work to support them.

METHODS

Semi-structured interviews were performed with 23 PWID (15 men and 8 women) and 13 NSP staff members (6 men and 7 women) in Bath and Bristol, England. Recruited PWID reflected varying demographic characteristics, drug use and injecting preferences. Interviews explored experiences of different types of injecting equipment, facilitators and barriers of changing this equipment and attitudes towards detachable LDSS. Interviews were audio recorded, transcribed verbatim and analysed using the Framework Method.

RESULTS

Decisions about injecting practices were underpinned by several factors, including early experiences and peer initiation; awareness and availability of alternatives; and the ability to inject successfully. Rinsing and re-using syringes represented a quandary where rinsing could encourage re-use, but not rinsing could result in the re-use of unclean equipment. Most PWID were reluctant to change equipment particularly in the absence of any problems injecting. Prioritising getting a 'hit' over the prevention of potential problems was an important barrier to change. Overall detachable LDSS are likely to be acceptable. Lower risk of transferring infections and reduced drug wastage were valued benefits of detachable LDSS. There was a preference for a gradual introduction of detachable LDSS in which PWID are given an opportunity to try the new equipment alongside their usual equipment.

CONCLUSION

Detachable LDSS are likely to be acceptable and should therefore be offered to those using detachable high dead space syringes and/or fixed 1ml LDSS syringes to inject into deeper femoral veins. An intervention is needed to support their introduction with 'training', 'education', 'persuasion' and eventual 'restriction' components.

HCV prevalence and risk behaviours among injectors of new psychoactive substances in a risk environment in Hungary-An expanding public health burden

BACKGROUND

In Hungary a large increase in injecting new psychoactive substances (NPS) coincided with decreasing harm reduction efforts and rising HCV infection. We describe these, and assess changes in HCV prevalence and risk behaviours, 2011-2014, among NPS injectors, using 2011-2015 syringe exchange programme (SEP) data as a key contextual ('risk environment') variable.

METHODS

We conducted repeated national sero-behavioural surveys in people who inject drugs (PWID) injecting in the last month and attending SEPs or drug treatment centres (n=399, 2011; 384, 2014), using face-to-face interviews and dried blood-spot samples. Prevalence of injected drugs and SEP coverage (2011-2015) were assessed through our national SEP monitoring system and using population size estimates.

RESULTS

NPS injecting tripled among PWID attending SEPs in Hungary (2011: 26%; 2015: 80%). Among NPS injectors, HCV prevalence, sharing syringes and sharing any injecting equipment (last month), doubled (2011-2014: 37%-74%, 20%-48%, 42%-71%, respectively), significantly exceeding prevalence in other PWID groups. Among young NPS injectors (aged<25), HCV prevalence increased 7-fold (12%-76%), among new injectors (injecting<2years) 4-fold (13%-42%), coupled with high levels of equipment sharing (79% and 72% respectively). Not using a condom at last intercourse (79%), ever-imprisonment (65%) and last-year homelessness (57%) were highly prevalent among NPS injectors (2014). The number of syringes distributed per estimated PWID nationally fell from 114 to 81 (2011-2014) and dropped to 28 in 2015.

CONCLUSION

NPS injectors in Hungary are at severe risk of blood-borne infections due to high levels of injecting and sexual risk behaviours within a high-risk environment, including continuously low SEP provision, imprisonment and homelessness. An HIV outbreak cannot be excluded. Stronger investment in evidence-based prevention measures, with special focus on young and new injectors, and expansion of hepatitis C treatment are urgently needed.

A needle in the haystack--the dire straits of needle exchange in Hungary

BACKGROUND

The two largest needle exchange programs (NEPs) in Hungary were forced to close down in the second half of 2014 due to extreme political attacks and related lack of government funding. The closures occurred against a background of rapid expansion in Hungary of injectable new psychoactive substances, which are associated with very frequent injecting episodes and syringe sharing. The aim of our analysis was to predict how the overall Hungarian NEP syringe supply was affected by the closures.

METHODS

We analyzed all registry data from all NEPs in Hungary for all years of standardized NEP data collection protocols currently in use (2008-2014) concerning 22 949 client enrollments, 9,211 new clients, 228,167 client contacts, 3,160,560 distributed syringes, and 2,077,676 collected syringes.

RESULTS

We found that while the combined share of the two now closed NEPs decreased over time, even in their partial year 2014 they still distributed and collected about half of all syringes, and attended to over half of all clients and client contacts in Hungary. The number of distributed syringes per PWID (WHO minimum target = 100) was 81 in 2014 in Hungary, but 39 without the two now closed NEPs.

CONCLUSIONS

There is a high probability that the combination of decreased NEP coverage and the increased injection risk of new psychoactive substances may lead in Hungary to a public health disaster similar to the HIV outbreaks in Romania and Greece. This can be avoided only by an immediate change in the attitude of the Hungarian government towards harm reduction.

Using Pharmacies in a Structural Intervention to Distribute Low Dead Space Syringes to Reduce HIV and HCV Transmission in People Who Inject Drugs

Ongoing injection drug use contributes to the HIV and HCV epidemics in people who inject drugs. In many places, pharmacies are the primary source of sterile syringes for people who inject drugs; thus, pharmacies provide a viable public health service that reduces blood-borne disease transmission. Replacing the supply of high dead space syringes with low dead space syringes could have far-reaching benefits that include further prevention of disease transmission in people who inject drugs and reductions in dosing inaccuracies, medication errors, and medication waste in patients who use syringes. We explored using pharmacies in a structural intervention to increase the uptake of low dead space syringes as part of a comprehensive strategy to reverse these epidemics.

Emerging Risks Due to New Injecting Patterns in Hungary During Austerity Times

As a consequence of the massive restructuring of drug availability, heroin injection in Hungary was largely replaced by the injecting of new psychoactive substances (NPS) starting in 2010. In the following years in our sero-prevalence studies we documented higher levels of injecting paraphernalia sharing, daily injection-times, syringe reuse, and HCV prevalence among stimulant injectors, especially among NPS injectors. Despite the increasing demand, in 2012 the number of syringes distributed dropped by 35% due to austerity measures. Effects of drug market changes and the economic recession may have future epidemiological consequences. Study limitations are noted and future needed research is suggested.

WHO guidance on the prevention of viral hepatitis B and C among people who inject drugs

Viral hepatitis B and C (HBV, HCV) disproportionately affect people who inject drugs (PWID) across the world. To date there has been little global action focusing on prevention, care and treatment of HBV and HCV among PWID. Here we report on the development process and discuss the implications of evidence informed WHO Guidelines for the Prevention of HBV and HCV in PWID. The World Health Organization (WHO) convened a Guideline Development Panel to develop recommendations on the prevention of HBV and HCV among PWID. The process followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. It included the development of PICO (Population, Interventions, Comparator, Outcomes) questions and conducting systematic reviews. Quality of evidence was classified into 4 levels: high, moderate, low, and very low. In the process of moving from evidence to recommendations, the following were considered: quality of evidence, balance of benefits and harms, community values and preferences and resource use. The WHO recommendations include the following for working with PWID: offer the rapid HBV vaccination regimen; offer incentives to increase uptake and completion of the HBV vaccine schedule; needle and syringe programs should also provide low dead-space syringes for distribution; and offer peer interventions to reduce the incidence of viral hepatitis. This guideline complements other WHO documents regarding PWID, including HIV prevention initiatives such as needle and syringe programs and opioid substitution therapy. This guidance offers a first step in the prevention of HBV and HCV among PWID. However, the lack of high quality evidence in this area necessitates further research and resources for implementation.

Low dead-space syringes for preventing HIV among people who inject drugs: promise and barriers

PURPOSE OF REVIEW

This review examines evidence regarding the differential effects of high dead-space syringes (HDSS) and low dead-space syringes (LDSS) on HIV transmission among people who inject drugs (PWID). It also identifies areas for additional research and examines potential barriers to interventions that promote LDSS.

RECENT FINDINGS

Results of laboratory experiments and cross-sectional bio-behavioral surveys provide circumstantial evidence that the probability of HIV transmission associated with sharing LDSS is less than the probability of HIV transmission associated with sharing HDSS. Mathematical models suggest that LDSS may prevent injection-related HIV epidemics among PWID.

SUMMARY

Circumstantial evidence suggests that LDSS may substantially reduce HIV transmission among PWID, who share syringes. Additional research that links LDSS to reductions in HIV incidence is needed. Most currently available LDSS are 1 ml or smaller and have fixed needles. These cannot be used by PWID 'injecting' larger volumes of fluid and they may be rejected by PWID, who prefer syringes with detachable needles. Nonetheless, LDSS represent a potentially promising intervention that deserves serious consideration.

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.

[Human immunodeficiency virus (HIV) and Hepatitis C virus (HCV) testing among injecting drug users]

In Hungary, there is a need for widely accessible HIV and HCV testing and counseling for injecting drug users. Theoretically, free and confidential rapid HIV and HCV testing would be the most suitable for this purpose. Low threshold agencies, such as needle and syringe programs, would provide ideal premises for such a testing system, Here, participants would be able to undergo regular testing every six months. Making rapid testing widely available raises the following three main issues: 1. validity of the testing results (or: the verification of positive rapid test results), 2. circumstances of taking blood (or: legislation regarding drawing blood), and 3. cost effectiveness (or: how important is it to prevent an HIV epidemic). The authors propose the establishment of a system that offers screening using rapid tests and which would be an expansion of a currently existing system of HIV and HCV testing based on finger prick blood. The current system would thus serve as a means to verify the results of the rapid tests. At the same time, there is a need to obtain permission from a public health body to enable in needle and syringe programs the provision of rapid testing and testing of blood using finger pricks. In many countries, test results are given to injecting drug users not by doctors but by trained social workers - such a system could also be established in Hungary. If preventing an HIV epidemic in Hungary is a priority, then wide access to rapid HIV testing is justified. Widely accessible free and confidential rapid HIV and HCV testing and counseling - combined with screening and verification using finger prick blood - may function not only as a testing and counseling service but also as a good quality public health monitoring system. Such a system, however, requires regular financial support from the government.

Prevalence of HIV, hepatitis B and hepatitis C and associated risk behaviours amongst injecting drug users in three Afghan cities

BACKGROUND

HIV amongst injecting drug users (IDUs) has been described in Kabul but little data exists for other Afghan cities. We assessed HIV, hepatitis B virus (HBV), and C virus (HCV) prevalence and associated risk behaviours amongst IDUs in Hirat, Jalalabad, and Mazar-i-Sharif, Afghanistan.

METHODS

Consented participants reporting injecting drugs within the previous 6 months completed interviewer-administered questionnaires and testing for HIV, hepatitis C antibody (HCV Ab), and hepatitis B surface antigen (HBsAg). Logistic regression was used to determine characteristics associated with each infection.

RESULTS

Of 623 participants, most (98.7%) were male. Prevalence of HIV, HCV, and HBV was 1.8% (95% CI: 0.88-3.2), 36.0% (95% CI: 33-41), and 5.8% (95% CI: 3.9-7.6), respectively. All HIV cases and highest HCV prevalence were detected in Hirat; HBV prevalence was highest in Jalalabad. Amongst male IDUs, 62.9% had been imprisoned, of whom 17.2% (n=66) injected in prison. High risk behaviours were common; 30.2% reported needle sharing in the last 6 months, 23.1% reported sex with another male, and 50.4% reported paying females for sex. Behaviours varied significantly by site; generally, Hirat participants reported fewer sexual risk behaviours. Sex with other males was negatively associated with both HBV and HCV in multivariate logistic regression analysis; no injecting behaviours were associated with both HBV and HCV.

CONCLUSIONS

Whilst HIV prevalence is low, HCV prevalence and high risk behaviours were common in these populations. Regional variations should be considered in programming to prevent transmission of HIV and viral hepatitis amongst IDUs in Afghanistan.

Infection disclosure in the injecting dyads of Hungarian and Lithuanian injecting drug users who self-reported being infected with hepatitis C virus or human immunodeficiency virus

The aim of this study was to assess the prevalence and correlates of disclosure to network members of being hepatitis C virus (HCV)- or human immunodeficiency virus (HIV)-infected among injecting dyads of infected injection drug users (IDUs) in Budapest, Hungary and Vilnius, Lithuania,. Multivariate generalized estimating equations (GEE) were used to assess associations. Very strong infection disclosure norms exist in Hungary, and HCV disclosure was associated with using drugs and having sex within the dyad. Non-ethnic Russian IDUs in Lithuania were more likely to disclose HCV infection to non-Roma, emotionally close and HCV-infected network members, and to those with whom they shared cookers, filters, drug solutions or rinse water or got used syringes from, and if they had fewer non-IDU or IDU network members. Ethnic Russian Lithuanian IDUs were more likely to disclose HCV if they had higher disclosure attitude and knowledge scores, 'trusted' network members, and had lower non-injecting network density and higher injecting network density. HIV-infected Lithuanian IDUs were more likely to disclose to 'trusted' network members. Disclosure norms matched disclosure behaviour in Hungary, while disclosure in Lithuania to 'trusted' network members suggests possible stigmatization. Ongoing free and confidential HCV/HIV testing services for IDUs are needed to emphasize and strengthen disclosure norms, and to decrease stigma.

Modeling the effect of high dead-space syringes on the human immunodeficiency virus (HIV) epidemic among injecting drug users

AIMS

To illustrate the impact of different proportions of injecting drug users (IDUs) sharing high dead-space syringes (HDSS) or low dead-space syringes (LDSS) on the probability of human immunodeficiency virus (HIV) transmission; and thus the impact on injection-related HIV prevalence and incidence.

DESIGN

A stochastic mathematical model was used to evaluate the impact of HDSS use in high- and low-risk IDU populations. Model parameters were obtained from peer-reviewed publications. Analytical solutions of a simplified deterministic model were obtained to explain the effect of HDSS on HIV endemic states.

FINDINGS

Simulation analysis shows that the HIV epidemic could be sustained even when a small percentage of sharing (10%) involved HDSS. The effect is much stronger in high-risk compared with low-risk populations. Steady state HIV prevalence increases with the proportion of HDSS, and for high- and low-risk populations reaches around 80% and 20%, respectively. For low-risk populations, the use of LDSS could result in the virtual elimination of HIV. These results are dependent upon an evidence-supported assumption of a significant difference in HIV transmission risk associated with HDSS versus LDSS.

CONCLUSIONS

Our models suggest that injection-related HIV epidemics may not occur when most (e.g. 95% or more) IDUs use LDSS. While these results are based on indirect risk measures and a number of simplifying assumptions, the effect of blood retained in high dead-space syringes on HIV prevalence seems to be very strong, even using relatively conservative assumptions. The findings have potential implications for needle exchange programs and the types of syringes produced and distributed world-wide.

Epidemiology of hepatitis C and human immunodeficiency virus infections among injecting drug users in Hungary – what’s next?

Jelenleg hazánkban az injektáló kábítószer-használók körében a hepatitis C (HCV) előfordulási aránya Budapesten 35% körüli, vidéken pedig 20% alatti, és verifikált emberi immunhiányt okozó vírus (HIV) -fertőzést nem regisztráltak körükben. Matematikai modellek szerint a HCV és a HIV járványtana ebben a kockázati csoportban egybefonódik: amíg a HCV előfordulása körülbelül 35% alatti, a HIV-járvány valószínűsége nagyon csekély, e határ átlépése után viszont egyre terjedő HIV-járványra számíthatunk. E modellek szerint a hazai, főleg a fővárosi, injektáló kábítószer-használók körében egyre nő egy átfogó HIV-járvány valószínűsége. Négy fő módon lehet egy ilyen HIV-járványt késleltetni, illetve minimalizálni: 1. helyettesítő kezelési programokkal; 2. injektáló eszközök legális hozzáférésével; 3. tanácsadással egybekötött, ingyenes, anonim HIV- és HCV-gyorsteszteléssel; és 4. higiénikus injektálási körülmények biztosításával. Az injektáló kábítószer-használók jelenlegi HCV-járványtani helyzete nemcsak mielőbbi széles körű és átfogó megelőzési választ kíván az előrejelzéseken alapuló HIV-járvány elkerülése érdekében, főleg a fővárosban, hanem a járványtani helyzet rendszeres monitorozását is. A megelőzési programok sikeressége két kulcstényezőn múlik: 1. széles körű hozzáférhetőség és 2. folyamatos állami finanszírozás.

Liquid Drugs and High Dead Space Syringes May Keep HIV and HCV Prevalence High – A Comparison of Hungary and Lithuania

Despitevery similar political, drug policy and HIV prevention backgrounds, HIV and HCV prevalence is considerably different in Hungary (low HIV and moderate HCV prevalence) and Lithuania (high HCV and moderate HIV prevalence). Wecompared the drug use profile of Hungarian (n = 215) and Lithuanian (n = 300) injecting drug users (IDUs). Overall, compared with IDUs in Hungary, IDUs in Lithuania often injected opiates purchased in liquid form ('shirka'), used and shared 2-piece syringes (vs. 1-piece syringes) disproportionately more often, were less likely to acquire their syringes from legal sources and had significantly more experience with injected and less experience with non-injected drugs. It may not be liquid drugs per se that contribute to a higher prevalence of HCV and/or HIV, but it is probably factors associated with the injecting of liquid drugs, such as the wide-spread use and sharing of potentially contaminated 2-piece syringes acquired often from non-legal sources, and syringe-mediated drug sharing with 2-piece syringes. Scaling up substitution therapy, especially heroin replacement, combined with reducing the supply of liquid drugs may decrease the prevalence of high-risk injecting behaviours related to the injecting of liquid drugs and drug injecting-related infections among IDUs in Lithuania.