Serosorting for hepatitis C status in the sharing of injection equipment among Seattle area injection drug users

Cocaine/crack and cannabis use among transgender women in Goiás, Central Brazil

INTRODUCTION

Illicit drug use is a significant public health problem. Studies have shown a high prevalence of cocaine and cannabis use in transgender women (TGW).

OBJECTIVE

To describe the consumption patterns of cannabis and cocaine/crack use and variables associated with their use in TGW in Central Brazil.

METHODS

A cross-sectional study was conducted on TGW in Goiás, Brazil. Participants were recruited using a respondent-driven sampling method and were interviewed face-to-face about cannabis and crack-cocaine and the variables associated with them. The Alcohol Smoking and Substance Involvement Screening Test was used to assess substance use. Unweighted logistic regression was used to identify variables associated with cannabis and crack cocaine use. P-values < 0.05 were considered statistically significant.

RESULTS

A total of 440 transgender women participated in the study. Their median age was 25 years (interquartile range: 20.5-29.5 years). Most participants were single (85.5%) and had engaged in sex work in their lifetime (58.6%). Cannabis was reported by 68.9% and 53.4% of participants in their lifetime and in the past three months, respectively, and cocaine/crack use was reported by 59.8% and 44.1% of participants in their lifetime and the past three months, respectively. Of the participants, 10.2% reported high-risk cannabis use, and 9.1% reported high-risk cocaine/crack use. Furthermore, 35% of participants reported using both drugs. Previous physical violence (Adjusted Odds Ratio (AOR): 2.37), inconsistent condom uses during anal sex (AOR: 2.17), and moderate-/high-risk cocaine/crack use (AOR: 3.14) were associated with high-risk cannabis use. Previous sexual violence (AOR: 2.84), previous STI (AOR: 2.90), moderate-/high-risk cannabis (AOR: 3.82), and binge drinking (AOR; 3.28) were associated with high-risk cocaine/crack use.

CONCLUSION

Our study found a high frequency, significant overlap in the use of cannabis and cocaine/crack use and violence associated with these drugs consumption among TGW, highlighting the urgent need for health policies for drug disorders among this socially marginalized group.

HCV communication within ego-centric networks of men and women who inject drugs

INTRODUCTION

Leveraging interpersonal communication among social networks of people who inject drugs (PWID) may be an innovative strategy to increase awareness and access to hepatitis C (HCV) care. However, little is known about HCV communication patterns among PWID and if these patterns vary by gender.

METHODS

Egocentric network data collected at baseline from HCV-infected PWID enrolled in a randomized HCV treatment intervention trial in Baltimore, Maryland were analyzed. Logistic generalized estimating models were conducted to identify predictors of HCV communication.

RESULTS

Among 227 PWID, the mean age was 43.8 (SD=10.3), 28.2% (n = 64) were women and 71.8% (n = 163) were men. Female participants reported 516 dyadic relationships and male participants 1139 dyadic relationships. While there were significant gender differences based on socio-demographics, risk behavior and network composition, there were few differences in HCV communication patterns. Both men and women had increased odds of HCV communication with alters who are currently enrolled in drug treatment (AOR 1.7, 95% CI: 1.3-2.4), alters with whom participants share drug preparation equipment (AOR 3.0, 95% CI: 1.9-4.6), alters who are sex partners compared to kin (AOR 3.0; 95% CI: 1.9-4.9) and alters with whom respondents have increased trust (AOR 1.1; 95% CI: 1.11.2) and daily/weekly interactions (AOR 1.7; 95% CI 1.3-2.1).

CONCLUSION

PWID engaged with trusted alters about HCV disclosure and information, highlighting the important role network interventions could play in this vulnerable population.

Combination interventions for Hepatitis C and Cirrhosis reduction among people who inject drugs: An agent-based, networked population simulation experiment

Hepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with prevalence estimates above 60% for PWID in the United States. Previous modeling studies suggest that direct acting antiviral (DAA) treatment can lower overall prevalence in this population, but treatment is often delayed until the onset of advanced liver disease (fibrosis stage 3 or later) due to cost. Lower cost interventions featuring syringe access (SA) and medically assisted treatment (MAT) have shown mixed results in lowering HCV rates below current levels. However. little is known about the potential cumulative effects of combining DAA and MAT treatment. While simulation experiments can reveal likely long-term effects, most prior simulations have been performed on closed populations of model agents—a scenario quite different from the open, mobile populations known to most health agencies. This paper uses data from the Centers for Disease Control’s National HIV Behavioral Surveillance project, IDU round 3, collected in New York City in 2012 to parameterize simulations of open populations. To test the effect of combining DAA treatment with SA/MAT participation, multiple, scaled implementations of the two intervention strategies were simulated. Our results show that, in an open population, SA/MAT by itself has only small effects on HCV prevalence, while DAA treatment by itself can lower both HCV and HCV-related advanced liver disease prevalence. More importantly, the simulation experiments suggest that combinations of the two strategies can, when implemented together and at sufficient levels, dramatically reduce HCV incidence. We conclude that adopting SA/MAT implementations alongside DAA interventions can play a critical role in reducing the long-term consequences of ongoing HCV infection.

Knowledge of hepatitis C status moderates the relationship between history of drug treatment and sterile syringe use

High-risk injection related behavior including use of non-sterile syringes is associated with negative health outcomes among people who inject drugs (PWID). Drug treatment programs have been reported to curb hepatitis C (HCV) transmission. This study aims to assess the role of drug treatment programs and knowledge of HCV status, and how they influence current injection-related risk. Data were collected in 2012 by the New Orleans arm of the CDC funded National HIV Behavioral Surveillance. Respondent driven sampling was used to recruit a sample of PWID. The analytic sample consisted of 473 participants. Univariate, bivariate, and linear regression analyses were performed. Findings indicated that history of drug treatment is associated with sterile syringe use among PWID. Further, knowledge of HCV status modifies the relationship between history of drug treatment and sterile syringe use in this sample. These findings highlight the importance of scaling up prevention efforts by expanding testing, counselling, and treatment for HCV among PWID who enter drug treatment facilities.

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.

Hepatitis C bio-behavioural surveys in people who inject drugs-a systematic review of sensitivity to the theoretical assumptions of respondent driven sampling

Background

New, more effective and better-tolerated therapies for hepatitis C (HCV) have made the elimination of HCV a feasible objective. However, for this to be achieved, it is necessary to have a detailed understanding of HCV epidemiology in people who inject drugs (PWID).

Respondent-driven sampling (RDS) can provide prevalence estimates in hidden populations such as PWID. The aims of this systematic review are to identify published studies that use RDS in PWID to measure the prevalence of HCV, and compare each study against the STROBE-RDS checklist to assess their sensitivity to the theoretical assumptions underlying RDS.

Method

Searches were undertaken in accordance with PRISMA systematic review guidelines. Included studies were English language publications in peer-reviewed journals, which reported the use of RDS to recruit PWID to an HCV bio-behavioural survey. Data was extracted under three headings: (1) survey overview, (2) survey outcomes, and (3) reporting against selected STROBE-RDS criteria.

Results

Thirty-one studies met the inclusion criteria. They varied in scale (range 1–15 survey sites) and the sample sizes achieved (range 81–1000 per survey site) but were consistent in describing the use of standard RDS methods including: seeds, coupons and recruitment incentives.

Twenty-seven studies (87%) either calculated or reported the intention to calculate population prevalence estimates for HCV and two used RDS data to calculate the total population size of PWID. Detailed operational and analytical procedures and reporting against selected criteria from the STROBE-RDS checklist varied between studies. There were widespread indications that sampling did not meet the assumptions underlying RDS, which led to two studies being unable to report an estimated HCV population prevalence in at least one survey location.

Conclusion

RDS can be used to estimate a population prevalence of HCV in PWID and estimate the PWID population size. Accordingly, as a single instrument, it is a useful tool for guiding HCV elimination. However, future studies should report the operational conduct of each survey in accordance with the STROBE-RDS checklist to indicate sensitivity to the theoretical assumptions underlying the method.

Systematic review registration

PROSPERO CRD42015019245

Hepatitis C serosorting among people who inject drugs in rural Puerto Rico

Due to the high cost of treatment, preventative measures to limit Hepatitis C (HCV) transmission among people who inject drugs (PWID) are encouraged by many public health officials. A key one of these is serosorting, where PWID select risk partners based on concordant HCV status. Research on the general U.S. population by Smith et al. (2013) found that knowledge of one's own HCV status facilitated serosorting behaviors among PWID, such that respondents with knowledge of their own status were more likely to ask potential partners about their status prior to sharing risk. Our objective was to see if this held true in rural Puerto Rico. We replicate this study using a sample of PWID in rural Puerto Rico to draw comparisons. We used respondent driven sampling to survey 315 participants, and have a final analytic sample of 154. The survey was heavily modeled after the National HIV Behavioral Survey, which was the dataset used by the previous researchers. We found that among PWID in rural Puerto Rico, unlike in the general population, knowledge of one's own HCV status had no significant effect on the selection of one's most recent injection partner, based on his/her HCV status. We conclude that PWID in rural Puerto Rico differ from the general U.S. population when it comes to serosorting behaviors, and that these differences should be taken into account in future outreaches and intervention strategies.

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Recent study finds PWID ask potential partners about infections once own status known.

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We replicate this using similar measures with a sample in rural Puerto Rico.

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Find no evidence this happens in rural Puerto Rico, though women more likely to ask.

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Null finding may be due to small sample size, but pattern still appears unique.

Social mixing and correlates of injection frequency among opioid use partnerships

BACKGROUND

As resources are deployed to address the opioid overdose epidemic in the USA, it is essential that we understand the correlates of more frequent opioid injections-which has been associated not only with HIV and HCV transmission, but also with overdose risk-to inform the development and targeting of effective intervention strategies like overdose prevention and naloxone distribution programs. However, no studies have explored how characteristics of opioid use partnerships may be associated within injection frequency with opioid partnerships.

METHODS

Using baseline data from a trial of a behavioural intervention to reduce overdose among opioid users in San Francisco, CA, we calculated assortativity among opioid use partnerships by race, gender, participant-reported HIV- and HCV-status, and opioids used using Newman's assortativity coefficient (NC). Multivariable generalized estimating equations linear regression was used to examine associations between individual- and partnership-level characteristics and injection frequency within opioid use partnerships.

RESULTS

Opioid use partnerships (n=134) reported by study participants (n=55) were assortative by race (NC=0.42, 95%CI=0.33-0.50) and participant-reported HCV-status (NC=0.42, 95%CI=0.31-0.52). In multivariable analyses, there were more monthly injections among sexual/romantic partnerships (β=114.4, 95%CI=60.2-168.7, p<0.001), racially concordant partnerships reported by white study participants (β=71.4, 95%CI=0.3-142.5, p=0.049), racially discordant partnerships reported by African American study participants (β=105.7, 95%CI=1.0-210.5, p=0.048), and partnerships in which either member had witnessed the other experience an overdose (β=81.8, 95%CI=38.9-124.6, p<0.001).

CONCLUSION

Social segregation by race and HCV-status should potentially be considered in efforts to reach networks of opioid users. Due to higher injection frequency and greater likelihood of witnessing their partners experience an overdose, individuals in sexual/romantic opioid use partnerships, white individuals in racially homogenous partnerships, and African American individuals in heterogeneous partnerships may warrant focused attention as part of peer- and network-based overdose prevention efforts, as well as broader HIV/HCV prevention strategies. Developing and targeting overdose prevention education programs that provide information on risk factors and ways to identify overdose, as well as effective responses, including naloxone use and rescue breathing, for more frequently injecting networks may help reduce opioid morbidity and mortality in these most at risk groups.

[Which place for point-of-care screening tests in the diagnosis of hepatitis C infection among drug users?]

Hepatitis C is a severe disease, which often evolves into chronicity and for which there is no vaccine available. Therefore its screening is essential, especially among drug users who are the main reservoir of the hepatitis C virus (HCV). Current guidelines for screening are based on the detection of total anti-HCV antibodies (Ab) by means of third generation EIA. This test is performed in a laboratory from a venous sample. Alternative methods have been recently developed, including point-of-care tests (POCT) that offer many advantages. Their excellent diagnostic performance, their quick results and their ease of use by a large number of professionals are arguments in favor of widespread use of these tests. The expected benefits of the use of POCT are individual (better knowledge of HCV status, better access to care and treatment) but also collective (reduction of morbidity and mortality related to HCV and its cost in terms of public health) Because of their clinical interest, POCT should be refunded as well as the currently recommended screening test. In order to optimize their ease of use, POCT use should be integrated into an organized screening and hepatology follow-up system.

Examining the associations between sex trade involvement, rape, and symptomatology of sexual abuse trauma

The high prevalence of rape and sexual trauma symptomatology among women involved in street-based sex trades is well-established. Because prior research has lacked appropriate, non-sex trade involved comparison groups, it is unknown whether differences exist among similarly situated women who do and do not trade sex. This article explores experiences of childhood and adult rape and symptomatology of sexual abuse trauma among a community-based sample of 322 women who use methamphetamine in San Francisco, California, 61% of whom were involved in the sex trade. Study participants were recruited via respondent-driven sampling and eligible if they were cisgender women, aged 18 or older, current methamphetamine users, and sexually active with at least one cisgender man in the past 6 months. The dependent variable was sexual abuse trauma symptomatology, as measured by the Sexual Abuse Trauma Index (SATI) subscale of the Trauma Symptom Checklist-40 (TSC-40), and the explanatory variable was sex trade involvement. Potential covariates were age, current homelessness, methamphetamine dependence, and experiences of childhood and adult rape. Sixty-one percent of participants had a SATI subscale score suggestive of sexual abuse trauma. The overall prevalence of rape in childhood and adulthood was 52% and 73%, respectively. In bivariate analysis, sex trade involvement and all of the potential covariates except for homelessness and age were associated with a SATI score suggestive of sexual abuse trauma. In multivariate models controlling for significant covariates, there was no longer a statistically significant association between sex trade involvement or childhood rape and an elevated SATI score. Elevated levels of psychological dependence on methamphetamine and experiences of rape as an adult were still associated with a high SATI score. These findings highlight that urban poor women, regardless of sex trade involvement, suffer high levels of rape and related trauma symptomatology.

Disinfection of syringes contaminated with hepatitis C virus by rinsing with household products

PWID “disinfect” used syringes with readily available household products when new syringes are inaccessible. Household products tested were more effective in fixed-needle syringes (low residual volume) than in syringes with detachable-needles (high residual volume). Bleach was the most effective disinfectant.

Background. Hepatitis C virus (HCV) transmission among people who inject drugs (PWID) is associated with the sharing of injection paraphernalia. People who inject drugs often “disinfect” used syringes with household products when new syringes are unavailable. We assessed the effectiveness of these products in disinfecting HCV-contaminated syringes.

Methods. A genotype-2a reporter virus assay was used to assess HCV infectivity in syringes postrinsing. Hepatitis C virus-contaminated 1 mL insulin syringes with fixed needles and 1 mL tuberculin syringes with detachable needles were rinsed with water, Clorox bleach, hydrogen peroxide, ethanol, isopropanol, Lysol, or Dawn Ultra at different concentrations. Syringes were either immediately tested for viable virus or stored at 4°C, 22°C, and 37°C for up to 21 days before viral infectivity was determined.

Results. Most products tested reduced HCV infectivity to undetectable levels in insulin syringes. Bleach eliminated HCV infectivity in both syringes. Other disinfectants produced virus recovery ranging from high (5% ethanol, 77% ± 12% HCV-positive syringes) to low (1:800 Dawn Ultra, 7% ± 7% positive syringes) in tuberculin syringes.

Conclusions. Household disinfectants tested were more effective in fixed-needle syringes (low residual volume) than in syringes with detachable needles (high residual volume). Bleach was the most effective disinfectant after 1 rinse, whereas other diluted household products required multiple rinses to eliminate HCV. Rinsing with water, 5% ethanol (as in beer), and 20% ethanol (as in fortified wine) was ineffective and should be avoided. Our data suggest that rinsing of syringes with household disinfectants may be an effective tool in preventing HCV transmission in PWID when done properly.

Intimate injection partnerships are at elevated risk of high-risk injecting: a multi-level longitudinal study of HCV-serodiscordant injection partnerships in San Francisco, CA

Background

It is increasingly recognized that the risk for HIV and hepatitis C (HCV) transmission among people who inject drugs (PWID), such as syringe sharing, occurs in the context of relationships between (at least) two people. Evidence suggests that the risk associated with injection behavior varies with injection partner types.

Methods

We utilized longitudinal dyad-level data from a study of young PWID from San Francisco (2006 to 2013) to investigate the relationship-level factors influencing high-risk injecting within HCV-serodiscordant injection partners (i.e., individuals who injected together ≥5 times in the prior month). Utilizing data from 70 HCV-serodiscordant injection partnerships, we used generalized linear models to examine relationship-level predictors (i.e., partnership composition, partnership closeness, and partnership dynamics) of: (1) receptive syringe sharing (RSS); and (2) receptive cooker use (RCU), as reported by the HCV-negative injection partner.

Results

As reported by the “at-risk” HCV-negative injection partner, receptive syringe sharing (RSS) and receptive cooker use (RCU) were 19% and 33% at enrollment, and 11% and 12% over all visits (total follow-up time 55 person-years) resulting in 13 new HCV-infections (incidence rate: 23.8/100 person-years). Person-level factors, injection partnership composition, and partnership dynamics were not significantly associated with either RSS or RCU. Instead, intimate injection partnerships (those who lived together and were also in a sexual relationship) were independently associated with a 5-times greater risk of both RSS and a 7-times greater risk of RCU when compared to injecting only partnerships.

Conclusion

Our findings suggest a positive, and amplified effect of relationship factors on injecting drug risk behaviors among young PWID injection partnerships. The majority of interventions to reduce injection drug use related harms focus on individual-based education to increase drug use knowledge. Our findings support the need to expand harm reduction strategies to relationship-based messaging and interventions.

Non-partner violence against women who use drugs in San Francisco

This article examines non-partner violence among women who use methamphetamine (N = 322), recruited in an inner-city neighborhood of San Francisco. The combined prevalence of non-partner physical or sexual violence in the past 6 months was 28%, roughly equal to the prevalence of partner violence (26%). In multivariate analysis, factors associated with non-partner violence included frequent subsistence difficulty (adjusted odds ratio [AOR] = 2.43, 95% confidence interval [CI] = [1.3, 4.6]) and sex trade (AOR = 2.27, 95% CI = [1.4, 4.1]). Having a steady male partner was not protective against non-partner violence. Violence perpetrated by non-partners should be considered when assessing social and structural factors that influence women's health.

Preference, acceptability and implications of the rapid hepatitis C screening test among high-risk young people who inject drugs

Background

People who inject drugs (PWID) are at highest risk for hepatitis C virus (HCV) infection, yet many remain unaware of their infection status. New anti-HCV rapid testing has high potential to impact this.

Methods

Young adult (<30 years) active PWID were offered either the rapid OraQuick® or standard anti-HCV test involving phlebotomy, then asked to complete a short questionnaire about testing perceptions and preferences. Sample characteristics, service utilization, and injection risk exposures are assessed with the HCV testing choice as the outcome, testing preferences, and reasons for preference.

Results

Of 129 participants: 82.9% (n = 107) chose the rapid test. There were no significant differences between those who chose rapid vs. standard testing. A majority (60.2%) chose the rapid test for quick results; most (60.9%) felt the rapid test was accurate, and less painful (53.3%) than the tests involving venipuncture.

Conclusions

OraQuick® anti-HCV rapid test was widely accepted among young PWID. Our results substantiate the valuable potential of anti-HCV rapid testing for HCV screening in this high risk population.

Unmet healthcare need among women who use methamphetamine in San Francisco

Methamphetamine use has increased substantially in the United States since the 1990s. Few studies have examined the healthcare service needs of women who use methamphetamine. This study describes unmet medical needs in a community-based sample of women who use methamphetamine in San Francisco, CA. Women who use methamphetamine were recruited in San Francisco and participated in a computer-assisted survey (N = 298 HIV-negative women). Multivariate analysis was performed to explore associations among sociodemographic variables, drug use, use of health and social services, and unmet healthcare need across three domains: chronic health problems, dermatologic problems, and women's preventive healthcare. Sixty-nine percent of participants reported a need for care for a chronic health condition, and 31% of them had an unmet need for care, in the last six months. Thirty-five percent of participants reported a need for dermatologic healthcare, and 66% had an unmet need for care in the last 6 months. Ninety-two percent of participants reported a need for women's preventive healthcare and 46% had an unmet need for care in the last year. Women who reported having a healthcare provider had lower odds of reporting an unmet need for a chronic health condition or women's preventive healthcare. Women who used a case manager had lower odds of having an unmet need for dermatologic care. A significant proportion of women who use methamphetamine in this sample had an unmet need for women's preventive healthcare, and overall these women had a significant unmet need for healthcare. These findings suggest that contact with a healthcare provider or a caseworker could help to expand access to healthcare for this vulnerable population.

"To share or not to share?" Serosorting by hepatitis C status in the sharing of drug injection equipment among NHBS-IDU2 participants

BACKGROUND

Persons who inject drugs (PWID) are at high risk for acquiring hepatitis C virus (HCV) infection. The Centers for Disease Control and Prevention estimates there are 17 000 new infections per year, mainly among PWID. This study examines injection equipment serosorting-considering HCV serostatus when deciding whether and with whom to share injection equipment.

OBJECTIVE

To examine whether injection equipment serosorting is occurring among PWID in selected cities.

METHODS

Using data from the National HIV Behavioral Surveillance System-Injection Drug Users (NHBS-IDU2, 2009), we developed multivariate logistic regression models to examine the extent to which participants' self-reported HCV status is associated with their injection equipment serosorting behavior and knowledge of last injecting partner's HCV status.

RESULTS

Participants who knew their HCV status were more likely to know the HCV status of their last injecting partner, compared to those who did not know their status (HCV+: adjusted odds ratio [aOR] 4.1, 95% confidence interval [CI], 3.4-4.9; HCV-: aOR 2.5, 95% CI, 2.0-3.0). Participants who reported being HCV+, relative to those of unknown HCV status, were 5 times more likely to share injection equipment with a partner of HCV-positive status (aOR 4.8, 95% CI, 3.9-6.0).

CONCLUSIONS

Our analysis suggests PWID are more likely to share injection equipment with persons of concordant HCV status.

Half a diagnosis: gap in confirming infection among hepatitis C antibody-positive patients

BACKGROUND

Recent guidelines recommend testing all individuals born during 1945-1965 for hepatitis C virus (HCV) antibody. For antibody-positive patients, subsequent RNA testing is necessary to determine current infection status. This study aimed to assess whether clinicians order HCV RNA tests as recommended for antibody-positive patients and to identify barriers to such testing.

METHODS

We sampled individuals newly reported to the New York City Department of Health and Mental Hygiene's HCV surveillance system and collected information from clinicians. For patients without RNA test results, we asked the reason an RNA test was not ordered and requested that the clinician order the test.

RESULTS

Of 245 antibody-positive patients, 67% were tested for HCV RNA (for 21% of these, the test was ordered only after our request); 33% had no RNA testing despite our request. Patients without RNA testing were seen in medical facilities (47%), detox facilities (30%), and jail/prison (15%). Reasons RNA testing was not done were that the patient did not return for follow-up (35%), the facility does not do RNA testing (22%), and the patient was tested in jail (15%).

CONCLUSIONS

In our study, one third of patients did not get complete testing for accurate diagnosis of HCV, which is essential for medical management. Additional education for clinicians about the importance of RNA testing may help. However, with improved antiviral treatments now available for HCV, it is time for reflex HCV RNA testing for positive antibody tests to become routine, just as reflex Western blot testing is standard for human immunodeficiency virus.

Missed opportunities for hepatitis C testing in opioid treatment programs

HCV has surpassed HIV as a cause of death in the United States and is particularly prevalent among injection drug users. I examined the availability of on-site HCV testing in a nationally representative sample of opioid treatment programs. Nearly 68% of these programs had the staff required for HCV testing, but only 34% offered on-site testing. Availability of on-site testing increased only slightly with the proportion of injection drug users among clients. The limited HCV testing services in opioid treatment programs is a key challenge to reducing HCV in the US population.

Social networks and HCV viraemia in anti-HCV-positive rural drug users

Although social networks are known to play an important role in drug-using behaviours associated with hepatitis C virus (HCV) infection, literature on social networks and HCV is inconsistent. This exploratory study examined HCV RNA distribution within a social network of anti-HCV-positive non-medical prescription opioid users (NMPOUs) in rural Appalachia. Participants were tested serologically for HCV RNA, and behavioural, demographic, and network data were collected using interview-administered questionnaires. Multivariate analyses were performed using logistic regression. Behavioural and demographic characteristics did not differ by RNA status. In the multivariate model, recent injecting drug users (IDUs) were more likely to be RNA positive [odds ratio (OR) 4·06, 95% confidence interval (CI) 1·04-15·83], and turnover into an IDU's drug network was significantly protective (OR 0·15, 95% CI 0·03-0·75). This is the first study to date to examine HCV distribution in rural NMPOUs from a network perspective and demonstrates that network characteristics significantly contribute to the epidemiology of HCV in this understudied, high-risk population.

Cost effectiveness of screening strategies for early identification of HIV and HCV infection in injection drug users

OBJECTIVE

To estimate the cost, effectiveness, and cost effectiveness of HIV and HCV screening of injection drug users (IDUs) in opioid replacement therapy (ORT).

DESIGN

Dynamic compartmental model of HIV and HCV in a population of IDUs and non-IDUs for a representative U.S. urban center with 2.5 million adults (age 15-59).

METHODS

We considered strategies of screening individuals in ORT for HIV, HCV, or both infections by antibody or antibody and viral RNA testing. We evaluated one-time and repeat screening at intervals from annually to once every 3 months. We calculated the number of HIV and HCV infections, quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs).

RESULTS

Adding HIV and HCV viral RNA testing to antibody testing averts 14.8-30.3 HIV and 3.7-7.7 HCV infections in a screened population of 26,100 IDUs entering ORT over 20 years, depending on screening frequency. Screening for HIV antibodies every 6 months costs $30,700/QALY gained. Screening for HIV antibodies and viral RNA every 6 months has an ICER of $65,900/QALY gained. Strategies including HCV testing have ICERs exceeding $100,000/QALY gained unless awareness of HCV-infection status results in a substantial reduction in needle-sharing behavior.

DISCUSSION

Although annual screening for antibodies to HIV and HCV is modestly cost effective compared to no screening, more frequent screening for HIV provides additional benefit at less cost. Screening individuals in ORT every 3-6 months for HIV infection using both antibody and viral RNA technologies and initiating ART for acute HIV infection appears cost effective.

Concordance between self-reported and actual hepatitis C virus infection status in a cohort of people who inject drugs

INTRODUCTION AND AIMS

Accurate knowledge of individual hepatitis C virus (HCV) status is an important component of comprehensive health services for people who inject drugs (PWID). In this paper we compare the perceived HCV status of PWID in a longitudinal cohort study with their actual status, as verified by HCV-RNA testing.

METHODS

Participants who consented to blood testing at first follow up (352/688) were included. Self-reported HCV status (positive/negative/don't know), was compared with serology test results for participants.

RESULTS

In comparing self-report with HCV-RNA results, 274 of 352 participants had valid serology and self-report results; of these, 220 (80%) accurately reported their HCV status.

DISCUSSION AND CONCLUSIONS

The findings of this study suggest that large proportions of PWID know their true HCV infection status, but the discordant participants represent potential HCV infection risks. Despite the majority of participants displaying concordance, this study reinforces the need for regular blood testing and the giving of accurate, practical and comprehensive HCV result information.

Injection behaviors among injection drug users in treatment: the role of hepatitis C awareness

BACKGROUND

Injection drug use (IDU) is a primary vector for blood-borne infections. Awareness of Hepatitis C virus (HCV) infection status may affect risky injection behaviors. This study determines the prevalence of risky injection practices and examines associations between awareness of positive HCV status and risky injection behaviors.

METHODS

We surveyed individuals seeking treatment for substance use at 12 community treatment programs as part of a national HIV screening trial conducted within the National Drug Abuse Treatment Clinical Trials Network. Participants reported socio-demographic characteristics, substance use, risk behaviors, and HCV status. We used multivariable logistic regression to test associations between participant characteristics and syringe/needle sharing.

RESULTS

The 1281 participants included 244 (19.0%) individuals who reported injecting drugs in the past 6 months and 37.7% of IDUs reported being HCV positive. During the six months preceding baseline assessment, the majority of IDUs reported obtaining sterile syringes from pharmacies (51.6%) or syringe exchange programs (25.0%), but fewer than half of IDUs always used a sterile syringe (46.9%). More than one-third (38.5%) shared syringe/needles with another injector in the past 6 months. Awareness of positive HCV vs. negative/unknown status was associated with increased recent syringe/needle sharing (aOR 2.37, 95% CI 1.15, 4.88) in multivariable analysis.

CONCLUSIONS

Risky injection behaviors remain prevalent and awareness of HCV infection was associated with increased risky injection behaviors. New approaches are needed to broadly implement HCV prevention interventions for IDUs seeking addiction treatment.

Is injection serosorting occurring among HIV-positive injection drug users? Comparison by injection partner's HIV status

Research needs to build evidence for the roles that HIV status of injection partners may or may not play in injection risk behaviors of injection drug users (IDUs). Using baseline data collected from a randomized controlled study (INSPIRE) conducted in four cities (Baltimore, Miami, New York, and San Francisco) from 2001 to 2005, we categorized 759 primarily heterosexual HIV-positive IDUs into four groups based on HIV serostatus of drug injection partners. Thirty-two percent of the sample injected exclusively with HIV-positive partners in the past 3 months and more than 60% had risky injection behavior with these partners. Eight percent injected exclusively with HIV-negative partners and 49% injected with any unknown status partners. The remaining 11% reported having both HIV-positive and -negative injection partners, but no partners of unknown HIV status. Riskier injection behavior was found among the group with mixed status partners. The risk among the group with any unknown status partners appeared to be driven by the greater number of injection partners. No major group differences were observed in socio-demographic and psychosocial factors. Our analysis suggests that serosorting appeared to be occurring among some, but not an overwhelming majority of HIV-positive IDUs, and knowledge of HIV status of all injection partners per se did not appear to be as important as knowledge of sexual partner's HIV status in its association with risk behavior.

Evaluation of three rapid screening assays for detection of antibodies to hepatitis C virus

BACKGROUND

The Centers for Disease Control and Prevention (CDC) estimates that 3.2 million Americans are living with chronic hepatitis C virus (HCV) infection and 50%-70% are unaware of their status. Although therapies are available that can suppress or eliminate infection, identifying persons infected with HCV is challenging. Rapid tests could help identify many of these persons more expeditiously.

METHODS

Three manufacturers, Chembio, OraSure, and MedMira, submitted HCV antibody (anti-HCV) rapid screening assays to the CDC for evaluation and comparison with established anti-HCV screening assays. The panel consisted of 1100 specimens drawn during 1997-1999 from persons reporting injection drug use. Sensitivity and specificity were assessed using 2 reference approaches, one based on the reactivity of samples in an anti-HCV screening assay and the other based on CDC HCV testing algorithm.

RESULTS

The sensitivities of the Chembio, MedMira, and OraSure assays across the 2 approaches were 96.2%-98.0%, 86.8%-88.3%, and 97.8%-99.3%, respectively. The 3 assays had specificity of 99.5% or higher with no differences between assays. False rapid assay results were associated with human immunodeficiency virus positivity for both approaches for Chembio and MedMira.

CONCLUSIONS

Rapid anti-HCV tests can provide sensitive and specific anti-HCV results for high-risk patients.

Hepatitis C virus risk behaviors within the partnerships of young injecting drug users

AIMS

Young injection drug users (IDU) are at high risk for hepatitis C virus (HCV). We sought to determine whether perceiving one's injecting partner to be HCV positive was associated with decreased odds of engaging in receptive needle/syringe sharing (RNS) or ancillary equipment sharing (AES) with that partner.

DESIGN

Cross sectional study.

SETTING

2003 to 2007 in San Francisco.

PARTICIPANTS

212 young (under age 30) IDU who were HCV antibody negative reported on 492 injecting partnerships.

MEASUREMENTS

Self-reported RNS and AES within injecting partnerships.

FINDINGS

RNS and AES (in the absence of RNS) occurred in 23% and 64% of injecting partnerships in the prior month. The odds of engaging in RNS were significantly lower for relationships in which the participant reported that his/her partner was HCV positive (odds ratio [OR] 0.49; 95% confidence interval [CI] 0.25-0.95). This association was attenuated when adjusted for reusing one's own needle/syringe (adjusted OR 0.57; 95% CI 0.28-1.15). The odds of engaging in AES were lower for participants who did not know the HCV status of their partner, only among non-sexual partnerships (OR 0.47; 95% CI 0.29-0.76).

CONCLUSIONS

Because perceiving one's partner to be HCV positive was associated with decreased RNS, increased HCV testing and partner disclosure may be warranted. AES was common and was decreased only among non-sexual partnerships in which the HCV status of the partner was not known. This suggests that interventions to reduce AES in young IDU must be widespread.