Access to syringes in three Russian cities: Implications for syringe distribution and coverage

Stigma and other correlates of sharing injection equipment among people with HIV in St. Petersburg, Russia

Stigma that people with HIV who inject drugs experience negatively impacts HIV and substance use care, but stigma's association with sharing injection equipment is not known. This is a cross-sectional analysis of data from two studies of people with HIV reporting drug injection (N = 319) in St. Petersburg, Russia (September 2018-December 2020). We used logistic regression to examine associations between HIV stigma and substance use stigma scores (categorised into quartiles) and past 30-day equipment sharing, adjusting for demographic and clinical characteristics. Secondary analyses examined associations of arrest history and social support with sharing equipment. Almost half (48.6%) of participants reported sharing injection equipment. Among groups who did and did not share, mean HIV stigma (2.3 vs 2.2) and substance use stigma (32 vs 31) scores were similar. Adjusted analyses detected no significant associations between HIV stigma quartiles (global p-value = 0.85) or substance use stigma quartiles (global p-value = 0.51) and sharing equipment. Neither arrest history nor social support were significantly associated with sharing equipment. In this cohort, sharing injection equipment was common and did not vary based on stigma, arrest history, or social support. To reduce equipment sharing, investments in sterile injection equipment access in Russia should be prioritised over interventions to address stigma.

Accessing needle exchange services in disasters for remote areas of Aotearoa New Zealand

BACKGROUND

Needle Exchange Programme (NEP) mobile outreach services in Aotearoa New Zealand distribute injecting equipment to people who inject drugs (PWID) living in remote regions. In disasters, continued access to such services is imperative for the health and wellbeing of PWID. Disasters can compound existing inequities, particularly in regions characterised by poor or limited infrastructure, smaller populations, and challenging socioeconomic conditions. To gain insight into the barriers that prevent access to NEP harm-reduction services and understand the needs of PWID prior to and during disasters, this study foregrounds the voices of PWID based on the West Coast of the South Island, Aotearoa New Zealand.

METHODS

This qualitative study applied an interpretive phenomenological analysis approach, where 14 PWID and one key NEP staff member took part in semi-structured interviews. The interviews provided the opportunity for participants to share their experiences and perspectives about accessing sterile drug-injecting equipment during disasters, including the four-week COVID-19 Level 4 lockdown in March 2020. In total five superordinate and 14 subordinate themes were identified from the interveiws.

RESULTS

This study focuses on four of the key themes that impacted accessibility to NEP services: infrastructural hazards and equipment costs; social capital and practical support from peers and key contact networks; social stigma in public locations, including NEP-based pharmacies and emergency centres; and potential solutions to NEP equipment accessibility as frequently suggested by participants.

CONCLUSIONS

Access to NEP services is essential during natural hazard and human-generated disasters, as such NEP mobile outreach services and disaster resilience efforts should focus on maintaining service continuity for PWID during adverse times. This study champions a needs-based, stigma free approach to inclusive harm-reduction and emergency management practices for groups with specific needs in a disaster context.

Young and invisible: a qualitative study of service engagement by people who inject drugs in India

OBJECTIVES

The HIV epidemic in India is concentrated in key populations such as people who inject drugs (PWID). New HIV infections are high among young PWID (≤30 years of age), who are hard to engage in services. We assessed perspectives of young PWID to guide development of youth-specific services.

SETTING

We conducted focus group discussions (FGDs) with PWID and staff at venues offering services to PWID in three Indian cities representing historical and emerging drug use epidemics.

PARTICIPANTS

PWID were eligible to participate if they were between 18 and 35 years, had initiated injection as adolescents or young adults and knew adolescent PWID in their networks. 43 PWID (81% male, 19% female) and 10 staff members participated in FGDs. A semistructured interview guide was used to elicit participants' narratives on injection initiation experiences, barriers to seeking harm reduction services, service delivery gaps and recommendations to promote engagement. Thematic analysis was used to develop an explanatory model for service engagement in each temporal stage across the injection continuum.

RESULTS

Injection initiation followed non-injection opioid dependence. Lack of services for non-injection opioid dependence was a key gap in the preinjection initiation phase. Lack of knowledge and reliance on informal sources for injecting equipment were key reasons for non-engagement in the peri-injection phase. Additionally, low-risk perception resulted in low motivation to seek services. Psychosocial and structural factors shaped engagement after established injection. Housing and food insecurity, and stigma disproportionately affected female PWID while lack of confidential adolescent friendly services impeded engagement by adolescent PWID.

CONCLUSIONS

Development of youth-specific services for young PWID in India will need to address unique vulnerabilities and service gaps along each stage of the injection continuum. Scaling-up of tailored services is needed for young female PWID and adolescents, including interventions that prevent injection initiation and provision of confidential harm reduction services.

Barriers to using new needles encountered by rural Appalachian people who inject drugs: implications for needle exchange

Background

Using a new needle for every injection can reduce the spread of infectious disease among people who inject drugs (PWID). No previous study has examined new needle use barriers among PWIDs residing in the rural Appalachian part of the United States, an area currently in the midst of a heroin epidemic.

Objective

Therefore, our primary aim was to explore self-reported barriers to using a new needle by PWID attending a needle exchange program (NEP).

Methods

We conducted a cross-sectional survey of PWID attending two NEPs in rural West Virginia located in the heart of Central Appalachia. A convenience sample of PWID (n = 100) completed the Barriers to Using New Needles Questionnaire.

Results

The median number of barriers reported was 5 (range 0–19). Fear of arrest by police (72% of PWID “agreed” or “strongly agreed”) and difficulty with purchasing needles from a pharmacy (64% “agreed” or “strongly agreed”) were the most frequently cited barriers.

Conclusions/Importance

Congruent with previous findings from urban locations, in rural West Virginia, the ability of PWID to use a new needle obtained from a needle exchange for every injection may be compromised by fear of arrest. In addition, pharmacy sales of new needles to PWID may be blunted by an absence of explicit laws mandating nonprescription sales. Future studies should explore interventions that align the public health goals of NEPs with the occupational safety of law enforcement and health outreach goals of pharmacists.

Electronic supplementary material

The online version of this article (10.1186/s12954-019-0295-5) contains supplementary material, which is available to authorized users.

Qualitative case study of needle exchange programs in the Central Appalachian region of the United States

Background

The Central Appalachian region of the United States is in the midst of a hepatitis C virus epidemic driven by injection of opioids, particularly heroin, with contaminated syringes. In response to this epidemic, several needle exchange programs (NEP) have opened to provide clean needles and other supplies and services to people who inject drugs (PWID). However, no studies have investigated the barriers and facilitators to implementing, operating, and expanding NEPs in less populous areas of the United States.

Methods

This qualitative case study consisted of interviews with program directors, police chiefs, law enforcement members, and PWID affiliated with two NEPs in the rural state of West Virginia. Interview transcripts were coded inductively and analyzed using qualitative data analysis software. Final common themes related to barriers and facilitators of past program openings, current program operations, and future program plans, were derived through a consensus of two data coders.

Results

Both NEPs struggled to find existing model programs, but benefited from broad community support that facilitated implementation. The largest operational barrier was the legal conundrum created by paraphernalia laws that criminalize syringe possession. However, both PWID and law enforcement appreciated the comprehensive services provided by these programs. Program location and transportation difficulties were additional noted barriers. Future program operations are threatened by funding shortages and bans, but necessitated by unexpected program demand.

Conclusion

Despite broad community support, program operations are threatened by growing participant volumes, funding shortages, and the federal government’s prohibition on the use of funds to purchase needles. Paraphernalia laws create a legal conundrum in the form of criminal sanctions for the possession of needles, which may inadvertently promote needle sharing and disease transmission. Future studies should examine additional barriers to using clean needles provided by rural NEPs that may blunt the effectiveness of NEPs in preventing disease transmission.

Potential impact of implementing and scaling up harm reduction and antiretroviral therapy on HIV prevalence and mortality and overdose deaths among people who inject drugs in two Russian cities: a modelling study

BACKGROUND

Most new HIV infections among people who inject drugs (PWID) in eastern Europe and central Asia occur in Russia, where PWID have a high risk of overdose. In Russia, use of opioid agonist therapy (OAT) is prohibited, and coverage of needle and syringe programmes (NSPs) and antiretroviral therapy (ART) is poor. We aimed to assess the effects that scaling up harm reduction (ie, use of OAT and coverage of NSPs) and use of ART might have on HIV incidence and the frequency of fatal overdoses among PWID in two cities in the Ural Federal District and Siberian Federal District, where the prevalence of HIV is high or increasing in PWID.

METHODS

In this modelling study, we developed a dynamic deterministic model that simulated transmission of HIV through injection drug use and sex among PWID. We calibrated this model to HIV prevalence data among PWID in two Russian cities: Omsk (which has high but increasing prevalence of HIV among PWID) and Ekaterinburg (which has very high but stable prevalence of HIV). The source data were from research studies supported by the Global Fund to Fight AIDS, Tuberculosis, and Malaria and US Centers for Disease Control and Prevention and surveillance studies from WHO and regional AIDS centres. We modelled the effects of no intervention scale-up (no use of harm reduction measures and 30% of HIV-positive PWID receiving ART) versus combinations of scaling up of OAT, receipt of high coverage of NSPs, and use of ART on the incidence of HIV infections, mortality from HIV, and the frequency of fatal overdoses from 2018 to 2028.

FINDINGS

Without intervention, HIV prevalence among PWID in Omsk could increase from 30% in 2018 to 36% (2·5-97·5 percentile interval 22-52) in 2028 and remain high in Ekaterinburg, estimated at 60% (57-67) in 2028. Scaling up OAT to 50% coverage for a duration of 2 years could prevent 35% of HIV infections and 19% of deaths associated with HIV in Omsk and 20% (11-29) of HIV infections and 10% (4-14) of deaths associated with HIV in Ekaterinburg. Further, this scaling up could prevent 33% of overdose deaths over the next 10 years. Scaling up of NSPs and OAT to 50% coverage and tripling recruitment to ART (reaching about 65% of HIV-positive PWID) could prevent 58% (46-69) of HIV infections and 45% (36-54) of deaths associated with HIV in Omsk and 38% (26-50) of HIV infections and 32% (23-41) of deaths associated with HIV in Ekaterinburg by 2028.

INTERPRETATION

Legalisation of OAT and increased use of ART and NSPs for PWID are urgently needed to prevent HIV and fatal overdose among PWID in Russia.

FUNDING

National Institutes of Health and Elton John AIDS Foundation.

Estratégias de redução de danos no uso prejudicial de álcool e outras drogas: revisão de literatura

O presente estudo traz uma sistematização acerca de experiências de atenção à saúde a pessoas que fazem uso prejudicial de álcool e outras drogas que têm por base as diretrizes da redução de danos no Brasil e no mundo. Foi realizado um levantamento bibliográfico em publicações de língua portuguesa e inglesa dos últimos dez anos hospedadas nas bases de dados SciELO, Lilacs, Medline e PsycINFO. Após a seleção do corpus, recorreu-se à metassíntese a fim de integrar o material obtido. Foi possível identificar e analisar avanços e impasses na implantação de estratégias de redução de danos, bem como comparar as diferentes abordagens identificadas nos serviços e ações de cuidado oferecidas aos usuários. Nota-se que a Redução de Danos tem se consolidado como estratégia de prevenção e tratamento e, dessa forma, torna-se imprescindível ampliar as produções acadêmica e científica na área.

Uptake of needle and syringe program services in the Kyrgyz Republic: Key barriers and facilitators

BACKGROUND

In Kyrgyzstan, injection drug use accounts for the majority of HIV infections. Needle and syringe programs (NSPs) are one of three core HIV interventions for people who inject drugs (PWID). However, in Kyrgyzstan all persons diagnosed with drug dependence are subject to compulsory registration for governmental drug dependence treatment services, which creates barriers for PWID to access any health services, including NSPs.

METHODS

In 2015, we conducted an assessment at 19 NSP sites in six cities to identify barriers and facilitators that affect PWID uptake of NSP services in Kyrgyzstan. The study involved the conduct of 10 focus groups with 99 PWID (62 males/37 females) and individual interviews with 24 full-time NSP staff.

RESULTS

We found that access of PWID to NSPs was limited by stigma and discrimination around drug use, fear of police encounters, inconvenient hours of operation, lack of information and motivation from PWID to use NSP services and a limited menu of available injection supplies. At the same time, availability of outreach services and additional health services were highly valued by PWID.

CONCLUSIONS

Stigma and discrimination, combined with the criminalization of drug use and the requirement for official registration of PWID remain key barriers to effective NSP utilization. Law enforcement and health care providers need to be sensitized about the unique context and needs of PWID.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

Insights on the Russian HCV Care Cascade: Minimal HCV Treatment for HIV/HCV Co-infected PWID in St. Petersburg

Background

The human immunodeficiency virus (HIV) epidemic in Russia, driven by injection drug use, has seen a steady rise in the past two decades. Hepatitis C virus (HCV) infection is highly prevalent in people who inject drugs (PWID). The study aimed to describe the current frequency of HCV testing and treatment among HIV-infected PWID in St. Petersburg, Russia.

Methods

This study examined baseline data from the “Linking Infectious and Narcology Care” (LINC) and “Russia Alcohol Research Collaboration on HIV/AIDS” (Russia ARCH) studies. Participants included in this analysis were HIV-infected with a history of injection drug use. Descriptive statistics were performed to assess frequency of HCV testing and treatment.

Results

Participants (n = 349 [LINC], 207 [Russia ARCH]) had a mean age of 33.8 years (IQR: 31–37) in LINC and 33.0 (IQR: 30–36) in Russia ARCH; 26.6 % (LINC) and 29.0 % (Russia ARCH) were female; 100 % were Caucasian. Nearly all participants had been tested for HCV (98.9 % in LINC, 97.1 % in Russia ARCH). Almost all reported being diagnosed HCV positive (98.9 % in LINC, 97.1 % in Russia ARCH). Only 2.3 % of LINC and 5.0 % of Russia ARCH participants reported ever receiving HCV treatment.

Conclusions

Among these cohorts of HIV-infected PWID in St. Petersburg, Russia, as of 2015 nearly all reported being tested for HCV and testing positive, while only 3.3 % received any HCV treatment. In this new era of effective HCV pharmacotherapy, an enormous chasm in the HCV treatment cascade in Russia exists providing substantial opportunities for curing HCV in HIV-infected Russians with a history of injection drug use.

Trial registration

The studies described were registered with ClinicalTrials.gov through the National Institutes of Health: Linking Infectious and Narcology Care in Russia (LINC) - NCT01612455, registered 1 June 2012, first participant enrolled 3 July 2012; Alcohol’s Impact on Inflammatory Markers in HIV Disease - Russia ARCH Cohort - NCT01614626, registered 25 May 2012, first participant enrolled 15 November 2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s41124-016-0020-x) contains supplementary material, which is available to authorized users.

Community reentry challenges after release from prison among people who inject drugs in St. Petersburg, Russia

PURPOSE

Little is known about the context of the post-release risk environment among formerly incarcerated people who inject drugs (PWID) in Russia. The purpose of this paper is to explore these challenges as they relate to reentry, relapse to injection opioid use, and overdose.

DESIGN/METHODOLOGY/APPROACH

The authors conducted 25 in-depth semi-structured interviews among PWID living in St Petersburg, Russia who had been incarcerated within the past two years. Participants were recruited from street outreach (n=20) and a drug treatment center (n=5).

FINDINGS

Emergent themes related to the post-release environment included financial instability, negative interactions with police, return to a drug using community, and reuniting with drug using peers. Many respondents relapsed to opioid use immediately after release. Those whose relapse occurred weeks or months after their release expressed more motivation to resist. Alcohol or stimulant use often preceded the opioid relapse episode. Among those who overdosed, alcohol use was often reported prior to overdosing on opioids.

PRACTICAL IMPLICATIONS

Future post-release interventions in Russia should effectively link PWID to social, medical, and harm reduction services. Particular attention should be focussed on helping former inmates find employment and overdose prevention training prior to leaving prison that should also cover the heightened risk of concomitant alcohol use.

ORIGINALITY/VALUE

In addition to describing a syndemic involving the intersection of incarceration, injection drug use, poverty, and alcohol abuse, the findings can inform future interventions to address these interrelated public health challenges within the Russian setting.

HIV Risks, Testing, and Treatment in the Former Soviet Union: Challenges and Future Directions in Research and Methodology

Background

The dissolution of the USSR resulted in independence for constituent republics but left them battling an unstable economic environment and healthcare. Increases in injection drug use, prostitution, and migration were all widespread responses to this transition and have contributed to the emergence of an HIV epidemic in the countries of former Soviet Union. Researchers have begun to identify the risks of HIV infection as well as the barriers to HIV testing and treatment in the former Soviet Union. Significant methodological challenges have arisen and need to be addressed. The objective of this review is to determine common threads in HIV research in the former Soviet Union and provide useful recommendations for future research studies.

Methods

In this systematic review of the literature, Pubmed was searched for English-language studies using the key search terms "HIV", "AIDS", "human immunodeficiency virus", "acquired immune deficiency syndrome", "Central Asia", "Kazakhstan", "Kyrgyzstan", "Uzbekistan", "Tajikistan", "Turkmenistan", "Russia", "Ukraine", "Armenia", "Azerbaijan", and "Georgia". Studies were evaluated against eligibility criteria for inclusion.

Results

Thirty-nine studies were identified across the two main topic areas of HIV risk and barriers to testing and treatment, themes subsequently referred to as "risk" and "barriers". Study design was predominantly cross-sectional. The most frequently used sampling methods were peer-to-peer and non-probabilistic sampling. The most frequently reported risks were condom misuse, risky intercourse, and unsafe practices among injection drug users. Common barriers to testing included that testing was inconvenient, and that results would not remain confidential. Frequent barriers to treatment were based on a distrust in the treatment system.

Conclusion

The findings of this review reveal methodological limitations that span the existing studies. Small sample size, cross-sectional design, and non-probabilistic sampling methods were frequently reported limitations. Future work is needed to examine barriers to testing and treatment as well as longitudinal studies on HIV risk over time in most-at-risk populations.

Stigma and Human Rights Abuses against People Who Inject Drugs in Russia--A Qualitative Investigation to Inform Policy and Public Health Strategies

INTRODUCTION

Drug policing practices in the Russian Federation (Russia) are often punitive and have been shown to be associated with HIV risk behaviors among people who inject drugs (PWID). Less is known about strategies to address the problem in that setting, where substance use stigma is highly persistent. A better understanding of forms, causes and consequences of drug policing in Russia could inform drug policy in a context of substantial policy resistance. This qualitative study's goal is to characterize the phenomenon of police involvement with Russian PWID and to explore strategies for drug policing in the Russian country context.

METHODS

Using a semi-structured interview guide, we collected data from a purposive sample of 23 key informants including PWID, police officers, and experts from civil society and international organizations in Russia. We used a thematic analysis approach to inductively generate new insight into the phenomenon of police involvement and potential strategies to address it.

RESULTS

Policing practices involving PWID include unjustified arrests, planting of false evidence and extrajudicial syringe confiscations, and often constitute human rights violations. Russian PWID personally experienced police violence as ubiquitous, taking on various forms such as beating, unjustified arrests, verbal harassment, and coercion. The persistent societal stigma dehumanizes PWID, and such stigmatization facilitates police abuse. To address stigma and overcome the PWID-police adversity, study participants suggested fostering a mutual understanding between the police and public health sectors.

CONCLUSIONS

Participants describe substantial human rights violations as part of policing illicit drug use in Russia. Police should include principles of effective prevention of substance use and HIV risk reduction in their trainings. Alignment of public safety and public health goals could address drug use-related risks and HIV prevention among key populations in Russia.

Hepatitis C virus seroprevalence among people who inject drugs and factors associated with infection in eight Russian cities

Background

Behavioural surveillance among people who inject drugs (PWID) and testing for hepatitis C virus (HCV) and HIV is needed to understand the scope of both epidemics in at-risk populations and to suggest steps to improve their health.

Methods

PWID were recruited using respondent-driven sampling (RDS) in eight Russian cities. A standardized survey was administered to collect sociodemographic and behavioral information. Blood specimens were obtained for serological testing for HCV and HIV-1. Data across the eight sites were pooled to identify individual-, network-, and city-level factors associated with positive HCV serostatus.

Results

Among 2,596 PWID participating in the study, 1,837 tested positive for HCV (71%). The sample was 73% male and the mean age was 28. Very few PWID reported regular contact with harm reduction programs. Factors associated with testing positive for HCV were longer duration of injection drug use, testing positive for HIV-1, sharing non-syringe injection paraphernalia and water for rinsing syringes, and larger social network size. Factors negatively associated with HCV-positive serostatus were injecting with a used syringe and two city-level factors: longer mean RDS recruitment chain in a city and higher levels of injecting stimulants.

Conclusions

HCV prevalence in all eight Russian cities is at the higher end of the range of HCV prevalence among PWID in Europe, which provides evidence that more resources, better prevention programs, and accelerated treatment targeting PWID are needed to control the HCV epidemic.

Risk behaviors, prevalence of HIV and hepatitis C virus infection and population size of current injection drug users in a China-Myanmar border city: results from a Respondent-Driven Sampling Survey in 2012

Background

Injection drug use has been the major cause of HIV/AIDS in China in the past two decades. We measured the prevalences of HIV and hepatitis C virus (HCV) prevalence and their associated risk factors among current injection drug users (IDUs) in Ruili city, a border region connecting China with Myanmar that has been undergoing serious drug use and HIV spread problems. An estimate of the number of current IDUs is also presented.

Methods

In 2012, Chinese IDUs who had injected within the past six months and aged ≥18 years were recruited using a respondent-driven sampling (RDS) technique. Participants underwent interviews and serological testing for HIV, HBV, HCV and syphilis. Logistic regression indentified factors associated with HIV and HCV infections. Multiplier method was used to obtain an estimate of the size of the current IDU population via combining available service data and findings from our survey.

Results

Among 370 IDUs recruited, the prevalence of HIV and HCV was 18.3% and 41.5%, respectively. 27.1% of participants had shared a needle/syringe in their lifetime. Consistent condom use rates were low among both regular (6.8%) and non-regular (30.4%) partners. Factors independently associated with being HIV positive included HCV infection, having a longer history of injection drug use and experience of needle/syringe sharing. Participants with HCV infection were more likely to be HIV positive, have injected more types of drugs, have shared other injection equipments and have unprotected sex with regular sex partners. The estimated number of current IDUs in Ruili city was 2,714 (95% CI: 1,617–5,846).

Conclusions

IDUs may continue to be a critical subpopulation for transmission of HIV and other infections in this region because of the increasing population and persistent high risk of injection and sexual behaviours. Developing innovative strategies that can improve accessibility of current harm reduction services and incorporate more comprehensive contents is urgently needed.

Punitive policing and associated substance use risks among HIV-positive people in Russia who inject drugs

INTRODUCTION

Drug law enforcement is part of the HIV risk environment among people who inject drugs (PWID). Punitive policing practices such as extrajudicial arrests for needle possession and police planting of drugs have been described anecdotally in Russia, but these experiences and their associations with risky drug behaviours have not been quantified. This study aims to quantify the burden of extrajudicial police arrests among a cohort of HIV-positive PWID in Russia and to explore its links to drug-related health outcomes.

METHODS

In a cross-sectional study of 582 HIV-positive people with lifetime injection drug use (IDU) in St. Petersburg, Russia, we estimated the prevalence of self-reported extrajudicial police arrests. We used multiple logistic regression to evaluate associations between arrests and the following outcomes: overdose, recent IDU and receptive needle sharing.

FINDINGS

This cohort's mean age was 29.8 years, 60.8% were male; 75.3% reported non-fatal drug overdose, 50.3% recent IDU and 47.3% receptive needle sharing. Extrajudicial arrests were reported by more than half (60.5%, 95% confidence interval [CI]: 56.5-64.5) and were associated with higher odds of non-fatal drug overdose (AOR 1.52, 95% CI: 1.02-2.25) but not with recent IDU (AOR 1.17, arrests were associated with receptive needle sharing (AOR 1.84, 95% CI: 1.09-3.09).

CONCLUSIONS

Extrajudicial police arrests were common among this cohort of Russian HIV-positive PWID and associated with non-fatal overdose and, among those with recent IDU, receptive needle sharing. As a part of the HIV risk environment of PWIDs, these practices might contribute to HIV transmission and overdose mortality. Further research is needed to relate these findings to the operational environment of law enforcement and to better understand how police interventions among PWIDs can improve the HIV risk environment.

'Safer environment interventions': a qualitative synthesis of the experiences and perceptions of people who inject drugs

There is growing acknowledgment that social, structural, and environmental forces produce vulnerability to health harms among people who inject drugs (PWID), and safer environment interventions (SEI) have been identified as critical to mitigating the impacts of these contextual forces on drug-related harm. To date, however, SEIs have been under-theorized in the literature, and how they minimize drug-related risks across intervention types and settings has not been adequately examined. This article presents findings from a systematic review and meta-synthesis of qualitative studies reporting PWID's experiences with three types of SEIs (syringe exchange programmes, supervised injection facilities and peer-based harm reduction interventions) published between 1997 and 2012. This meta-synthesis sought to develop a comprehensive understanding of SEIs informed by the experiences of PWID. Twenty-nine papers representing twenty-one unique studies that included an aggregate of more than 800 PWID were included in this meta-synthesis. This meta-synthesis found that SEIs fostered social and physical environments that mitigated drug-related harms and increased access to social and material resources. Specifically, SEIs: (1) provided refuge from street-based drug scenes; (2) enabled safer injecting by reshaping the social and environmental contexts of injection drug use; (3) mediated access to resources and health care services; and, (4) were constrained by drug prohibition and law enforcement activities. These findings indicate that it is critical to situate SEIs in relation to the lived experiences of PWID, and in particular provide broader environmental support to PWID. Given that existing drug laws limit the effectiveness of interventions, drug policy reforms are needed to enable public health, and specifically SEIs, to occupy a more prominent role in the response to injection drug use.

High HIV incidence among persons who inject drugs in Pakistan: greater risk with needle sharing and injecting frequently among the homeless

Background

The incidence of HIV among persons who inject drugs (PWIDU) has fallen in many nations, likely due to successes of clean needle/syringe exchange and substance abuse treatment and service programs. However in Pakistan, prevalence rates for PWID have risen dramatically. In several cities, prevalence exceeded 20% by 2009 compared to a 2003 baseline of just 0.5%. However, no cohort study of PWID has ever been conducted.

Methods

We enrolled a cohort of 636 HIV seronegative PWID registered with three drop-in centers that focus on risk reduction and basic social services in Karachi. Recruitment began in 2009 (March to June) and PWID were followed for two years. We measured incidence rates and risk factors associated with HIV seroconversion.

Results

Incidence of HIV was 12.4 per 100 person-years (95% exact Poisson confidence interval [CI]: 10.3–14.9). We followed 474 of 636 HIV seronegative persons (74.5%) for two years, an annual loss to follow-up of <13 per 100 person years. In multivariable Cox regression analysis, HIV seroconversion was associated with non-Muslim religion (Adjusted risk ratio [ARR] = 1.7, 95%CI:1.4, 2.7, p = 0.03), sharing of syringes (ARR = 2.3, 95%CI:1.5, 3.3, p<0.0001), being homeless (ARR = 1.7, 95%CI:1.1, 2.5, p = 0.009), and daily injection of drugs (ARR = 1.1, 95%CI:1.0, 1.3, p = 0.04).

Conclusions

Even though all members of the cohort of PWID were attending risk reduction programs, the HIV incidence rate was very high in Karachi from 2009–2011. The project budget was low, yet we were able to retain three-quarters of the population over two years. Absence of opiate substitution therapy and incomplete needle/syringe exchange coverage undermines success in HIV risk reduction.

Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness

BACKGROUND

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

METHODS

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

RESULTS

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission.

CONCLUSION

Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

Individual-level, network-level and city-level factors associated with HIV prevalence among people who inject drugs in eight Russian cities: a cross-sectional study

OBJECTIVES

To ascertain HIV prevalence among people who inject drug (injection drug users (IDUs)) in the Russian Federation and identify explanations for the disparity in different cities.

DESIGN

Cross-sectional survey with serological testing for HIV and hepatitis C virus prevalent infections.

SETTING

8 Russian cities-Irkutsk, Omsk, Chelyabinsk, Yekaterinburg, Naberezhnye Chelny, Voronezh, Orel and St Petersburg.

PARTICIPANTS

In 2007-2009 active IDUs were recruited by respondent-driven sampling with a target sample size of 300 or more in each city.

MAIN OUTCOME MEASURES

Participants were administered a questionnaire covering sociodemographics, injection risk and protective behaviours, sexual behaviours, HIV knowledge, experiences with drug treatment and harm reduction programmes and social networks. Participants were tested for HIV and hepatitis C by enzyme immunoassay. Data were analysed to identify individual-level, network-level and city-level characteristics significantly associated with HIV prevalence. Factors significant at p≤0.1 were entered into a hierarchical regression model to control for multicollinearity.

RESULTS

A total of 2596 active IDUs were recruited, interviewed and tested for HIV and hepatitis C virus infection. HIV prevalence ranged from 3% (in Voronezh) to 64% (in Yekaterinburg). Although individual-level and network-level variables explain some of the difference in prevalence across the eight cities, the over-riding variable that seems to account for most of the variance is the emergence of commercial, as opposed to homemade, heroin as the predominant form of opioid injected.

CONCLUSIONS

The expansion of commercial heroin markets to many Russian cities may have served as a trigger for an expanding HIV epidemic among IDUs in that country.

Access to syringes for HIV prevention for injection drug users in St. Petersburg, Russia: syringe purchase test study

Background

The HIV epidemic in Russia is concentrated among injection drug users (IDUs). This is especially true for St. Petersburg where high HIV incidence persists among the city’s estimated 80,000 IDUs. Although sterile syringes are legally available, access for IDUs may be hampered. To explore the feasibility of using pharmacies to expand syringe access and provide other prevention services to IDUs, we investigated the current access to sterile syringes at the pharmacies and the correlation between pharmacy density and HIV prevalence in St. Petersburg.

Methods

965 pharmacies citywide were mapped, classified by ownership type, and the association between pharmacy density and HIV prevalence at the district level was tested. We selected two districts among the 18 districts – one central and one peripheral – that represented two major types of city districts and contacted all operating pharmacies by phone to inquire if they stocked syringes and obtained details about their stock. Qualitative interviews with 26 IDUs provided data regarding syringe access in pharmacies and were used to formulate hypotheses for the pharmacy syringe purchase test wherein research staff attempted to purchase syringes in all pharmacies in the two districts.

Results

No correlation was found between the density of pharmacies and HIV prevalence at the district level. Of 108 operating pharmacies, 38 (35%) did not sell syringes of the types used by IDUs; of these, half stocked but refused to sell syringes to research staff, and the other half did not stock syringes at all. Overall 70 (65%) of the pharmacies did sell syringes; of these, 49 pharmacies sold single syringes without any restrictions and 21 offered packages of ten.

Conclusions

Trainings for pharmacists need to be conducted to reduce negative attitudes towards IDUs and increase pharmacists’ willingness to sell syringes. At a structural level, access to safe injection supplies for IDUs could be increased by including syringes in the federal list of mandatory medical products sold by pharmacies.

HIV among people who inject drugs in Central and Eastern Europe and Central Asia: a systematic review with implications for policy

BACKGROUND AND OBJECTIVES

HIV among people who inject drugs (PWID) is a major public health concern in Eastern and Central Europe and Central Asia. HIV transmission in this group is growing and over 27 000 HIV cases were diagnosed among PWID in 2010 alone. The objective of this systematic review was to examine risk factors associated with HIV prevalence among PWID in Central and Eastern Europe and Central Asia and to describe the response to HIV in this population and the policy environments in which they live.

DESIGN

A systematic review of peer-reviewed and grey literature addressing HIV prevalence and risk factors for HIV prevalence among PWID and a synthesis of key resources describing the response to HIV in this population. We used a comprehensive search strategy across multiple electronic databases to collect original research papers addressing HIV prevalence and risk factors among PWID since 2005. We summarised the extent of key harm reduction interventions, and using a simple index of 'enabling' environment described the policy environments in which they are implemented.

STUDIES REVIEWED

Of the 5644 research papers identified from electronic databases and 40 documents collected from our grey literature search, 70 documents provided unique estimates of HIV and 14 provided multivariate risk factors for HIV among PWID.

RESULTS

HIV prevalence varies widely, with generally low or medium (<5%) prevalence in Central Europe and high (>10%) prevalence in Eastern Europe. We found evidence for a number of structural factors associated with HIV including gender, socio-economic position and contact with law enforcement agencies.

CONCLUSIONS

The HIV epidemic among PWID in the region is varied, with the greatest burden generally in Eastern Europe. Data suggest that the current response to HIV among PWID is insufficient, and hindered by multiple environmental barriers including restricted access to services and unsupportive policy or social environments.

Spatial Epidemiology of HIV among Injection Drug Users in Tijuana, Mexico

The northwest border city of Tijuana is Mexico's fifth largest and is experiencing burgeoning drug use and human immunodeficiency virus (HIV) epidemics. Since local geography influences disease risk, we explored the spatial distribution of HIV among injection drug users (IDUs). From 2006-2007, 1056 IDUs were recruited using respondent-driven sampling, and then followed for eighteen months. Participants underwent semi-annual surveys, mapping, and testing for HIV, tuberculosis, and syphilis. Using Average Nearest Neighbor and Getis-Ord Gi* statistics, locations where participants lived, worked, bought and injected drugs were compared with HIV status and environmental and behavioral factors. Median age was thirty-seven years; 85 percent were male. Females had higher HIV prevalence than males (10.2 percent vs. 3.4 percent; p=0.001). HIV cases at baseline (n=47) most strongly clustered by drug injection sites (Z-Score -6.173; p < 0.001), with a 16 km² hotspot near the Mexico/U.S. border, encompassing the red-light district. Spatial correlates of HIV included syphilis infection, female gender, younger age, increased hours on the street per day, and higher number of injection partners. Almost all HIV seroconverters injected within a 2.5 block radius of each other immediately prior to seroconversion. Only history of syphilis infection and female gender were strongly associated with HIV in the area where incident cases injected. Directional trends suggested a largely static epidemic until July-December 2008, when HIV spread to the southeast, possibly related to intensified violence and policing that spiked in the latter half of 2008. While clustering allows for targeting interventions, the dynamic nature of epidemics suggests the importance of mobile treatment and harm reduction programs.

Regional differences in AIDS and non-AIDS related mortality in HIV-positive individuals across Europe and Argentina: the EuroSIDA study

Background

Differences in access to care and treatment have been reported in Eastern Europe, a region with one of the fastest growing HIV epidemics, compared to the rest of Europe. This analysis aimed to establish whether there are regional differences in the mortality rate of HIV-positive individuals across Europe, and Argentina.

Methods

13,310 individuals under follow-up were included in the analysis. Poisson regression investigated factors associated with the risk of death.

Findings

During 82,212 person years of follow-up (PYFU) 1,147 individuals died (mortality rate 14.0 per 1,000 PYFU (95% confidence interval [CI] 13.1–14.8). Significant differences between regions were seen in the rate of all-cause, AIDS and non-AIDS related mortality (global p<0.0001 for all three endpoints). Compared to South Europe, after adjusting for baseline demographics, laboratory measurements and treatment, a higher rate of AIDS related mortality was observed in East Europe (IRR 2.90, 95%CI 1.97–4.28, p<.0001), and a higher rate of non-AIDS related mortality in North Europe (IRR 1.51, 95%CI 1.24–1.82, p<.0001). The differences observed in North Europe decreased over calendar-time, in 2009–2011, the higher rate of non-AIDS related mortality was no longer significantly different to South Europe (IRR 1.07, 95%CI 0.66–1.75, p = 0.77). However, in 2009–2011, there remained a higher rate of AIDS-related mortality (IRR 2.41, 95%CI 1.11–5.25, p = 0.02) in East Europe compared to South Europe in adjusted analysis.

Interpretations

There are significant differences in the rate of all-cause mortality among HIV-positive individuals across different regions of Europe and Argentina. Individuals in Eastern Europe had an increased risk of mortality from AIDS related causes and individuals in North Europe had the highest rate of non-AIDS related mortality. These findings are important for understanding and reviewing HIV treatment strategies and policies across the European region.

Syringe coverage in an Australian setting: does a high level of syringe coverage moderate syringe sharing behaviour?

We examined individual-level syringe coverage among 417 people who inject drugs who were recruited from pharmacies in New South Wales in 2009. There was a U-shaped distribution of syringe coverage with many people having very high (51%) or very low (23%) coverage. Overall, two-thirds of respondents (63%) reported adequate coverage (≥ 100%). Respondents who had not used a needle and syringe program in the previous month were more likely to report inadequate coverage (AOR 2.25, 95% CI 1.25-4.05) as were those who reported daily or more frequent injecting (AOR 3.69, 95% CI 2.00-6.81). Inadequate syringe coverage was not independently associated with receptive needle sharing. The level of syringe coverage was high among this sample, and met targets set out by UNAIDS and other organisations. We found that inadequate syringe coverage was not independently correlated with receptive needle sharing, possibly because coverage is sufficient to diminish the relationship between syringe availability and sharing behaviours.

The HIV Epidemic: High-Income Countries

The HIV epidemic in higher-income nations is driven by receptive anal intercourse, injection drug use through needle/syringe sharing, and, less efficiently, vaginal intercourse. Alcohol and noninjecting drug use increase sexual HIV vulnerability. Appropriate diagnostic screening has nearly eliminated blood/blood product-related transmissions and, with antiretroviral therapy, has reduced mother-to-child transmission radically. Affected subgroups have changed over time (e.g., increasing numbers of Black and minority ethnic men who have sex with men). Molecular phylogenetic approaches have established historical links between HIV strains from central Africa to those in the United States and thence to Europe. However, Europe did not just receive virus from the United States, as it was also imported from Africa directly. Initial introductions led to epidemics in different risk groups in Western Europe distinguished by viral clades/sequences, and likewise, more recent explosive epidemics linked to injection drug use in Eastern Europe are associated with specific strains. Recent developments in phylodynamic approaches have made it possible to obtain estimates of sequence evolution rates and network parameters for epidemics.

Intraurban mobility and its potential impact on the spread of blood-borne infections among drug injectors in Tijuana, Mexico

We explored intraurban mobility of Tijuana, Mexico, injection drug users (IDUs). In 2005, 222 IDUs underwent behavioral surveys and infectious disease testing. Participants resided in 58 neighborhoods, but regularly injected in 30. From logistic regression, "mobile" IDUs (injecting ≥3 km from their residence) were more likely to cross the Mexico/U.S. border, share needles, and get arrested for carrying syringes-but less likely to identify hepatitis as an injection risk. Mobile participants lived in neighborhoods with less drug activity, treatment centers, or migrants, but higher marriage and home ownership rates. Mobile IDUs should be targeted for outreach and further investigation. The study's limitations are noted.

Estimating national-level syringe availability to injecting drug users and injection coverage: Switzerland, 1996-2006

BACKGROUND

Measuring syringe availability and coverage is essential in the assessment of HIV/AIDS risk reduction policies. Estimates of syringe availability and coverage were produced for the years 1996 and 2006, based on all relevant available national-level aggregated data from published sources.

METHODS

We defined availability as the total monthly number of syringes provided by harm reduction system divided by the estimated number of injecting drug users (IDU), and defined coverage as the proportion of injections performed with a new syringe, at national level (total supply over total demand). Estimates of supply of syringes were derived from the national monitoring system, including needle and syringe programmes (NSP), pharmacies, and medically prescribed heroin programmes. Estimates of syringe demand were based on the number of injections performed by IDU derived from surveys of low threshold facilities for drug users (LTF) with NSP combined with the number of IDU. This number was estimated by two methods combining estimates of heroin users (multiple estimation method) and (a) the number of IDU in methadone treatment (MT) (non-injectors) or (b) the proportion of injectors amongst LTF attendees. Central estimates and ranges were obtained for availability and coverage.

RESULTS

The estimated number of IDU decreased markedly according to both methods. The MT-based method (from 14,818 to 4809) showed a much greater decrease and smaller size of the IDU population compared to the LTF-based method (from 24,510 to 12,320). Availability and coverage estimates are higher with the MT-based method. For 1996, central estimates of syringe availability were 30.5 and 18.4 per IDU per month; for 2006, they were 76.5 and 29.9. There were 4 central estimates of coverage. For 1996 they ranged from 24.3% to 43.3%, and for 2006, from 50.5% to 134.3%.

CONCLUSION

Although 2006 estimates overlap 1996 estimates, the results suggest a shift to improved syringe availability and coverage over time.

People who use drugs, HIV, and human rights

We reviewed evidence from more than 900 studies and reports on the link between human rights abuses experienced by people who use drugs and vulnerability to HIV infection and access to services. Published work documents widespread abuses of human rights, which increase vulnerability to HIV infection and negatively affect delivery of HIV programmes. These abuses include denial of harm-reduction services, discriminatory access to antiretroviral therapy, abusive law enforcement practices, and coercion in the guise of treatment for drug dependence. Protection of the human rights of people who use drugs therefore is important not only because their rights must be respected, protected, and fulfilled, but also because it is an essential precondition to improving the health of people who use drugs. Rights-based responses to HIV and drug use have had good outcomes where they have been implemented, and they should be replicated in other countries.

Policing drug users in Russia: risk, fear, and structural violence

We undertook qualitative interviews with 209 injecting drug users (IDUs) (primarily heroin) in three Russian cities: Moscow, Barnaul, and Volgograd. We explored IDU's accounts of HIV and health risk. Policing practices and how these violate health and self, emerged as a primary theme. Findings show that policing practices violate health and rights directly, but also indirectly, through the reproduction of social suffering. Extrajudicial policing practices produce fear and terror in the day-to-day lives of drug injectors, and ranged from the mundane (arrest without legal justification; the planting of evidence to expedite arrest or detainment; and the extortion of money or drugs for police gain) to the extreme (physical violence as a means of facilitating "confession" and as an act of "moral" punishment without legal cause or rationale; the use of methods of "torture"; and rape). We identify the concept of police bespredel-living with the sense that there are "no limits" to police power-as a key to perpetuating fear and terror, internalized stigma, and a sense of fatalist risk acceptance. Police besprediel is analyzed as a form of structural violence, contributing to "oppression illness." Yet, we also identify cases of resistance to such oppression, characterized by strategies to preserve dignity and hope. We identify hope for change as a resource of risk reduction as well as escape, if only temporarily, from the pervasiveness of social suffering. Future drug use(r)-related policies, and the state responses they sponsor, should set out to promote public health while protecting human rights, hope, and dignity.

HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage

BACKGROUND

Previous reviews have examined the existence of HIV prevention, treatment, and care services for injecting drug users (IDUs) worldwide, but they did not quantify the scale of coverage. We undertook a systematic review to estimate national, regional, and global coverage of HIV services in IDUs.

METHODS

We did a systematic search of peer-reviewed (Medline, BioMed Central), internet, and grey-literature databases for data published in 2004 or later. A multistage process of data requests and verification was undertaken, involving UN agencies and national experts. National data were obtained for the extent of provision of the following core interventions for IDUs: needle and syringe programmes (NSPs), opioid substitution therapy (OST) and other drug treatment, HIV testing and counselling, antiretroviral therapy (ART), and condom programmes. We calculated national, regional, and global coverage of NSPs, OST, and ART on the basis of available estimates of IDU population sizes.

FINDINGS

By 2009, NSPs had been implemented in 82 countries and OST in 70 countries; both interventions were available in 66 countries. Regional and national coverage varied substantially. Australasia (202 needle-syringes per IDU per year) had by far the greatest rate of needle-syringe distribution; Latin America and the Caribbean (0.3 needle-syringes per IDU per year), Middle East and north Africa (0.5 needle-syringes per IDU per year), and sub-Saharan Africa (0.1 needle-syringes per IDU per year) had the lowest rates. OST coverage varied from less than or equal to one recipient per 100 IDUs in central Asia, Latin America, and sub-Saharan Africa, to very high levels in western Europe (61 recipients per 100 IDUs). The number of IDUs receiving ART varied from less than one per 100 HIV-positive IDUs (Chile, Kenya, Pakistan, Russia, and Uzbekistan) to more than 100 per 100 HIV-positive IDUs in six European countries. Worldwide, an estimated two needle-syringes (range 1-4) were distributed per IDU per month, there were eight recipients (6-12) of OST per 100 IDUs, and four IDUs (range 2-18) received ART per 100 HIV-positive IDUs.

INTERPRETATION

Worldwide coverage of HIV prevention, treatment, and care services in IDU populations is very low. There is an urgent need to improve coverage of these services in this at-risk population.

FUNDING

UN Office on Drugs and Crime; Australian National Drug and Alcohol Research Centre, University of New South Wales; and Australian National Health and Medical Research Council.

Injecting equipment sharing in Russian drug injecting dyads

In this study, we investigated how individual attributes, dyad characteristics and social network characteristics may influence engaging in receptive syringe sharing, distributive syringe sharing and sharing cookers in injecting partnerships of IDUs in St Petersburg, Russia. We found that all three levels were associated with injecting equipment sharing, and that dyad characteristics were modified by characteristics of the social network. Self-reported HIV discordance and male gender concordance played a role in the risk of equipment sharing. Dyad interventions may not be sufficient to reduce injecting risk in IDU partnerships, but a combination of dyad and network interventions that target both IDU partnerships and the entire IDU population may be more appropriate to address injecting risk among IDUs.

Should pharmacists have a role in harm reduction services for IDUs? A qualitative study in Tallinn, Estonia

Despite the high number of injecting drug users (IDUs) in Estonia, little is known about involving pharmacies into human immunodeficiency virus (HIV) prevention activities and potential barriers. Similarly, in other Eastern European countries, there is a need for additional sources for clean syringes besides syringe exchange programmes (SEPs), but data on current practices relating to pharmacists' role in harm reduction strategies is scant. Involving pharmacies is especially important for several reasons: they have extended hours of operation and convenient locations compared to SEPs, may provide access for IDUs who have avoided SEPs, and are a trusted health resource in the community. We conducted a series of focus groups with pharmacists and IDUs in Tallinn, Estonia, to explore their attitudes toward the role of pharmacists in HIV prevention activities for IDUs. Many, but not all, pharmacists reported a readiness to sell syringes to IDUs to help prevent HIV transmission. However, negative attitudes toward IDUs in general and syringe sales to them specifically were identified as important factors restricting such sales. The idea of free distribution of clean syringes or other injecting equipment and disposal of used syringes in pharmacies elicited strong resistance. IDUs stated that pharmacies were convenient for acquiring syringes due to their extended opening hours and local distribution. IDUs were positive toward pharmacies, although they were aware of stigma from pharmacists and other customers. They also emphasized the need for distilled water and other injection paraphernalia. In conclusion, there are no formal or legislative obstacles for providing HIV prevention services for IDUs at pharmacies. Addressing negative attitudes through educational courses and involving pharmacists willing to be public health educators in high drug use areas would improve access for HIV prevention services for IDUs.

Associations between availability and coverage of HIV-prevention measures and subsequent incidence of diagnosed HIV infection among injection drug users

HIV-prevention measures specific to injection drug users (IDUs), such as opioid substitution treatment and needle-and-syringe programs, are not provided in many countries where injection drug use is endemic. We describe the incidence of diagnosed HIV infection in IDUs and the availability and coverage of opioid substitution and needle-and-syringe programs in the European Union and 5 middle- and high-income countries. Countries with greater provision of both prevention measures in 2000 to 2004 had lower incidence of diagnosed HIV infection in 2005 and 2006.

Comparison of injecting drug users who obtain syringes from pharmacies and syringe exchange programs in Tallinn, Estonia

BACKGROUND

Both syringe exchange programs (SEPs) and pharmacy sales of syringes are available in Estonia, though the current high incidence and high prevalence of HIV among injection drug users (IDUs) in Tallinn, Estonia requires large-scale implementation of additional harm reduction programs as a matter of great urgency. The aims of this report were to compare risk behavior and HIV infection and to assess the prevention needs among IDUs who primarily use pharmacies as their source of sterile syringes with IDUs who primarily use SEPs in Tallinn.

METHODS

A cross-sectional study using respondent-driven sampling was used to recruit 350 IDUs for an interviewer-administered survey and HIV testing. IDUs were categorized into two groups based on their self-reported main source for syringes within the last six months. Odds ratios with 95% CI were used to compare characteristics and risk factors between the groups.

RESULTS

The main sources of sterile needles for injection drug users were SEP/SEP outreach (59%) and pharmacies (41%). There were no differences in age, age at injection drug use initiation, the main drug used or experiencing overdoses. Those IDUs using pharmacies as a main source of sterile needles had lower odds for being infected with either HIV (AOR 0.54 95% CI 0.33-0.87) or HCV (AOR 0.10 95% CI 0.02-0.50), had close to twice the odds of reporting more than one sexual partner within the previous 12 months (AOR 1.88 95% CI 1.17-3.04) and engaging in casual sexual relationships (AOR 2.09 95% CI 1.24-3.53) in the last six months.

CONCLUSION

The data suggest that the pharmacy users were at a less "advanced" stage of their injection career and had lower HIV prevalence than SEP users. This suggests that pharmacies could be utilized as a site for providing additional HIV prevention messages, services for IDUs and in linking IDUs with existing harm reduction services.

Setting targets for universal access to HIV prevention, treatment and care for injecting drug users (IDUs): towards consensus and improved guidance

Scaling-up access to HIV/AIDS prevention, treatment and care for injecting drug users (IDUs) has been frustrated by the lack of a framework, indicators and agreed targets for interventions specifically targeting IDUs. Major progress in this regard has been achieved with the recent development of a joint Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users and related technical consultations. This guide provides technical guidance to countries on setting ambitious, but achievable national targets for scaling-up towards universal access (UA). The guide has been developed as a collaboration between the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United Nations Office on Drugs and Drugs (UNODC), the World Health Organization (WHO) and with national and international expertise and builds on previous UNAIDS guidelines. The guide serves to provide more consistent methods of measuring and comparing countries' progress towards universal access and offers consensus as to which interventions should be included in a comprehensive package. It provides guidance on defining and estimating denominator populations and proposes a set of indicators to measure coverage, as well as indicative targets or benchmarks against which to measure progress towards UA. The guide moves on from a narrow focus on coverage that neglects other important aspects of access, namely availability and quality of interventions. Finally, the guide encourages country involvement in, and ownership of, what are sometimes perceived as politically motivated coverage targets. Technical consultations, with country experts using the guide to set national targets, suggested a tendency for targets to be proposed that are achievable but fall short of what is required to achieve universal access and have a real impact on HIV/AIDS epidemics. Consensus and improved guidance on achieving universal access needs to be supported by political will, good leadership and, in some countries, remedies to inadequacies in health systems.