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Behzadifar M, Ehsanzadeh SJ, Darvishi Teli B, Azari S, Bakhtiari A, Behzadifar M. Prevalence of HIV in slums area: a systematic review and meta-analysis. BMC Infect Dis 2024; 24:52. [PMID: 38183027 PMCID: PMC10770918 DOI: 10.1186/s12879-023-08877-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 12/06/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Human Immunodeficiency Virus (HIV) remains a significant global health burden, particularly affecting vulnerable populations residing in slum areas which is characterized by overcrowding, poverty, and limited access to healthcare services, create an environment conducive to the transmission and spread of HIV. Despite the recognition of this issue, there is a lack of comprehensive understanding regarding the prevalence of HIV in slums. The aim of this study was to systematically synthesize the existing global evidence on HIV prevalence in slum populations. METHODS A rigorous systematic literature review was conducted by searching multiple electronic databases, including Medline via PubMed, Scopus, Embase, Web of Sciences, and Directory of Open Access Journals (DOAJ), covering the period from January 1, 1990, to March 31, 2023. The quality and risk of bias for each included study were assessed using the Newcastle-Ottawa Scale. The pooled prevalence with its corresponding 95% confidence interval (CI) was calculated using a random-effects model with the Freeman-Tukey double arcsine transformation. The degree of heterogeneity among the studies was evaluated using the I2 test. Publication bias was also assessed using Egger's test. Additionally, subgroup analysis was performed to explore potential factors contributing to the observed heterogeneity. RESULTS A systematic examination of the relevant literature resulted in the inclusion of a total of 22 studies for the purpose of this meta-analysis. These studies collectively assessed a sizable cohort consisting of 52,802 participants. Utilizing a random-effects model, an estimation of the overall prevalence of HIV in the slum area was determined to be 10% (95% CI: 7-13%). Further delineation through subgroup analysis based on the gender revealed a higher prevalence of HIV among women, standing at 13% (95% CI: 8-19%, 18 studies: I2 = 98%), as opposed to men, where the prevalence was found to be 8% (95% CI: 6-12%, 16 studies: I2 = 95%). A geographical breakdown of the included studies revealed that Africa exhibited the highest prevalence, with a figure of 11% (95% CI: 9-13%, 18 studies: I2 = 98%). Subsequently, studies conducted in the American continent reported a prevalence of 9% (95% CI: 7-11%, 2 studies: I2 = 57%). The Asian continent, on the other hand, displayed the lowest prevalence of 1% (95% CI: 0-3%, 2 studies: I2 = 94%). Notably, studies employing rapid tests indicated a prevalence of 13% (95% CI: 9-17%, 6 studies: I2 = 94%), while those relying on self-reported data reported a lower prevalence of 8% (95% CI: 5-11%, 6 studies: I2 = 99%). Moreover, studies utilizing ELISA reported a prevalence of 9% (95% CI: 6-12%, 10 studies: I2 = 96%). Finally, it was determined that studies conducted in upper-middle-income countries reported a higher prevalence of 20% (95% CI: 16-24%, 5 studies: I2 = 45%), whereas studies conducted in lower- and middle-income countries reported a prevalence of 8% (95% CI: 6-10%, 12 studies: I2 = 98%). CONCLUSION The current study elucidates the troublingly high prevalence of HIV infection within slums area. Also, this finding underscores the urgent necessity for targeted and tailored interventions specifically aimed at curtailing the spread of HIV within slums. Policymakers must take cognizance of these results and devote their efforts towards the implementation of effective strategies to mitigate gender disparities, address poverty alleviation, and empower the inhabitants of these marginalized areas.
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Affiliation(s)
- Meysam Behzadifar
- Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Seyed Jafar Ehsanzadeh
- English Language Department, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Banafshe Darvishi Teli
- Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Samad Azari
- Hospital Management Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Ahad Bakhtiari
- Health Equity Research Center (HERC), Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Masoud Behzadifar
- Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran.
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Khodadost M, Ghalekhani N, Hajebi A, Gouya MM, Afsar Kazerooni P, Ghoddousi SE, Fathih HR, Khojasteh Bojnordi T, Sarvi F, Vashani J, Zare Banad Kokie F, Hashemvarzi MR, Davasazirani R, Sharifi H, Motevalian SA. Mapping and size estimation of people who inject drugs: an innovative approach for targeted harm reduction program in Iran. JOURNAL OF SUBSTANCE USE 2022. [DOI: 10.1080/14659891.2022.2077247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Mahmoud Khodadost
- Department of Public Health, School of Health, Larestan University of Medical Sciences, Larestan, Iran
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Nima Ghalekhani
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Ahmad Hajebi
- Research Center for Addiction & Risky Behaviors (ReCARB), Psychosocial Health Research Institute, Psychiatric Department, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mahdi Gouya
- National Communicable Disease Control Centre, Ministry of Health and Medical Education, Tehran, Iran
| | | | - Seyyed Ebrahim Ghoddousi
- Mental Health Social Health and Addiction Department, Ministry of Health and Medical Education, Tehran, Ira
| | - Hamid R. Fathih
- Secretary of the Coordinating Council for Prevention, Treatment and Harm Reduction of Substance Use Disorders, Mashhad University of Medical Sciences
| | - Toktam Khojasteh Bojnordi
- Mental Health Social Health and Addiction Department, Ministry of Health and Medical Education, Tehran, Ira
| | - Fatemeh Sarvi
- Department of Public Health, School of Health, Larestan University of Medical Sciences, Larestan, Iran
| | - Jamshid Vashani
- Mental and Social Health department, Iran University of Medical Sciences, Tehran, Iran
| | | | - Mahmoud Reza Hashemvarzi
- Mental and Social Health department, Mazandaran University of Medical Sciences, Mazandaran, Iran
| | - Reza Davasazirani
- Health Center of Khuzestan Province, Ahvaz Jundishapur University of Medical Science, Ahvaz, Iran
| | - Hamid Sharifi
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Seyed Abbas Motevalian
- Department of Public Health, School of Health, Larestan University of Medical Sciences, Larestan, Iran
- Manager of Tobacco, Alcohol and substance use disorders prevention and harm reduction office, Ministry of health, IR of Iran
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Nagot N, Hai VV, Dong TTT, Hai OKT, Rapoud D, Hoang GT, Quillet C, Minh KP, Vallo R, Nham TTT, Castellani J, Feelemyer J, Des Jarlais DC, Nguyen LP, Van Le H, Nguyen NV, Vo LNQ, Duong HT, Moles JP, Laureillard D. Alarming Tuberculosis Rate Among People Who Inject Drugs in Vietnam. Open Forum Infect Dis 2022; 9:ofab548. [PMID: 35106311 PMCID: PMC8801226 DOI: 10.1093/ofid/ofab548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 11/03/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The tuberculosis (TB) epidemic is not homogeneous in the general population but presents high-risk groups. People who inject drugs (PWID) are such a group. However, TB among PWID remains largely undocumented. Our goal was to assess the prevalence of TB and the risk factors associated with TB among PWID in Vietnam. METHODS We implemented a cross-sectional survey among 2 community-based cohorts of human immunodeficiency virus (HIV)-positive and HIV-negative PWID in Hai Phong. Participants were screened for TB using questions on TB symptoms. Those who reported any symptom were accompanied by peers to the TB clinic for chest x-ray. If the latter was abnormal, a sputum was collected to perform an Xpert MTB/RIF test. RESULTS A total of 885 PWID were screened for TB. For both cohorts, most PWID were male (>90.0%), with a median age of 42 years. Beside heroin injection, 52.5% of participants reported smoking methamphetamine, and 63.2% were on methadone. Among HIV-positive PWID (N = 451), 90.4% were on antiretroviral therapy and 81.6% had a viral load <1000 copies/mL. Using a complete-case analysis, the estimated TB prevalence was 2.3% (95% confidence interval [CI], 1.0-4.5) and 2.1% (95% CI, 0.8-4.2) among HIV-positive and HIV-negative people, respectively. Living as a couple, arrest over the past 6 months, homelessness, and smoking methamphetamine were independently associated with TB but not HIV infection. CONCLUSIONS In the context of very large antiretroviral therapy coverage, this extremely high rate of TB among PWID requires urgent actions.
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Affiliation(s)
- Nicolas Nagot
- Pathogenesis and Control of Chronic & Emerging Infections, University of Montpellier, INSERM, Etablissement Français du Sang, University of Antilles-Guyane, Montpellier, France
| | - Vinh Vu Hai
- Infectious and Tropical Diseases Department, Viet Tiep Hospital, Hai Phong, Vietnam
| | | | | | - Delphine Rapoud
- Pathogenesis and Control of Chronic & Emerging Infections, University of Montpellier, INSERM, Etablissement Français du Sang, University of Antilles-Guyane, Montpellier, France
| | - Giang Thi Hoang
- Department of Public Health, Hai Phong University of Medicine and Pharmacy, Hai Phong, Vietnam
| | - Catherine Quillet
- Pathogenesis and Control of Chronic & Emerging Infections, University of Montpellier, INSERM, Etablissement Français du Sang, University of Antilles-Guyane, Montpellier, France
| | - Khue Pham Minh
- Department of Public Health, Hai Phong University of Medicine and Pharmacy, Hai Phong, Vietnam
| | - Roselyne Vallo
- Pathogenesis and Control of Chronic & Emerging Infections, University of Montpellier, INSERM, Etablissement Français du Sang, University of Antilles-Guyane, Montpellier, France
| | | | - Joëlle Castellani
- Pathogenesis and Control of Chronic & Emerging Infections, University of Montpellier, INSERM, Etablissement Français du Sang, University of Antilles-Guyane, Montpellier, France
| | - Jonathan Feelemyer
- School of Global Public Health, New York University, New York, New York, USA
| | - Don C Des Jarlais
- School of Global Public Health, New York University, New York, New York, USA
| | | | - Hoi Van Le
- National TB control program, Hanoi, Vietnam
| | | | | | - Huong Thi Duong
- Department of Public Health, Hai Phong University of Medicine and Pharmacy, Hai Phong, Vietnam
| | - Jean-Pierre Moles
- Pathogenesis and Control of Chronic & Emerging Infections, University of Montpellier, INSERM, Etablissement Français du Sang, University of Antilles-Guyane, Montpellier, France
| | - Didier Laureillard
- Pathogenesis and Control of Chronic & Emerging Infections, University of Montpellier, INSERM, Etablissement Français du Sang, University of Antilles-Guyane, Montpellier, France
- Infectious Diseases Department, Caremeau University Hospital, Nimes, France
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Vinh VH, Vallo R, Giang HT, Huong DT, Oanh KTH, Khue PM, Thanh NTT, Quillet C, Rapoud D, Michel L, de Perre PV, Feelemyer J, Moles JP, Cournil A, Jarlais DD, Laureillard D, Nagot N. A cohort study revealed high mortality among people who inject drugs in Hai Phong, Vietnam. J Clin Epidemiol 2021; 139:38-48. [PMID: 34280476 PMCID: PMC10116693 DOI: 10.1016/j.jclinepi.2021.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 06/28/2021] [Accepted: 07/12/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To estimate the residual mortality rate among people who inject drugs (PWID) in a Low-Middle Income Countries context where the HIV epidemic has been controlled and methadone coverage is high. STUDY DESIGN AND SETTING PWID from Haiphong, Vietnam, were recruited through three annual respondent-driven sampling surveys that fueled two cohorts of PWID with HIV (n = 761) and without HIV (n = 897), with bi-annual follow-up. Presumed causes of death were ascertained from medical records and/or interviews of participants family. RESULTS Among the 1658 participants with a median follow-up of 2 years, 67 and 36 died in the HIV-positive and HIV-negative cohort, respectively, yielding crude mortality rates of 4.3 (95% Confidence interval (CI): 3.3-5.4) per 100 person-years of follow-up (PYFU) and 1.9 (CI: 1.4-2.6) per 100 PYFU. In the HIV-positive cohort, in which 81% of participants had undetectable viral load, the two main causes of death were tuberculosis and HIV-related diseases. In the HIV-negative cohort, the two main causes of death were liver-related diseases and overdose. In a time-dependent multivariable model, "unsuppressed viral load" was associated with increased risk of mortality, whereas "being on methadone" or "being employed" was associated with a lower risk. CONCLUSION Despite a very successful HIV and methadone program, the mortality remains high among PWID in Vietnam, largely due to curable infectious diseases such as tuberculosis and viral hepatitis.
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Affiliation(s)
- Vu Hai Vinh
- Department of Infectious and Tropical Diseases, Viet Tiep Hospital, Hai Phong, Vietnam
| | - Roselyne Vallo
- Pathogenesis and control of chronic infections, University of Montpellier, INSERM, Etablissement Français du Sang, University of Antilles, Montpellier, France
| | - Hoang Thi Giang
- Hai Phong University of Medicine and Pharmacy, Hai Phong, Vietnam
| | - Duong Thi Huong
- Hai Phong University of Medicine and Pharmacy, Hai Phong, Vietnam
| | | | - Pham Minh Khue
- Hai Phong University of Medicine and Pharmacy, Hai Phong, Vietnam
| | | | - Catherine Quillet
- Pathogenesis and control of chronic infections, University of Montpellier, INSERM, Etablissement Français du Sang, University of Antilles, Montpellier, France
| | - Delphine Rapoud
- Pathogenesis and control of chronic infections, University of Montpellier, INSERM, Etablissement Français du Sang, University of Antilles, Montpellier, France
| | - Laurent Michel
- Pierre Nicole Centre, French Red Cross, CESP/Inserm 1018, Paris, France
| | - Philippe Van de Perre
- Pathogenesis and control of chronic infections, University of Montpellier, INSERM, Etablissement Français du Sang, University of Antilles, Montpellier, France
| | | | - Jean Pierre Moles
- Pathogenesis and control of chronic infections, University of Montpellier, INSERM, Etablissement Français du Sang, University of Antilles, Montpellier, France.
| | - Amandine Cournil
- Pathogenesis and control of chronic infections, University of Montpellier, INSERM, Etablissement Français du Sang, University of Antilles, Montpellier, France
| | | | - Didier Laureillard
- Pathogenesis and control of chronic infections, University of Montpellier, INSERM, Etablissement Français du Sang, University of Antilles, Montpellier, France; Department of Infectious Diseases, Caremeau University Hospital, Nîmes, France
| | - Nicolas Nagot
- Pathogenesis and control of chronic infections, University of Montpellier, INSERM, Etablissement Français du Sang, University of Antilles, Montpellier, France.
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Wulandari LPL, Guy R, Kaldor J. The burden of HIV infection among men who purchase sex in low- and middle-income countries - a systematic review and meta-analysis. PLoS One 2020; 15:e0238639. [PMID: 32886695 PMCID: PMC7473528 DOI: 10.1371/journal.pone.0238639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/20/2020] [Indexed: 12/03/2022] Open
Abstract
Background Since the start of the HIV epidemic, transactional sexual relationships have been considered to present a high risk of HIV transmission to both the client and the person offering the sexual service. However, prevention research and programs have focused predominantly on sex workers rather than on their clients, who are generally men. To support effective and targeted interventions, we undertook a systematic review and meta-analysis of the evidence of the prevalence of HIV infection among men who purchase sex (MWPS) in low- and middle-income countries (LMICs), and the association between HIV infection and purchase of sex. Methods We included articles that reported from LMICs on the prevalence of HIV in MWPS and those that reported on HIV prevalence among both MWPS and non-MWPS in the same study, or any information which allowed calculation of the prevalence. We defined MWPS as heterosexual males (not men who purchase sex or individuals of other sexual orientation) who purchased sex mostly from women (and not men), or who have had sexual contact with female sex workers (FSWs). We searched Medline, Global Health, Scopus, Embase and Cinahl for articles published up until 1 March 2020. Meta-analysis was conducted using a random effects model to estimate the pooled HIV prevalence and the relative risk (RR) of HIV infection associated with purchasing sex. Results Of 34862 studies screened, we included 44 studies (59515 men, 47753 MWPS) from 21 countries. The pooled HIV prevalence among MWPS was 5% (95%CI: 4%-6%; I2 = 95.9%, p < 0.001). The pooled HIV prevalence calculated from studies that reported data collected pre-2001 was highest, i.e. 10% (95% CI: 6%-14%; I2 = 91.2%, p < 0.001), compared to studies whose data was collected between 2001–2010, i.e. 4% (95%CI: 2%-6%; I2 = 96.6%, p < 0.001), and from 2011 and beyond, i.e. 3% (95% CI: 2%-5%; I2 = 94.3%, p < 0.001). For studies which included comparisons of HIV infection among MWPS and non-MWPS, the relative risk of HIV infection was consistently higher among MWPS than among non-MWPS within the same study, with the overall pooled relative risk of 1.95 (95%CI: 1.56–2.44; I2 = 84.3%, p < 0.001), and 2.85 (95%CI: 1.04–7.76; I2 = 86.5%, p < 0.001) for more recent studies. Conclusions This review represents the first comprehensive assessment of the burden of HIV among MWPS in LMICs. We found that HIV prevalence was elevated compared to the population as a whole, and that there was a strong association between purchasing sex and HIV prevalence. Despite a reduction over time in prevalence, these data highlight that MWPS need better access to HIV preventive interventions.
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Affiliation(s)
- Luh Putu Lila Wulandari
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
- Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University, Bali, Indonesia
- * E-mail: ,
| | - Rebecca Guy
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - John Kaldor
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
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Bernier A, Perrineau S, Reques L, Kouamé A, N'Guessan R, N'Zi L, Diomandé M, Evanno J, Collin G, Deze C, Adjahi LHP, Bouscaillou J, Luhmann N. Prevalence and management of tuberculosis among people who use drugs in Abidjan, Ivory Coast. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 83:102862. [PMID: 32707477 DOI: 10.1016/j.drugpo.2020.102862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/27/2020] [Accepted: 07/02/2020] [Indexed: 11/30/2022]
Abstract
Background Although people who use drugs (PWUD) are a high-risk group for tuberculosis (TB), there is practically no data on TB prevalence in Ivory Coast. The aim of the study was to estimate pulmonary TB prevalence and assess the cascade of care with confirmed pulmonary TB (TB+) among PWUD in Abidjan. Methods The study targeted adult people who had used heroin and/or cocaine/crack in the previous six months. A first part consisted in a cross-sectional prevalence estimation survey using mobile facility testing in smoking spots. A multivariable logistic regression was performed to determine the factors associated with TB infection. In a second part, all participants who tested positive for pulmonary TB were offered follow-up for the duration of their treatment and invited to participate in a community-based support program (e.g. family mediation visits or self-support groups). Results Between October 2016 and May 2017, 545 PWUD were informed about the survey and 532 agreed to participate. Most of them were male (n = 484; 91.0%) single (n = 434; 81.6%), with an average age of 34.9 (SD 8.3) years. Drugs most commonly consumed were heroin and crack (n = 530; 99.6% and n = 353; 66.4% respectively) and were inhaled (i.e. smoked). Out of the 531 participants with an Xpert MTB/RIF® test result, 52 were diagnosed with pulmonary TB, i.e. a prevalence of 9.8%, 95% CI [7.5%-12.7%]. Among them, 17.3% had rifampicin-resistant TB. Factors significantly associated with TB infection in the multivariable analysis were: having been recruited in Treichville smoking spot (OR=2.0 [1.1 - 3.7]; p = 0.03), being unemployed (OR = 1.8 [1.0 - 3.4]; p = 0.05), and being co-infected with HIV (OR=3.3 [1.2 - 8.1]; p = 0.01); 60.0% of the patients were successfully treated. Conclusion TB prevalence among the PWUD is high. The community-based support model enables good treatment efficacy among this usually hard-to-reach population.
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Affiliation(s)
| | | | - Laura Reques
- Médecins du Monde, 62 rue Marcadet, 75018 Paris, France.
| | - Amenan Kouamé
- Programme National de Lutte contre la Tuberculose, Côte d'Ivoire
| | | | - Lucien N'Zi
- Médecins du Monde, 62 rue Marcadet, 75018 Paris, France
| | | | - Jerôme Evanno
- Médecins du Monde, 62 rue Marcadet, 75018 Paris, France
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DeMasi SC, Goyack LE, Shufflebarger EF, Hess EP, Skains RM, Thompson MA, Burleson SL, Gullett JP, Pigott DC. Clinical ultrasonography in patients who inject drugs (the CUPID protocol): an illustrated case series. J Am Coll Emerg Physicians Open 2020; 1:244-251. [PMID: 33000039 PMCID: PMC7493592 DOI: 10.1002/emp2.12028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/22/2020] [Accepted: 01/23/2020] [Indexed: 11/06/2022] Open
Abstract
In 2017, there were ≈47,600 opioid overdose-related deaths in the United States. US emergency department (ED) visits for suspected opioid overdose increased by 30% between July 2016 and September 2017.2 The current US opioid epidemic makes it critical for emergency physicians to be aware of common and uncommon infectious and non-infectious complications of injection drug use. Point-of-care ultrasound has become a widely available, non-invasive diagnostic tool in EDs across the United States and worldwide. The increasing population of injection drug use patients is at risk for serious morbidity and mortality from an array of disease states amenable to ultrasound-based diagnosis. We propose a protocol for clinical ultrasonography in patients who inject drugs (the CUPID protocol), a focused, 3-system point-of-care ultrasound approach emphasizing cardiovascular, thoracic, and musculoskeletal imaging. The protocol is a screening tool, designed to detect high risk infectious and noninfectious complications of injection drug use.
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Affiliation(s)
- Stephanie C. DeMasi
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabama
| | - Laura E. Goyack
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabama
| | - Erin F. Shufflebarger
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabama
| | - Erik P. Hess
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabama
| | - Rachel M. Skains
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabama
| | - Maxwell A. Thompson
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabama
| | - Samuel Luke Burleson
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabama
| | - John P. Gullett
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabama
| | - David C. Pigott
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabama
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Rashti R, Sharafi H, Alavian SM, Moradi Y, Mohamadi Bolbanabad A, Moradi G. Systematic Review and Meta-Analysis of Global Prevalence of HBsAg and HIV and HCV Antibodies among People Who Inject Drugs and Female Sex Workers. Pathogens 2020; 9:pathogens9060432. [PMID: 32486342 PMCID: PMC7350380 DOI: 10.3390/pathogens9060432] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 05/01/2020] [Accepted: 05/29/2020] [Indexed: 02/06/2023] Open
Abstract
The main objective of this study was to evaluate the prevalence of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), hepatitis C virus (HCV) and hepatitis B virus (HBV) and their co-infections among people who inject drugs (PWID) and female sex workers (FSWs). Data sources were searched from January 2008 to October 2018 in different databases. Data were analyzed in Stata 16 software using the Metaprop command. The results showed that the prevalence of HIV, HCV and HBV among PWID was 15%, 60% and 6%, respectively. The prevalence of HIV, HCV and HBV among FSWs was 5%, 1% and 3%, respectively. The prevalence of HIV/HCV, HIV/HBV, HCV/HBV and HIV/HCV/HBV co-infections among PWID was 13%, 2%, 3% and 2%, respectively. The prevalence of HIV/HCV and HIV/HBV co-infections among FSWs was 3% and 1%, respectively. The results show that the prevalence of HCV and HIV infections in PWID and the prevalence of HIV in FSWs is higher than their prevalence in the general population. Interventions for the prevention of HIV and HCV in PWID appear to be poor, and may not be sufficient to effectively prevent HIV and HCV transmission.
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Affiliation(s)
- Roya Rashti
- Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj 6617713446, Iran; (R.R.); (A.M.B.)
| | - Heidar Sharafi
- Middle East Liver Diseases Center, Tehran 1598976513, Iran;
| | - Seyed Moayed Alavian
- Professor of Gastroenterology and Hepatology, Middle East Liver Disease Center, Tehran 1598976513, Iran;
| | - Yousef Moradi
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran 1449614535, Iran;
| | - Amjad Mohamadi Bolbanabad
- Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj 6617713446, Iran; (R.R.); (A.M.B.)
| | - Ghobad Moradi
- Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj 6617713446, Iran; (R.R.); (A.M.B.)
- Correspondence:
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Stannah J, Dale E, Elmes J, Staunton R, Beyrer C, Mitchell KM, Boily MC. HIV testing and engagement with the HIV treatment cascade among men who have sex with men in Africa: a systematic review and meta-analysis. Lancet HIV 2019; 6:e769-e787. [PMID: 31601542 PMCID: PMC6993044 DOI: 10.1016/s2352-3018(19)30239-5] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 06/27/2019] [Accepted: 07/04/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND HIV disproportionately affects gay, bisexual, and other men who have sex with men (MSM) in Africa, where many countries criminalise same-sex behaviour. We assessed changes in the engagement of African MSM with HIV testing and treatment cascade stages over time, and the effect of anti-LGBT legislation and stigma. METHODS We systematically searched Embase, Global Health, MEDLINE, Scopus, and Web of Science for peer-reviewed cross-sectional or longitudinal studies recruiting at least ten MSM, published from Jan 1, 1980, to Oct 10, 2018. We extracted or derived estimates of HIV testing, engagement with the HIV treatment cascade, or both among African MSM from published reports. We derived pooled estimates using inverse-variance random-effects models. We used subgroup and meta-regression analysis to assess associations between testing and status awareness outcomes and study and participant characteristics, including the severity of country-level anti-LGBT legislation. FINDINGS Our searches identified 75 independent eligible studies that provided estimates for 44 993 MSM across one or more of five testing and treatment cascade outcomes. HIV testing increased significantly over time overall, with pooled proportions of MSM ever tested for HIV of 67·3% (95% CI 62·1-72·3; 44 estimates) and tested in the past 12 months of 50·1% (42·4-57·8, 31 estimates) after 2011, which were 14·8 percentage points and 17·9 percentage points higher than before 2011, respectively. After 2011, ever testing was highest in southern Africa (80·0%), and lowest in northern Africa (34·4%), with the greatest increase in western Africa (from 42·4% to 70·9%). Levels of testing ever, in the past 12 months, and status awareness were statistically significantly lower in countries with the most severe anti-LGBT legislation compared with countries with the least severe legislation (57·4% vs 71·6%, p=0·0056; 35·5% vs 49·3%, p=0·010; 6·7% vs 22·0%, p=0·0050). Few estimates were available for later stages of the treatment cascade. Available data after 2011 suggest that the pooled proportion of MSM HIV-positive aware has remained low (18·5%, 12·5-25·3; 28 estimates), whereas proportions of current antiretroviral therapy (ART) use were 23·7% (15·5-33·0; 13 estimates) among all MSM living with HIV and 60·1% (48·6-71·1; five estimates) among MSM HIV-positive aware of their status. Pooled levels of viral suppression among MSM currently on ART were 75·6% (64·4-85·5; four estimates), but only 24·7% (18·8-31·2; four estimates) among all MSM living with HIV. INTERPRETATION Despite improvements in HIV testing among MSM in Africa, HIV status awareness, ART coverage, and viral suppression remain much lower than required to achieve UNAIDS 90-90-90 targets. Further studies are urgently needed to provide more accurate estimates of levels of status awareness, engagement in care, ART coverage, and viral suppression among MSM to inform prevention efforts aimed at improving access to HIV services for MSM. Severe anti-LGBT legislation might be associated with lower HIV testing and status awareness; therefore, further research is needed to assess the effect of such legislation on HIV testing and engagement with the HIV treatment cascade among MSM. FUNDING US National Institutes of Health, UK Medical Research Council.
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Affiliation(s)
- James Stannah
- Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Elizabeth Dale
- Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Jocelyn Elmes
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK
| | - Roisin Staunton
- Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Chris Beyrer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA
| | - Kate M Mitchell
- Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK; HIV Prevention Trials Network Modelling Centre, Imperial College London, London, UK
| | - Marie-Claude Boily
- Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK; HIV Prevention Trials Network Modelling Centre, Imperial College London, London, UK.
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Sopheab H, Chhea C, Tuot S, Muir JA. HIV prevalence, related risk behaviors, and correlates of HIV infection among people who use drugs in Cambodia. BMC Infect Dis 2018; 18:562. [PMID: 30424727 PMCID: PMC6234604 DOI: 10.1186/s12879-018-3472-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 10/31/2018] [Indexed: 11/30/2022] Open
Abstract
Background Although HIV prevalence in Cambodia has declined to 0.6% among the general population, the prevalence remains high among female sex workers (14.0%) and men who have sex with men (2.3%). Over the past 10 years, the number of people who use drugs (PWUDs) has increased considerably. PWUDs, especially people who inject drugs (PWIDs), who have multiple sex partners or unprotected sex contribute to a higher HIV prevalence. This paper aims to estimate the prevalence of HIV across PWUD groups and to identify factors associated with HIV infection. Methods Respondent-driven sampling (RDS) was used to recruit 1626 consenting PWUDs in 9 provinces in 2012. Questionnaires and blood specimens were collected. HIV prevalence estimates were calculated using RDSAT 7.1. Individual weightings for HIV were generated with RDSAT and used for a weighted analysis in STATA 13. Multivariate logistic regression was used to identify the independent factors associated with HIV prevalence. Results Most of the PWUDs were men (82.0%), and 7.3% were PWIDs. Non-PWIDs, especially users of amphetamine-type stimulants (ATS), represented the larger proportion of the participants (81.5%). The median age for of the PWUDs was 24.0 years (IQR: 20–29). The HIV prevalence among the PWUDs was 5.1% (95% CI: 4.1–6.2), 24.8%, among PWIDs and 4.0% among non-PWIDs. The HIV prevalence among female PWIDs was 37.5, and 22.5% among male PWIDs. Four factors were independently associated with HIV infection: female sex, with AOR = 7.8 (95% CI: 3.00–20.35); age groups 21–29 and older (AOR = 10.3, 95% CI: 1.2–20.4); and using drugs for ≥12 months (AOR = 4.0, 95% CI: 1.38–11.35). Finally, injecting drugs remained a strong predictor of HIV infection, with an AOR = 4.1 (95% CI: 1.53–10.96). Conclusion HIV prevalence remains high among PWIDs. Harm reduction efforts, such as needle and syringe provision programs, must improve their coverage. Innovative strategies are needed to reach sub-groups of PWUDs, especially women who inject drugs. Furthermore, the large proportion of non-PWIDs, especially ATS users, should not be ignored. Therefore, combined HIV prevention and harm reduction programs should integrate ATS users.
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Affiliation(s)
- Heng Sopheab
- School of Public Health at the National Institute of Public Health, Lot #80, Samdech Penn Nouth Blvd. Tuol Kork District, Phnom Penh, Cambodia.
| | - Chhorvann Chhea
- School of Public Health at the National Institute of Public Health, Lot #80, Samdech Penn Nouth Blvd. Tuol Kork District, Phnom Penh, Cambodia
| | - Sovannary Tuot
- Center for Population and Health Research, KHANA, Phnom Penh, Cambodia
| | - Jonathan A Muir
- Department of Epidemiology, University of Washington, Seattle, USA
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Abstract
Purpose of review Opioid use disorder (OUD) is a global phenomenon and is on the rise in Africa, denoting a shift from historical patterns of drug transport to internal consumption. In contrast, opioids for clinical pain management in Africa remain among the least available globally. This region also has the highest HIV and HCV disease burden, and the greatest shortages of health workers and addiction treatment. We undertook a systematic review of the literature to describe opioid use in Africa and how it is being addressed. Recent findings A total of 84 articles from 2000 to 2018 were identified. Descriptions of country-specific populations and patterns of opioid misuse were common. A smaller number of articles described interventions to address OUD. Summary OUD occurs in sub-Saharan Africa, with attendant clinical and social costs. Evidence-based policies and health system resources are needed to promote OUD prevention and management, and infectious disease transmission reduction.
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Ndayongeje J, Msami A, Laurent YI, Mwankemwa S, Makumbuli M, Ngonyani AM, Tiberio J, Welty S, Said C, Morris MD, McFarland W. Illicit Drug Users in the Tanzanian Hinterland: Population Size Estimation Through Key Informant-Driven Hot Spot Mapping. AIDS Behav 2018; 22:4-9. [PMID: 29435795 DOI: 10.1007/s10461-018-2057-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We mapped hot spots and estimated the numbers of people who use drugs (PWUD) and who inject drugs (PWID) in 12 regions of Tanzania. Primary (ie, current and past PWUD) and secondary (eg, police, service providers) key informants identified potential hot spots, which we visited to verify and count the number of PWUD and PWID present. Adjustments to counts and extrapolation to regional estimates were done by local experts through iterative rounds of discussion. Drug use, specifically cocaine and heroin, occurred in all regions. Tanga had the largest numbers of PWUD and PWID (5190 and 540, respectively), followed by Mwanza (3300 and 300, respectively). Findings highlight the need to strengthen awareness of drug use and develop prevention and harm reduction programs with broader reach in Tanzania. This exercise provides a foundation for understanding the extent and locations of drug use, a baseline for future size estimations, and a sampling frame for future research.
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Affiliation(s)
- Joel Ndayongeje
- Global Programs, University of California, San Francisco, Dar es Salaam, United Republic of Tanzania
| | - Amani Msami
- Drug Control Commission, Dar es Salaam, United Republic of Tanzania
| | | | - Syangu Mwankemwa
- Drug Control Commission, Dar es Salaam, United Republic of Tanzania
| | - Moza Makumbuli
- Drug Control Commission, Dar es Salaam, United Republic of Tanzania
| | - Alois M Ngonyani
- Drug Control Commission, Dar es Salaam, United Republic of Tanzania
| | - Jenny Tiberio
- Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94158, USA
| | - Susie Welty
- Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94158, USA
| | - Christen Said
- Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94158, USA
| | - Meghan D Morris
- Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94158, USA
| | - Willi McFarland
- Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94158, USA.
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Stengel CM, Mane F, Guise A, Pouye M, Sigrist M, Rhodes T. "They accept me, because I was one of them": formative qualitative research supporting the feasibility of peer-led outreach for people who use drugs in Dakar, Senegal. Harm Reduct J 2018; 15:9. [PMID: 29486774 PMCID: PMC5830063 DOI: 10.1186/s12954-018-0214-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 02/18/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Peer outreach harm reduction initiatives are being developed with and for people who use drugs in Dakar, Senegal. This is in response to growing injecting drug use across the West Africa region and linked emerging epidemics of HIV and hepatitis C. We undertook formative qualitative research to explore the feasibility and potential of peer outreach in this context and in particular how outreach could be linked to fostering community-level processes of change. METHODS We undertook a total of 44 semi-structured qualitative interviews. Thirty-four interviews were with people who used drugs (comprised of 25 participants who had injected at least once in their life) and included 11 peer educators who delivered "awareness-raising" harm reduction activities. We also interviewed 10 service providers involved in the planning and monitoring of peer outreach initiatives. We used thematic analysis to identify key characteristics of how peer-led outreach is being delivered, beneficiary need, and the nature of the social networks in which the awareness-raising activities operate. RESULTS Through interviews with peer educators, people who use drugs, and service providers, four main overlapping themes are identified as follows: peer educators as a bridge to responsibilization through awareness-raising activities, awareness-raising activities as an enactment of recovery, awareness raising through social network diffusion, and the contexts and constraints of peer outreach engagement through awareness-raising activities. CONCLUSIONS The study results suggest that peer education is on a trajectory to develop into a central role for harm reduction interventions in Dakar, Senegal. This research shows how peer education is bound in processes of responsibilization and self-change, which link to varying possibilities for risk reduction or recovery. For peer education to achieve a range of significant goals, broader structural and system changes should be implemented in the region. We caution that without such changes, awareness-raising activities and the role of peer educators may instead become part of state- and agency-sponsored processes of seeking to responsibilize individuals for health and harm reduction.
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Affiliation(s)
- Camille May Stengel
- University of Greenwich, Old Royal Naval College, Park Row, London, SE10 9LS, UK.
| | - Famara Mane
- Alliance Nationale des Communautés pour la Santé, Cité Keur Gorgui Villa 41, 10297, Dakar, Senegal
| | - Andrew Guise
- Addison House, Guy's Hospital, King's College London, London, SE1 9RT, UK
| | - Magath Pouye
- Alliance Nationale des Communautés pour la Santé, Cité Keur Gorgui Villa 41, 10297, Dakar, Senegal
| | - Monika Sigrist
- International HIV/AIDS Alliance, Preece House, 91-101 Davigdor Rd, Brighton, BN3 1RE, UK
| | - Tim Rhodes
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
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Major genotype families and epidemic clones of Mycobacterium tuberculosis in Omsk region, Western Siberia, Russia, marked by a high burden of tuberculosis-HIV coinfection. Tuberculosis (Edinb) 2017. [PMID: 29523319 DOI: 10.1016/j.tube.2017.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This population-based study characterized Mycobacterium tuberculosis isolates from HIV-positive and HIV-negative tuberculosis (TB) patients in the Omsk region in Western Siberia, Russia. We sought to gain insight into the major genotype families and epidemic and endemic clones of M. tuberculosis in the area with a high burden and adverse trend of TB/HIV coinfection. The study collection included M. tuberculosis isolates from 207 newly-diagnosed patients with pulmonary TB; 55 (26.5%) of patients were HIV-infected. The M. tuberculosis isolates were subjected to drug susceptibility testing and molecular typing based on spoligotyping and analysis of the robust genotype and cluster-specific markers. Patients with disseminated TB disease were more prevalent in the HIV-positive (34.5%) than in the HIV-negative group (4.6%) (P < .001). The Beijing genotype was predominant (62.3% of isolates), and its major subtypes were 94-32-cluster (Central Asian/Russian strain, n = 80) and B0/W148-cluster (successful Russian strain, n = 28). The main non-Beijing families were represented by Latin-American Mediterranean (14.5%), T family (11.1%), Ural (5.8%), and Haarlem (3.9%). Under multivariate logistic regression analysis, MDR was associated with Beijing genotype and not associated with HIV coinfection status (P < .001). Beijing genotype isolates were found more frequently in TB/HIV patients than in TB HIV-negative patients (74.5% versus 57.9%, respectively; P = .031). The non-Beijing genotypes were mainly drug susceptible except for the drug-resistant Ural SIT262 isolates. To summarize, the alarming situation in the Omsk region in Siberia regarding TB/HIV coinfection is seriously influenced by the active circulation of M. tuberculosis isolates of MDR-associated Beijing genotype. Among the non-Beijing families, emergence of the drug-resistant Ural family strains of spoligotype SIT262 warrants attention.
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Health outcomes associated with crack-cocaine use: Systematic review and meta-analyses. Drug Alcohol Depend 2017; 180:401-416. [PMID: 28982092 DOI: 10.1016/j.drugalcdep.2017.08.036] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 08/29/2017] [Accepted: 08/29/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Crack-cocaine use is prevalent largely in socio-economically marginalized populations in the Americas. Its use has been associated with diverse health outcomes, yet no recent or systematic reviews of these exist. METHODS A systematic review of health outcomes associated with crack-cocaine use was performed, using MEDLINE, Scopus, Web of Science, CINAHL, PsycINFO, and LILACS up to October 2016. Search terms included crack-cocaine and health outcome-related keywords, targeting peer-reviewed studies on quantified health outcomes associated with crack-cocaine use. Random effects meta-analyses produced pooled odds ratios. Levels of evidence for major results were assessed using the GRADE approach. A review protocol was registered with PROSPERO (CRD42016035486). RESULTS Of 4700 articles returned, 302 met eligibility criteria, reporting on health outcomes for 14 of 22 ICD-10 chapters. Conclusive evidence and meta-analyses showed positive associations between crack-cocaine use and blood/sexually transmitted diseases (HIV and hepatitis C virus, others); moderate evidence and meta-analyses supported associations with neonatal health, and violence. There were mixed associations for mental and other health outcomes, yet insufficient evidence to perform meta-analyses for many categories (e.g., mortality). Most underlying research was of limited or poor quality, with crack-cocaine commonly assessed as a secondary covariate. CONCLUSIONS Crack-cocaine use was associated with a range of health outcomes, although it was unclear if there was direct causal impact, interactions between risk factors, or external drivers of both crack-cocaine use and outcomes. Rigorous epidemiological studies are needed to systematically assess health outcomes of crack-cocaine use and underlying pathways, also to inform evidence-based interventions.
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Abdool R. Policy change towards implementing harm reduction in Sub-Saharan Africa. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2016; 30:140-2. [PMID: 27017377 DOI: 10.1016/j.drugpo.2016.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Reychad Abdool
- Consultant HIV Expert, Formerly United Nations Office of Drugs and Crime, Nairobi, Kenya.
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Rhodes T, Abdool R. Drug harms and drug policies in Sub-Saharan Africa: Implementation science and HIV epidemics. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2016; 30:1-6. [PMID: 26997543 DOI: 10.1016/j.drugpo.2016.02.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Tim Rhodes
- London School of Hygiene and Tropical Medicine, UK; National Centre for Social Research on Health, University of New South Wales, Australia.
| | - Reychad Abdool
- Senior HIV Consultant, formerly United Nations Office of Drugs and Crime, Nairobi, Kenya
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