Oral contraception and unprotected sex with occasional partners of women HIV-infected through injection drug use

Impact of drug consumption rooms on risk practices and access to care in people who inject drugs in France: the COSINUS prospective cohort study protocol

INTRODUCTION

The high prevalence of hepatitis C and the persistence of HIV and hepatitis C virus (HCV) risk practices in people who inject drugs (PWID) in France underlines the need for innovative prevention interventions. The main objective of this article is to describe the design of the COSINUS cohort study and outline the issues it will explore to evaluate the impact of drug consumption rooms (DCR) on PWID outcomes. Secondary objectives are to assess how DCR (a) influence other drug-related practices, such as the transition from intravenous to less risky modes of use, (b) reduce drug use frequency/quantity, (c) increase access to treatment for addiction and comorbidities (infectious, psychiatric and other), (d) improve social conditions and (e) reduce levels of violence experienced and drug-related offences. COSINUS will also give us the opportunity to investigate the impact of other harm reduction tools in France and their combined effect with DCR on reducing HIV-HCV risk practices. Furthermore, we will be better able to identify PWID needs.

METHODS AND ANALYSIS

Enrollment in this prospective multi-site cohort study started in June 2016. Overall, 680 PWID in four different cities (Bordeaux, Marseilles, Paris and Strasbourg) will be enrolled and followed up for 12 months through face-to-face structured interviews administered by trained staff to all eligible participants at baseline (M0), 3 month (M3), 6 month (M6) and 12 month (M12) follow-up visits. These interviews gather data on socio-demographic characteristics, past and current drug and alcohol consumption, drug-use related practices, access to care and social services, experience of violence (as victims), offences, other psychosocial issues and perception and needs about harm reduction interventions and services. Longitudinal data analysis will use a mixed logistic model to assess the impact of individual and structural factors, including DCR attendance and exposure to other harm reduction services, on the main outcome (HIV-HCV risk practices).

ETHICS AND DISSEMINATION

This study was reviewed and approved by the institutional review board of the French Institute of Medical Research and Health (opinion number: 14-166). The findings of this cohort study will help to assess the impact of DCR on HIV-HCV risk practices and other psycho-social outcomes and trajectories. Moreover, they will enable health authorities to shape health and harm reduction policies according to PWID needs. Finally, they will also help to improve current harm reduction and therapeutic interventions and to create novel ones.

Another frontier for harm reduction: contraceptive needs of females who inject drugs in Estonia, a cross-sectional study

Background

Despite increasing contraceptive availability, unintended pregnancy remains a global problem. Developing strategies to reverse this trend and increasing occurrence of withdrawal syndrome among newborn children of females currently injecting drugs warrants special attention. The knowledge base on the uptake of effective contraception among females who inject drugs (FWID) is scant. We aimed to examine the prevalence of and factors associated with the use of non-condom contraceptives among sexually active FWID with the focus on effective contraception.

Methods

In a series of cross-sectional studies (2007–2013), 265 current FWID were recruited through respondent-driven sampling (RDS), interviewed, and tested for HIV. RDS weights were used to estimate the prevalence of effective contraception (hormonal contraception, intrauterine device, sterilization) use in the last 6 months.

Results

Of the sexually active women with main partners (n = 196) 4.8% (95% CI 2.3–9.7) were using effective contraception, 52.7% (95% CI 42.5–62.7) less-effective or no contraception. 42.5% (95% CI 32.7–52.9) relied on condoms for contraception. The odds for using effective contraception were higher among women with > 10 years of education (OR 7.29, 95% CI 1.4–38.8). None of the women lacking health insurance (n = 84) were using effective contraception.

Conclusions

The very low coverage with effective contraception highlights the need to improve contraceptive services for FWID. Reproductive health service including contraception should be considered essential components of harm reduction and of comprehensive prevention and care for HIV among persons who use drugs.

Use and knowledge of contraceptive methods by patients in two substance use disorders treatment centers in Paris

Background

Studies on contraceptive use by patients with substance use disorders (SUD) show a concerning low use of contraception. Mainly conducted in USA, they could be irrelevant to patients attending European SUD treatment centers, especially since these studies mostly investigate women suffering from social exclusion, severe material deprivation andopiates use with frequent high-risk drug use and sexual behaviors including sex trade, frequently not currently attending treatment centers. The purpose of this study is to describe contraceptive use by patients, both male and female, since contraception can not only be considered as a female problem, with severe SUD in two free clinics in Paris, France.

Methods

An anonymous self-report questionnaire was distributed to literate patients followed in two generalist substance use disorders treatment centers in hospitals of Paris, France: Espace Murger and Centre Cassini, during 5 weeks between February and March 2016.

Results

Out of the 78 respondents (with an age mean 40.7 years, in which women are represented as 48.1%, and 29.7% of them have children), 53 have had at least one sexual partner in the last 6 months. Contraception was “always” used by 55.3% of sexually active patients, “sometimes” by 19.1%, and “not” used by 25.5%. Male condoms were the main contraceptive method. The use of intrauterine devices was low, contrarily to what is observed in the French general population. However, the knowledge of contraceptive methods was common.

Conclusions

In this population, with a high prevalence of at risk sexual behavior, the use of contraceptive methods is lower than in French general population. During standard care for SUD, contraception and desire to be a parent should be discussed and patients empowered to make their own choices. Lack of knowledge does not seem to be a hindrance to the use of contraception, but other sociological, psychological, or medical factors may limit contraceptive access and long-term use, especially for the long-acting reversible contraception methods. It is necessary to further develop this reflection by discussing the individual contraceptive choices with the patients themselves to clarify the nature of these constraints and maybe provide several contraceptive methods within the SUD care settings.

Behavioral risk assessment for infectious diseases (BRAID): Self-report instrument to assess injection and noninjection risk behaviors in substance users

BACKGROUND

Infectious diseases such as Human Immunodeficiency Virus and Hepatitis C are a significant problem among substance abusers. Current risk behavior measures [e.g., HIV Risk Taking Behaviour Scale (HRBS) and Risk Assessment Battery (RAB)] were developed for injection drug users and do not include newly identified risks or noninjection drug use behaviors. This study developed and provided initial, internal validation of the Behavioral Risk Assessment for Infectious Diseases (BRAID) to assess infectious disease risk behaviors among alcohol and other drug users.

METHODS

A self-report measure was developed from literature regarding risk behaviors. Participants (total N=998) with alcohol/substance use disorder completed the measure in 2 phases to establish initial psychometric validity.

RESULTS

Phase 1 (N=270) completed 65 self-report questions; factor analysis revealed a 12-item solution with 5 factors (Unprotected Sex with Risky Partners, Injection Use, Sex on Cocaine/Crack, Condom Availability, and Intranasal Drug Use). Infectious disease history was positively associated with Injection Use (Sample 1) and Unprotected Sex with Risky Partners (Sample 2) and negatively associated with Intranasal Drug Use (Samples 1 and 2). Phase 2 (N=728) added additional injection-related items and confirmed the factor structure of the existing BRAID.

CONCLUSIONS

The BRAID is a 5-factor, 14-item self-report measure of past 6 month risk behaviors that is composed of noninjection and injection risk behaviors and was psychometrically confirmed. Though additional external (convergent/divergent) validation is needed, this report provides preliminary support for the use of the BRAID to assess infectious disease risk in substance users.

Contraceptive use and method choice among women with opioid and other substance use disorders: A systematic review

AIM

To systematically review the literature on contraceptive use by women with opioid and other substance use disorders in order to estimate overall contraceptive use and to examine method choice given the alarmingly high rate of unintended pregnancy in this population.

METHOD

Pubmed (1948-2014) and PsycINFO (1806-2014) databases were searched for peer-reviewed journal articles using a systematic search strategy. Only articles published in English and reporting contraceptive use within samples of women with opioid and other substance use disorders were eligible for inclusion.

RESULTS

Out of 580 abstracts reviewed, 105 articles were given a full-text review, and 24 studies met the inclusion criteria. The majority (51%) of women in these studies reported using opioids, with much smaller percentages reporting alcohol and cocaine use. Across studies, contraceptive prevalence ranged widely, from 6%-77%, with a median of 55%. Results from a small subset of studies (N=6) suggest that women with opioid and other substance use disorders used contraception less often than non-drug-using comparison populations (56% vs. 81%, respectively). Regarding method choice, condoms were the most prevalent method, accounting for a median of 62% of contraceptives used, while use of more effective methods, especially implants and intrauterine devices (IUDs), was far less prevalent 8%.

CONCLUSIONS

Women with opioid and other substance use disorders have an unmet need for contraception, especially for the most effective methods. Offering contraception services in conjunction with substance use treatment and promoting use of more effective methods could help meet this need and reduce unintended pregnancy in this population.

Contraceptive methods and risk of HIV acquisition or female-to-male transmission

Effective family planning with modern contraception is an important intervention to prevent unintended pregnancies which also provides personal, familial, and societal benefits. Contraception is also the most cost-effective strategy to reduce the burden of mother-to-child HIV transmission for women living with HIV who wish to prevent pregnancy. There are concerns, however, that certain contraceptive methods, in particular the injectable contraceptive depot medroxyprogesterone acetate (DMPA), may increase a woman's risk of acquiring HIV or transmitting it to uninfected males. These concerns, if confirmed, could potentially have large public health implications. This paper briefly reviews the literature on use of contraception among women living with HIV or at high risk of HIV infection. The Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) recommendations place no restrictions on the use of hormonal contraceptive methods by women with or at high risk of HIV infection, although a clarification recommends that, given uncertainty in the current literature, women at high risk of HIV who choose progestogen-only injectable contraceptives should be informed that it may or may not increase their risk of HIV acquisition and should also be informed about and have access to HIV preventive measures, including male or female condoms.

Inconsistent condom use among HIV-positive women in the "Treatment as Prevention Era": data from the Italian DIDI study

Introduction

Translation of the evidence regarding the protective role of highly active antiretroviral therapy (HAART) on HIV sexual transmission rates into sexual behaviour patterns of HIV-infected subjects remains largely unexplored. This study aims to describe frequency of self-reported condom use among women living with HIV in Italy and to investigate the variables associated with inconsistent condom use (ICU).

Methods

DIDI (Donne con Infezione Da HIV) is an Italian multicentre study based on a questionnaire survey performed during November 2010 and February 2011. Women-reported frequency of condom use was dichotomized in “always” versus “at times”/“never” (ICU).

Results

Among 343 women, prevalence of ICU was 44.3%. Women declared a stable partnership with an HIV-negative (38%) and with an HIV-positive person (43%), or an occasional sexual partner (19%). Among the 194 women engaged in a stable HIV-negative or an occasional partnership, 51% reported fear of infecting the partner. Nonetheless, 43% did not disclose HIV-positive status. Less than 5% of women used contraceptive methods other than condoms. At multivariable analysis, variables associated with ICU in the subgroup of women with a stable HIV-negative or an occasional HIV-unknown partner were: having an occasional partner (AOR 3.51, 95% confidence interval [CI] 1.44–8.54, p=0.005), and reporting fear of infecting the sexual partner (AOR 3.20, 95% CI 1.43–7.16, p=0.004). Current use of HAART together with virological control in plasma level did not predict ICU after adjusting for demographic, behavioural and HIV-related factors. With regard to socio-demographic factors, lower education was the only variable significantly associated with ICU in the multivariate analysis (AOR 2.27, 95% CI 1.07–4.82, p=0.03). No association was found between high adherence to HAART and ICU after adjusting for potential confounders (AOR 0.89, 95% CI 0.39–2.01, p=0.78).

Conclusions

Currently in Italy, the use of HAART with undetectable HIV RNA in plasma as well as antiretroviral adherence is not associated with a specific condom use pattern in women living with HIV and engaged with a sero-discordant or an HIV-unknown partner. This might suggest that the awareness of the protective role of antiretroviral treatment on HIV sexual transmission is still limited among HIV-infected persons, at least in this country.

How does HIV affect the reproductive choices of women of childbearing age?

The majority of women living with HIV are of childbearing age and many of these women wish to have a family. As a result of advances in the treatment and management of HIV, more reproductive opportunities are now available to this group. However, women living with HIV may still require education and guidance in a range of reproductive situations, including avoiding pregnancy, seeking fertility treatment or having a child. HIV physicians should be aware of recent data and guidance on these situations--including areas where more data are required--and consider them when deciding on appropriate management for their patients.

HIV infection and contraception

HIV infection primarily affects women of childbearing age worldwide, in both developed and developing countries. With the advent of effective antiretroviral treatment, women are living longer and healthier lives, and the opportunity to have a child with minimal fear of vertical transmission is now a reality. For HIV-infected women, contraception and reproductive planning have become essential. Limited information is available on the variety of contraceptive options for HIV-infected women. It is important for all health care practitioners to educate themselves on contraceptive options so that they can provide optimal reproductive care to their HIV-infected female patients.