Responding to HIV infection associated with drug injecting in Eastern Europe

Prevalence and Correlates of the Use of Prefilled Syringes Among Persons Who Inject Drugs in San Diego, CA

Persons who inject drugs (PWID) are at increased risk for blood-borne virus (BBV) infections and overdose resulting from high-risk injecting practices. Studies of prefilled syringe use ([PFSU] using a syringe that already contained drug solution when it was obtained by the user), an injection practice previously described in Eastern Europe, suggest that it increases susceptibility to BBV. However, little is known about this practice in the USA. Data were obtained from an ongoing cohort study of PWID to determine the prevalence and assess correlates of PFSU in San Diego, CA. Baseline interviews assessed socio-demographics and drug use behaviors. Logistic regression was used to identify factors independently associated with ever using a prefilled syringe (yes/no). Participants (n = 574) were predominately males (73.9%) and white (50.9%) with a mean age of 43.4 years (range 18-80); 33.3% reported ever using prefilled syringes, although only 4.9% reported use in the past 6 months. In multivariable analyses, PFSU was independently associated with ever having a rushed injection due to police presence [adjusted odds ratio (AOR) = 2.51, 95% CI 1.66, 3.79], ever being in prison (AOR = 1.80, 95% CI 1.23, 2.63), injecting most often in public versus private places in the past 6 months (AOR = 1.66, 95% CI 1.11, 2.48), and injecting drugs in Mexico (AOR = 1.70, 95% CI 1.16, 2.49). Results indicate that a history of PFSU is common and associated with environmental factors that may also increase risk for adverse health outcomes. Studies are needed to better understand PFSU in order to develop interventions to prevent adverse outcomes associated with their use.

HIV incidence and factors associated with HIV acquisition among injection drug users in St Petersburg, Russia

BACKGROUND

The Russian HIV-1 epidemic has been driven by injection drug use.

OBJECTIVE

To determine HIV incidence and identify demographic and behavioral correlates of infection to facilitate the development of longitudinal HIV prevention programs.

METHODS

In 2002, a cohort of 520 injection drug users (IDU) in St Petersburg, Russia were recruited and tested and counseled for HIV-1. HIV-seronegative IDU were enrolled and reevaluated at 6 and 12 months. HIV testing was performed and sociodemographic and behavioral data were collected during each study visit. The relationship of sociodemographic and behavioral factors to HIV-1 incidence was assessed.

RESULTS

Most enrolled subjects were young, male, living at home, educated, heroin users, and frequently shared needles and other injection paraphernalia. The retention rate at the 12 month follow-up was 80%. The HIV-1 incidence rate was 4.5/100 person-years. In univariate analysis, psychostimulant use, especially frequent use, three or more sex partners in the past 6 months, and females selling sex were associated with HIV seroconversion. In the multivariate analysis, psychostimulant use three or more times per week was the only factor still associated with HIV seroconversion.

CONCLUSIONS

The high incidence of HIV infection places St Petersburg among the worst IDU-concentrated epidemics in Europe. Interventions targeting psychostimulant and heroin users and their accompanying behaviors such as frequent injections and increased sexual activity are needed immediately.

Drug interactions between psychoactive substances and antiretroviral therapy in individuals infected with human immunodeficiency and hepatitis viruses

The liver disease characteristic of alcohol dependence encompasses three main related entities: steatosis, alcoholic hepatitis, and cirrhosis. Alcoholic cirrhosis is a leading cause of global morbidity and mortality. Alcohol intake among injecting drug users is a major contributor to transmission of viral infections, such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C viruses (HCV). HIV and HCV coinfected patients develop liver diseases earlier and more severely than the monoinfected individuals, including hepatocellular carcinoma. Interactions exist between the therapeutic drugs used to minimize and control the drug and alcohol dependence. Furthermore, drug-drug interactions occur between the highly active antiretroviral therapy (HAART) and alcohol, different HAART components and methadone, or each one of the therapies with the other, thus contributing to a higher toxicity level. With the evolution of effective antiretroviral therapy, survival of persons with HIV, and the syndrome it causes, acquired immunodeficiency syndrome (AIDS) has increased dramatically. Drug-drug interactions may appear between alcohol and anti-HBV or anti-HCV, therapy in the presence or absence of anti-HIV therapy. Several other medical-, social-, and drug-related factors of this population have to be considered when providing HAART. Because many coinfected patients also have problems with substance use, dealing with their drug dependence is an important first step in an attempt to improve adherence to and tolerance of antiviral therapy. It is necessary to minimize the risk of liver disease acceleration and/or reinfection with hepatitis viruses. Knowledge of potential drug interactions between methadone, antiretroviral therapy, psychoactive drugs, and antipsychotics and the role of coinfection with HBV or HCV and the drugs used in eradicating viral hepatitis permits suitable antiretroviral combinations.

Social change and HIV in the former USSR: the making of a new epidemic

This paper describes the development of the recent HIV epidemic in countries of the former Soviet Union. It explores the socio-political and economic roots of an injection-drug-driven HIV epidemic associated with a drug culture that facilitates HIV transmission. This review, based on many unpublished reports, studies and field notes, discusses the new social and health context in which the epidemic is developing. The evidence of a growing number of drug users in the region is discussed and drug injection behaviour described. The authors present selected data on the heterosexual transmission of HIV and linkages between the drug-linked HIV epidemic and its further spread into the non-injecting population. The potential overlap with the still uncontrolled syphilis epidemic that began in 1990 is probably a key factor in the future of HIV spread in the region. Until now, HIV infection among STD patients has been extremely low. However, rapid changes in sexual norms and behaviours, the growing commercial sex industry, and increased mobility soon may affect the current situation. The huge economic and socio-political crises currently affecting the region have created a "risk situation" for the spread of HIV. Concerns are raised about the appropriateness and the scope of government and non-governmental approaches to the exploding HIV and STD epidemics.

Origins of an epidemic: the methodological and political emergence of rapid assessment

The recent emergence of rapid assessment as a public health tool in the drug and alcohol field has been a relatively ahistorical process. The lack of such an explicit historical biography is understandable - the findings and impact of rapid assessment have rarely made their way into mainstream journals. However, its continued absence presents the manifest danger of an inward-looking field. This paper describes the development of rapid assessment during the past two decades, with a detailed focus on the emergence of rapid assessment in the drug and alcohol field. This focuses on the central role played by international agencies during the 1980s and 1990s, and the development of rapid methodologies by the World Health Organization to prevent epidemics of HIV among injecting drug users, and the use of rapid methodologies by the United Nations International Drug Control Programme to instruct drug policy reform. The paper also describes key events in other fields including: the emergence of the first formal rapid methodologies in the late 1970s, and the production of the first formal guidelines on conducting rapid assessment during the mid-1980s. The paper concludes by highlighting common challenges that rapid methodologies have faced throughout their history.

Processes and outcomes of training on rapid assessment and response methods on injecting drug use and related HIV infection in the Russian Federation

In September 1997, Médecins Sans Frontières-Holland (MSF-H) began a project to provide training and support for HIV/AIDS prevention among injecting drug users (IDUs) in the Russian Federation, focusing on the use of the World Health Organization Rapid Assessment and Response Guide on Injecting Drug Use, and the European Peer Support Manual. As part of the training, participants are asked to carry out a rapid situation assessment (RSA) in their city or region as a major step towards designing and implementing an effective program to prevent HIV transmission among IDUs. This paper focuses on the first four training cycles of the programme (from January 1998 to January 1999), in which 89 health professionals and others from 32 Russian cities took part. A total of 28 rapid situation assessments were completed or almost completed by participants during these four cycles. The paper provides an overview of the methods used and major problems faced by participants undertaking these assessments, as well as summarising the 14 harm reduction programmes which resulted.

The empirical and methodological comparative value of the rapid assessment of drug use patterns

This paper examines the comparative value of rapid assessment in the field of illicit drug use. Three aims of rapid assessment are highlighted: one, to collect quality data to inform policy and practice; two, to encourage a multi-method research approach; and three, to promote and support greater local involvement and ownership of the project itself. A number of manuals and guidelines have been produced for rapid assessment. A key issue to address, therefore, is the extent to which a structured and standardised approach can provide sufficient flexibility to take into account the political, social and cultural differences in the respective countries in which assessment takes place. Using the empirical experience derived from four rapid assessment projects, a four-phase strategy is outlined: developing infrastructure and formative evaluation; research training and mapping exercises; data collection; and report writing and dissemination. In place of the current reactive approach, we need more strategic thinking at the macro-level. To enable comparison between projects we should move towards basic methodological standardisation, but this should be accomplished without stifling the sociological imagination, which is a crucial ingredient to successful rapid assessment.

The HIV/AIDS Epidemic among Drug Injectors in Eastern Europe: Patterns, Trends and Determinants

Our objective is to describe recent patterns and trends in HIV and injecting drug use and to explore possible determinants of the epidemics in eastern Europe. The available data confirm a rapid spread of HIV among injecting drug users (IDUs) in the newly independent states (NIS) and suggest that all successor states of the former Soviet Union are now threatened by such epidemics, while central and southeast Europe have so far been spared from large-scale outbreaks and seem at lower risk. The future course of the epidemic in the NIS will largely depend on trends in drug injecting and on the success of harm reduction programs. Furthermore, there is potential for the further spread of HIV, via heterosexual intercourse, into the general population.