Using a jail-based survey to monitor HIV and risk behaviors among Seattle area injection drug users

Prevalence of hepatitis C virus in young people who inject drugs in four Colombian cities: A cross-sectional study using Respondent Driven Sampling

BACKGROUND

Colombia has a growing population of young people who inject drugs (PWID). Despite the previously reported association of injection drug use with hepatitis c virus (HCV) in other countries, studies on HCV prevalence in PWID in Colombia are lacking. The objective of this study is to determine the prevalence, demographics, and correlations of risky injection behaviours in HCV seropositive PWID in four Colombian cities (Armenia, Bogotá, Cúcuta and Pereira).

METHODS

This was a cross-sectional study carried out between January and June of 2014 that included 918 PWID from four Colombian cities, recruited by Respondent Driven Sampling. A survey was administered to each participant, and blood samples were collected. Binary logistic regression and multivariate analyses for each city were conducted.

RESULTS

Average participant age was 26 years (SD 6.5). Of all participants, 27.3% of PWID were HCV seropositive, of which 52% were 25 years old or younger. In Pereira, increased risk of HCV infection was found for PWID that: had a history of injection drug use of 5 years or more (AOR: 3.0, CI: 1.7-7.8); were between 25 and 28 years of age (AOR: 5.2, CI: 1.0-26.3); had higher injection frequency (AOR: 2.5, CI: 1.4-4.2), and daily use of gifted, sold, or rented needles or syringes (AOR: 4.5, CI: 1.0-7.1). Additionally, in Cucuta, being HIV seropositive appeared to be greatly associated with risk of HCV seropositivity (AOR: 16.9, CI: 3.5-81.5).

CONCLUSION

Although prevalence of HCV in PWID in Colombia is lower than that reported for other countries, the described demographic characteristics and diverse risky injection behaviors on each city, in the context of a young PWID population with a short injection drug use history, should be taken into account in order to guide efforts towards preventing and reducing risk of HCV infection in PWID in Colombia.

Reduction in Needle Sharing Among Seattle-Area Injection Drug Users Across 4 Surveys, 1994-2013

OBJECTIVES

We evaluated time trends in sharing needles and other injection equipment from 1994 to 2013 among injection drug users in the Seattle, Washington area.

METHODS

We combined data from 4 sources: the Risk Activity Variables, Epidemiology, and Network (RAVEN) study, recruited from institutional settings; the Kiwi study, recruited from jails; National HIV Behavioral Surveillance system (NHBS) surveys, which used respondent-driven sampling; and surveys at needle-exchange sites.

RESULTS

Levels of needle sharing were higher in the earlier studies: RAVEN, 1994 to 1997 (43%) and Kiwi, 1998 to 2002 (61%). In the NHBS surveys, the initial level of 44% in 2005 declined to 31% in the period 2009 to 2012. Across needle-exchange surveys (2009-2013) the level was 21%. There was a parallel reduction in sharing other injection equipment. These trends persisted after control for sociodemographic and risk-associated variables. There was a contemporaneous increase in the number of needles distributed by local needle exchanges and a decline in the number of reported HIV cases among injection drug users.

CONCLUSIONS

The apparent long-term reduction in sharing injection equipment suggests substantial success in public health efforts to reduce the sharing of injection equipment.

Evidence for risk reduction among amphetamine-injecting men who have sex with men; results from national HIV behavioral surveillance surveys in the Seattle area 2008-2012

In the Seattle area men who have sex with men and also inject amphetamines (amphetamine-injecting MSM/IDU) are disproportionately likely to be infected with HIV. To characterize their distinctive characteristics, we combined data from two Seattle-area surveys of men who have sex with men (MSM) and two surveys of injection drug users (IDU). Amphetamine-injecting MSM/IDU were compared with: male IDU, MSM and other MSM/IDU. Amphetamine-injecting MSM/IDU were older than MSM but younger than IDU, more likely to be white than either group, and had an educational level higher than IDU but below MSM. They had the highest HIV prevalence (56 vs. 4-19 %). However, reported HIV cases among them fell from 92 in 1990 to 25 in 2012. They were most likely to report ten or more sex partners (49 vs. 4-26 %), an STD diagnosis (22 vs. 1-7 %) and be tested for HIV (odds ratio 1.00 vs. 0.34-0.52), and least likely to share needles (odds ratio 1.00 vs. 6.80-10.50). While sexual risk remains high, these data suggest measurable and effective risk reduction with respect to sharing injection equipment and HIV testing among Seattle-area amphetamine-injecting MSM/IDU.

Assessment of risky injection practices associated with hepatitis B, hepatitis C, and human immunodeficiency virus and using the blood-borne virus transmission risk assessment questionnaire

Risky injection practices among injection drug users (IDUs) contribute to the spread of blood-borne infections such as human immunodeficiency virus, hepatitis B, and hepatitis C. The Blood-borne Virus Transmission Risk Assessment Questionnaire (BBV-TRAQ). was developed in Australia to determine risk behaviors for specific infections. Blood testing for human immunodeficiency virus, hepatitis B, and hepatitis C was performed on all participants, and data on blood tests were linked to questionnaires. The BBV-TRAQ was administered to 242 current and former injection drug users in Long Beach, California, and the Long Beach data were compared with the original Australian data. In the comparison of the mean scores on the three subscales and total scores on the BBV-TRAQ between the samples, means for all three subscales and the total BBV-TRAQ score were significantly different, with Long Beach scores consistently lower than the Australian sample. The injecting and sexual risk subscales were significantly different across levels of AIDS risk perception for all three types of injectors; however, the other skin penetration practices subscale had no significant association with AIDS risk perception for any of the injection drug user groups. Despite recent efforts to educate injectors about the risks associated with practices captured by the other skin penetration practices subscale, such as tattooing and sharing razors, this subscale does not have an association with AIDS risk perception. injection drug users in Australia may have better access to health care, giving their self-report of infection greater validity than the California sample.

Evaluating consistency in repeat surveys of injection drug users recruited by respondent-driven sampling in the Seattle area: results from the NHBS-IDU1 and NHBS-IDU2 surveys

PURPOSE

We compared data from two respondent-driven sampling (RDS) surveys of Seattle-area injection drug users (IDU) to evaluate consistency in repeat RDS surveys.

METHODS

The RDS-adjusted estimates for 16 key sociodemographic, drug-related, sexual behavior, and HIV- and hepatitis C virus-related variables were compared in the 2005 and the 2009 National HIV Behavioral Surveillance system surveys (NHBS-IDU1 and NHBS-IDU2). Time trends that might influence the comparisons were assessed by the use of data from reported HIV cases in IDU, surveys of needle exchange users, and two previous IDU studies.

RESULTS

NHBS-IDU2 participants were more likely than NHBS-IDU1 participants to report older age, heroin as their primary injection drug, male-to-male sex, unprotected sex with a partner of nonconcordant HIV status, and to self-report HIV-positive status. NHBS-IDU2 participants were less likely to report residence in downtown Seattle, amphetamine injection, and a recent HIV test. Time trends among Seattle-area IDU in age, male-to-male sex, and HIV testing could have influenced these differences.

CONCLUSIONS

The number and magnitude of the estimated differences between the two RDS surveys appeared to describe materially different populations. This could be a result of changes in the characteristics of Seattle-area IDU over time, of accessing differing subpopulations of Seattle IDU, or of high variability in RDS measurements.

Evaluating respondent-driven sampling in a major metropolitan area: Comparing injection drug users in the 2005 Seattle area national HIV behavioral surveillance system survey with participants in the RAVEN and Kiwi studies

PURPOSE

To empirically evaluate respondent-driven sampling (RDS) recruitment methods, which have been proposed as an advantageous means of surveying hidden populations.

METHODS

The National HIV Behavioral Surveillance system used RDS to recruit 370 injection drug users (IDU) in the Seattle area in 2005 (NHBS-IDU1). We compared the NHBS-IDU1 estimates of participants' area of residence, age, race, sex, and drug most frequently injected to corresponding data from two previous surveys, the RAVEN and Kiwi Studies, and to persons newly diagnosed with HIV/AIDS and reported from 2001 through 2005.

RESULTS

The NHBS-IDU1 population was estimated to be more likely to reside in downtown Seattle (52%) than participants in the other data sources (22%-25%), be older than 50 years of age (29% vs. 5%-10%), and report multiple races (12% vs. 3%-5%). The NHBS-IDU1 population resembled persons using the downtown needle exchange in age and race distribution. An examination of cross-group recruitment frequencies in NHBS-IDU1 suggested barriers to recruitment across different areas of residence, races, and drugs most frequently injected.

CONCLUSIONS

The substantial differences in age and area of residence between NHBS-IDU1 and the other data sources suggest that RDS may not have accessed the full universe of Seattle area injection networks. Further empirical data are needed to guide the evaluation of RDS-generated samples.

The 2004 Australian prison entrants' blood-borne virus and risk behaviour survey

OBJECTIVES

To assess the prevalence of blood-borne viruses and associated risk factors among prison entrants at seven Australian prisons across four States.

DESIGN

Consecutive cross-sectional design. Voluntary confidential testing of all prison entrants for serological markers of human immunodeficiency virus (HIV), hepatitis C (HCV) and hepatitis B (HBV) over 14 consecutive days in May 2004. Demographic data and data related to risks for blood-borne virus transmission, such as sexual activity, body piercing, tattooing, and injecting drug use, were collected.

RESULTS

National prevalence for HIV was 1%, hepatitis B core antibody 20%, and hepatitis C antibody 34%. Fifty-nine per cent of participants had a history of injecting drug use. Among injecting drug users, the prevalence of HIV was 1%, hepatitis C antibody 56%, and hepatitis B core antibody 27%. Forty-one per cent of those screened reported a previous incarceration. In the multivariate model, Queensland and Western Australian (WA) prison entrants were significantly less likely to test positive to HCV than those in New South Wales (NSW). Amphetamine was the most commonly injected drug in Queensland, Tasmania and WA. In NSW, heroin was the most common drug injected. In the multivariate analysis a history of injecting drug use, being aged 30 years or more, and a prior incarceration were positively associated with hepatitis C infection. For hepatitis B core antibody, age over 30 years and a history of injecting drug use were associated with an increased risk.

CONCLUSIONS

The findings support the view that prisoner populations are vulnerable to blood-borne virus infection, particularly hepatitis B and C. Prisoner populations should be included in routine surveillance programs so as to provide a more representative picture of blood-borne virus epidemiology in Australia.

Trends in hepatitis B virus, hepatitis C virus, and human immunodeficiency virus prevalence, risk behaviors, and preventive measures among Seattle injection drug users aged 18-30 years, 1994-2004

Injection drug users (IDUs) are at risk for infection with hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Information on time trends in prevalence of these viruses among IDUs and in behaviors influencing their transmission can help define the status of these epidemics and of public health efforts to control them. We conducted a secondary data analysis combining cross-sectional data from IDUs aged 18-30 years enrolled in four Seattle-area studies from 1994 to 2004. Participants in all four studies were tested for antibody to HIV (anti-HIV), hepatitis B core antigen (anti-HBc), and HCV (anti-HCV), and completed behavioral risk assessments. Logistic regression was used to investigate trends in prevalence over time after controlling for sociodemographic, drug use, and sexual behavior variables. Between 1994 and 2004, anti-HBc prevalence declined from 43 to 15% (p < 0.001), anti-HCV prevalence fell from 68 to 32% (p < 0.001) and anti-HIV prevalence remained constant at 2-3%. Declines in anti-HBc and anti-HCV prevalence were observed within the individual studies, although not all these declines were statistically significant. The declines in anti-HBc and anti-HCV prevalence remained significant after control for confounding. Although we did not observe coincident declines in injection equipment sharing practices, there were increases in self-reported needle-exchange use, condom use, and hepatitis B vaccination. We conclude that there has been a substantial and sustained reduction in prevalence rates for HBV and HCV infection among young Seattle IDUs, while HIV rates have remained low and stable.

HIV among injection drug users in large US metropolitan areas, 1998

This article estimates HIV prevalence rates among injection drug users (IDUs) in 95 large US metropolitan areas to facilitate social and policy analyses of HIV epidemics. HIV prevalence rates among IDUs in these metropolitan areas were calculated by taking the mean of two estimates: (1) estimates based on regression adjustments to Centers for Disease Control and Prevention (CDC) Voluntary HIV Counseling and Testing data and (2) estimates based on the ratio of the number of injectors living with HIV to the number of injectors living in the metropolitan area. The validity of the resulting estimates was assessed. HIV prevalence rates varied from 2 to 28% (median 5.9%; interquartile range 4.0-10.2%). These HIV prevalence rates correlated with similar estimates calculated for 1992 and with two theoretically related phenomena: laws against over-the-counter purchase of syringes and income inequality. Despite limitations in the accuracy of these estimates, they can be used for structural analyses of the correlates, predictors and consequences of HIV prevalence rates among drug injectors in metropolitan areas and for assessing and targeting the service needs for drug injectors.

Risk factors for hepatitis B in an outbreak of hepatitis B and D among injection drug users

During January-April, 2000, 12 cases of acute hepatitis B were reported in Pierce County, Washington, compared with seven in all of 1999. Seven (58.3%) case patients were injection drug users (IDUs), three of whom were coinfected with hepatitis D virus (HDV) and died of fulminant hepatitis. Vaccination clinics were implemented at the local health department and needle exchange program to control the outbreak. We investigated this outbreak to determine risk factors for hepatitis B virus (HBV) transmission among IDUs. Hepatitis B cases were ascertained through routine surveillance and prevaccination testing at vaccination clinics. We conducted a case-control study comparing IDU case patients with HBV-susceptible IDUs identified at the vaccination clinics. Fifty-eight case patients were identified during January-December, 2000, 20 (34.5%) of whom were coinfected with HDV. Thirty-eight case patients (65.5%) reported current IDU. In the case-control study, the 17 case patients were more likely than the 141 controls to report having more than one sex partner [odds ratio (OR) =4.8, 95% confidence interval (CI) =1.5-15.0], injecting more than four times a day (OR = 4.5, 95% CI =1.2-15.6) and sharing drug cookers with more than two people (58.8% vs. 14.0%, OR =14.0, 95% CI =2.4-81.5). Results were similar after controlling for syringe sharing in multivariable analysis. IDUs should be vaccinated against hepatitis B and should be advised against sharing drug injection equipment.

Review of sampling hard-to-reach and hidden populations for HIV surveillance

Adequate surveillance of hard-to-reach and 'hidden' subpopulations is crucial to containing the HIV epidemic in low prevalence settings and in slowing the rate of transmission in high prevalence settings. For a variety of reasons, however, conventional facility and survey-based surveillance data collection strategies are ineffective for a number of key subpopulations, particularly those whose behaviors are illegal or illicit. This paper critically reviews alternative sampling strategies for undertaking behavioral or biological surveillance surveys of such groups. Non-probability sampling approaches such as facility-based sentinel surveillance and snowball sampling are the simplest to carry out, but are subject to a high risk of sampling/selection bias. Most of the probability sampling methods considered are limited in that they are adequate only under certain circumstances and for some groups. One relatively new method, respondent-driven sampling, an adaptation of chain-referral sampling, appears to be the most promising for general applications. However, as its applicability to HIV surveillance in resource-poor settings has yet to be established, further field trials are needed before a firm conclusion can be reached.

Updating the infection risk reduction hierarchy: preventing transition into injection

Current approaches to prevention of blood-borne infections in injection drug users include referral to drug abuse treatment, access to sterile syringes, bleach disinfection of injection equipment, and education about not sharing equipment. However, rates of some blood-borne infections (e.g., hepatitis C virus) remain elevated among injection drug users, especially early after initiation into injection drug use. With lower infection rates in noninjectors and transition into injection drug use occurring most commonly among these noninjectors, prevention of transition into injection drug use as an additional step to reduce risk for acquisition and transmission of blood-borne infections merits closer attention.

HIV risk behavior history of prison inmates in Hungary

As part of an intervention in correctional facilities in Hungary, we conducted research on AIDS-related attitudes and the HIV risk behavior history of 551 male and 81 female inmates to assess needs for and to tailor AIDS education programs. Although lifetime injection drug use was uncommon (8% of men, 3% of women), many Hungarian inmates had engaged in unprotected sex and had had high-risk sex partners: a quarter of men had primary partners who sold sex, about half of them had sex with female prostitutes, 13% of women had worked as prostitutes, and 9% of all inmates indicated having had sex in prison. Because many prison inmates may constitute a potential bridge population for the sexual transmission of HIV between the general population and high-risk populations, interventions among prison inmates may provide an opportunity to reach an at-risk population and to prevent the wider spread of sexually transmitted HIV.

Type and location of injection drug use-related soft tissue infections predict hospitalization

The prevalence of soft tissue infections (abscesses, cellulitides, infected ulcers) among injection drug users (IDUs) is estimated to be between 21% and 32%. Little is known regarding the health care utilization associated with these infections. This study describes IDUs seeking emergency department (ED) care for soft tissue infections, their inpatient health care utilization, including operating room procedures, and the types and locations of infections associated with increased inpatient health care utilization. This study used a medical record case series of all IDUs seeking initial care for soft tissue infections at an urban, public emergency department from November 1999 through April 2000. Initial care for IDU-related soft tissue infections was sought by 242 patients. Most were male (63.6%), Caucasian (69.4%) and without health insurance (52.0%), and most had abscesses (72.3%). All patients with only cellulitis had arm or leg infections, while most abscesses were arm, deltoid, or buttock infections (81.1%). Forty percent of the patients were hospitalized, and 44.3% of the hospitalizations were for 3 or more days. Patients with only cellulitis were more likely to be hospitalized compared to those with abscesses. Among those with abscesses, deltoid abscesses were 5.2 times more likely to receive an operating room procedure compared to other abscess locations. IDUs with cellulitis and deltoid abscesses commonly required inpatient care and operating room procedures. The morbidity associated with such infections and the intensive use of hospital services needed to treat these infections provide strong rationale for the development of preventive interventions and improved care for this neglected clinical problem.

Jails, prisons, and the health of urban populations: a review of the impact of the correctional system on community health

This review examined the interactions between the correctional system and the health of urban populations. Cities have more poor people, more people of color, and higher crime rates than suburban and rural areas; thus, urban populations are overrepresented in the nation's jails and prisons. As a result, US incarceration policies and programs have a disproportionate impact on urban communities, especially black and Latino ones. Health conditions that are overrepresented in incarcerated populations include substance abuse, human immunodeficiency virus (HIV) and other infectious diseases, perpetration and victimization by violence, mental illness, chronic disease, and reproductive health problems. Correctional systems have direct and indirect effects on health. Indirectly, they influence family structure, economic opportunities, political participation, and normative community values on sex, drugs, and violence. Current correctional policies also divert resources from other social needs. Correctional systems can have a direct effect on the health of urban populations by offering health care and health promotion in jails and prisons, by linking inmates to community services after release, and by assisting in the process of community reintegration. Specific recommendations for action and research to reduce the adverse health and social consequences of current incarceration policies are offered.