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Samo RN, Agha A, Shah SA, Altaf A, Memon A, Blevins M, Qian HZ, Vermund SH. Risk Factors for Loss to Follow-Up among People Who Inject Drugs in a Risk Reduction Program at Karachi, Pakistan. A Case-Cohort Study. PLoS One 2016; 11:e0147912. [PMID: 26840414 PMCID: PMC4739707 DOI: 10.1371/journal.pone.0147912] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 01/11/2016] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Retention of male people who inject drugs (PWIDs) is a major challenge for harm reduction programs that include sterile needle/syringe exchange in resource-limited settings like Pakistan. We assessed the risk factors for loss to follow-up among male PWIDs enrolled in a risk reduction program in Karachi, Pakistan. METHODS We conducted a prospective cohort study among 636 HIV-uninfected male PWIDs enrolled during March-June 2009 in a harm reduction program for the estimation of incidence rate. At 24 months post-enrollment, clients who had dropped out of the program were defined as lost to follow-up and included as cases for case-cohort study. RESULTS The median age of the participants was 29 years (interquartile range: 23-36). Active outreach accounted for 76% (483/636) of cohort recruits. Loss to follow-up at 24 months was 25.5% (162/636). In multivariable logistic regression, younger age (AOR: 0.97, 95% CI: 0.92-0.99, p = 0.028), clients from other provinces than Sindh (AOR: 1.49, 95% CI: 1.01-2.22, p = 0.046), having no formal education (AOR: 3.44, 95% CI: 2.35-4.90, p<0.001), a history of incarceration (AOR: 1.68, 95% CI: 1.14-2.46, p<0.008), and being homeless (AOR: 1.47, 95% CI: 1.00-2.19, p<0.049) were associated with loss to follow-up. CONCLUSIONS Our cohort retained 74.5% of male PWIDs in Karachi for 24 months. Its loss to follow up rate suggested substantial ongoing programmatic challenges. Programmatic enhancements are needed for the highest risk male PWIDs, i.e., younger men, men not from Sindh Province, men who are poorly educated, formerly incarcerated, and/or homeless.
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Affiliation(s)
- Rab Nawaz Samo
- Polio Eradication Initiative, World Health Organization, Larkana, Pakistan
- * E-mail:
| | - Ajmal Agha
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | | | - Arshad Altaf
- Bridge Consultants Foundation, Karachi, Pakistan
| | | | - Meridith Blevins
- Vanderbilt Institute for Global Health & Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Han-Zhu Qian
- Vanderbilt Institute for Global Health & Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Sten H. Vermund
- Vanderbilt Institute for Global Health & Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
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Chen W, Xia Y, Hong Y, Hall BJ, Ling L. Predictors of continued HIV-risk behaviors among drug users in methadone maintenance therapy program in China--a prospective study. Harm Reduct J 2013; 10:23. [PMID: 24107380 PMCID: PMC3853934 DOI: 10.1186/1477-7517-10-23] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Accepted: 09/30/2013] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND To examine the predictors of continued drug- and sex-related HIV-risk behaviors among drug users in methadone maintenance therapy (MMT) programs in China. METHODS We followed a sample of 5,035 drug users enrolled for the first time in MMT programs at baseline, 6 months, and 12 months utilizing a longitudinal prospective study design. Drug users' HIV-risk behaviors, MMT characteristics, and drug use, were assessed at all three waves using a structured interview and HIV/HCV status was assessed at baseline and 12-month follow-up using biological specimens. RESULTS The point prevalence of HIV was 7.6% and 78.4% for HCV at baseline. Results of generalized linear mixed logistic regression models revealed that HIV-positive MMT clients were more likely to engage in drug injection (aOR = 1.70) and syringe sharing (aOR = 4.73). HCV-positive clients were more likely to inject drugs (aOR = 2.58), share syringes (aOR = 1.97), and have multiple sexual partners (aOR = 1.47). Adherence to MMT was the most significant predictor of reduced HIV-risk behaviors. CONCLUSIONS Our data confirmed the positive effects of MMT on HIV prevention and underscored the urgency for programs to reduce HIV risk in HIV- and HCV-positive clients. There is a pressing need to strengthen existing counseling services for HIV-positive drug users to reduce their drug-related risk behaviors and to provide counseling for HCV-positive drug users. Further studies are needed to explore interventions to address high dropout rates and low adherence among MMT clients.
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Affiliation(s)
- Wen Chen
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, #74, Zhongshan Road II, Guangzhou 510080, P.R China
- Sun Yat-sen Center for Migrant Health Policy, #74, Zhongshan Road II, Guangzhou 510080, P.R China
| | - Yinghua Xia
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, #74, Zhongshan Road II, Guangzhou 510080, P.R China
- Sun Yat-sen Center for Migrant Health Policy, #74, Zhongshan Road II, Guangzhou 510080, P.R China
| | - Yan Hong
- Department of Social and Behavioral Health School of Rural Public Health Texas A&M University, TAMU 1266, College Station, TX 77843-1266, USA
| | - Brian J Hall
- Sun Yat-sen Center for Migrant Health Policy, #74, Zhongshan Road II, Guangzhou 510080, P.R China
- UNC-Project China, Guangdong STD Control Center, Guangzhou 510095, P.R China
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Hampton House, 8th Floor, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Li Ling
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, #74, Zhongshan Road II, Guangzhou 510080, P.R China
- Sun Yat-sen Center for Migrant Health Policy, #74, Zhongshan Road II, Guangzhou 510080, P.R China
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Meader N, Li R, Des Jarlais DC, Pilling S. Psychosocial interventions for reducing injection and sexual risk behaviour for preventing HIV in drug users. Cochrane Database Syst Rev 2010; 2010:CD007192. [PMID: 20091623 PMCID: PMC8060015 DOI: 10.1002/14651858.cd007192.pub2] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Drug users (including both injection drug users and crack cocaine users), are at high levels of risk for contracting HIV. Therefore it is important to reduce the injection and/or sexual risk behaviours of these groups both for the benefit of themselves and for society as a whole. OBJECTIVES To assess the efficacy of multi-session psychosocial interventions in comparison with standard education and minimal intervention controls for the reduction of injection and sexual risk behaviour. SEARCH STRATEGY Electronic searches were conducted of a number of bibliographic databases (including Cochrane Library, CINAHL, MEDLINE, PsycINFO). In addition, other methods of locating papers were employed including contacting various authors working in the field of HIV risk reduction and examining reference lists of applicable papers identified in the electronic search. SELECTION CRITERIA The inclusion criteria consisted of randomised and quazi-randomised trials assessing the efficacy of psychosocial interventions in the reduction of injection and sexual risk behaviour for people who misused opiates, cocaine, or a combination of these drugs. DATA COLLECTION AND ANALYSIS Two authors independently assessed the eligibility of studies identified by the search strategy, quality assessed these studies and extracted the data. A total of 35 trials met the eligibility criteria of the review providing data on 11,867 participants. MAIN RESULTS There were minimal differences identified between multi-session psychosocial interventions and standard educational interventions for both injection and sexual risk behaviour. Although it should be noted there were large pre-post changes for both groups suggesting both were effective in reducing risk behaviours. In addition, there was some evidence of benefit for multi-session psychosocial interventions when compared with minimal controls. Subgroup analyses suggest that people in formal treatment are likely to respond to multi-session psychosocial interventions. It also appears single-gender groups may be associated with greater benefit. AUTHORS' CONCLUSIONS There is limited support for the widespread use of formal multi-session psychosocial interventions for reducing injection and sexual risk behaviour. Brief standard education interventions appear to be a more cost-effective option. Further research is required to assess if there are particular groups of drug users more likely to respond to such interventions.
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Affiliation(s)
- Nicholas Meader
- Royal College of Psychiatrists Research and Training UnitNational Collaborating Centre for Mental HealthUniversity College, LondonStandon House, 4th Floor, 21 Mansell StreetLondonUKE1 8AA
| | - Ryan Li
- Royal College of Psychiatrists Research and Training UnitNational Collaborating Centre for Mental HealthUniversity College, LondonStandon House, 4th Floor, 21 Mansell StreetLondonUKE1 8AA
| | | | - Stephen Pilling
- National Collaborating Centre for Mental HealthCentre for Outcomes Research and EffectivenessSub‐Department of Clinical Health Psychology, 1‐19 Torrington PlaceLondonUKWC1E 7HB
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Todd CS, Abed AMS, Scott PT, Safi N, Earhart KC, Strathdee SA. A cross-sectional assessment of utilization of addiction treatment among injection drug users in Kabul, Afghanistan. Subst Use Misuse 2009; 44:416-30. [PMID: 18979391 PMCID: PMC7153687 DOI: 10.1080/10826080802347669] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The purpose of this study was to describe prior use of detoxification and addiction-treatment programs among injection drug users (IDUs) in Kabul, Afghanistan. From 2005-2006, IDUs (n = 464) recruited into this cross-sectional study completed an interviewer-administered questionnaire and whole blood rapid testing with fingerstick samples for HIV, syphilis, and hepatitis C antibody and B surface antigen testing. Participants were predominantly male (99.8%), Afghan (98.9%), and had little formal education. Correlates of detoxification and addiction treatment were identified with logistic regression. The majority (94.0%, n = 435) felt great/urgent need for treatment, of whom 56.3% (n = 245) reported inability to access treatment. Prior detoxification was associated with new needle use with each injection (AOR = 1.91, 95% CI: 1.12-3.26) and prior incarceration (AOR = 1.81, 95% CI: 1.04-3.13). The study's limitations are noted. Rapid scale-up and subsidy of needle and syringe programs and opioid agonist treatment is urgently needed in Kabul.
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Affiliation(s)
- Catherine S Todd
- Department of Family & Preventive Medicine, University of California, San Diego, California, USA.
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Ouellet LJ. Cautionary comments on an ethnographic tale gone wrong. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2008; 19:238-40; discussion 246-7. [PMID: 18434125 DOI: 10.1016/j.drugpo.2008.02.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2008] [Accepted: 02/29/2008] [Indexed: 10/22/2022]
Abstract
Greg Scott's paper, "'They got their program, and I got mine": a cautionary tale concerning the ethical implications of using respondent-driven sampling to study injection drug users' (Scott, 2008) is seriously flawed by (1) a near complete lack of context in assessing ethical implications of respondent-driven sampling, (2) ignoring the ethnographer's impact on what is observed, (3) a seemingly bedrock belief that the intimacy of ethnographic interviews produces truth, and (4) a misreading of power relationships. Some scenarios depicted in the paper appear inauthentic and the consistency of reported hustles strains credibility. The paper fails further by not situating respondent-driven sampling within the broader array of word-of-mouth recruiting methods and by ignoring advantages RDS may confer both in improving the quality of data and in anticipating the possibility of coercive recruiting.
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Baral S, Sherman SG, Millson P, Beyrer C. Vaccine immunogenicity in injecting drug users: a systematic review. THE LANCET. INFECTIOUS DISEASES 2007; 7:667-74. [PMID: 17897609 DOI: 10.1016/s1473-3099(07)70237-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Injection drug use is a prevalent global phenomenon; one not bound by a country's level of development or geographical location. Injection drug users (IDUs) are at high risk for a variety of parenterally acquired and transmitted infections. Licensed vaccines are available for some of these infectious diseases, such as tetanus, influenza, and hepatitis A and B viruses; however, there have been conflicting reports as to their immunogenicity in IDUs. We summarise the lessons learned from studies evaluating the immunogenicity of vaccination strategies in IDUs. A common theme across these diseases is that although there is a tendency towards decreased antibody responses after immunisation, there is no conclusive evidence linking these observations to a decrease in clinical protection from infection. There is a clear need for definitive studies of vaccination strategies in IDUs; however, a synthesis of the available published evidence suggests that immunisation does result in effective clinical protection from disease in this population. The inclusion of IDUs as a high-risk study population in future trials evaluating HIV and hepatitis C virus vaccines will help to assess the immunogenicity of candidate vaccines against parenteral exposure, and also to evaluate the efficacy of candidates as promising antigens become available.
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Affiliation(s)
- Stefan Baral
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD 21205, USA.
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Abstract
OBJECTIVE To examine whether needle exchange program (NEP) use by injecting drug users (IDUs) affects injection risk behaviors over time. METHODS Between 1997 and 2000, 901 IDUs in Chicago were recruited for a cohort study from a multisite NEP and an area with no NEP. Participants were interviewed and tested for HIV at baseline and 3 annual follow-ups. Non-NEP users received HIV prevention services consistent with the Indigenous Leader Outreach Model. Random-effect logistic models were used to compare 5 injection-related risk behaviors between NEP users and nonusers. RESULTS The 30-day prevalence of receptive needle sharing decreased from 27.6% at baseline to 10.0% at visit 4 in NEP users and from 47.1% to 20.0% in nonusers. Similar patterns were observed for lending used needles, and NEP users were less likely to reuse their own needles. In multivariate analyses, NEP use was significantly associated with reduced odds of greater than 60% for receptive needle sharing, 45% for lending used needles, and 30% for sharing other injection paraphernalia as well as approximately a 2-fold increase in the odds of always bleaching used needles. CONCLUSIONS NEP use facilitates long-term reductions in injection risk practices, and the reductions are in addition to the effects of a behavioral intervention alone.
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Affiliation(s)
- Dezheng Huo
- Department of Health Studies, University of Chicago, 5841 South Maryland Avenue, MC2007, Chicago, IL 60637, USA.
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Excler JL. AIDS vaccine efficacy trials: expand capacity and prioritize. 'Throughout Africa, Asia and Latin America state-of-the-art clinics and laboratories...exist where, 4 years ago, there were none'. Expert Rev Vaccines 2006; 5:167-70. [PMID: 16608417 DOI: 10.1586/14760584.5.2.167] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Sullivan LE, Metzger DS, Fudala PJ, Fiellin DA. Decreasing international HIV transmission: the role of expanding access to opioid agonist therapies for injection drug users. Addiction 2005; 100:150-8. [PMID: 15679744 DOI: 10.1111/j.1360-0443.2004.00963.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS To examine the role of expanded access to opioid agonist treatment as a means to decrease international HIV transmission. DESIGN Review of the English language literature via Medline. MEASUREMENTS Estimates of prevalence rates for injection drug use, HIV infection and treatment effect sizes for changes in opioid use, opioid injection, needle-sharing, injection-related HIV risk behavior and cost. FINDINGS An estimated 12.6 million injection drug users internationally accounted for 10% of the 4.2 million new HIV infections in 2003. Ninety-three of the 136 countries (68%) that report injection drug use identify HIV infection related to this behavior. Observational studies of methadone treatment demonstrate decreases in opioid use, opioid injection, needle-sharing and lower rates of HIV prevalence and incidence. The effectiveness of buprenorphine in demonstrating similar findings is expected, although implementations and research are still emerging. The cost-effectiveness of opioid agonist treatment has been established. The barriers to international adoption of opioid agonist treatment, despite the research evidence and international guidelines, are discussed. CONCLUSIONS Untreated opioid dependence leads to HIV transmission, on an international level. Opioid agonist treatments are associated with reductions in the frequency of opioid use, fewer injections and injection-related HIV risk behaviors and lower rates of HIV prevalence and incidence. Despite international recommendations, treatment for opioid-dependent injection drug users with methadone and buprenorphine is limited. Research, implementation efforts and political strategies to expand access to opioid agonist treatment are needed in order to combat the spread of HIV, especially in the developing world.
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Affiliation(s)
- Lynn E Sullivan
- Yale University School of Medicine, New Haven, CT 06520-8025, USA.
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