Predictors of Self-Reported HIV Infection Among Drug Injectors in Ukraine

'Yeah, they suck. It's like they don't care about our health.' Medical mistrust among Black women under community supervision in New York city

Black women in the USA experience some of the poorest health outcomes and this is especially true for those involved in the carceral system who are at elevated risks for HIV/STIs, reproductive health, and chronic diseases. This study aimed to investigate Black women's experience accessing healthcare services. We conducted semi-structured interviews with 43 women from Project EWORTH under community supervision in New York City. We analysed responses focusing on barriers to healthcare engagement. All interviews were recorded, and data analysis was conducted using NVivo. Themes influencing Black women's ability to engage with healthcare providers and systems included: 1) disclosed provider mistrust/judgement; 2) feeling disrespected by providers and the medical system; 3) mistrust of medical providers/system/hospital/government; 4) lack of health communication; 5) low health literacy; 6) provider gender preference. Findings highlight the need to improve trust and collaboration between healthcare providers and Black women. This study addresses the critical gap in understanding perceptions of discrimination, stigma, and barriers to attaining health care. Funders and accreditation agencies must hold providers and organisations accountable for acquiring and making available diversity, equity and inclusion training for providers, demonstrating increasingly equitable medical relationships through responsiveness to patient feedback, and increasing the number of Black providers.

Correlates of Unmet Need for Modern Contraception Among Reproductive-Aged Women Involved in New York City Criminal Legal Systems

Introduction

The population of women involved in criminal legal systems (WICL), a majority of whom are reproductive-aged, has risen steadily in the United States. They contend with numerous barriers to sexual and reproductive health services resulting in high rates of unmet need for contraception and unintended pregnancy.

Materials and Methods

This study included 132 non-pregnancy seeking reproductive-aged WICL enrolled in the baseline assessment of the HIV prevention intervention, "Women on the Road to Health" (WORTH). A multivariate generalized linear logistic regression model with robust estimation examined effects of past 6-month intimate partner violence (IPV; sexual and physical/injurious), past 3-month substance use (binge drinking, cannabis, other illegal drug use), and lifetime mental health diagnoses (anxiety, depression, bipolar disorder) on women's unmet need for modern contraception, adjusting for significant demographic and socioeconomic factors.

Results

Women who were younger in age (odds ratio [OR]: 0.74; 95% confidence interval [CI]: 0.63-0.88) and reporting lifetime diagnoses of anxiety disorders (OR: 13.64; 95% CI: 2.71-68.34) were significantly more likely to meet the criteria for unmet need for modern contraception. Women with a regular gynecologist (OR: 0.11; 95% CI: 0.01-0.86) reporting lifetime diagnoses of bipolar disorder and past 6-month sexual IPV histories (OR: 0.04; 95% CI: 0.002-0.86) were significantly less likely to meet the criteria for unmet need for modern contraception.

Conclusions

Distinct mental health diagnoses and experiences of IPV may uniquely impact unmet need for modern contraception among WICL. These findings emphasize the need for a more nuanced comprehension of these relationships to deliver comprehensive and holistic health services that address the intersecting needs of this population.

Trial registration: ClinicalTrials.gov NCT01784809. Registered 6 February 2013.

Associations between Cannabis Use and Sexual Risk Behavior among Women under Community Supervision: A Brief Report

OBJECTIVES

Cannabis use and sexual risk behavior have been found to co-occur, but more research on these associations is needed among criminal justice-involved women (i.e., courts, jails, or prisons).

METHODS

Regression models examined past 90-day cannabis use on unprotected sex, multiple sexual partners, and STIs/HIV among 306 women under NYC community supervision, adjusting for alcohol, other illicit substances, and socio-demographics.

RESULTS

Cannabis use, but not alcohol or other illicit substance use, was positively associated with having unprotected sex and multiple sexual partners, but not STIs or HIV.

CONCLUSIONS

Criminal justice-involved women may benefit from sexual risk reduction interventions incorporating cannabis content.

HIV, Drug Injection, and Harm Reduction Trends in Eastern Europe and Central Asia: Implications for International and Domestic Policy

PURPOSE OF REVIEW

Scaling up evidence-based HIV prevention strategies like opioid agonist therapies (OAT), syringe services programs (SSPs), and antiretroviral therapy (ART) to mitigate the harms of drug injection is crucial within Eastern Europe and Central Asia (EECA), the only region globally where HIV incidence and mortality are increasing.

RECENT FINDINGS

Though the proportion of new HIV cases directly attributable to drug injection has recently declined, it remains a critical driver of HIV, especially to sexual partners. Concurrently, scale-up of OAT, SSPs, and ART has remained low, contributing to a volatile HIV epidemic among people who inject drugs (PWID). Despite evidence that drug injection contributes to an evolving HIV epidemic in EECA, coverage of evidence-based harm reduction programs remains substantially below needed targets. Due to a combination of punitive drug laws, ideological resistance to OAT among clinicians and policymakers, and inadequate domestic and international funding, limited progress has been observed in increasing the availability of these programs.

Traumatic Events and HIV Sexual Risk Behaviors Among Migrant and Non-Migrant Male Market Workers in Central Asia

We examined potentially traumatic events (PTEs) and the relationship between PTEs and HIV risk behaviors among male market workers in Kazakhstan, comparing Kazakhstani to external migrants. Using respondent-driven sampling, participants were 1342 male marketplace workers in Almaty, Kazakhstan. Univariate, bivariate, and logistic regressions were conducted. We found high prevalence of PTEs among participants, and significant differences between PTEs and HIV risk by migrant status. Kazakhstanis reporting 1-2 or three-or-more traumatic events were more likely to report engaging in sex trading, compared to Kazakhstanis who reported no PTEs (OR = 3.65, CI 1.20-11.11, p = 0.022; OR = 8.17, 95% CI 2.66-25.09, p = 0.000, respectively). Kazakhstanis who reported three-or-more PTEs were more likely to report unprotected sex (OR = 2.17, CI 2.17-3.89, p = 0.009). Results did not support this relationship among external migrants. Findings underscore the need for attention on services that address trauma and HIV risk among this population and more research to understand differences by migrant status.

Social Support and HIV Risks Among Migrant and Non-Migrant Market Workers in Almaty, Kazakhstan

Migration processes are listed within the primary factors facilitating the heterosexual spread of HIV. The study examines the relationship between social support, sexual HIV risk behaviors and sexually transmitted infections (STIs) among 1342 male migrant and non-migrant market workers from Barakholka Market in Almaty, Kazakhstan.

RESULTS

(1) higher level of perceived social support [Enhancing Recovery in Coronary Heart Disease (ENRICHD) Social Support Instrument (ESSI score)] was associated with a lower likelihood of having sex with a female sex worker (FSW) [OR = 0.952 (0.927, 0.978) p < .001]; (2) higher availability of friends was associated with a higher likelihood of having STIs [OR = 1.244 (1.007, 1.537), p < .05]; (3) larger network size was associated with a higher likelihood of having STIs [OR = 1.201 (1.026, 1.407), p < .05]; (4) loneliness was associated with an increased likelihood of having unprotected sex with any female partner [RR = 1.102 (1.027, 1.182), p < .05]. Results suggest that social support factors should be considered as a component of HIV and STI prevention programs for male migrant workers from Central Asia in Kazakhstan.

Preventing blood-borne virus infection in people who inject drugs in the UK: systematic review, stakeholder interviews, psychosocial intervention development and feasibility randomised controlled trial

BACKGROUND

Opioid substitution therapy and needle exchanges have reduced blood-borne viruses (BBVs) among people who inject drugs (PWID). Some PWID continue to share injecting equipment.

OBJECTIVES

To develop an evidence-based psychosocial intervention to reduce BBV risk behaviours and increase transmission knowledge among PWID, and conduct a feasibility trial among PWID comparing the intervention with a control.

DESIGN

A pragmatic, two-armed randomised controlled, open feasibility trial. Service users were Steering Group members and co-developed the intervention. Peer educators co-delivered the intervention in London.

SETTING

NHS or third-sector drug treatment or needle exchanges in Glasgow, London, Wrexham and York, recruiting January and February 2016.

PARTICIPANTS

Current PWID, aged ≥ 18 years.

INTERVENTIONS

A remote, web-based computer randomisation system allocated participants to a three-session, manualised, psychosocial, gender-specific group intervention delivered by trained facilitators and BBV transmission information booklet plus treatment as usual (TAU) (intervention), or information booklet plus TAU (control).

MAIN OUTCOME MEASURES

Recruitment, retention and follow-up rates measured feasibility. Feedback questionnaires, focus groups with participants who attended at least one intervention session and facilitators assessed the intervention's acceptability.

RESULTS

A systematic review of what works to reduce BBV risk behaviours among PWID; in-depth interviews with PWID; and stakeholder and expert consultation informed the intervention. Sessions covered improving injecting technique and good vein care; planning for risky situations; and understanding BBV transmission. Fifty-six per cent (99/176) of eligible PWID were randomised: 52 to the intervention group and 47 to the control group. Only 24% (8/34) of male and 11% (2/18) of female participants attended all three intervention sessions. Overall, 50% (17/34) of men and 33% (6/18) of women randomised to the intervention group and 47% (14/30) of men and 53% (9/17) of women randomised to the control group were followed up 1 month post intervention. Variations were reported by location. The intervention was acceptable to both participants and facilitators. At 1 month post intervention, no increase in injecting in 'risky' sites (e.g. groin, neck) was reported by participants who attended at least one session. PWID who attended at least one session showed a trend towards greater reduction in injecting risk behaviours, a greater increase in withdrawal planning and were more confident about finding a vein. A mean cost of £58.17 per participant was calculated for those attending one session, £148.54 for those attending two sessions and £270.67 for those attending all three sessions, compared with £0.86 in the control group. Treatment costs across the centres vary as a result of the different levels of attendance, as total session costs are divided by attendees to obtain a cost per attendee. The economic analysis suggests that a cost-effectiveness study would be feasible given the response rates and completeness of data. However, we have identified aspects where the service use questionnaire could be abbreviated given the low numbers reported in several care domains. No adverse events were reported.

CONCLUSIONS

As only 19% of participants attended all three intervention sessions and 47% were followed up 1 month post intervention, a future definitive randomised controlled trial of the intervention is not feasible. Exposure to information on improving injecting techniques did not encourage riskier injecting practices or injecting frequency, and benefits were reported among attendees. The intervention has the potential to positively influence BBV prevention. Harm reduction services should ensure that the intervention content is routinely delivered to PWID to improve vein care and prevent BBVs.

FUTURE WORK

The intervention did not meet the complex needs of some PWID, more tailoring may be needed to reach PWID who are more frequent injectors, who are homeless and female.

LIMITATIONS

Intervention delivery proved more feasible in London than other locations. Non-attendance at the York trial site substantially influenced the results.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN66453696 and PROSPERO 014:CRD42014012969.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 72. See the NIHR Journals Library website for further project information.

Women in community corrections in New York City: HIV infection and risks

Although the incidence of HIV among women on probation, parole and alternatives to incarceration programs is significant to public health, drivers of this concentrated epidemic among women under community corrections remain understudied. This study examined prevalence of HIV and sexually transmitted infections and the associations between substance use, socio-demographic factors and the prevalence of biologically-confirmed HIV and other sexually transmitted infections among a sample of 337 substance-using women recruited from community correction sites in New York City. Prevalence of HIV was 13% and sexually transmitted infections was 26% ( Chlamydia, trachomatis and Neisseria gonorrhea). After adjusting for covariates, HIV-positive women were 1.42 times more likely to use crack/cocaine than HIV-negative women (95% CI = 1.05-1.92). HIV-positive women were 25% less likely than HIV-negative women to report any unprotected vaginal and anal sex with their main partner (95% CI = 0.57-0.99). They were 70% less likely than HIV-negative women to report unprotected vaginal sex with a non-paying casual partner (95% CI = 0.1-0.9) and 22% less likely to report unprotected vaginal sex across all partners (95% CI = 0.61-0.99). Community corrections settings may be optimal venues to launch HIV/sexually transmitted infections prevention that have potential to reach and engage an ever-growing number of substance-using women.

Depression Among People Who Inject Drugs and Their Intimate Partners in Kazakhstan

This paper examines individual, social, and structural factors associated with depression among 728 people who inject drugs (PWID) and their intimate partners in Kazakhstan, with separate multivariate models by gender. Depression scores were higher on average among participants of both genders who recently experienced sexual intimate partner violence, food insecurity, and who had lower levels of self-rated health. Among females, higher depression scores were associated with experiencing childhood sexual abuse, lower levels of social support, and not having children. Findings highlight a need to incorporate gender differences and factors associated with depression in designing mental health services for PWID in Kazakhstan.

HIV incidence among people who inject drugs (PWIDs) in Ukraine: results from a clustered randomised trial

BACKGROUND

HIV prevalence among people who inject drugs (PWID) in Ukraine is among the highest in the world. In this study, we aimed to assess whether a social network intervention was superior to HIV testing and counselling in affecting HIV incidence among PWID. Although this was not the primary aim of the study, it is associated with reducing drug and sex risk behaviours, which were primary aims.

METHODS

In this clustered randomised trial, PWID who were 16 years of age or older, had used self-reported drug injection in the past 30 days, were willing to be interviewed for about 1 hour and tested for HIV, were not too impaired to comprehend and provide informed consent, and, for this paper, who tested HIV negative at baseline were recruited from the streets by project outreach workers in three cities in southern and eastern Ukraine: Odessa, Donetsk, and Nikolayev. Index or peer leaders, along with two of their network members, were randomly assigned (1:1) by the study statistician to the testing and counselling block (control group) or the testing and counselling plus a social network intervention block (intervention group). No stratification or minimisation was done. Participants in the network intervention received five sessions to train their network members in risk reduction. Those participants assigned to the control group received no further intervention after counselling. The main outcome of this study was HIV seroconversion in the intent-to-treat population as estimated with Cox regression and incorporating a γ frailty term to account for clustering. This trial is registered with ClinicalTrial.gov, number NCT01159704.

FINDINGS

Between July 12, 2010, and Nov 23, 2012, 2304 PWIDs were recruited, 1200 of whom were HIV negative and are included in the present study. 589 index or peer leaders were randomly assigned to the control group and 611 were assigned to the intervention group. Of the 1200 HIV-negative participants, 1085 (90%) were retained at 12 months. In 553·0 person-years in the intervention group, 102 participants had seroconversion (incidence density 18·45 per 100 person-years; 95% CI 14·87-22·03); in 497·1 person-years in the control group 158 participants seroconverted (31·78 per 100 person-years; 26·83-36·74). This corresponded to a reduced hazard in the intervention group (hazard ratio 0·53, 95% CI 0·38-0·76, p=0·0003). No study-related adverse events were reported.

INTERPRETATION

These data provide strong support for integrating peer education into comprehensive HIV prevention programmes for PWID and suggest the value in developing and testing peer-led interventions to improve access and adherence to pre-exposure prophylaxis and antiretroviral therapy.

FUNDING

The National Institute on Drug Abuse.

The Silk Road Health Project: How Mobility and Migration Status Influence HIV Risks among Male Migrant Workers in Central Asia

OBJECTIVES

We examined whether mobility, migrant status, and risk environments are associated with sexually transmitted infections (STIs) and HIV risk behaviors (e.g. sex trading, multiple partners, and unprotected sex).

METHODS

We used Respondent Driven Sampling (RDS) to recruit external male migrant market vendors from Kyrgyzstan, Uzbekistan, and Tajikistan as well internal migrant and non-migrant market vendors from Kazakhstan. We conducted multivariate logistic regressions to examine the effects of mobility combined with the interaction between mobility and migration status on STIs and sexual risk behaviors, when controlling for risk environment characteristics.

RESULTS

Mobility was associated with increased risk for biologically-confirmed STIs, sex trading, and unprotected sex among non-migrants, but not among internal or external migrants. Condom use rates were low among all three groups, particularly external migrants. Risk environment factors of low-income status, debt, homelessness, and limited access to medical care were associated with unprotected sex among external migrants.

CONCLUSION

Study findings underscore the role mobility and risk environments play in shaping HIV/STI risks. They highlight the need to consider mobility in the context of migration status and other risk environment factors in developing effective prevention strategies for this population.

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.

Tuberculosis report among injection drug users and their partners in Kazakhstan

OBJECTIVES

Tuberculosis (TB) is a major threat to global public health. Kazakhstan has the second highest percentage of multidrug-resistant tuberculosis (MDR-TB) cases among incident tuberculosis cases in the world (WHO 2013). A high burden of MDR-TB suggests TB prevention, control, and treatment programs are failing. This study provides an epidemiologic profile of TB among injection drug users (IDUs), a high-risk and chronically underserved population, in Kazakhstan.

STUDY DESIGN

Cross-sectional study.

METHODS

The authors studied the characteristics and risk environment of IDUs with self-reported previous active TB and their primary sexual partners in Almaty, Kazakhstan. 728 individuals (364 couples) participated in a couple-based study in 2009.

RESULTS

16.75% of participants reported at least one positive TB test (x-ray) in their lifetime. In a multivariable logistic regression adjusting for couple-based sampling, persons with positive TB test were significantly more likely to be older (odds ratio (OR) 7.26, 95% confidence interval (CI): 1.73, 30.43), male (OR 5.53, 95% CI: 2.74, 11.16), have a shorter duration of injection drug use (OR 0.17, 95% CI: 0.04, 0.65), have received high social support from their significant other (OR 2.13, 95% CI: 1.03, 4.40) and more likely (non-significantly) to have been incarcerated (OR 7.03, 95% CI: 0.64, 77.30).

CONCLUSIONS

Older men with a history of incarceration and recent injection drug use were more likely to have positive TB test in Kazakhstan. Social network support, while potentially positive for many aspects of population health, may increase risk of TB among IDUs in this context. Public health policies that target high-risk populations and their at-risk networks may be necessary to stem the rise of MDR-TB in Central Asia.

Efficacy of a group-based multimedia HIV prevention intervention for drug-involved women under community supervision: project WORTH

IMPORTANCE

This study is designed to address the need for evidence-based HIV/STI prevention approaches for drug-involved women under criminal justice community supervision.

OBJECTIVE

We tested the efficacy of a group-based traditional and multimedia HIV/STI prevention intervention (Project WORTH: Women on the Road to Health) among drug-involved women under community supervision.

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTION

We randomized 306 women recruited from community supervision settings to receive either: (1) a four-session traditional group-based HIV/STI prevention intervention (traditional WORTH); (2) a four-session multimedia group-based HIV/STI prevention intervention that covered the same content as traditional WORTH but was delivered in a computerized format; or (3) a four-session group-based Wellness Promotion intervention that served as an attention control condition. The study examined whether the traditional or multimedia WORTH intervention was more efficacious in reducing risks when compared to Wellness Promotion; and whether multimedia WORTH was more efficacious in reducing risks when compared to traditional WORTH.

MAIN OUTCOMES AND MEASURES

Primary outcomes were assessed over the 12-month post-intervention period and included the number of unprotected sex acts, the proportion of protected sex acts, and consistent condom use. At baseline, 77% of participants reported unprotected vaginal or anal sex (n = 237) and 63% (n = 194) had multiple sex partners.

RESULTS

Women assigned to traditional or multimedia WORTH were significantly more likely than women assigned to the control condition to report an increase in the proportion of protected sex acts (β = 0.10; 95% CI = 0.02-0.18) and a decrease in the number of unprotected sex acts (IRR = 0.72; 95% CI = 0.57-0.90).

CONCLUSION AND RELEVANCE

The promising effects of traditional and multimedia WORTH on increasing condom use and high participation rates suggest that WORTH may be scaled up to redress the concentrated epidemics of HIV/STIs among drug-involved women in the criminal justice system.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01784809.

Effects of a couple-based intervention to reduce risks for HIV, HCV, and STIs among drug-involved heterosexual couples in Kazakhstan: a randomized controlled trial

OBJECTIVE

Project Renaissance is a randomized controlled trial of an HIV/hepatitis C virus (HCV)/sexually transmitted infection (STI) prevention intervention conducted in Almaty, Kazakhstan. We hypothesized that couples assigned to the intervention of interest will have lower incidence of HIV, HCV, STIs, rates of unprotected sex, and unsafe injection over the 12-month follow-up period compared with those assigned to an attention control arm.

DESIGN

A total of 300 couples (600 participants) where one or both partners reported injecting drugs in the past 90 days were randomized to 1 of 2 arms: (1) a 5-session HIV/HCV/STI prevention intervention (risk reduction: RR) or (2) a 5-session Wellness Promotion (WP) intervention.

RESULTS

Over the 12-month follow-up period, assignment to RR compared with WP significantly lowered the incidence of HCV infection by 69% [incidence rate ratios (IRR) = 0.31, 95% (CI) confidence interval: 0.10 to 0.90, P = 0.031]. Although differences were not statistically significant, RR participants had a lower incidence of HIV infection by 51% (IRR = 0.49, 95% CI: 0.16 to 1.48, P = 0.204) and any STI by 37% (IRR = 0.63, 95% CI: 0.21 to 1.93, P = 0.418) than WP participants. RR participants reported significantly fewer numbers of unprotected vaginal sex acts with their study partners (IRR = 0.58, 95% CI: 0.36 to 0.93, P = 0.024) and more consistent condom use (odds ratios = 2.30, 95% CI: 1.33 to 4.00, P = 0.003) over the entire follow-up period compared with WP participants.

CONCLUSIONS

Project Renaissance demonstrated a significant effect for biological and behavioral endpoints. Findings draw attention to an HIV/HCV/STI prevention intervention strategy that can be scaled up for drug-involved couples in harm reduction programs, drug treatment, and criminal justice settings.

Gender differences between predictors of HIV status among PWID in Ukraine

BACKGROUND

The HIV epidemic in Ukraine is among the largest in Europe. While traditionally the epidemic has spread through injection risk behavior, sexual transmission is becoming more common. Previous research has found that women in Ukraine have higher rates of HIV and engage in more HIV risk behavior than men. This study extended that work by identifying risk factors that differentially predict men and women's HIV status among people who inject drugs (PWID) in Ukraine.

METHODS

From July 2010 to July 2013, 2480 sexually active PWID with unknown HIV status were recruited from three cities in Ukraine through street outreach. The average age was 31 years old.

RESULTS

Women, who made up twenty-eight percent of the sample, had higher safe sex self-efficacy (p<.01) and HIV knowledge (p<.001) than men, but scored higher on both the risky injection (p<.001) and risky sex (p<.001) composite scores than men. Risky sex behaviors were associated with women's HIV status more than men's. We also report results identifying predictors of risky injection and sex behaviors.

CONCLUSIONS

Gender-specific interventions could address problem of HIV risk among women who inject drugs in a country with a growing HIV epidemic. Our findings suggest specific ways in which intervention efforts might focus on groups and individuals who are at the highest risk of contracting HIV (or who are already HIV positive) to halt the spread of HIV in Ukraine.

Methadone maintenance for HIV positive and HIV negative patients in Kyiv: acceptability and treatment response

BACKGROUND

With up to 40% of opioid injectors infected with HIV, Ukraine has one of the most concentrated HIV epidemics in the world, mainly due to unsterile injection practices and a historical absence of effective prevention services. Harm reduction programs, including syringe exchange and a small buprenorphine treatment program, were introduced in 2004 and methadone maintenance was allowed in 2007. Despite an initial expansion, by 2009, only 3221 injectors were receiving methadone treatment. A growing body of research on methadone maintenance has found high retention rates with reduction in opioid use and HIV risk behaviors. We report on the acceptability and initial outcome of methadone treatment as a function of HIV status, an issue that has not yet been reported for injectors in Ukraine.

METHODS

Longitudinal observational study of a 12-week course of methadone treatment in 25 HIV+ and 25 HIV- opioid addicted individuals recruited from a harm reduction program and the city AIDS Center. Drug use and HIV risk were assessed at baseline and weeks 4, 8, 12 and 20; all patients were offered continued methadone maintenance in the Kyiv city program at the end of 12 weeks.

RESULTS

Fifty-four individuals were asked if they were interested in the study and 50, demographically similar to other samples of opioid addicted Ukrainians, agreed to participate. Two died of non-study related causes; the other 48 completed assessments at weeks 4, 8 and 12, and 47 completed followups at week 20. Significant reductions were seen in use of heroin (p<0.0001), other opiates/analgesics (p<0.0001), and HIV risk behaviors (drug, sex, total; all p<0.0001). All 48 patients chose to continue methadone after the 12-weeks of study medication ended. Unlike most opioid treatment studies, sexual risk was somewhat higher than injecting risk at study intake.

CONCLUSIONS

Methadone maintenance was well accepted by HIV+ and HIV- opioid dependent individuals and has the potential for significant public health impact if made more widely available with sustained access and support.

Syringe access, syringe sharing, and police encounters among people who inject drugs in New York City: a community-level perspective

BACKGROUND

Injection drug user (IDU) experience and perceptions of police practices may alter syringe exchange program (SEP) use or influence risky behaviour. Previously, no community-level data had been collected to identify the prevalence or correlates of police encounters reported by IDUs in the United States.

METHODS

New York City IDUs recruited through respondent-driven sampling were asked about past-year police encounters and risk behaviours, as part of the National HIV Behavioural Surveillance study. Data were analysed using multiple logistic regression.

RESULTS

A majority (52%) of respondents (n=514) reported being stopped by police officers; 10% reported syringe confiscation. In multivariate modelling, IDUs reporting police stops were less likely to use SEPs consistently (adjusted odds ratio [AOR]=0.59; 95% confidence interval [CI]=0.40-0.89), and IDUs who had syringes confiscated may have been more likely to share syringes (AOR=1.76; 95% CI=0.90-3.44), though the finding did not reach statistical significance.

CONCLUSIONS

Findings suggest that police encounters may influence consistent SEP use. The frequency of IDU-police encounters highlights the importance of including contextual and structural measures in infectious disease risk surveillance, and the need to develop approaches harmonizing structural policing and public health.

Law enforcement practices associated with HIV infection among injection drug users in Odessa, Ukraine

Despite HIV prevention efforts over the past 10 years in Odessa, Ukraine, HIV rates among injection drug users (IDUs) remain high. We explored whether IDUs' experiences with the police and court system in Odessa were associated with HIV serostatus, after controlling for other factors. Qualitative methods, including semi-structured interviews with the police and members of court (N = 19), and focus groups with IDUs (N = 42), were employed to aid in developing a survey instrument for a larger quantitative phase and to assist in interpreting the findings from the quantitative phase, which included 200 participants who were interviewed and tested for HIV. Overall, 55 % tested positive for HIV. Negative experiences with the police were noted by 86 % and included having preloaded syringes taken (66 %), rushed injections due to fear of the police (57 %), police planting drugs (18 %), paying police to avoid arrest (61 %) and threatened by the police to inform on other IDUs (23 %). HIV positive participants were more likely than those who were negative to report these experiences. In a multiple logistic regression, the most significant correlate of HIV infection was rushed injections due to fear of the police. Police actions in Odessa may be contributing to the continued escalation of HIV among IDUs, underscoring the need for structural interventions.

HIV among injection drug users and their intimate partners in Almaty, Kazakhstan

This paper examines prevalence rates of HIV, HCV, and syphilis among a sample of injecting drug users (IDUs) and their heterosexual intimate partners (N = 728) from Almaty, Kazakhstan. The study uses baseline data from Project Renaissance, a couple-based HIV prevention intervention delivered to a couple where one or both partners are IDUs. HIV prevalence rates among female and male IDUs were 28 %. Among the full sample, 75 % had HCV, and 13 % tested positive for the syphilis antibody test. Only 10 % of the sample ever visited a needle exchange program. One-fourth (25.3 %) had never been tested for HIV. One-quarter of those who tested positive were unaware of their status. Being HIV positive was associated with a history of incarceration, being an IDU, and having access to needle exchange programs. The findings call for increasing efforts to improve access to HIV testing, prevention, treatment, and care for IDUs in Almaty, Kazakhstan.

Frequency of alcohol use in adolescence as a marker for subsequent sexual risk behavior in adulthood

PURPOSE

Although a number of studies have demonstrated an association between alcohol use frequency and sexual risk behavior, few have used longitudinal data. This study examined alcohol use frequency in adolescence as a predictor of HIV sexual risk behavior in adulthood.

METHODS

We collected data among 1,368 participants in Colorado. During adolescence (time 1), respondents were asked about the frequency of using alcohol during the previous 12 months. In adulthood (time 2), the same respondents were asked about their sexual risk behavior during the previous 12 months. Sexual risk behavior items were used to construct an index, which was categorized to indicate low-, medium-, and high-risk study participants. The relationship between alcohol use patterns and risky sexual behavior was modeled using ordinal regression.

RESULTS

Compared with individuals who drank no alcohol in the past 12 months at time 1, the odds of being in a higher risk group of sexual behavior as opposed to a lower one at time 2 were 1.56 (95% CI, 1.04-2.35) among those who drank 6-19 times. Similarly, the odds of being in a higher risk group relative to a lower one among those who drank ≥20 times or were 1.78 (95% CI, 1.05-3.02).

CONCLUSIONS

Alcohol use patterns in adolescence may be useful markers for programs that aim to prevent risky sexual behavior. Based on alcohol intake patterns, it may be possible to identify frequent alcohol users that need to be targeted with appropriate alcohol use and HIV risk reduction messages.

Characteristics of HIV-infected women and factors associated with HCV seropositivity in the Republic of Georgia

BACKGROUND

The aim of this study was to describe the extent of the HIV epidemic among women in the Republic of Georgia and to identify factors associated with HCV co-infection in this population.

FINDINGS

All women aged ≥18 years who were diagnosed with HIV between 1989 and 2006 were identified through the National HIV/AIDS surveillance database. Medical records were reviewed for demographic characteristics, risk factors and HCV serostatus. A total of 249 women were identified. Only 4% declared injection drug use (IDU); sex work was reported by 9%. Substantial risk factors were identified among the women's sexual partners, nearly 69% of whom were IDUs, 84% were HIV positive and 66% HCV positive. Seventeen percent of women were seropositive for HCV. Factors significantly associated with HCV seropositivity in bivariate analyses among non-IDU women were partner IDU+ [Prevalence ratio (PR): 4.5 (95% CI: 1.4, 14.2)], and partner HCV+ [PR: 7.2 (95% CI: 1.8, 29.5)].

CONCLUSIONS

The HIV epidemic in the Republic of Georgia is closely tied to the IDU community. Evidence-based interventions targeting IDU and partners of IDU are urgently required to halt the spread of the HIV epidemic in the country.

Effectiveness and cost effectiveness of expanding harm reduction and antiretroviral therapy in a mixed HIV epidemic: a modeling analysis for Ukraine

BACKGROUND

Injection drug use (IDU) and heterosexual virus transmission both contribute to the growing mixed HIV epidemics in Eastern Europe and Central Asia. In Ukraine-chosen in this study as a representative country-IDU-related risk behaviors cause half of new infections, but few injection drug users (IDUs) receive methadone substitution therapy. Only 10% of eligible individuals receive antiretroviral therapy (ART). The appropriate resource allocation between these programs has not been studied. We estimated the effectiveness and cost-effectiveness of strategies for expanding methadone substitution therapy programs and ART in mixed HIV epidemics, using Ukraine as a case study.

METHODS AND FINDINGS

We developed a dynamic compartmental model of the HIV epidemic in a population of non-IDUs, IDUs using opiates, and IDUs on methadone substitution therapy, stratified by HIV status, and populated it with data from the Ukraine. We considered interventions expanding methadone substitution therapy, increasing access to ART, or both. We measured health care costs, quality-adjusted life years (QALYs), HIV prevalence, infections averted, and incremental cost-effectiveness. Without incremental interventions, HIV prevalence reached 67.2% (IDUs) and 0.88% (non-IDUs) after 20 years. Offering methadone substitution therapy to 25% of IDUs reduced prevalence most effectively (to 53.1% IDUs, 0.80% non-IDUs), and was most cost-effective, averting 4,700 infections and adding 76,000 QALYs compared with no intervention at US$530/QALY gained. Expanding both ART (80% coverage of those eligible for ART according to WHO criteria) and methadone substitution therapy (25% coverage) was the next most cost-effective strategy, adding 105,000 QALYs at US$1,120/QALY gained versus the methadone substitution therapy-only strategy and averting 8,300 infections versus no intervention. Expanding only ART (80% coverage) added 38,000 QALYs at US$2,240/QALY gained versus the methadone substitution therapy-only strategy, and averted 4,080 infections versus no intervention. Offering ART to 80% of non-IDUs eligible for treatment by WHO criteria, but only 10% of IDUs, averted only 1,800 infections versus no intervention and was not cost effective.

CONCLUSIONS

Methadone substitution therapy is a highly cost-effective option for the growing mixed HIV epidemic in Ukraine. A strategy that expands both methadone substitution therapy and ART to high levels is the most effective intervention, and is very cost effective by WHO criteria. When expanding ART, access to methadone substitution therapy provides additional benefit in infections averted. Our findings are potentially relevant to other settings with mixed HIV epidemics. Please see later in the article for the Editors' Summary.

Individual and network interventions with injection drug users in 5 Ukraine cities

OBJECTIVES

We evaluated the effects of an individual intervention versus a network intervention on HIV-related injection and sexual risk behaviors among street-recruited opiate injection drug users in 5 Ukraine cities.

METHODS

Between 2004 and 2006, 722 opiate injection drug users were recruited to participate in interventions that were either individually based or based on a social network model in which peer educators intervened with their network members. Audio computer-assisted self-interview techniques were used to interview participants at baseline and follow-up.

RESULTS

Multiple logistic analyses controlling for baseline injection and sexual risks revealed that both peer educators and network members in the network intervention reduced injection-related risk behaviors significantly more than did those in the individually based intervention and that peer educators increased condom use significantly more than did those in the individual intervention. Individual intervention participants, however, showed significantly greater improvements than did network members with respect to reductions in sexual risk behaviors.

CONCLUSIONS

Social network interventions may be more effective than individually based interventions in changing injection risk behaviors among both peer educators and network members. The effectiveness of network interventions in changing sexual risk behaviors is less clear, probably owing to network composition and inhibitions regarding discussing sexual risk behaviors.

Correlates of HIV risk among injecting drug users in sixteen Ukrainian cities

We present findings from a HIV survey using respondent driven sampling among 3,711 injecting drug users (IDUs) in 16 cities in Ukraine in 2008. Eligible participants were males and females who injected drugs in the past 1 month, ≥ 16 years and lived/worked in their respective interview area. The impact of injecting and sexual risk behaviors on HIV-infection were analyzed using four logistic models. Overall HIV prevalence was 32%. In the sexual risk model, paying for sex in the past 3 months and condom use during last sex increased the odds of HIV infection. Being female, having greater than 3 years of injection drug use, always sharing equipment and using alcohol with drugs in the past month remained significant in all four models. These findings indicate the urgent need to scale up peer education, needle exchange and methadone substitution programs for IDUs with specific programs targeting the needs of female injectors.

HIV and risk environment for injecting drug users: the past, present, and future

We systematically reviewed reports about determinants of HIV infection in injecting drug users from 2000 to 2009, classifying findings by type of environmental influence. We then modelled changes in risk environments in regions with severe HIV epidemics associated with injecting drug use. Of 94 studies identified, 25 intentionally examined risk environments. Modelling of HIV epidemics showed substantial heterogeneity in the number of HIV infections that are attributed to injecting drug use and unprotected sex. We estimate that, during 2010-15, HIV prevalence could be reduced by 41% in Odessa (Ukraine), 43% in Karachi (Pakistan), and 30% in Nairobi (Kenya) through a 60% reduction of the unmet need of programmes for opioid substitution, needle exchange, and antiretroviral therapy. Mitigation of patient transition to injecting drugs from non-injecting forms could avert a 98% increase in HIV infections in Karachi; whereas elimination of laws prohibiting opioid substitution with concomitant scale-up could prevent 14% of HIV infections in Nairobi. Optimisation of effectiveness and coverage of interventions is crucial for regions with rapidly growing epidemics. Delineation of environmental risk factors provides a crucial insight into HIV prevention. Evidence-informed, rights-based, combination interventions protecting IDUs' access to HIV prevention and treatment could substantially curtail HIV epidemics.

Liquid Drugs and High Dead Space Syringes May Keep HIV and HCV Prevalence High – A Comparison of Hungary and Lithuania

Despitevery similar political, drug policy and HIV prevention backgrounds, HIV and HCV prevalence is considerably different in Hungary (low HIV and moderate HCV prevalence) and Lithuania (high HCV and moderate HIV prevalence). Wecompared the drug use profile of Hungarian (n = 215) and Lithuanian (n = 300) injecting drug users (IDUs). Overall, compared with IDUs in Hungary, IDUs in Lithuania often injected opiates purchased in liquid form ('shirka'), used and shared 2-piece syringes (vs. 1-piece syringes) disproportionately more often, were less likely to acquire their syringes from legal sources and had significantly more experience with injected and less experience with non-injected drugs. It may not be liquid drugs per se that contribute to a higher prevalence of HCV and/or HIV, but it is probably factors associated with the injecting of liquid drugs, such as the wide-spread use and sharing of potentially contaminated 2-piece syringes acquired often from non-legal sources, and syringe-mediated drug sharing with 2-piece syringes. Scaling up substitution therapy, especially heroin replacement, combined with reducing the supply of liquid drugs may decrease the prevalence of high-risk injecting behaviours related to the injecting of liquid drugs and drug injecting-related infections among IDUs in Lithuania.

Interventions with injection drug users in Ukraine

AIMS

To assess the effectiveness of a brief human immunodeficiency virus (HIV) testing and counseling intervention compared to a more time-consuming and expensive street-based intervention with injection drug users (IDUs).

DESIGN

Cross-over experimental design in which 900 IDUs were recruited, followed by a 'wash-out' period with no recruitment, a reversal of intervention assignment areas and an additional recruitment of 900 IDUs with baseline and 6-month follow-up assessments.

SETTING

Kiev, Odessa and Makeevka/Donesk Ukraine.

PARTICIPANTS

A total of 1798 IDUs.

MEASUREMENTS

HIV testing and audio computer-assisted self-interview (ACASI) data on socio-demographics, drug use and injection and sex-related risk behaviors.

FINDINGS

Participants in both conditions reduced their injection and sex risks significantly; however, there was little difference in outcomes between conditions. IDUs who knew they were HIV-infected at baseline were significantly more likely to practice safe sex than those unaware or HIV-negative; those who first learned that they were infected at baseline changed their safe sex practices significantly more than those who already knew that they were infected at baseline and those who were HIV-negative. Younger IDUs and those injecting for a shorter period of time reported higher injection and sex risk behaviors following interventions.

CONCLUSIONS

Awareness of HIV infection by street-recruited drug injectors is associated with reduced sex risks. Additional interventions are required for younger IDUs and those injecting for shorter periods of time.

Needle exchange and sexual risk behaviors among a cohort of injection drug users in Chicago, Illinois

OBJECTIVE

To examine the impact of a needle exchange program (NEP) on sexual risk behaviors of injecting drug users (IDUs).

METHODS

: Between 1997 and 2000, 889 IDUs in Chicago were recruited from NEPs and an area with no NEP into a cohort study. They were interviewed and tested for HIV at baseline and 3 annual follow-up visits. Random-effect logistic models were used to compare NEP users and nonusers regarding the number of sex partners, number of unprotected sex acts, and frequency of condom use.

RESULTS

Compared to NEP nonusers, NEP users had a similar number of sex partners over time, but had 49% higher odds of using condoms with their main partners (P = 0.047). At baseline, there was no difference between NEP users and nonusers in episodes of vaginal intercourse, but over time the odds of having a higher number of unprotected instances of vaginal intercourse were reduced by 26% per year for NEP users but only 10% per year for nonusers (P = 0.02).

CONCLUSION

This study suggests that NEP participation may help reduce the absolute risk of HIV sexual transmission.

Stimulant injectors in Ukraine: the next wave of the epidemic?

This study was designed to assess differences in drug and sex-related risk behaviors between injectors of opiates only, opiate/sedative mix only and stimulants only. Participants were current out-of-treatment injection drug users (IDUs), unaware of their HIV status, recruited through street outreach in Kiev, Odessa and Makeevka/Donetsk, Ukraine. Overall, 22% tested positive for HIV, including 39% among opiate/sedative injectors, 19% among opiate injectors and 17% among stimulant injectors. Despite these differences, stimulant injectors were at higher risk than other IDUs in sharing a used needle/syringe, always injecting with others, injecting a drug solution drawn from a common container, having an IDU sex partner, not using condoms during vaginal or anal sex and on composite measures of injection and sex risks. After controlling for age differences, stimulant injectors remained at higher risk in their needle and sex risk behaviors. Without intervention, it is likely that HIV will increase among stimulant injectors.

Injecting equipment sharing and perception of HIV and hepatitis risk among injecting drug users in Budapest

In central European states, rates of HIV among injection drug users (IDUs) have been low although Hepatitis C (HCV) infection is widespread. The goal of our study was to assess HIV infection, risk perceptions and injecting equipment sharing among IDUs in Budapest, Hungary. Altogether 150 IDUs were interviewed (121 structured interviews between 1999 and 2000 and 29 ethnographic interviews between 2003 and 2004). The majority of them injected heroin (52% and 79%) and many injected amphetamines (51% and 35%). One person tested positive for HIV. Two thirds (68%) shared injecting equipment (syringes, cookers and filters). Some participants said they shared syringes because they were not carrying them for fear of police harassment and that they reused filters as a backup drug supply. In multivariate analysis, sharing of injecting equipment was associated with higher perceived susceptibility to HIV/AIDS, lower self-efficacy for sterile equipment use, higher motivation to comply with peer pressure to use dirty injecting equipment and with having a criminal record. The high levels of injecting risk-behaviors found in this study are a cause for serious concern. Interventions for HIV-prevention need to address not only sharing syringes but also sharing and reusing of other injecting equipment and drug filters.

The mother-to-child HIV transmission epidemic in Europe: evolving in the East and established in the West

OBJECTIVES

To carry out an epidemiological analysis of the emerging epidemic in an Eastern European country and to compare the approach to prevention of mother-to-child transmission (MTCT) with that in Western Europe.

DESIGN

Prospective cohort study established in 1985 in Western Europe and extended to Ukraine in 2000.

METHODS

Data on 5967 HIV-infected pregnant women and their infants (1251 from Ukraine and 4716 from Western/Central Europe) was analysed. Factors associated with transmission were identified with logistic regression.

RESULTS

HIV-infection among pregnant women enrolled in Western European centres has shifted from being largely injecting drug use (IDU)-related to heterosexually-acquired; in Ukraine IDU also gradually declined with women increasingly identified without specific risk factors. In Ukraine in 2000-2004 most (80%) women received single dose nevirapine (sdNVP) and/or short-course zidovudine prophylaxis [MTCT rate 4.2%; 95% confidence interval (CI), 1.8-8.0 for sdNVP with short-course zidovudine]; 2% (n = 27) received antenatal HAART and 33% (n = 418) delivered by elective caesarean section (CS); in Western European centres 72% of women received HAART (MTCT rate 1.0%; 95% CI, 0.4-1.9) and 66% delivered by elective CS during the same period.

CONCLUSIONS

Our findings indicate distinct differences in the epidemics in pregnant women across Europe. The evolution of the MTCT epidemic in Ukraine does not appear to be following the same pattern as that in Western Europe in the 1980s and 1990s. Although uptake of preventive MTCT prophylaxis has been rapid in both Western Europe and Ukraine, substantial challenges remain in the more resource-constrained setting in Eastern Europe.

Strong HIV and hepatitis disclosure norms and frequent risk behaviors among Hungarian drug injectors

Ethnographic interviews and focus groups were conducted between May 2003 and January 2004 among injection drug users (IDUs; n=29) in Budapest, Hungary, to assess knowledge related to HIV, hepatitis B (HBV), and hepatitis C (HCV) and norms, attitudes, and behaviors. Participants perceived themselves at low risk for infection with HIV but at high risk for hepatitis through injection but not sexual exposure. They reported strong disclosure norms for HIV and hepatitis infections, while sexual and injection risk behaviors were influenced by trust about partners' self-report of infection status. Injection networks were small, with infrequent syringe sharing among a few close friends. Cookers and drug filters often were shared, and filters were reused as a backup drug supply. Most sexual relationships were monogamous, and condoms were used rarely. Although participant norms supported HIV/HBV/HCV testing, the lack of available behaviors with injection and sex partners who are close friends. Network interventions among IDUs in Hungary should build on disclosure norms and trust to reduce injection and sex risk. Testing services should be expanded and access increased so that IDUs can act on and reinforce their norms for testing.

Predictors of risky needle use following interventions with injection drug users in Ukraine

This study was designed to assess factors associated with change in needle-related risk behaviors as well as predictors of continued high-risk behavior following intervention efforts among injection drug users (IDUs) in Ukraine. In each of three locations--Kiev, Odessa, and Makeevka/Donesk--100 IDUs were recruited using modified targeted sampling methods. Following a baseline interview, participants were offered free HIV testing and, over the course of the next 5 months, individualized interventions focusing on reducing HIV-related risk behaviors. Former IDUs conducted interventions through street outreach. The intervention model was based on the Indigenous Leader Outreach Model (ILOM) and stressed assessing an individual's unique risks and developing strategies by which to minimize those risks. Follow-up assessments showed significant reductions in every risk behavior measured. Following the intervention, however, approximately one of four participants reported front- or backloading, using drugs obtained from a common container or injecting with a used needle/syringe. Although the sample as a whole averaged only 28 years of age, those who were younger were significantly more likely to engage in each of these behaviors than those who were older. In light of the overall young age of the Ukrainian IDUs observed in this study, the consistent finding that younger IDUs were at highest risk foreshadows a worsening HIV epidemic in Ukraine.

Marginalized and socially integrated groups of IDUs in Hungary: potential bridges of HIV infection

The discrepancy in HIV rates among Eastern and central European injecting drug users (IDUs) suggests that, in addition to risk behaviors, social contact patterns also play an important role. We identify two groups of IDUs in Budapest, Hungary, marginalized IDUs (M-IDUs) and socially integrated IDUs (SI-IDUs) and compare their HIV/hepatitis B virus (HBV)/hepatitis C virus (HCV) social and risk network characteristics, risk behaviors, and travel patterns. Between May 2003 and January 2004, 29 nontreatment-recruited young IDUs in Budapest participated in ethnographic interviews and focus groups. The mean age was 23.6 years (SD=3.6); eight were female and two Roma/Gypsy. Most injected heroin (n=23) and/or amphetamines (n=10) in the past 30 days. M-IDUs had no legal employment, injected heroin and sniffed glue, and stopped using drugs in treatment/prison. SI-IDUs had regular jobs or were students, injected heroin and sniffed cocaine, and stopped using drugs before exams/tests. Both M-IDUs and SI-IDUs shared injecting equipment on occasion and used condoms rarely. M-IDUs had a large social network of "buddies" and a small risk network of "friends". SI-IDUs had two separate large social networks of "buddies": a M-IDU and a non-IDU network; and a small risk network of "friends". Both groups reported monogamous sexual relationships. M-IDUs traveled within Hungary, whereas SI-IDUs traveled to Western Europe. If an HIV epidemic among IDUs in Hungary is not prevented, SI-IDUs may form a potential "bridge" of HIV infection between high-risk IDU populations and the low-risk general population, whereas M-IDUs may become cores of infection. Different approaches may be appropriate for M-IDUs and SI-IDUs to prevent HIV.

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.