Progress in HIV reduction and prevention among injection and noninjection drug users

Injection and Non-Injection Drug Use Among Adults with Diagnosed HIV in the United States, 2015-2018

Understanding behavioral characteristics and health outcomes of people with HIV (PWH) who inject drugs and PWH who use drugs, but do not inject, can help inform public health interventions and improve HIV clinical outcomes. However, recent, nationally representative estimates are lacking. We used 2015-2018 Medical Monitoring Project data to examine health outcome differences among adults with diagnosed HIV who injected drugs or who only used non-injection drugs in the past year. Data were obtained from participant interviews and medical record abstraction. We reported weighted percentages and prevalence ratios with predicted marginal means to assess differences between groups (P < 0.05). PWH who injected drugs were more likely to engage in high-risk sex; experience depression and anxiety symptoms, homelessness, and incarceration; and have lower levels of care retention, antiretroviral therapy adherence, and viral suppression. Tailored, comprehensive interventions are critical for improving outcomes among PWH who use drugs, particularly among those who inject drugs.

Translation of basic research in cognitive science to HIV-risk: a randomized controlled trial

Many people enrolled in drug diversion programs are not receiving evidence-based prevention for HIV or hepatitis. This study translated basic research from cognitive science to increase screening for infection and condom use in this population. A parallel three-condition randomized trial was conducted in a drug diversion sample (N = 358), comparing a memory practice condition with two active control conditions. Outcomes were condom use frequency and testing for infection (hepatitis B/C, HIV). At 3-month follow-up, participants in the memory practice condition were at least twice as likely (OR = 2.10 or greater, p < .01) to self-report testing compared to those in the control conditions and also reported more frequent condom use compared to a health education condition [B = .37, t(1) = 2.02, p = .02]. Basic research on memory can be effectively translated to brief interventions on infection screening and risk prevention in existing drug diversion programs.

Associating conditional cash transfer to universal access to treatment could be the solution to the HCV epidemic among drug users (DUs)

Background

To understand the limits of HCV screening programs to reach all drug users (DUs).

Method

The association of the recruitment of a representative sample of a population of DUs in a specific area with the use of a questionnaire that included 250 items allowed the use of uni- and multifactorial analysis to explore the relationship between HCV screening and dimensions until now restricted to qualitative studies.

Results

We recruited, in less than 2 months, 327 DUs representing about 6% of the total population of DUs. They belonged to a single community whose drug use was the only common characteristic. While almost all DUs (92.6%) who had access to care providers had been screened, this proportion was much lower in out-of-care settings (64%). HCV prevalence among those who had performed a test was low (22.8%). For DUs, the life experience of hepatitis C has not changed in the last 10 years. Screening, studied for the first time according to this life experience, was not influenced by a rational knowledge of the risk taken or the knowledge of treatment efficacy, showing a gap between DUs’ representations and medical recommendations which explains the low level of active screening. Police crackdown on injections, disrupting the previous illusion of safe practices, was the only prior history leading to active screenings. Screenings were related to an access to care providers. GPs held a preponderant position as a source of information and care by being able to give appropriate answers regarding hepatitis C and prescribing opioid substitution treatments (OST). If 48 % of DUs screened positive for HCV had been treated, half of them had been prescribed before 2006.

Conclusion

While hepatitis has become a major issue for society and, consequently, for services for DUs (SDUs) and GPs, it is not the case for DUs. A widespread screening, even in a city where the offer of care is diversified and free, seems unlikely to reach a universal HCV screening over a short time. The model of respondent-driven sampling recruitment could be a new approach to conditional cash transfer, recruiting and treating DUs who remain outside the reach of care providers, a prerequisite for the universal access to HCV treatments to impact the HCV epidemic.

Exchange Sex and HIV Infection Among Women Who Inject Drugs-20 US Cities, 2009

BACKGROUND

Women who inject drugs and who also exchange sex are at increased risk for HIV infection, but data on this population in the United States remain sparse.

METHODS

This study assessed the prevalence of exchanging sex for money or drugs among women who inject drugs using data from the 2009 US National HIV Behavioral Surveillance (NHBS) system. Prevalence of being HIV-positive (testing positive in NHBS), HIV-positive-unaware (reporting being HIV-negative or unknown status but testing positive in NHBS), and risk behaviors and use of services were compared between women who did and did not exchange sex. The association between exchange sex and being HIV-positive-unaware of the infection was examined using multivariate Poisson models with robust standard errors.

RESULTS

Among 2305 women who inject drugs, 39% reported receiving things like money or drugs from ≥1 male partners in exchange for oral, vaginal, or anal sex in the previous 12 months. Women who exchanged sex were more likely to be unemployed, homeless, lack health insurance, have multiple condomless vaginal or anal sex partners, and receptively share syringes. In multivariate analysis, exchange sex was associated with being HIV-positive-unaware (adjusted prevalence ratio 1.97, 95% confidence intervals: 1.31 to 2.97).

CONCLUSIONS

Prevalence of exchange sex was high in this population. Women who exchange sex were more likely to be socially disadvantaged, report sexual and injection risk, and be HIV-positive-unaware. They represent an important group to reach with HIV prevention, testing, and care services.

Predictive utility and measurement properties of the Strength of Implementation Intentions Scale (SIIS) for condom use

BACKGROUND

Implementation intentions are situation-linked action plans that increase health behaviors such as condom use. Few studies have measured the strength of implementation intentions, especially regarding condom use. Non-injection drug users are at high risk for HIV due to risky sexual practices. Substance use before sex may increase risky sexual behaviors, and implementation intentions are a promising, practical route for HIV prevention.

PURPOSE

This prospective study assessed the measurement properties of the newly developed Strength of Implementation Intentions Scale (SIIS) for condom use and investigated whether the SIIS predicted condom use one-year later. The study evaluated whether behavioral intentions and alcohol or methamphetamine use before sex modified the relationship between the SIIS and condom use.

METHODS

Participants were 590 non-injection drug users convicted of nonviolent drug offenses in court-mandated outpatient drug diversion programs. They completed self-directed computer assessments at baseline and at one-year follow-up. Measures included demographics, behavioral intentions to use condoms, the SIIS for condom use, alcohol and methamphetamine use before or during sex, and condom use. Psychometric properties, direct, and interaction effects of the SIIS were evaluated using structural equation modeling and general linear regressions.

RESULTS

The SIIS, behavioral intentions, and condom use were positively correlated and there was discriminant validity between all three constructs. In addition, the SIIS predicted condom use one-year later in this high-risk population. No significant interactions were detected.

CONCLUSIONS

The SIIS is predictive of condom use behavior, is psychometrically sound and distinct from behavioral intentions, and can be incorporated into HIV prevention interventions and used as a mediator variable. In addition, it can be used as an outcome measure where a follow-up is not feasible. The SIIS can also be tailored for additional HIV-related behaviors such as HIV-testing, adhering to antiretroviral medication, prescribing and adhering to pre-exposure prophylaxis, and other health behaviors.

HIV Testing in Non-Injection Drug Users: Prevalence and Associated Factors

The objective of this study was to estimate the prevalence of and identify factors associated with lifetime testing for the human immunodeficiency virus (HIV) in non-injection drug users (NIDU). A cross-sectional study was conducted with 323 individuals in clinics for chemical dependency in the state of Goiás in the Central-West region of Brazil. Logistic regression analysis was used to identify factors associated with lifetime HIV testing. Testing for HIV was associated with age, female gender, crack use, history of sexually transmitted infections, acquaintance with people living with HIV/AIDS and/or who had died from AIDS, and history of having received some instruction on HIV/AIDS prevention methods. It was found that only 26.6% reported having access to the HIV rapid test. We concluded determinants for HIV testing must be taken into account when planning prevention and programming strategies. These include the widening of testing coverage among NIDU, educational health actions, establishment of links between sexually transmitted infection prevention services and addiction treatment services, and the use of rapid tests to help people who are in contact with the virus learn about their HIV status, enter treatment, and improve their quality of life.

Protocol of a cluster randomised stepped-wedge trial of behavioural interventions targeting amphetamine-type stimulant use and sexual risk among female entertainment and sex workers in Cambodia

INTRODUCTION

HIV risk among female entertainment and sex workers (FESW) remains high and use of amphetamine-type stimulants (ATS) significantly increases this risk. We designed a cluster randomised stepped wedge trial (The Cambodia Integrated HIV and Drug Prevention Implementation (CIPI) study) to test sequentially delivered behavioural interventions targeting ATS use.

METHODS AND ANALYSIS

The trial combines a 12-week Conditional Cash Transfer (CCT) intervention with 4 weeks of cognitive-behavioural group aftercare (AC) among FESW who use ATS. The primary goal is to reduce ATS use and unprotected sex among FESW. The CCT+AC intervention is being implemented in 10 provinces where order of delivery was randomised. Outcome assessments (OEs) including biomarkers and self-reported measures of recent sexual and drug use behaviours are conducted prior to implementation, and at three 6-month intervals after completion. Consultation with multiple groups and stakeholders on implementation factors facilitated acceptance and operationalisation of the trial. Statistical power and sample size calculations were based on expected changes in ATS use and unprotected sex at the population level as well as within subjects.

ETHICS AND DISSEMINATION

Ethical approvals were granted by the Cambodia National Ethics Committee; University of New Mexico; University of California, San Francisco; and FHI360. The trial is registered with ClinicalTrials.gov. Dissemination of process indicators during the multiyear trial is carried out through annual in-country Stakeholder Meetings. Provincial 'Close-Out' forums are held at the conclusion of data collection in each province. When analysis is completed, dissemination meetings will be held in Cambodia with stakeholders, including community-based discussion sessions, policy briefs and results published and presented in the HIV prevention scientific journals and conferences.

CONCLUSIONS

CIPI is the first trial of an intervention to reduce ATS use and HIV risk among FESW in Cambodia.

RESULTS

Will inform both CCT+AC implementation in low and middle-income countries and programmes designed to reach FESW.

TRIAL REGISTRATION NUMBER

NCT01835574; Pre-results.

Qualitative research and implementation science: Informing the acceptability and implementation of a trial of a conditional cash transfer intervention designed to reduce drug use and HIV risk

HIV risk remains high among Cambodian female entertainment and sex workers, driven by amphetamine-type substance use and sexual risk. Conditional cash transfer is an evidence-based approach to reduce stimulant use and optimize HIV/AIDS prevention, but questions remain regarding implementation in resource-limited settings. We conducted formative qualitative research to enhance acceptability of a conditional cash transfer intervention aimed at reducing amphetamine-type substance use and HIV risk among female entertainment/sex workers and inform implementation as part of a large cluster randomized trial. We conducted in-depth interviews with 30 female entertainment/sex workers. Interviews were digitally recorded and conducted and transcribed in Khmer. English transcripts were read for emerging themes and an initial coding scheme was developed. Data were coded using open and axial coding to clarify and consolidate initial themes. While most participants expressed enthusiasm for the intervention, financial and transportation issues emerged as key barriers to participation. The proposed incentive of USD$1 per screen was regarded as unacceptable and participants identified a need for transportation assistance. Participants also expressed concerns about directly observed urine specimen collection. Finally, while most participants found the 4-week aftercare program acceptable, the need for enjoyable as well as educational content was emphasized. Revisions to the protocol taking these data into account were made to optimize the acceptability of the intervention and the implementation of the trial. Findings identified key concerns and preferences that were taken into account in the final trial protocol. In particular, financial and transportation issues were identified as critical barriers to participation, with the potential to impact both intervention uptake and trial feasibility. Results demonstrate the value of formative qualitative research for clinical trial planning and implementation, particularly in settings where little is known about acceptability of interventions or willingness to participate.

Individual and Neighborhood Characteristics Associated with HIV Among Black and Latino Adults Who Use Drugs and Unaware of Their HIV-Positive Status, New York City, 2000-2004

With mounting evidence of how neighborhood socioeconomic context influences individual behavior, investigation of neighborhood social context and sex/drug use risk behavior could help explain and provide insight into solutions to solve persistent racial disparities in HIV. Interviewer-administered surveys and HIV testing among street-recruited individuals who reported illicit drug use in New York City were conducted from 2000 to 2004. Individuals were geocoded to census tracts, and generalized estimating equations were used to determine correlates of being newly diagnosed with HIV at study enrollment. Analyses were completed in 2014. Of the 920 participants, 10.5 % were HIV-positive, and among those, 45 % were diagnosed at study enrollment. After restricting the sample to those who self-reported negative HIV status (n = 867), 72 % were male, 65 % Latino, and 5.1 % tested HIV-positive. After adjustment, those testing HIV-positive were more likely to report male same-sex partnership (p < 0.01) and less likely to be homeless compared with those confirmed HIV-negative (p < 0.01). Neighborhood-adjusted models indicated those from neighborhoods with less deprivation (p < 0.05), and a higher proportion of owner-occupied homes (p < 0.01) were more likely to test HIV-positive. Additionally, Black individuals who used drugs and were from neighborhoods with a higher proportion of Black residents were more likely to be newly diagnosed compared to Latino individuals who used drugs and were from neighborhoods with lower proportions of Black residents (p < 0.05). These data suggest that HIV prevention and treatment efforts should continue widening its reach to those unaware of their HIV infection, namely men who have sex with men, heavy, drug-involved Black communities, and both Black and Latino communities from relatively less disadvantaged neighborhoods.

Efficacy of a Multi-level Intervention to Reduce Injecting and Sexual Risk Behaviors among HIV-Infected People Who Inject Drugs in Vietnam: A Four-Arm Randomized Controlled Trial

Introduction

Injecting drug use is a primary driver of HIV epidemics in many countries. People who inject drugs (PWID) and are HIV infected are often doubly stigmatized and many encounter difficulties reducing risk behaviors. Prevention interventions for HIV-infected PWID that provide enhanced support at the individual, family, and community level to facilitate risk-reduction are needed.

Methods

455 HIV-infected PWID and 355 of their HIV negative injecting network members living in 32 sub-districts in Thai Nguyen Province were enrolled. We conducted a two-stage randomization: First, sub-districts were randomized to either a community video screening and house-to-house visits or standard of care educational pamphlets. Second, within each sub-district, participants were randomized to receive either enhanced individual level post-test counseling and group support sessions or standard of care HIV testing and counseling. This resulted in four arms: 1) standard of care; 2) community level intervention; 3) individual level intervention; and 4) community plus individual intervention. Follow-up was conducted at 6, 12, 18, and 24 months. Primary outcomes were self-reported HIV injecting and sexual risk behaviors. Secondary outcomes included HIV incidence among HIV negative network members.

Results

Fewer participants reported sharing injecting equipment and unprotected sex from baseline to 24 months in all arms (77% to 4% and 24% to 5% respectively). There were no significant differences at the 24-month visit among the 4 arms (Wald = 3.40 (3 df); p = 0.33; Wald = 6.73 (3 df); p = 0.08). There were a total of 4 HIV seroconversions over 24 months with no significant difference between intervention and control arms.

Discussion

Understanding the mechanisms through which all arms, particularly the control arm, demonstrated both low risk behaviors and low HIV incidence has important implications for policy and prevention programming.

Trial Registration

ClinicalTrials.gov NCT01689545

Acceptability of HIV Pre-exposure Prophylaxis (PREP) Among People Who Inject Drugs (PWID) in a Canadian Setting

A recent clinical trial provided evidence that pre-exposure prophylaxis (PrEP) has the potential to prevent HIV infection among people who inject drugs (PWID). We examined willingness to use PrEP among HIV-negative PWID in Vancouver, Canada (n = 543) to inform PrEP implementation efforts. One third (35.4 %) expressed willingness to use PrEP, with adjusted models indicating that younger age, no regular employment, requiring help injecting, engaging in sex work, and reporting multiple recent sexual partners were positively associated with willingness to use PrEP. Although willingness to use PrEP was low, PrEP was acceptable to some PWID at heightened risk for HIV infection.

Tailored combination prevention packages and PrEP for young key populations

INTRODUCTION

Young key populations, defined in this article as men who have sex with men, transgender persons, people who sell sex and people who inject drugs, are at particularly high risk for HIV. Due to the often marginalized and sometimes criminalized status of young people who identify as members of key populations, there is a need for HIV prevention packages that account for the unique and challenging circumstances they face. Pre-exposure prophylaxis (PrEP) is likely to become an important element of combination prevention for many young key populations.

OBJECTIVE

In this paper, we discuss important challenges to HIV prevention among young key populations, identify key components of a tailored combination prevention package for this population and examine the role of PrEP in these prevention packages.

METHODS

We conducted a comprehensive review of the evidence to date on prevention strategies, challenges to prevention and combination prevention packages for young key populations. We focused specifically on the role of PrEP in these prevention packages and on young people under the age of 24, and 18 in particular.

RESULTS AND DISCUSSION

Combination prevention packages that include effective, acceptable and scalable behavioural, structural and biologic interventions are needed for all key populations to prevent new HIV infections. Interventions in these packages should meaningfully involve beneficiaries in the design and implementation of the intervention, and take into account the context in which the intervention is being delivered to thoughtfully address issues of stigma and discrimination. These interventions will likely be most effective if implemented in conjunction with strategies to facilitate an enabling environment, including increasing access to HIV testing and health services for PrEP and other prevention strategies, decriminalizing key populations' practices, increasing access to prevention and care, reducing stigma and discrimination, and fostering community empowerment. PrEP could offer a highly effective, time-limited primary prevention for young key populations if it is implemented in combination with other programs to increase access to health services and encourage the reliable use of PrEP while at risk of HIV exposure.

CONCLUSIONS

Reductions in HIV incidence will only be achieved through the implementation of combinations of interventions that include biomedical and behavioural interventions, as well as components that address social, economic and other structural factors that influence HIV prevention and transmission.

Prevention of human immunodeficiency virus and AIDS: postexposure prophylaxis (including health care workers)

Postexposure prophylaxis (PEP), which is designed to prevent human immunodeficiency virus (HIV) infection after an exposure, is one of several strategies for HIV prevention. PEP was first used after occupational HIV exposures in the late 1980s, with the Centers for Disease Control and Prevention issuing the first set of guidelines that included considerations regarding the use of antiretroviral agents for PEP after occupational HIV exposures in 1990. Use of PEP has been extended to nonoccupational exposures, including after sexual contact or injection-drug use. This article provides a rationale for PEP, assessment of the need for PEP, and details of its implementation.

HIV infection: epidemiology, pathogenesis, treatment, and prevention

HIV prevalence is increasing worldwide because people on antiretroviral therapy are living longer, although new infections decreased from 3.3 million in 2002, to 2.3 million in 2012. Global AIDS-related deaths peaked at 2.3 million in 2005, and decreased to 1.6 million by 2012. An estimated 9.7 million people in low-income and middle-income countries had started antiretroviral therapy by 2012. New insights into the mechanisms of latent infection and the importance of reservoirs of infection might eventually lead to a cure. The role of immune activation in the pathogenesis of non-AIDS clinical events (major causes of morbidity and mortality in people on antiretroviral therapy) is receiving increased recognition. Breakthroughs in the prevention of HIV important to public health include male medical circumcision, antiretrovirals to prevent mother-to-child transmission, antiretroviral therapy in people with HIV to prevent transmission, and antiretrovirals for pre-exposure prophylaxis. Research into other prevention interventions, notably vaccines and vaginal microbicides, is in progress.

The impact of buprenorphine/naloxone treatment on HIV risk behaviors among HIV-infected, opioid-dependent patients

BACKGROUND

Opioid dependence is a major risk factor for HIV infection, however, the impact of buprenorphine/naloxone treatment on HIV risk behaviors among HIV-infected opioid-dependent patients is unknown.

METHODS

We conducted a longitudinal analysis of 303 HIV-infected opioid-dependent patients initiating buprenorphine/naloxone treatment. Outcomes included self-reported past 90-day needle-sharing and non-condom use. We assessed trends over the 12 months using the Cochran-Armitage trend test. Using generalized estimating equations, after multiple imputation, we determined factors independently associated with needle-sharing and non-condom use, including time-updated variables. We then conducted a mediation analysis to determine whether substance use explained the relationship between time since treatment initiation and needle-sharing.

RESULTS

Needle-sharing decreased from baseline to the fourth quarter following initiation of buprenorphine/naloxone (9% vs. 3%, p<0.001), while non-condom use did not (23% vs. 21%, p=0.10). HIV risk behaviors did not vary based on the presence of a detectable HIV-1 RNA viral load. Patients who were homeless and used heroin, cocaine/amphetamines or marijuana were more likely to report needle-sharing. Heroin use fully mediated the relationship between time since treatment initiation and needle-sharing. Women, patients who identified as being gay/lesbian/bisexual, those married or living with a partner and who reported heroin or alcohol use were more likely to report non-condom use. Older patients were less likely to report non-condom use.

CONCLUSIONS

While buprenorphine/naloxone is associated with decreased needle-sharing among HIV-infected opioid-dependent patients, sexual risk behaviors persist regardless of viral load. Targeted interventions to address HIV risk behaviors among HIV-infected opioid-dependent populations receiving buprenorphine/naloxone are needed.

Community Impact of Pharmacy-Randomized Intervention to Improve Access to Syringes and Services for Injection Drug Users

OBJECTIVES

In an effort to reduce HIV transmission among injection drug users (IDUs), New York State deregulated pharmacy syringe sales in 2001 through the Expanded Syringe Access Program by removing the requirement of a prescription. With evidence suggesting pharmacists' ability to expand their public health role, a structural, pharmacy-based intervention was implemented to determine whether expanding pharmacy practice to include provision of HIV risk reduction and social/medical services information during the syringe sale would (a) improve pharmacy staff attitudes toward IDUs (b) increase IDU syringe customers, and (c) increase prescription customer base in New York City neighborhoods with high burden of HIV and illegal drug activity.

METHODS

Pharmacies (n = 88) were randomized into intervention (recruited IDU syringe customers into the study and delivered intervention activities), primary control (recruited IDU syringe customers only) and secondary control (did not recruit IDUs or deliver intervention activities) arms.

RESULTS

Pharmacy staff in the intervention versus secondary control pharmacies showed significant decreases in the belief that selling syringes to IDUs causes community loitering.

CONCLUSIONS

Structural interventions may be optimal approaches for changing normative attitudes about highly stigmatized populations.

Prevalence of HIV infection and risk behaviors among younger and older injecting drug users in the United States, 2009

This study compared HIV sero-prevalence and risk behaviors between younger and older injecting drug users (IDUs). IDUs aged ≥18 years were interviewed for the 2009 National HIV Behavioral Surveillance System. Using GEE regression, we assessed characteristics of younger (18-29 years) and older (≥30 years) IDUs, and factors associated with past 12-month receptive syringe sharing and unprotected sex (vaginal/anal). Of 10,090 participants, 10 % were younger. HIV sero-prevalence was lower among younger than older IDUs (4 vs. 10 %, p = 0.001). Younger IDUs were more likely (p ≤ 0.002) to be non-black race/ethnicity, report higher household income, homelessness, being arrested and to engage in receptive syringe sharing and unprotected sex. In multivariable models, age remained associated (p < 0.001) with receptive syringe sharing (aPR = 1.14, 95 % CI1.07-1.22) and unprotected sex (aPR = 1.10, 95 % CI1.06-1.14). Although younger IDUs had lower HIV prevalence, their behaviors place them at increased risk of HIV infection and could lead to a rapid spread in this susceptible population.

HIV pre-exposure prophylaxis for people who inject drugs: a review of current results and an agenda for future research

Introduction

Studies examining the use of pre-exposure prophylaxis (PrEP) to prevent HIV transmission among people who inject drugs (PWIDs) have not been adequately summarized. Recently, the Bangkok Tenofovir Study has shown that PrEP may be effective at reducing new HIV infections among this high-risk group. This randomized controlled trial was the first study to specifically examine the efficacy of PrEP among PWIDs. In this review, we present the current state of evidence regarding the use of PrEP to prevent HIV infection in PWID populations, and set an agenda for future research to inform the most effective implementation of PrEP in the context of existing evidence-based HIV prevention strategies.

Discussion

Despite positive trial results confirming that PrEP may prevent HIV transmission among PWIDs, there remain many questions regarding the interpretation of these results, as well as obstacles to the implementation of PrEP regimens within highly diverse drug-using communities. Aside from the Bangkok Tenofovir Study, we identified only one other published study that has collected empirical data to inform the use of PrEP among PWIDs. The large gap in research regarding the use and implementation of PrEP for PWIDs signals the need for further research and attention.

Conclusions

We recommend that future research efforts focus on elucidating the generalizability of the Bangkok Tenofovir Study results in other injection drug–using populations, examining the willingness of PWIDs to use PrEP in diverse contexts, identifying barriers to adherence to PrEP regimens and determining the most effective ways to implement PrEP programmes within the context of existing evidence-based prevention strategies, including opioid substitution therapy and needle and syringe distribution programmes.

The relationship between discrimination and high-risk social ties by race/ethnicity: examining social pathways of HIV risk

High-risk social ties portend differences in opportunity for HIV exposures and may contribute to racial/ethnic disparities in HIV transmission. Discrimination may affect the formation of high-risk social ties and has not been explored as a possible explanation for these persistent disparities. Using data from injection and non-injection drug users, we examined the association between the number of high-risk sex and drug ties with discrimination due to race, drug use, and incarceration stratified by race/ethnicity. Negative binomial regression models were used. While blacks had significantly fewer injecting ties than Latinos and whites, blacks who reported racial discrimination compared to blacks who did not, had more sex and injecting ties. Latinos who reported drug use discrimination compared to Latinos who did not also had more sex ties. Latinos and whites who reported drug use discrimination had more injecting ties than Latinos and whites who did not. Discrimination is associated with high-risk social ties among all racial/ethnic groups. But, these data highlight different forms of discrimination within racial/ethnic group are associated with risky social ties. More research is needed to confirm these findings and further explore the association between various forms of discrimination and social ties that may help explain racial/ethnic disparities in HIV.

Latent class analysis of polysubstance use, sexual risk behaviors, and infectious disease among South African drug users

BACKGROUND

HIV transmission risk among non-injection drug users is high due to the co-occurrence of drug use and sexual risk behaviors. The purpose of the current study was to identify patterns of drug use among polysubstance users within a high HIV prevalence population.

METHODS

The study sample included 409 substance users from the Pretoria region of South Africa. Substances used by 20% or more the sample included: cigarettes, alcohol, marijuana and heroin in combination, marijuana and cigarettes in combination, and crack cocaine. Latent class analysis was used to identify patterns of polysubstance use based on types of drugs used. Multivariate logistic regression analyses compared classes on demographics, sexual risk behavior, and disease status.

RESULTS

Four classes of substance use were found: MJ+Cig (40.8%), MJ+Her (30.8%), Crack (24.7%), and Low Use (3.7%). The MJ+Cig class was 6.7 times more likely to use alcohol and 3 times more likely to use drugs before/during sex with steady partners than the Crack class. The MJ+Cig class was 16 times more likely to use alcohol before/during sex with steady partners than the MJ+Her class. The Crack class was 6.1 times more likely to engage in transactional sex and less likely to use drugs before/during steady sex than the MJ+Her class.

CONCLUSIONS

Findings illustrate patterns of drug use among a polysubstance using population that differ in sexual risk behavior. Intervention strategies should address substance use, particularly smoking as a route of administration (ROA), and sexual risk behaviors that best fit this high-risk population.

Combination prevention: new hope for stopping the epidemic

HIV research has identified approaches that can be combined to be more effective in transmission reduction than any 1 modality alone: delayed adolescent sexual debut, mutual monogamy or sexual partner reduction, correct and consistent condom use, pre-exposure prophylaxis with oral antiretroviral drugs or vaginal microbicides, voluntary medical male circumcision, antiretroviral therapy (ART) for prevention (including prevention of mother to child HIV transmission [PMTCT]), treatment of sexually transmitted infections, use of clean needles for all injections, blood screening prior to donation, a future HIV prime/boost vaccine, and the female condom. The extent to which evidence-based modalities can be combined to prevent substantial HIV transmission is largely unknown, but combination approaches that are truly implementable in field conditions are likely to be far more effective than single interventions alone. Analogous to PMTCT, "treatment as prevention" for adult-to-adult transmission reduction includes expanded HIV testing, linkage to care, antiretroviral coverage, retention in care, adherence to therapy, and management of key co-morbidities such as depression and substance use. With successful viral suppression, persons with HIV are far less infectious to others, as we see in the fields of sexually transmitted infection control and mycobacterial disease control (tuberculosis and leprosy). Combination approaches are complex, may involve high program costs, and require substantial global commitments. We present a rationale for such investments and cite an ongoing research agenda that seeks to determine how feasible and cost-effective a combination prevention approach would be in a variety of epidemic contexts, notably that in a sub-Saharan Africa.

Clinical uncertainties, health service challenges, and ethical complexities of HIV "test-and-treat": a systematic review

Despite the HIV "test-and-treat" strategy's promise, questions about its clinical rationale, operational feasibility, and ethical appropriateness have led to vigorous debate in the global HIV community. We performed a systematic review of the literature published between January 2009 and May 2012 using PubMed, SCOPUS, Global Health, Web of Science, BIOSIS, Cochrane CENTRAL, EBSCO Africa-Wide Information, and EBSCO CINAHL Plus databases to summarize clinical uncertainties, health service challenges, and ethical complexities that may affect the test-and-treat strategy's success. A thoughtful approach to research and implementation to address clinical and health service questions and meaningful community engagement regarding ethical complexities may bring us closer to safe, feasible, and effective test-and-treat implementation.

Drug users in Amsterdam: are they still at risk for HIV?

Background and Aims

To examine whether drug users (DU) in the Amsterdam Cohort Study (ACS) are still at risk for HIV, we studied trends in HIV incidence and injecting and sexual risk behaviour from 1986 to 2011.

Methods

The ACS is an open, prospective cohort study on HIV. Calendar time trends in HIV incidence were modelled using Poisson regression. Trends in risk behaviour were modelled via generalized estimating equations. In 2010, a screening for STI (chlamydia, gonorrhoea and syphilis) was performed. Determinants of unprotected sex were studied using logistic regression analysis.

Results

The HIV incidence among 1298 participants of the ACS with a total follow-up of 12,921 person-years (PY) declined from 6.0/100 PY (95% confidence interval [CI] 3.2–11.1) in 1986 to less than 1/100 PY from 1997 onwards. Both injection and sexual risk behaviour declined significantly over time. Out of 197 participants screened for STI in 2010–2011, median age 49 years (IQR 43–59), only 5 (2.5%) were diagnosed with an STI. In multivariable analysis, having a steady partner (aOR 4.1, 95% CI 1.6–10.5) was associated with unprotected sex. HIV-infected participants were less likely to report unprotected sex (aOR 0.07, 95% CI 0.02–0.37).

Conclusions

HIV incidence and injection risk behaviour declined from 1986 onwards. STI prevalence is low; unprotected sex is associated with steady partners and is less common among HIV-infected participants. These findings indicate a low transmission risk of HIV and STI, which suggests that DU do not play a significant role in the current spread of HIV in Amsterdam.

Substance Abuse Treatment, HIV/AIDS, and the Continuum of Response for People Who Inject Drugs

The continuum of response (CoR) to HIV/AIDS is a framework for implementation of HIV prevention, care, and treatment programs based on a national strategic plan for HIV/AIDS services. The CoR for people who inject drugs (PWID) is an important extension of the developed CoR to HIV/AIDS. The CoR-PWID employs stakeholders who together plan, develop, pilot, and provide a full range of services that address the various prevention, care/support, and treatment needs of people, families, and communities infected or affected by HIV/AIDS and injection drug use. The CoR-PWID comprises a broad range of services that include but are not limited to the World Health Organization priority interventions for HIV/AIDS prevention, treatment, and care in the health sector and the package of essential interventions for the prevention, treatment, and care of HIV for people who inject drugs. Implementation of these well-defined, essential prevention, care/support, and treatment services, in addition to locally defined needed services, in a coordinated fashion is important to clients, their families, and communities. The CoR-PWID is, therefore, a necessary framework essential for service development for countries that address HIV/AIDS in populations of PWID.

Towards combination HIV prevention for injection drug users: addressing addictophobia, apathy and inattention

PURPOSE OF REVIEW

Recent breakthroughs in HIV-prevention science led us to evaluate the current state of combination HIV prevention for injection drug users (IDUs). We review the recent literature focusing on possible reasons why coverage of prevention interventions for HIV, hepatitis C virus (HCV) and tuberculosis among IDUs remains dismal. We make recommendations for future HIV research and policy.

RECENT FINDINGS

IDUs disproportionately under-utilize voluntary HIV counseling and testing (VCT), primary care and antiretroviral therapy (ART), especially in countries that have the largest burden of HIV among IDUs. IDUs present later in the course of HIV infection and experience greater morbidity and mortality. Why are IDUs under-represented in HIV-prevention research, access to treatment for both HIV and addiction, and access to HIV combination prevention? Possible explanations include addictophobia, apathy, and inattention, which we describe in the context of recent literature and events.

SUMMARY

This commentary discusses the current state of HIV-prevention interventions for IDUs including VCT, needle and syringe program (NSP), opioid substitution therapy (OST), ART and pre-exposure chemoprophylaxis (PrEP), and discusses ways to work towards true combination HIV prevention for IDU populations. Communities need to overcome tacit assumptions that IDUs can navigate through systems that are maintained as separate silos, and begin to take a rights-based approach to HIV prevention to ensure that IDUs have equitable access to life-saving prevention and treatments.

Circular migration by Mexican female sex workers who are injection drug users: implications for HIV in Mexican sending communities

Circular migration and injection drug use increase the risk of HIV transmission in sending communities. We describe female sex workers who are injection drug users' (FSW-IDUs) circular migration and drug use behaviors. Between 2008-2010, 258 migrant FSW-IDUs residing in Tijuana and Ciudad Juarez, Mexico responded to questionnaires. 24% of FSW-IDUs were circular migrants. HIV prevalence was 3.2% in circular migrants and 6.1% in non-circular migrants; 50% of circular and 75% of non-circular migrants were unaware of their HIV infection. Among circular migrants, 44% (n = 27) consumed illicit drugs in their birthplace; 74% of these (n = 20) injected drugs and one-half of injectors shared injection equipment in their birthplace. Women reporting active social relationships were significantly more likely to return home. Circular migrant FSW-IDUs exhibit multiple HIV risks and opportunities for bridging populations. Regular HIV testing and treatment and access to substance use services is critical for FSW-IDUs and their sexual/drug-using contacts.

The HIV Epidemic: High-Income Countries

The HIV epidemic in higher-income nations is driven by receptive anal intercourse, injection drug use through needle/syringe sharing, and, less efficiently, vaginal intercourse. Alcohol and noninjecting drug use increase sexual HIV vulnerability. Appropriate diagnostic screening has nearly eliminated blood/blood product-related transmissions and, with antiretroviral therapy, has reduced mother-to-child transmission radically. Affected subgroups have changed over time (e.g., increasing numbers of Black and minority ethnic men who have sex with men). Molecular phylogenetic approaches have established historical links between HIV strains from central Africa to those in the United States and thence to Europe. However, Europe did not just receive virus from the United States, as it was also imported from Africa directly. Initial introductions led to epidemics in different risk groups in Western Europe distinguished by viral clades/sequences, and likewise, more recent explosive epidemics linked to injection drug use in Eastern Europe are associated with specific strains. Recent developments in phylodynamic approaches have made it possible to obtain estimates of sequence evolution rates and network parameters for epidemics.

The unrealized potential of addiction science in curbing the HIV epidemic

The stubbornly high incidence of new HIV infections belies the overwhelming evidence showing that sustained highly active antiretroviral therapy (HAART) has the power to dramatically reduce the spread of HIV infection and forever change the face of this devastating epidemic. One of the main contributors to this public health paradox is the ongoing HIV epidemic among substance users who contribute significantly to HIV infection rates through injection drug use and high-risk sexual behaviours. Current evidence clearly shows that, in order to fill this gap, we need to integrate substance abuse treatment with HIV treatment programmes and provide substance abusers with universal access to HIV treatment through a focussed effort to seek, test, treat, and retain hard-to-reach high risk individuals. These aims will require structural changes in the health care system to overcome many of the obstacles that have inhibited the merging of substance abuse treatment with HIV programmes for far too long.