Prevention knowledge, risk behaviours and seroprevalence among nonurban injectors of southwest Connecticut

Potential impact of curative and preventive interventions toward hepatitis C elimination in people who inject drugs-A network modeling study

BACKGROUND

Injection-equipment-sharing networks play an important role in hepatitis C virus (HCV) transmission among people who inject drugs (PWID). Direct-acting antiviral (DAA) treatments for HCV infection and interventions to prevent HCV transmission are critical components of an overall hepatitis C elimination strategy, but how they contribute to the elimination outcomes in different PWID network settings are unclear.

METHODS

We developed an agent-based network model of HCV transmission through the sharing of injection equipment among PWID and parameterized and calibrated the model with rural PWID data in the United States. We modeled curative and preventive interventions at annual coverage levels of 12.5 %, 25 %, or 37.5 % (cumulative percentage of eligible individuals engaged), and two allocation approaches: random vs targeting PWID with more injection partners (hereafter 'degree-based'). We compared the impact of these intervention strategies on prevalence and incidence of HCV infections. We conducted sensitivity analysis on key parameters governing the effects of curative and preventive interventions and PWID network characteristics.

RESULTS

Combining curative and preventive interventions at 37.5 % annual coverage with degree-based allocation decreased prevalence and incidence of HCV infection by 67 % and 70 % over two years, respectively. Curative interventions decreased prevalence by six to 12 times more than preventive interventions, while curative and preventive interventions had comparable effectiveness on reducing incidence. Intervention impact increased with coverage almost linearly across all intervention strategies, and degree-based allocation was always more effective than random allocation, especially for preventive interventions. Results were sensitive to parameter values defining intervention effects and network mean degree.

CONCLUSION

DAA treatments are effective in reducing both prevalence and incidence of HCV infection in PWID, but preventive interventions play a significant role in reducing incidence when intervention coverage is low. Increasing coverage, including efforts in reaching individuals with the most injection partners, preventing reinfection, and improving compliance and retention in preventive services can substantially improve the outcomes. PWID network characteristics should be considered when designing hepatitis C elimination programs.

Progress and Unfinished Business: Hepatitis B in the United States, 1980-2019

During 1990-2019, universal infant and childhood vaccination for hepatitis B resulted in a 99% decline in reported cases of acute hepatitis B among children, adolescents, and young adults aged <19 years in the United States; however, during 2010-2019, cases of acute hepatitis B plateaued or increased among adults aged ≥40 years. We conducted a topical review of surveillance strategies that will be critical to support the elimination of hepatitis B as a public health threat in the United States. In 2019, notifiable disease surveillance for acute hepatitis B showed continued transmission, especially among people who inject drugs and people with multiple sexual partners; rates were highest among people who were aged 30-59 years, non-Hispanic White, and living in rural areas. In contrast, newly reported cases of chronic hepatitis B (CHB) were highest among people who were aged 30-49 years, Asian or Pacific Islander, and living in urban areas. The National Health and Nutrition Examination Survey documented the highest CHB prevalence among non-US-born, non-Hispanic Asian people during 2013-2018; only one-third of people with CHB were aware of their infection. In the context of universal adult vaccination (2022) and screening (2023) recommendations for hepatitis B, better data are needed to support programmatic strategies to improve (1) vaccination rates among people with behaviors that put them at risk for transmission and (2) screening and linkage to care among non-US-born people. Surveillance for hepatitis B needs to be strengthened throughout the health care and public health systems.

Syringe Services Programs to Reduce Intravenous Disease Transmission in Substance Use Disorders

Syringe services programs (SSPs) are evidence-based programs. SSPs are integral in preventing bloodborne diseases while increasing access to care and reducing drug overdose deaths. SSPs are often the only source of health care for people who use drugs. Several states in the United States support and offer community-based SPPs; however, US prisons do not offer such programs to those incarcerated. Nurses are bridging the gap in support of SSPs and are being backed by organizations such as the American Nurses Association and the Association of Nurses in AIDS Care.

Factors associated with receptive injection equipment sharing among people who inject drugs: findings from a multistate study at the start of the COVID-19 pandemic

BACKGROUND

Receptive injection equipment sharing (i.e., injecting with syringes, cookers, rinse water previously used by another person) plays a central role in the transmission of infectious diseases (e.g., HIV, viral hepatitis) among people who inject drugs. Better understanding these behaviors in the context of COVID-19 may afford insights about potential intervention opportunities in future health crises.

OBJECTIVE

This study examines factors associated with receptive injection equipment sharing among people who inject drugs in the context of COVID-19.

METHODS

From August 2020 to January 2021, people who inject drugs were recruited from 22 substance use disorder treatment programs and harm reduction service providers in nine states and the District of Columbia to complete a survey that ascertained how the COVID-19 pandemic affected substance use behaviors. We used logistic regression to identify factors associated with people who inject drugs having recently engaged in receptive injection equipment sharing.

RESULTS

One in four people who inject drugs in our sample reported having engaged in receptive injection equipment sharing in the past month. Factors associated with greater odds of receptive injection equipment sharing included: having a high school education or equivalent (adjusted odds ratio [aOR] = 2.14, 95% confidence interval [95% CI] 1.24, 3.69), experiencing hunger at least weekly (aOR = 1.89, 95% CI 1.01, 3.56), and number of drugs injected (aOR = 1.15, 95% CI 1.02, 1.30). Older age (aOR = 0.97, 95% CI 0.94, 1.00) and living in a non-metropolitan area (aOR = 0.43, 95% CI 0.18, 1.02) were marginally associated with decreased odds of receptive injection equipment sharing.

CONCLUSIONS

Receptive injection equipment sharing was relatively common among our sample during the early months of the COVID-19 pandemic. Our findings contribute to existing literature that examines receptive injection equipment sharing by demonstrating that this behavior was associated with factors identified in similar research that occurred before COVID. Eliminating high-risk injection practices among people who inject drugs requires investments in low-threshold and evidence-based services that ensure persons have access to sterile injection equipment.

Injection drug use, depression, and HIV screening in rural primary care settings: A retrospective cross-sectional study

Introduction

Antiretroviral therapy (ART) has reduced HIV viral replication and transmission of disease. However, continuing incidence of new HIV infections has been attributed to undiagnosed HIV infections among injection drug users. This purpose of this retrospective cross-sectional study was to determine whether depression moderates the relationship between injection drug use and HIV screening among people with substance use in the screening, brief intervention, and referral to treatment in Alabama (AL-SBIRT) program.

Methods

Electronic health record data were obtained from three consenting medical facilities (n = 103). Multivariable logistic regression analysis was conducted to determine the moderating effect of depression on the relationship between injection drug use and HIV screening.

Results

Bivariate analyses revealed that HIV screening was more common among individuals not engaged in injection drug use, 75% and 57% respectively. Participants who had never been screened had worse depressive symptoms on the PHQ-2 (M = 3.00, SE = 0.42) than individuals who had been screened for HIV (M = 1.45, SE = 0.17). After controlling for demographic variables, tobacco use, alcohol consumption, and drug abuse, results indicated a moderating effect of depression on the relationship between injection drug use and receipt of HIV screening (aOR = 0.85 [95% CI = 0.84, 0.86).

Discussion

Findings suggest that high risk subgroups such as injection drug users with severe depression may not be using HIV prevention services, leading to possible delays in HIV diagnosis. Integration of behavioral interventions and HIV prevention services may reduce risk factors among depressed injection drug users. Such interventions may improve retention for injection drug users who experience worse depressive symptoms post HIV diagnosis.

Depression, post-traumatic stress disorder, suicidality and self-harm among people who inject drugs: A systematic review and meta-analysis

BACKGROUND

A range of negative experiences and circumstances that are common among people who inject drugs (PWID) are risk factors for developing mental disorders. Despite this, there has been no systematic review of the prevalence of mental health indicators among PWID. Thus, we aimed to estimate the prevalence of depression, post-traumatic stress disorder (PTSD), suicidality and self-harm among PWID.

METHODS

We searched the peer-reviewed and grey literature for data on depression, PTSD, suicidality and non-suicidal self-harm among PWID from sources published from 2008-2018. We pooled estimates of depression and suicidality using random-effects meta-analysis and provided a narrative summary of estimates of PTSD and self-harm.

FINDINGS

We found 23 studies that reported on these mental health indicators among PWID. The pooled estimate for current severe depressive symptomology was 42.0 % (95 % confidence interval [CI] = 21.3, 62.8 %), and for a depression diagnosis was 28.7 % (95 % CI = 20.8, 36.6 %). With much variation, the pooled lifetime prevalence of a suicide attempt was 22.1 % (95 % CI = 19.3, 24.9 %). There were only two studies each that reported on PTSD and non-suicidal self-harm among PWID.

INTERPRETATION

Recent data investigating these mental health indicators among PWID was limited, particularly from low- and middle-income countries. Even so, estimates were high and call for further research into the epidemiology of such mental health disorders and self-harming behaviours, as well as the promotion of integrated mental health and substance dependence treatment. Finally, incorporating suicide prevention strategies into services accessed by PWID must be considered as a harm reduction priority.

Development, validation, and potential applications of the hepatitis C virus injection-risk knowledge scale (HCV-IRKS) among young opioid users in New York City

BACKGROUND

Hepatitis C virus (HCV) incidence has increased dramatically in the United States in recent years and is associated with the opioid epidemic due to high HCV transmission risk among people who inject drugs (PWID). HCV transmission knowledge is difficult to ascertain given the lack of psychometrically-tested measures. We developed and validated an HCV injection-risk knowledge scale.

METHODS

Analyses used data from 539 New York City opioid users ages 18-29 recruited via respondent-driven sampling in 2014-16. Blood samples yielded HCV antibody status. Principal components analysis (PCA) of nine knowledge items answered true, false, or don't know identified useful scale items. We evaluated internal consistency with the Cronbach's alpha coefficient and assessed construct validity by comparing knowledge levels with those from a previously validated general HCV knowledge scale and by comparing key sub-group knowledge levels.

RESULTS

PCA identified one component with five items that explained 45% of the total variance and had high internal consistency (alpha=0.91). All items referred to transmission through drug-injection equipment and practices: sharing cookers, cottons, diluting water, water containers, and cleaning syringes with water. The mean percent correct was 75%, and as expected, was moderately correlated with general HCV knowledge (Spearman's rho=0.55). As hypothesized, knowledge levels were highest for those previously tested for HCV, those with HCV antibody-positive status, PWID, and those who had received harm reduction information in various settings.

CONCLUSIONS

The 5-item, validated HCV Injection-Risk Knowledge Scale (HCV-IRKS) may provide educators, care providers, and researchers with critical information for reducing HCV among PWID.

Injection drug use, HIV/HCV, and related services in nonurban areas of the United States: A systematic review

BACKGROUND

Injection drug use (IDU) in nonurban areas of the United States is a growing public health concern, but there has been no comprehensive assessment of existing research on injection-related HIV and hepatitis C (HCV) in nonurban communities. We conducted a systematic review to assess the current literature and identify knowledge gaps.

METHODS

We systematically searched six databases for relevant articles published between January 1990 and June 2016 and screened, extracted, and analyzed the resulting data. Studies were included if they reported original findings from the nonurban U.S. related to 1) IDU and its role in HIV/HCV transmission, and/or 2) HIV/HCV services for people who inject drugs (PWID).

RESULTS

Of 2330 studies, 34 from 24 unique research projects in 17 states met inclusion criteria. Despite increasing HCV and high vulnerability to injection-related HIV outbreaks in nonurban areas, only three studies since 2010 recruited and tested PWID for HIV/HCV. Twelve reported on sharing injection equipment but used varying definitions of sharing, and only eight examined correlates of injection risk. Nine studies on syringe access suggest limited access through syringe exchange programs and pharmacies. Only two studies addressed HCV testing, none addressed HIV testing, and three examined behavioral or other interventions.

CONCLUSIONS

Despite growing concern regarding nonurban IDU there are few studies of HIV/HCV and related services for PWID, and the existing literature covers a very limited geographical area. Current research provides minimal insights into any unique factors that influence injection risk and HIV/HCV service provision and utilization among nonurban PWID.

Knowledge of hepatitis C and treatment willingness amongst people who inject drugs in an era of direct acting antivirals

BACKGROUND

Knowledge of hepatitis C virus (HCV) is believed to be important in altering risk behaviour, improving engagement in care, and promoting willingness to initiate HCV treatment. We assessed factors associated with HCV knowledge and treatment willingness amongst people who inject drugs (PWID) in an era of direct acting antivirals.

METHODS

Data were derived from three prospective cohort studies of PWID in Vancouver, Canada, between June 2014 and May 2015. HCV knowledge and treatment willingness were assessed using a Likert scale. Multivariable linear regression identified factors associated with higher HCV knowledge and treatment willingness.

RESULTS

Amongst 630 participants, mean scores for HCV knowledge and treatment willingness were 25.41 (standard deviation [SD]: 2.52) out of 30, and 6.83 (SD: 1.83) out of 10, respectively. In multivariable analyses, Caucasian ancestry (adjusted linear regression model estimate [β] 0.50; 95% confidence interval [CI] 0.17, 0.82), employment (β 0.76; 95% CI: 0.38, 1.13), diagnosed mental health disorder (β 0.44; 95% CI: 0.11, 0.78) and previous HCV treatment (β 0.94; 95% CI: 0.46, 1.43) were independently associated with higher knowledge. Downtown Eastside (DTES) residence (i.e., epicenter of Vancouver's drug scene) was independently associated with lower knowledge (β -0.48; 95% CI: -0.81, -0.15). Greater HCV knowledge (β 0.12; 95% CI: 0.07, 0.17) was independently associated with higher HCV treatment willingness. DTES residence (β -0.31; 95% CI: -0.56, -0.06) and daily crack cocaine smoking (β -0.52; 95% CI: -0.92, -0.13) were independently associated with lower treatment willingness.

CONCLUSION

Socioeconomic factors, such as neighborhood residence and employment, were associated with HCV knowledge. Higher HCV knowledge was associated with more HCV treatment willingness. Our findings suggest that increasing HCV knowledge amongst PWID may be an integral component of the HCV cascade of care and that efforts might be best targeted to individuals with greater socioeconomic disadvantage.