Risk factors associated with injection initiation among drug users in Northern Thailand

The global distribution and epidemiology of alcohol and drug use among street-involved children and youth: a meta-analysis

Background: Street-involved children and youth (SICY) who work and live on/of the streets are more likely to inject drugs and engage in psychoactive substance use.Objectives: The present study aimed to identify the prevalence, distribution, sociodemographic determinants, and risk-taking associated with alcohol and drug use among SICY.Methods: Studies published in English related to alcohol and drug use among SICY were searched for from December 1 1985 to July 1 2022, on PubMed, Scopus, Cochrane, and Web of Science.Results: After full-text paper evaluation, 73 studies were included in the meta-analysis. Results indicated that lifetime prevalence rates were 44% (alcohol), 44% (crack), 33% (inhalants), 44% (solvents), 16% (tranquilizer/sedatives), 22% (opioids), and 62% (polysubstance use). The current prevalence rates were 40% (alcohol), 21% (crack), 20% (inhalants), 11% (tranquilizer/sedatives), and 1% (opioids). Also, life-time and current prevalence of alcohol and crack use, current prevalence of tranquilizer/sedative use, and life-time prevalence of polysubstance use were higher among older age groups. Life-time prevalence of tranquilizer/sedative use was lower among older age groups.Conclusions: The high prevalence of using alcohol, crack, and inhalants is a major issue because they are used extensively among different age groups, including minors. Such findings are beneficial for policymakers, health authorities, and professionals in developing programs aimed at minimizing inhalant use and other types of substance use harms among this group. It is important to accurately monitor this risk-exposed population to understand the mechanisms that might help protect them from high-risk substance use.

Transition from nonmedical prescribed opioids to non-injection heroin use among young integrated Thai male users in Bangkok

Opioid use and misuse are understudied in Thailand despite evidence suggesting that a portion of young Thai male integrated drug users are initiating use of non-medical prescribed opioids with some transitioning to heroin. This study aims to capture and analyze the individual and social factors influencing these transitions. Twenty in-depth semi-structured interviews were conducted between December 2019 and January 2020 in the Bangkok metropolitan area with young male opioid users who transitioned to heroin. Sixteen respondents initiated opioid through a Tramadol cocktail named "YaPro" and tended to transition to heroin use within 21 months. The interaction of specific social and individual factors such as joining recreational activities, curiosity or experimentation gradually modified the opioid-related meanings, attitude and practices of Thai users, who ultimately transition to heroin use. These results indicate that drug prevention programs in Thailand should encompass young opioid users in their intervention and further research need to focus on nonmedical use of prescription opioids in Thailand.

Do sexual expectancies and inhibitions predict high-risk sexual behaviours? Evidence from a cross-sectional survey among young psychoactive substance users in informal settlements in Kampala, Uganda

BACKGROUND

Psychoactive substance use is a public health challenge among young people in informal settlements. Though rarely examined, psychoactive substance use is linked to sexual expectancies and inhibitions, and consequently high-risk sexual behaviours. This study examined the association between sexual expectancies and inhibitions, and high-risk sexual behaviours among young psychoactive substance users (PSUs) in informal settlements in Kampala, Uganda.

METHODS

This cross-sectional study recruited 744 young PSUs from informal settlements in Kampala. Respondent driven sampling was used to recruit respondents. A 'modified' Poisson regression model was used for inferential statistics. Data were analysed using the Stata 14 software.

RESULTS

Of the 744 study participants, 45.6% believed that psychoactive substance use improves sexual performance; 43.3% believed that psychoactive substances make sex more pleasurable, and 53.3% believed that psychoactive substances give courage or confidence to approach a partner for sex. The belief that psychoactive substance use improves sexual performance (PR 1.14, 95% CI: 1.01-1.30), increases the likelihood of engaging in sex (PR 1.20, 95% CI: 1.04-1.40) or gives courage or confidence to approach a sexual partner (PR 1.21, 95% CI: 1.05-1.39) were associated with having sex while under the influence of psychoactive substances. The belief that a psychoactive substance user under the influence of psychoactive substances is more likely to engage in sex (PR 1.48, 95% CI: 1.15-1.90), and likely to find it difficult to refuse sex (PR 1.28, 95% CI: 1.06-1.55) were positively associated with engaging in multiple sexual partnerships. The belief that one easily forgets to use a condom when under the influence of psychoactive substances was positively associated with inconsistent condom use (PR 1.26, 95% CI: 1.09-1.45).

CONCLUSION

Psychoactive substance use expectancies associated with high-risk sexual behaviours included the belief that psychoactive substances improve sexual performance and improve confidence in approaching a sexual partner. Psychoactive substance use inhibitions associated with high-risk sexual behaviours included an increased likelihood of engaging in sexual intercourse, difficulties in refusing to engage in sexual intercourse, and forgetting to use condoms while intoxicated. Interventions targeting a reduction in high-risk sexual behaviour should integrate the impact of psychoactive substance use on sexual behaviour.

Sociodemographic Factors Associated With HIV/HCV High-Risk Behaviors Among People Who Use Drugs on Methadone Maintenance Treatment: A 10-Year Observational Study

Background: Sociodemographic factors have an impact worldwide on the behavior of people who use drugs (PWUD). This study attempts to clarify the sociodemographic factors related to HIV/HCV high-risk behaviors (injection drug use, syringe sharing, and multiple sex partners) among PWUD on methadone maintenance treatment (MMT) in the long term. Methods: The 13,300 PWUD recruited into the MMT program were followed during 2006-2015. Generalized estimating equations were used to examine the relationship between sociodemographic characteristics and HIV/HCV high-risk behaviors. Results: We found that male (vs. female), living alone (vs. living with family or relatives), temporary income, financial support from family/friends, and financial support from social welfare (vs. regular salary) were positively associated with injection drug use. Age of initial drug use was negatively associated with injection drug use and syringe sharing. For both genders, being unmarried (vs. married or in cohabitation), living with friends, living alone (vs. living with family or relatives), temporary income, financial supports from family/friends (vs. regular salary), being employed (vs. unemployed/between jobs) was positively associated. In contrast, age at baseline was negatively associated with having multiple sexual partners for both genders. Ethnic of non-Han (vs. Han) was positively associated with having multiple sexual partners simply for males. Being divorced or widowed (vs. married or cohabitated) was positively associated with having multiple sexual partners merely for females. Conclusion: HIV/HCV high-risk behaviors correlated with certain sociodemographic factors of PWUD receiving MMT. There is a need for improving the well-being, employment, and housing status of PWUD on MMT to reduce their HIV/HCV risk behaviors.

Application of data mining techniques and logistic regression to model drug use transition to injection: a case study in drug use treatment centers in Kermanshah Province, Iran

BACKGROUND

Drug injection has been increasing over the past decades all over the world. Hepatitis B and C viruses (HBV and HCV) are two common infections among people who inject drugs (PWID) and more than 60% of new human immunodeficiency virus (HIV) cases are PWID. Thus, investigating risk factors associated with drug use transition to injection is essential and was the aim of this research.

METHODS

We used a database from drug use treatment centers in Kermanshah Province (Iran) in 2013 that included 2098 records of people who use drugs (PWUD). The information of 29 potential risk factors that are commonly used in the literature on drug use was selected. We employed four classification methods (decision tree, neural network, support vector machine, and logistic regression) to determine factors affecting the decision of PWUD to transition to injection.

RESULTS

The average specificity of all models was over 84%. Support vector machine produced the highest specificity (0.9). Also, this model showed the highest total accuracy (0.91), sensitivity (0.94), positive likelihood ratio [1] and Kappa (0.94) and the smallest negative likelihood ratio (0). Therefore, important factors according to the support vector machine model were used for further interpretation.

CONCLUSIONS

Based on the support vector machine model, the use of heroin, cocaine, and hallucinogens were identified as the three most important factors associated with drug use transition injection. The results further indicated that PWUD with the history of prison or using drug due to curiosity and unemployment are at higher risks. Unemployment and unreliable sources of income were other suggested factors of transition in this research.

Factors associated with time between using a drug and injection initiation among people who inject drugs in Kermanshah, Iran

Background The transition from non-injection to injection drug use dramatically increases the risk of transmitting HIV and other blood borne infections including hepatitis B virus (HBV) and hepatitis C virus (HCV). The aim of this study was to explore factors associated with the transition from first illicit drug use to first injection among drug users. Methods Using snowball sampling and convenience sampling through needle and syringe programmes (NSPs), we recruited 500 people who inject drugs (PWID) in Kermanshah, between September and December 2014. Trained interviewers collected data on socio-demographic characteristics, HIV testing and drug-related risk behaviors over the last month prior to interview using a structured questionnaire. Our main outcome variable was first illicit drug use to first injection (TIJ). TIJ was calculated by subtracting age at first drug injection from age of first illicit drug use. Results Overall, the average age at first drug use and injection were 21.4 [standard deviation (SD 5.6)] and 22.8 (SD 8.9), respectively. The average duration of injection was 6.0 (SD 4.6) years. Overall, the mean of TIJ for participants was 1.4 (IQR = 2, 4) years. Age of first injecting drug use negatively correlated with TIJ (R2 = 0.219, p = 0.001). Education level and socioeconomic status (SES), and negatively correlated with TIJ. Conclusion Some demographic factors and drug use characteristics including educational level, SES, knowledge of HIV status, age of initiating drug use, being a poly drug user and using methamphetamine were predictors of the time to transition.

Associations of the Neighborhood Environment With Substance Use: A Cross-sectional Investigation Among Patients in Compulsory Drug Detention Centers in Thailand

Objectives

To identify the associations of characteristics of the neighborhood environment with substance abuse among clients receiving treatment for drug abuse in Thailand.

Methods

A cross-sectional study was conducted of 1128 drug addicts from 28 neighborhoods who were receiving treatment at all 7 compulsory drug detention centers in Thailand. A trained interviewer conducted structured interviews with the subjects about substance use and the perceived neighborhood environment in their community. A multilevel logistic regression model was applied to estimate the effects of the neighborhood environment on substance use.

Results

The majority of participants, 53.8% only used methamphetamine pills, 31.3% used other illicit drugs as well as methamphetamine pills, and 14.9% used an illicit drug other than methamphetamine. Three neighborhood characteristics were associated with substance use. A 1-unit increase in the perceived neighborhood cohesion score was associated with a 15% reduction in methamphetamine pill use and an 11% reduction of the use of both methamphetamine pills and another illicit drug. Conversely, a 1-unit increase in perceived neighborhood crime predicted 19 and 14% increases in the use of methamphetamine pills and the use of both methamphetamine pills and another illicit drug, respectively. In addition, a 1-unit increase in the scores for stigma surrounding addiction corresponded to a 25% increase of the use of methamphetamine pills and a 12% increase in the use of both methamphetamine pills and another illicit drug.

Conclusions

Substance use among drug addicts was influenced by characteristics of the neighborhood environment. Therefore, prevention and intervention strategies should be designed based on a consideration of the impact of neighborhood context on substance use behaviors.

Transition from First Drug Use to Regular Injection among People Who Inject Drugs in Iran

BACKGROUND

The study aimed to evaluate the interval between first drug use and regular injection and factors associated with transition from first injection into premature regular injection among people who inject drugs (PWIDs).

METHODS

In a multicenter cross-sectional study, we recruited 400 PWIDs using snowball sampling. Age of first drug use, age of initiation of regular injection, and demographic and behavioral data were collected using face to face interview. Premature transition to regular injection was defined as initiation of regular injection within the five years of first injection. Data were analyzed using bivariate and multivariate logistic regression survey analysis.

FINDINGS

The mean age of first drug use and age of initiation of regular injection was 29.87 ± 6.54 years, respectively. Having history of sexual abuse in childhood [adjusted odds ratio (AOR) = 3.1], history of imprisonment (AOR = 3.4), use of heroin as the first drug (AOR = 4.3), and doing the first injection at friends' houses (AOR = 2.2) or in ruins (AOR = 2.2) significantly increased the chance of premature transition to regular injection, while being a female decreased the chance of premature transition to regular injection (AOR = 0.4). Compared to curiosity, being friend with a drug user (AOR = 0.4), having withdrawal symptoms (AOR = 0.2), and low cost of injection (AOR = 0.3) at the first occasion of drug injection reduced the chance of premature transition to regular injection.

CONCLUSION

New interventions to prevent injection initiation among drug users are needed and should be integrated in harm reduction programs.

Injection drug use among children and adolescents in India: Ringing the alarm bells

INTRODUCTION

Injection drug use (IDU) is intricately linked to preventive aspects for human immunodeficiency virus from a public health perspective. No large-scale data are yet available for injectable drug use among children and adolescents in India, apart from few anecdotal reports.

AIMS AND METHODS

The present paper reports on the profile and substance use pattern of 509 child IDU users, among a total sample of over 4000 children using substances across 100 sites from 27 states and 2 UTs in India. It was undertaken in 2012-2013 by the National Commission of Protection for Child Rights in collaboration with the National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi. For inclusion, participants had to be 18 years or less, should have used at least one other substance besides tobacco in the last 1 year, and should be living at home/street, in or out of school. Data were gathered using a 95-item semi-structured questionnaire.

RESULTS

A large proportion of ever users of IDU also reported use in the past year (96.5%) and past month (92.7%). Apart from IDU, tobacco, alcohol, cannabis, and pharmaceutical opioids were the most common substances of abuse in order of frequency. There was an interval of about 3 years from the initiation of tobacco to the initiation of IDU. Average age of onset for IDU was a year lesser in males than female users. The street children initiated IDU earlier than out-of-school and schoolgoing children. No quit attempt was made by more than half of the children. More than 40% had frequent familial conflicts, more than half had a familial history of substance use, and three-fourths had drug-using peers.

CONCLUSION

The paper highlights the profile and pattern of children and adolescents using IDU across many parts of India, dispelling the myth that IDU is largely an adult phenomenon in India. There is a clear need to promote different harm reduction and preventive strategies across the "hard-to-reach" younger age groups using injecting drugs.

Transition to injecting drug use in Iran: A systematic review of qualitative and quantitative evidence

BACKGROUND

Injection drug use, a behavior associated with significant adverse health effects, has been increasing over the past decade in Iran. This study aims to systematically review the epidemiological and qualitative evidence on factors that facilitate or protect the transition to injection drug use in Iran.

METHODS

We conducted electronic searches in five international (Medline, Web of Science, EMBASE, CINAHL, PsycINFO), one regional (IMEMR) and three Iranian (Iranmedex, Iranpsych, IranDoc) databases, as well as contacting experts in the field. Two trained researchers screened documents to identify relevant studies and independently dual-extracted data following pre-specified protocol. We applied principles of thematic analysis for qualitative data and applied a random effect meta-analysis model for age of first injection.

RESULTS

A total of 38 documents from 31 studies met eligibility criteria, from which more than 50% were implemented from 2006 to 2008. The weighted mean age of first injection was 25.8 (95% Confidence Interval: 25.3-26.2). Between 1998 and 2011, the age of first injection was relatively stable. Overall, drug users had used drugs for 6-7 years before they started injection use. Heroin was the first drug of injection in the majority of the cases. We identified factors influencing the initiation of or transition to injection use at various levels, including: (1) individual (pleasure-seeking behavior, curiosity and development of drug dependency commonly reported), (2) social and environmental (role of peer drug users in the first injection use, the economic efficiency associated with injections and the wide availability of injectable form of drugs in the market).

CONCLUSION

Harm reduction policies in Iran have almost exclusively focused on drug injectors in Iran. However, given the extent of the non-injection drug use epidemic, evidence from this study can provide insight on points of interventions for the prevention of the transition to injection use.

Factors associated with being asked to initiate someone into injection drug use

AIMS

Injection drug use initiation typically involves an established person who injects drugs (PWID) helping the injection-naïve person to inject. Prior to initiation, PWID may be involved in behaviors that elevate injection initiation risk for non-injectors such as describing how to inject and injecting in front of injection-naïve people. In this analysis, we examine whether PWID who engage in either of these behaviors are more likely to be asked to initiate someone into drug injection.

METHODS

Interviews with PWID (N = 602) were conducted in California between 2011 and 2013. Multivariate analysis was conducted to determine factors associated with being asked to initiate someone.

RESULTS

The sample was diverse in terms of age, race/ethnicity, and drug use patterns. Seventy-one percent of the sample had ever been asked to initiate someone. Being asked to initiate someone was associated with having injected in front of non-injectors (Adjusted Odds Ratio [AOR] = 1.80, 95% Confidence Interval [CI] = 1.12, 2.91), having described injection to non-injectors (AOR = 3.63; 95% CI = 2.07, 6.36), and doing both (AOR = 9.56; 95% CI = 4.43, 20.65) as compared to doing neither behavior (referent). Being female (AOR = 1.73; 95% CI = 1.10, 2.73) and non-injection prescription drug misuse in the last 30 days (AOR = 1.69; 95% CI = 1.12, 2.53) were also associated with having been asked to initiate someone.

CONCLUSION

Reducing initiation into injection drug use is an important public health goal. Intervention development to prevent injection initiation should include established PWID and focus on reducing behaviors associated with requests to initiate injection and reinforcing refusal skills and intentions among established PWID.

Selection of Variables that Influence Drug Injection in Prison: Comparison of Methods with Multiple Imputed Data Sets

BACKGROUND

Prisoners, compared to the general population, are at greater risk of infection. Drug injection is the main route of human immunodeficiency virus ý(HIV) transmission, in particular in Iran. What would be of interest is to determine variables that govern drug injection among prisoners. However, one of the issues that challenge model building is incomplete national data sets. In this paper, we addressed the process of model development when missing data exist.

METHODS

Complete data on 2720 prisoners was available. A logistic regression model was fitted and served as gold standard. We then randomly omitted 20%, and 50% of data. Missing date were imputed 10 times, applying multiple imputation by chained equations (MICE). Rubin's rule (RR) was applied to select candidate variables and to combine the results across imputed data sets. In S1, S2, and S3 methods, variables retained significant in one, five, and ten imputed data sets and were candidate for the multifactorial model. Two weighting approaches were also applied.

FINDINGS

Age of onset of drug use, recent use of drug before imprisonment, being single, and length of imprisonment were significantly associated with drug injection among prisoners. All variable selection schemes were able to detect significance of these variables.

CONCLUSION

We have seen that the performances of easier variable selection methods were comparable with RR. This indicates that the screening step can be used to select candidate variables for the multifactorial model.

The Age of Initiation of Drug Use and Sexual Behavior May Influence Subsequent HIV Risk Behavior: A Systematic Review

Researchers examining injection drug users (IDUs) in drug treatment have been trying for decades to determine the optimal way to intervene to prevent the transmission and spread of human immunodeficiency virus (HIV) in this population. Although efficacious HIV risk reduction interventions are widely available, questions remain about what specific factors are most related to HIV risk behavior and defined as unprotected sexual activity and/or high risk drug use. This review involved an evaluation of the research literature in order to better understand the association between drug use and sexual behavior debut on HIV risk behavior. Findings suggest that drug use debut and sexual behavior debut may be related to subsequent HIV risk behavior. Evidence to date implies that intervening at an earlier age to assist youth to avoid or delay these high risk behaviors may be an additional means of reducing subsequent HIV risk.

Neighborhood of residence and risk of initiation into injection drug use among street-involved youth in a Canadian setting

BACKGROUND

While research has suggested that exposure to environments where drug use is prevalent may be a key determinant of drug-related risk, little is known regarding the impact of such exposure on the initiation of illicit injection drug use. We assessed whether neighborhood of residence predicted rates of injecting initiation among a cohort of street-involved youth in Vancouver, British Columbia.

METHODS

We followed street-involved injecting naïve youth aged 14-26 and compared rates of injecting initiation between youth residing in Vancouver's Downtown Eastside (DTES) neighborhood (the site of a large street-based illicit drug market) to those living in other parts of the city. Univariate and multivariate Cox regression analyses were employed to determine whether residence in the DTES was independently associated with increased risk of initiation of injection drug use.

RESULTS

Between September, 2005 and November, 2011, 422 injection-naïve individuals were followed, among whom 77 initiated injecting for an incidence density of injecting of 10.3 (95% confidence interval [CI] 5.0-18.8) per 100 person years. In a multivariate model, residence in the DTES was independently associated with initiating injection drug use (adjusted hazard ratio [AHR]=2.16, 95% CI: 1.33-3.52, p=0.002).

CONCLUSIONS

These results suggest neighborhood of residence affects the risk of initiation into injection drug use among street-involved youth. The development of prevention interventions should target high-risk neighborhoods where risk of initiating into injecting drug use may be greatest.

Prevalence, correlates, and risk perception of HIV infection among heroin users in Central Taiwan

We investigated the prevalence and correlated factors of human immunodeficiency virus (HIV) among heroin users attending methadone maintenance treatment (MMT) programs in Central Taiwan, and explored the degree of risk perception of HIV infection among the participants. Our study participants were 781 heroin users seeking treatment at the MMT program at Tsaotun Psychiatric Center in Taiwan. The presence of HIV antibodies was identified by microparticle enzyme immunoassay and confirmed by western blot. Multivariate logistic regression was used to identify the independent correlates of HIV infection. The mean age of the sample was 36.1 years [standard deviation (SD) = 7.6]; of the patients, 710 (90.9%) were men. The prevalence of HIV infection among our study population was 20.7%. Multivariate logistic regression analysis revealed that HIV infection was independently associated with the age of the patients of initial heroin use, heroin injection use, nondrug-related criminal convictions, needle-sharing behaviors, and sharing injection paraphernalia. A strong agreement existed between self-reported HIV serostatus and the results of laboratory analyses, with 88.8% of patients reporting their condition correctly. We found a high rate of HIV infection among patients in the MMT program. Factors associated with HIV infection were mostly related to drug-use behaviors. These findings stress the importance of education regarding drug-risk behaviors.

Influence of pattern of missing data on performance of imputation methods: an example using national data on drug injection in prisons

BACKGROUND

Policy makers need models to be able to detect groups at high risk of HIV infection. Incomplete records and dirty data are frequently seen in national data sets. Presence of missing data challenges the practice of model development. Several studies suggested that performance of imputation methods is acceptable when missing rate is moderate. One of the issues which was of less concern, to be addressed here, is the role of the pattern of missing data.

METHODS

We used information of 2720 prisoners. RESULTS derived from fitting regression model to whole data were served as gold standard. Missing data were then generated so that 10%, 20% and 50% of data were lost. In scenario 1, we generated missing values, at above rates, in one variable which was significant in gold model (age). In scenario 2, a small proportion of each of independent variable was dropped out. Four imputation methods, under different Event Per Variable (EPV) values, were compared in terms of selection of important variables and parameter estimation.

RESULTS

In scenario 2, bias in estimates was low and performances of all methods for handing missing data were similar. All methods at all missing rates were able to detect significance of age. In scenario 1, biases in estimations were increased, in particular at 50% missing rate. Here at EPVs of 10 and 5, imputation methods failed to capture effect of age.

CONCLUSION

In scenario 2, all imputation methods at all missing rates, were able to detect age as being significant. This was not the case in scenario 1. Our results showed that performance of imputation methods depends on the pattern of missing data.

Socio-demographic factors, health risks and harms associated with early initiation of injection among people who inject drugs in Tallinn, Estonia: evidence from cross-sectional surveys

AIM

To explore socio-demographic factors, health risks and harms associated with early initiation of injecting (before age 16) among injecting drug users (IDUs) in Tallinn, Estonia.

METHODS

IDUs were recruited using respondent driven sampling methods for two cross-sectional interviewer-administered surveys (in 2007 and 2009). Bivariate and multivariate logistic regression analysis was used to identify factors associated with early initiation versus later initiation.

RESULTS

A total of 672 current IDUs reported the age when they started to inject drugs; the mean was 18 years, and about a quarter of the sample (n = 156) reported early initiation into injecting drugs. Factors significantly associated in multivariate analysis with early initiation were being female, having a lower educational level, being unemployed, shorter time between first drug use and injecting, high-risk injecting (sharing syringes and paraphernalia, injecting more than once a day), involvement in syringe exchange attendance and getting syringes from outreach workers, and two-fold higher risk of HIV seropositivity.

CONCLUSIONS

Our results document significant adverse health consequences (including higher risk behaviour and HIV seropositivity) associated with early initiation into drug injecting and emphasize the need for comprehensive prevention programs and early intervention efforts targeting youth at risk. Our findings suggest that interventions designed to delay the age of starting drug use, including injecting drug use, can contribute to reducing risk behaviour and HIV prevalence among IDUs.

Childhood sexual abuse and risk for initiating injection drug use: a prospective cohort study

OBJECTIVE

This study examined whether childhood sexual abuse predicts initiation of injection drug use in a prospective cohort of youth.

METHOD

From October 2005 to November 2010, data were collected from the At Risk Youth Study (ARYS), a prospective cohort study of street-involved youth in Vancouver, Canada. Inclusion criteria were age 14-26 years, no lifetime drug injection, and non-injection drug use in the month preceding enrollment. Participants were interviewed at baseline and semiannually thereafter. Cox regression was employed to identify risk factors for initiating injection.

RESULTS

Among 395 injection-naïve youth, 81 (20.5%) reported childhood sexual abuse. During a median follow-up of 15.9 months (total follow-up 606.6 person-years), 45 (11.4%) youth initiated injection drug use, resulting in an incidence density of 7.4 per 100 person-years. In univariate analyses, childhood sexual abuse was associated with increased risk of initiating injection (unadjusted hazard ratio [HR], 2.38; 95% confidence interval [CI], 1.29-4.38; p=0.006), an effect that persisted in multivariate analysis despite adjustment for gender, age, aboriginal ancestry and recent non-injection drug use (adjusted HR, 2.71; 95% CI, 1.42-5.20; p=0.003).

CONCLUSION

Childhood sexual abuse places drug users at risk for initiating injection. Addiction treatment programs should incorporate services for survivors of childhood maltreatment.

Correlates and contexts of US injection drug initiation among undocumented Mexican migrant men who were deported from the United States

Preventing the onset of injection drug use is important in controlling the spread of HIV and other blood borne infections. Undocumented migrants in the United States face social, economic, and legal stressors that may contribute to substance abuse. Little is known about undocumented migrants' drug abuse trajectories including injection initiation. To examine the correlates and contexts of US injection initiation among undocumented migrants, we administered quantitative surveys (N = 309) and qualitative interviews (N = 23) on migration and drug abuse experiences to deported male injection drug users in Tijuana, Mexico. US injection initiation was independently associated with ever using drugs in Mexico pre-migration, younger age at first US migration, and US incarceration. Participants' qualitative interviews contextualized quantitative findings and demonstrated the significance of social contexts surrounding US injection initiation experiences. HIV prevention programs may prevent/delay US injection initiation by addressing socio-economic and migration-related stressors experienced by undocumented migrants.

Prevalence of HCV risk behaviors among prison inmates: tattooing and injection drug use

Hepatitis C virus (HCV) is the most common blood-borne chronic viral infection in the United States and it is over represented in incarcerated populations. This study estimates if in prison tattooing is associated with self reported HCV infection in a probabilistic sample of 1,331 sentenced inmates in Puerto Rico prisons anonymously surveyed in 2004, who had previously been tested for HCV. Analysis were carried out with the total sample and among non-injectors (n=796) to control for injection drug use (IDU) and other confounders. Nearly 60% of inmates had acquired tattoos in prison. HCV was reported by 27% of subjects in the total sample and by 12% of non-injectors who had undergone tattoos in prison. IDU was the strongest predictor of HCV in the total sample (OR=5.6, 95% CI=3.2-9.7). Among non injectors, tattooing with reused needles or sharp objects and/ or reusing ink was positively associated with HCV self-report (OR=2.6, 95% CI=1.3-5.5). Tattooing is a common occurrence in this prison setting. Findings suggest that preventive interventions are required to reduce the risk of HCV transmission through unsterile tattooing and injection practices.

Socio-demographic and drug use factors associated with HIV-1 recombinants and dual infections in Northern Thai drug users: associations of risk with genetic complexity

BACKGROUND

Dual infection with diverse HIV strains can foster the emergence of recombinants. The resulting increase in viral genetic diversity is a major challenge for vaccine development HIV treatment. In this study we aim to investigate the socio demographic factors associated with an increasing level of genetic diversity among HIV strains in a population of drug-users in Northern Thailand.

METHODS

From 1999 through 2000, 2231 volunteers were enrolled in the Opiate-Users Research in Chiang Mai, Thailand. HIV subtype analysis was conducted among those HIV-1 seropositive (n=347) using a multi-region hybridization assay. Social and demographic variables were assessed using a structured questionnaire.

RESULTS

Overall, 336/347 (96.8%) of the samples could be typed. 81.8% were CRF01_AE, 3.9% were subtype B, 9.2% were recombinants (mostly between CRF01_AE and B) and 5.1% were dual infections. Dual infections were more frequent among those with a lower education level (AOR: 5.2; 95% CI 1.4-20.3), those who have initiated injecting in the last 3 years (AOR: 3.9; 95% CI 1.1-14.6), and those reporting frequent needle sharing in the last 3 months (AOR: 7.0; 95% CI 1.5-34.1). Both recombinant strains and dual infection were more frequent among those reporting frequent needle sharing in the last 3 months (AOR: 5.3; 95% CI 1.6-17.1).

CONCLUSION

To limit the expanding complexity of HIV-1 strains, early intervention should be aimed at reduction in needle sharing, especially among new intravenous drug users.

Predictors of incident and recurrent participation in the sale or delivery of drugs for profit amongst young methamphetamine users in Chiang Mai Province, Thailand, 2005-2006

BACKGROUND

Despite Thailand's war on drugs, methamphetamine ("yaba" in Thai) use and the drug economy both thrive. This analysis identifies predictors of incident and recurrent involvement in the sale or delivery of drugs for profit amongst young Thai yaba users.

METHODS

Between April 2005 and June 2006, 983 yaba users, ages 18-25, were enrolled in a randomized behavioural intervention in Chiang Mai Province (415 index and 568 of their drug network members). Questionnaires administered at baseline, 3-, 6-, 9-, and 12-month follow-up visits assessed socio-demographic factors, current and prior drug use, social network characteristics, sexual risk behaviours and drug use norms. Exposures were lagged by three months (prior visit). Outcomes included incident and recurrent drug economy involvement. Generalized linear mixed models were fit using GLIMMIX (SASv9.1).

RESULTS

Incident drug economy involvement was predicted by yaba use frequency (adjusted odds ratio [AOR]: 1.05; 95% confidence interval [CI]: 1.01, 1.10), recent incarceration (AOR: 2.37; 95% CI: 1.07, 5.25) and the proportion of yaba-using networks who quit recently (AOR: .34; 95% CI: .15, .78). Recurrent drug economy involvement was predicted by age (AOR: 0.81; 95% CI: 0.68, 0.96), frequency of yaba use (AOR: 1.06; 95% CI: 1.02, 1.09), drug economy involvement at the previous visit (AOR: 2.61; CI: 1.59, 4.28), incarceration in the prior three months (AOR: 2.29; 95% CI: 1.07, 4.86), and the proportion of yaba-users in his/her network who quit recently (AOR: .38; 95% CI: .20, .71).

CONCLUSION

Individual drug use, drug use in social networks and recent incarceration were predictors of incident and recurrent involvement in the drug economy. These results suggest that interrupting drug use and/or minimizing the influence of drug-using networks may help prevent further involvement in the drug economy. The emergence of recent incarceration as a predictor for both models highlights the need for more appropriate drug rehabilitation programmes and demonstrates that continued criminalization of drug users may fuel Thailand's yaba epidemic.

Initiation to drug injection among street youth: a gender-based analysis

OBJECTIVE(S)

To estimate the incidence rate of initiation into drug injection and to identify predictors of initiation into drug injection separately among street girls and boys.

DESIGN

Data from two consecutive prospective street youth cohort studies (1995-2001 and 2001-2005) were used to conduct these analyses, stratified by gender.

METHODS

Data were collected using semi-annual interviewer-administered questionnaires. Variables from the following domains were considered in Cox regression models: socio-demographic characteristics, early and current substance abuse, marginalization, childhood traumatic sexual events and injection exposure.

RESULTS

Of the 946 youth who had never injected drugs at study entry, 86.4% completed at least two questionnaires representing 243 girls and 574 boys. Incidence rates of injection of 7.0 and 5.9 per 100 person-years were observed among these girls and boys respectively. Among girls, cocaine or crack use (adjusted hazard ratio (AHR)=1.97), heroin use (AHR=2.86), homelessness (AHR=2.49) and hanging out regularly with people who inject (AHR=4.46) all independently increased risk of first injection. Among boys, age decreased risk of initiating injection (AHR=0.90/year), while cocaine or crack use (AHR=2.14), heroin use (AHR=3.56), homelessness before age 16 (AHR=1.68), incest or rape before age 14 (AHR=1.98) and hanging out regularly with people who inject (AHR=1.66) all independently increased this risk.

CONCLUSIONS

Our findings suggest similar rates of initiation among girls and boys; however, factors associated with initiation vary by gender. This might lead to the design of more effective programs to prevent initiation into drug injection.

Neighborhood perceptions and parent outcomes in family based prevention programs for Thai adolescents: the role of program engagement

Due to concerns over Thai adolescent risky behaviors, effective prevention strategies are needed. Determining the role neighborhood context plays in program engagement and outcomes may inform these strategies. This study includes 170 mother-adolescent pairs (M = 13.44, SD = .52) in Bangkok, Thailand in a prevention program for adolescent substance use and sexual risk. Neighborhoods were related to engagement, which was critical to outcomes. Neighborhood disorganization was related to confidence in program effects and program completion. Completion was related to increased ATOD communication. Neighborhood cohesion was related to less program enjoyment, while neighborhood social control was related to more enjoyment. Enjoyment was related to increased ATOD communication and formation and monitoring of alcohol rules. Prevention strategies should focus on neighborhood contexts and enhancing engagement.

The characteristics and risk factors for HIV infection among Beijing drug users in different settings

BACKGROUND

Treatment for drug addiction in China can take place in mandatory detoxification centers (MDC), voluntary detoxification centers (VDC), or at outreach programs located in the community. To date little is known about HIV prevalence or associated risk factors among the current and past drug users (DU) in each setting.

METHODS

Cross-sectional surveys were conducted at three different settings in Beijing, China; 795 subjects were enrolled at MDC, 824 at VDC, and 520 within the community. Subjects who provided informed consent took part in face-to-face interviews and provided blood samples for HIV and syphilis testing.

RESULTS

Significant differences were found across enrollment sites in terms of demographic, drug use and sexual behavior characteristics. Overall HIV sero-prevalence was 2.9%, and was particularly high in MDC (5.2% versus 1.0% in VDC and 2.3% among community drug users). Adjusted odds ratios (OR) for HIV infection were 50.5 (95% CI: 19.07-133.85) for being of Yi ethnicity, 29.4 (95% CI: 15.10-57.24) for Uyghur ethnicity, 3.4 (95% CI: 1.57-7.52) for injection drug users who did not share equipment, and 18.8 (95% CI: 8.31-42.75) among injection drug users who shared injection equipment.

CONCLUSIONS

The vast differences among DU in various enrollment sites in terms of demographic characteristics, socioeconomic status, and HIV related risk profiles underscore the importance of familiarity with population characteristics and drug user environment to better inform targeted prevention programs. Prevention programs targeting DU in Chinese settings must also consider differences in ethnicities, culture, and residential status.

Meth/amphetamine use and associated HIV: Implications for global policy and public health

Amphetamine type stimulants (ATS) have become the focus of increasing attention worldwide. There are understandable concerns over potential harms including the transmission of HIV. However, there have been no previous global reviews of the extent to which these drugs are injected or levels of HIV among users. A comprehensive search of the international peer-reviewed and grey literature was undertaken. Multiple electronic databases were searched and documents and datasets were provided by UN agencies and key experts from around the world in response to requests for information on the epidemiology of use. Amphetamine or methamphetamine (meth/amphetamine, M/A) use was documented in 110 countries, and injection in 60 of those. Use may be more prevalent in East and South East Asia, North America, South Africa, New Zealand, Australia and a number of European countries. In countries where the crystalline form is available, evidence suggests users are more likely to smoke or inject the drug; in such countries, higher levels of dependence may be occurring. Equivocal evidence exists as to whether people who inject M/A are at differing risk of HIV infection than other drug injectors; few countries document HIV prevalence/incidence among M/A injectors. High risk sexual behaviour among M/A users may contribute to increased risk of HIV infection, but available evidence is not sufficient to determine if the association is causal. A range of possible responses to M/A use and harm are discussed, ranging from supply and precursor control, to demand and harm reduction. Evidence suggests that complex issues surround M/A, requiring novel and sophisticated approaches, which have not yet been met with sufficient investment of time or resources to address them. Significant levels of M/A in many countries require a response to reduce harms that in many cases remain poorly understood. More active models of engagement with M/A users and provision of services that meet their specific needs are required.

Killing time with enjoyment: a qualitative study of initiation into injecting drug use in north-east India

Manipur and Nagaland are north-east Indian states characterized by a high prevalence of injecting drug use and HIV in a context of socio-economic underdevelopment and political instability. This qualitative study aims to increase understanding of the contextual factors associated with initiation into injecting drug use in these two states. Forty semi-structured in-depth interviews were conducted among injecting drug users (10 women, 30 men) aged 18-28 years in mid-2006. The interview transcripts were thematically analyzed. All participants were initiated into injecting by another person, most commonly a friend and often in the context of well-established social networks. Most were poly-drug users and unsafe injecting practices were frequently associated with the initiation experience. The subjective reasons for deciding to inject were pleasure-seeking, influence of peers, and economic reasons. We hypothesize that initiation into injecting in this part of the world is also linked to ideas of masculinity, and that young men engage in drug use in order to fill a social vacuum created by limited opportunities to meaningfully engage in adult roles within the community. The findings from this study suggest that harm reduction programs need to target (noninjecting) drug users, and that existing social networks could be creatively used to extend the reach of these programs.

Circumstances of first crystal methamphetamine use and initiation of injection drug use among high-risk youth

BACKGROUND

Despite the widely noted increase in crystal methamphetamine (CM) use, there are few studies on circumstances of first CM use or correlates of use among high-risk populations (e.g. street-involved youth).

METHODS

Street-involved youth in Vancouver, Canada, were enrolled in the At-Risk Youth Study (ARYS) prospective cohort. Extensive outreach produced a representative sample of Vancouver street youth who use illicit drugs. We examined circumstances of first CM use and factors associated with CM use among the cohort.

RESULTS

Among 478 participants, 339 (70.9%) had used CM previously. Despite intensive covariate adjustment, a history of CM use was associated independently with having initiated injection drug use [OR = 3.15 (95% CI: 1.89-5.2); p < 0.001]. Among those who had used CM, route of first administration included: 11 (3.2%) oral ingestion; 25 (7.4%) injected; 105 (31.0%) snorted; 231 (68.1%) smoked. The proportion of respondents reporting current CM injection was significantly greater than the proportion reporting injection as the route for first CM use (18.3% vs. 7.4%; McNemar's test p < 0.001). Ability to obtain CM the first time was reported as 'very easy' or 'easy' by 93.5% and 5.3% of participants, respectively.

CONCLUSIONS

Crystal methamphetamine use was independently associated with injection drug use, and significant increases in injecting as the primary mode of administration were observed when patterns of use were considered longitudinally. The easy accessibility of CM and its common use during transition into injection drug use demonstrate the need for innovative drug policy to address this growing concern.

My first time: initiation into injecting drug use in Manipur and Nagaland, north-east India

Background

The north-east Indian states of Manipur and Nagaland are two of the six high HIV prevalence states in the country, and the main route of HIV transmission is injecting drug use. Understanding the pathways to injecting drug use can facilitate early intervention with HIV prevention programs. While several studies of initiation into injecting drug use have been conducted in developed countries, little is known about the situation in developing country settings. The aim of this study was to increase understanding of the contextual factors associated with initiation into injecting drug use in north-east India, and the influence of these factors on subsequent initiation of others.

Method

In mid 2006 a cross-sectional survey among 200 injecting drug users (IDUs) was undertaken in partnership with local NGOs that provide HIV prevention and care services and advocacy for IDUs in Imphal, Manipur and Dimapur, Nagaland. The questionnaire elicited detailed information about the circumstances of the first injection and the contexts of participants' lives. Demographic information, self-reported HIV status, and details about initiation of others were also recorded.

Results

Initiation into injecting drug use occurred at 20 years of age. The drugs most commonly injected were Spasmo-proxyvon (65.5%) and heroin (30.5%). In 53.5% cases, a needle belonging to someone else was used. Two-thirds (66.7%) had used the drug previously, and 91.0% had known other IDUs prior to initiation (mean = 7.5 others). The first injection was usually administered by another person (94.5%), mostly a friend (84.1%). Initiation is a social event; 98% had others present (mean = 2.7 others). Almost 70% of participants had initiated at least one other (mean = 5 others). Initiation of others was independently associated with being male and unemployed; having IDU friends and using alcohol around the time of initiation; and having been taught to inject and not paid for the drug at the time of initiation.

Conclusion

Targeting harm reduction messages to (non-injecting) drug users and capitalising on existing IDU social networks to promote safe injecting and deter initiation of others are possible strategies for reducing the impact of injecting drug use and the HIV epidemic in north-east India.

Co-infection with human immunodeficiency virus and tuberculosis in Asia

Asia has the highest numbers of tuberculosis cases (60% of the global total) and has experienced a marked rise in HIV seroprevalence (22% of the global total) in key subpopulations of these highly populous nations. Thus, co-infected patients are a challenge for practitioners and public health workers alike. The U.S.-Japan Cooperative Medical Science Program is spearheading interdisciplinary collaborations in Asia to address the many outstanding research priorities for HIV-tuberculosis co-infection. There is an urgency to this agenda for many reasons, including the frequency with which tuberculosis accounts for the death of HIV-infected persons in Asia, and the continued rise of multiple drug-resistant Mycobacterium tuberculosis. We review briefly the public health situation in Asia, highlighting research questions from US-Japan-Asian partner joint meetings, and cite salient studies to indicate trends and challenges.