Controlling HIV epidemics among injection drug users: eight years of Cross-Border HIV prevention interventions in Vietnam and China

The Impact of Needle and Syringe Exchange Programs on HIV-Related Risk Behaviors in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis Examining Individual- Versus Community-Level Effects

We conducted a systematic review and meta-analysis of the impact of needle and syringe exchange programs (NSP) on both individual- and community-level needle-sharing behaviors and other HIV-related outcomes in low- and middle-income countries (LMIC). A search of five databases for peer-reviewed trial or quasi-experimental studies reported through July 2021 identified 42 interventions delivered in 35 studies, with a total of 56,751 participants meeting inclusion criteria. Random-effects meta-analysis showed a significant protective association between NSP exposure and needle-sharing behaviors at the individual-level (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.16-0.39, 8 trials, n = 3947) and community-level (OR 0.39, CI 0.22-0.69, 12 trials, n = 6850), although with significant heterogeneity. When stratified by needle-sharing directionality, NSP exposure remained associated with reduced receptive sharing, but not distributive sharing. NSP exposure was also associated with reduced HIV incidence and increased HIV testing but there were no consistent associations with prevalence of bloodborne infections. Current evidence suggests positive impacts of NSPs in LMICs.

Interventions to prevent HIV and Hepatitis C among people who inject drugs: Latest evidence of effectiveness from a systematic review (2011 to 2020)

BACKGROUND

Hepatitis C virus (HCV) and HIV remain prevalent among people who inject drugs (PWID) and transmission is usually associated with injecting risk behaviour (IRB). We update a 2011 review of reviews (RoR) to assess the latest evidence on the effectiveness of harm reduction interventions - drug treatment (including opioid agonist therapy [OAT]), needle and syringe programmes (NSP) and other interventions - in the prevention of HCV and HIV transmission, and related measures of infection risk (IRB and injecting frequency [IF]), among PWID.

METHODS

We undertook an initial search for systematic reviews (i.e. an Overview of Reviews [OoR]) and subsequent systematic searches for primary studies where required. Where there was sufficient evidence based on synthesis of multiple robust studies for an intervention effect in the 2011 RoR, new evidence was not sought. Medline, CINAHL, The Cochrane Library, EMBASE, PsycINFO and Web of Science were searched (2011-2020). Two reviewers screened papers, extracted data, and graded reviews/studies. We classified evidence as 'sufficient', 'tentative', 'insufficient', or 'no evidence'.

RESULTS

We screened 8513 reviews and 7133 studies, with 27 and 61 identified as relevant, respectively. The level of evidence increased since the 2011 RoR and is now 'sufficient' for OAT (regarding all outcomes), NSP (for reducing HIV transmission and IRB), and combination OAT/NSP (for reducing HCV transmission). There is also now sufficient evidence for in-prison OAT, psychosocial interventions, pharmacy-based NSP and provision of sterile drug preparation equipment for reducing IRB.

CONCLUSION

There is now a strong body of empirical evidence for the effectiveness of OAT and NSP, alone and in combination, in reducing IRB, and HCV and HIV transmission. However, there is still a relative lack of evidence for other interventions, including heroin-assisted treatment, pharmacological treatment for stimulant dependence, contingency management, technology-based interventions, low dead space syringes and drug consumption rooms on HCV or HIV risk.

Promising outcomes from a cognitive behavioral therapy text-messaging intervention targeting drug use, antiretroviral therapy adherence, and HIV risk behaviors among adults living with HIV and substance use disorders

BACKGROUND

To date, no studies have reported the use of text messaging to deliver cognitive behavioral therapy (CBT) to people living with HIV and substance use disorders.

OBJECTIVE

We developed and evaluated a 12-week, CBT-based text-messaging intervention (TXT-CBT) targeting drug use and adherence to antiretroviral therapy (ART) for adults with HIV and comorbid opioid and stimulant use disorders.

MATERIALS AND METHODS

Participants were randomly assigned to receive either TXT-CBT (n = 25) or an informational pamphlet (INFO) discussing substance use and medication adherence (n = 25). ART adherence, drug use, and HIV-risk behaviors were assessed at baseline, monthly during treatment, and treatment-end, and were compared between groups using a mixed-model repeated-measures analysis. Injection drug use was examined as a moderator of outcomes.

RESULTS

Relative to the INFO group, TXT-CBT participants evidenced increased ART adherence, measured by phone-based unannounced pill counts and biochemically by viral load and CD4 count. TXT-CBT participation was also associated with reductions in opioid use and HIV risk behaviors. While reductions in cocaine use were observed in the TXT-CBT group, relative to the INFO group, other stimulant use did not change. Among people who inject drugs, TXT-CBT produced increases in ART adherence and corresponding changes in viral load, relative to injection drug users in the control condition.

CONCLUSIONS

Findings demonstrated promising preliminary evidence for the efficacy of TXT-CBT in improving ART adherence and reducing drug use and HIV-risk behaviors among people with HIV infection and comorbid opioid and stimulant use disorders.

Peer-delivered services for substance use in low- and middle-income countries: A systematic review

BACKGROUND AND AIMS

Addressing the burden of disease associated with substance use is a global priority, yet access to treatment is limited, particularly in low- and middle-income countries (LMICs). Peers, individuals with lived experience of substance use, may play an important role in expanding access to treatment, supporting outcomes, and reducing stigma. While peer-delivered services for substance use have been scaling up in high-income countries (HICs), less is known about their application in LMICs. This systematic review synthesizes the evidence of peer-delivered services for substance use in LMICs.

METHODS

PsycINFO, Embase, Global Health, PubMed, and six region-specific databases were searched, and articles that described peer-delivered services for substance use and related outcomes in LMICs were included. Risk of bias was evaluated using tools appropriate for each study design. To provide a more stringent evaluation of structured interventions, a subset of articles was analyzed using the Cochrane Effective Practice and Organization of Care (EPOC) framework.

RESULTS

The search yielded 6540 articles. These were narrowed down to 34 included articles. Articles spanned four continents, included quantitative and qualitative methodologies, and primarily targeted infectious disease risk behaviors. Ten articles were included in the EPOC sub-analysis. In the context of high risk of bias, some of these articles demonstrated positive impacts of the peer-delivered services, including reductions in risk behaviors and increases in infectious disease knowledge scores, while many others showed no significant difference in outcomes between peer intervention and control groups.

CONCLUSIONS

Peer-delivered services may be feasible for addressing substance use and reducing infectious disease risk behaviors in LMICs, where there are severe human resource shortages. Globally, peers' lived experience is valuable for engaging patients in substance use treatment and harm reduction services. Further research is needed to better characterize and quantify outcomes for peer-delivered services for substance use in LMICs.

Peer driven or driven peers? A rapid review of peer involvement of people who use drugs in HIV and harm reduction services in low- and middle-income countries

Introduction

Peer involvement of people who use drugs within HIV and harm reduction services is widely promoted yet under-utilised. Alongside political and financial barriers is a limited understanding of the roles, impacts, contexts and mechanisms for peer involvement, particularly in low- and middle-income settings. We conducted a rapid review of available literature on this topic.

Methods

Within a community-academic partnership, we used a rapid review approach, framed by realist theory. We used a network search strategy, focused on core journals and reference lists of related reviews. Twenty-nine studies were included. We developed thematic summaries framed by a realist approach of exploring interventions, their mechanisms, outcomes and how they are shaped by contexts.

Results

Reported outcomes of peer involvement included reduced HIV incidence and prevalence; increased service access, acceptability and quality; changed risk behaviours; and reduced stigma and discrimination. Mechanisms via which these roles work were trust, personal commitment and empathy, using community knowledge and experience, as well as ‘bridge’ and ‘role model’ processes. Contexts of criminalisation, under-resourced health systems, and stigma and discrimination were found to shape these roles, their mechanisms and outcomes. Though contexts and mechanisms are little explored within the literature, we identified a common theme across contexts, mechanisms and outcomes. Peer outreach interventions work through trust, community knowledge and expertise, and ‘bridge’ mechanisms (M) to counter criminalisation and constraining clinic and service delivery environments (C), contributing towards changed drug-using behaviours, increased access, acceptability and quality of harm reduction services and decreased stigma and discrimination (O).

Conclusion

Peer involvement in HIV and harm reduction services in low- and middle-income settings is linked to positive health outcomes, shaped by contexts of criminalisation, stigma, and resource scarcity. However, peer involvement is under-theorised, particularly on how contexts shape mechanisms and ultimately outcomes. Efforts to study peer involvement need to develop theory and methods to evaluate the complex mechanisms and contexts that have influence. Finally, there is a need to expand the range of peer roles, to embrace the capacities and expertise of people who use drugs.

Towards Targeted Interventions in Low- and Middle-Income Countries: Risk Profiles of People Who Inject Drugs in Haiphong (Vietnam)

People who inject drugs (PWID) are a dominant risk group afflicted by blood-borne viruses, mental health disorders, and social precariousness. Risk reduction interventions are administered to PWID regardless of their characteristics or specific risks. The objective of this cross-sectional analysis was to empirically identify profiles of PWID regarding their drug use, risk behaviors, and mental health in order to tailor adapted interventions taking into account limited access to comprehensive care in middle-income countries. PWID were recruited using respondent-driven sampling. PWID with urine testing positive for heroin or methamphetamine and manifesting recent skin injection marks were enrolled. Classification of participants was based on drug use, injection, risky sexual behavior, and mental health data. This was subjected to multiple correspondence analysis followed by hierarchical cluster analysis combined with K-means methodology. From October 2016 to January 2017, 1490 participants were recruited of which 1383 were eligible and enrolled. HCV prevalence was 70.5% and HIV prevalence 29.4%. The cluster analysis identified five distinct profiles: profile 1: recent injection practices and high alcohol consumption, profile 2: at-risk injection and sexual behaviors with precarious situations, profile 3: no sexual activity and older age, profile 4: frequent injections with high methamphetamine use, and profile 5: stable partnerships and less frequent injections. Our study has identified profiles of PWID at particularly high risks, and they should thus be targeted for interventions tailored to their specific risks.

Peer education for HIV prevention among high-risk groups: a systematic review and meta-analysis

Background

Peer education has become a strategy for health promotion among high-risk groups for HIV infection worldwide. However, the extent to which peer education could have an impact on HIV prevention or the long-term effect of this impact is still unknown. This study thus quantifies the impact of peer education over time among high-risk HIV groups globally.

Method

Following the PRISMA guidelines, a systematic review and meta-analysis was used to assess the effects and duration of peer education. A thorough literature search of PubMed, Web of Science, Embase and Cochrane Library was performed, and studies about peer education on high-risk HIV groups were reviewed. Pooled effects were calculated and the sources of heterogeneity were explored using meta-regression and subgroup analysis.

Results

A total of 60 articles with 96,484 subjects were identified, and peer education was associated with 36% decreased rates of HIV infection among overall high risk groups (OR: 0.64; 95%CI: 0.47–0.87). Peer education can promote HIV testing (OR = 3.19; 95%CI:2.13,4.79) and condom use (OR = 2.66, 95% CI: 2.11–3.36) while reduce equipment sharing (OR = 0.50; 95%CI:0.33,0.75) and unprotected sex (OR = 0.82; 95%CI: 0.72–0.94). Time trend analysis revealed that peer education had a consistent effect on behavior change for over 24 months and the different follow-up times were a source of heterogeneity.

Conclusion

Our study shows that peer education is an effective tool with long-term impact for behavior change among high-risk HIV groups worldwide. Low and middle-income countries are encouraged to conduct large-scale peer education.

Adapting a peer recovery coach-delivered behavioral activation intervention for problematic substance use in a medically underserved community in Baltimore City

Low-income, racial/ethnic minority groups have disproportionately high rates of problematic substance use yet face barriers in accessing evidence-based interventions (EBIs). Peer recovery coaches (PRCs), individuals with lived experience with problematic substance use, may provide an effective approach to reaching these individuals. Traditionally PRCs have focused on bridging to other types of care rather than delivering EBIs themselves. The aim of this study was to assess perceptions of the appropriateness of a PRC-delivered adapted behavioral activation (BA) intervention to reduce problematic substance use for individuals not engaged in care. This study was conducted at a community resource center in Baltimore, Maryland serving low-income and homeless clients who have high rates of problematic substance use yet also face barriers to accessing care. Guided by the ADAPT-ITT framework, we conducted semi-structured key informant interviews with clients (n = 30) with past or present problematic substance use, and a focus group with community providers, including staff at the community resource center (n = 5) and PRCs (n = 6) from the community. Thirty percent (n = 9) of clients interviewed reported past problematic substance use and 70% (n = 21) met criteria for current use, most commonly cocaine and opioids. Clients, center staff, and PRCs shared that PRC-delivered BA could be acceptable and appropriate with suggested adaptations, including adding peer-delivered case-management and linkage to care alongside BA, and tailoring BA to include activities that are accessible and feasible in the community. These findings will inform the adaptation of PRC-delivered BA to address problematic substance use in this setting.

Effectiveness of community outreach HIV prevention programs in Vietnam: a mixed methods evaluation

BACKGROUND

In 2014, Vietnam was the first Southeast Asian country to commit to achieving the World Health Organization's 90-90-90 global HIV targets (90% know their HIV status, 90% on sustained treatment, and 90% virally suppressed) by 2020. This pledge represented further confirmation of Vietnam's efforts to respond to the HIV epidemic, one feature of which has been close collaboration with the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). Starting in 2004, PEPFAR supported community outreach programs targeting high-risk populations (people who inject drugs, men who have sex with men, and sex workers). To provide early evidence on program impact, in 2007-2008 we conducted a nationwide evaluation of PEPFAR-supported outreach programs in Vietnam. The evaluation focused on assessing program effect on HIV knowledge, high-risk behaviors, and HIV testing among high-risk populations-results relevant to Vietnam's push to meet global HIV goals.

METHODS

We used a mixed-methods cross-sectional evaluation design. Data collection encompassed a quantitative survey of 2199 individuals, supplemented by 125 in-depth interviews. Participants were members of high-risk populations who reported recent contact with an outreach worker (intervention group) or no recent contact (comparison group). We assessed differences in HIV knowledge, risky behaviors, and HIV testing between groups, and between high-risk populations.

RESULTS

Intervention participants knew significantly more about transmission, prevention, and treatment than comparison participants. We found low levels of injection drug-use-related risk behaviors and little evidence of program impact on such behaviors. In contrast, a significantly smaller proportion of intervention than comparison participants reported risky sexual behaviors generally and within each high-risk population. Intervention participants were also more likely to have undergone HIV testing (76.1% vs. 47.0%, p < 0.0001) and to have received pre-test (78.0% vs. 33.7%, p < 0.0001) and post-test counseling (80.9% vs. 60.5%, p < 0.0001). Interviews supported evidence of high impact of outreach among all high-risk populations.

CONCLUSIONS

Outreach programs appear to have reduced risky sexual behaviors and increased use of HIV testing services among high-risk populations in Vietnam. These programs can play a key role in reducing gaps in the HIV care cascade, achieving the global 90-90-90 goals, and creating an AIDS-free generation.

Working With Persons Who Inject Drugs and Live in Rural Areas: Implications From China/Vietnam for the USA

PURPOSE OF REVIEW

To describe a small city/rural area HIV prevention project (the Cross Border Project) implemented in Ning Ming County, Guangxi Province, China, and Lang Son province, Vietnam, and consider its implications for addressing the opioid/heroin epidemic in small cities/rural areas in the USA. The description and the outcomes of the Cross Border project were taken from published reports, project records, and recent data provided by local public health authorities. Evaluation included serial cross-sectional surveys of people who inject drugs to assess trends in risk behaviors and HIV prevalence. HIV incidence was estimated from prevalence among new injectors and through BED testing.

RECENT FINDINGS

The Cross Border project operated from 2002 to 2010. Key components of the project 2 included the use of peer outreach workers for HIV/AIDS education, distribution of sterile injection equipment and condoms, and collection of used injection equipment. The project had the strong support of local authorities, including law enforcement, and the general community. Significant reductions in risk behavior, HIV prevalence, and estimated HIV incidence were observed. Community support for the project was maintained. Activities have been continued and expanded since the project formally ended. The Cross Border project faced challenges similar to those occurring in the current opioid crisis in US small cities/rural areas: poor transportation, limited resources (particularly trained staff), poverty, and potential community opposition to helping people who use drugs. It should be possible to adapt the strategies used in the Cross Border project to small cities/rural areas in the US opioid epidemic.

Elimination of HIV transmission through novel and established prevention strategies among people who inject drugs

Despite the effectiveness of existing HIV prevention strategies for people who inject drugs (PWID), uncontrolled outbreaks of HIV among this group are common and occur around the world. In this Review, we summarise recent evidence for novel and established HIV prevention approaches to eliminate HIV transmission among PWID. Effective HIV prevention strategies include mobile needle and syringe programmes, pre-exposure prophylaxis, supervised injection facilities, and, to a lesser extent, some behavioural interventions. Studies have also shown the cost-effectiveness of long-standing HIV prevention strategies including needle and syringe programmes, opioid agonist therapy, and antiretroviral therapy for prevention. Although each individual intervention can reduce the risk of HIV acquisition among PWID, there is a consensus that a combination of approaches is required to achieve substantial and durable reductions in HIV transmission. Unfortunately, in many settings, the implementation of these interventions is often limited by public and political opposition that manifests as structural barriers to HIV prevention, such as the criminalisation of drug use. Given that there is ample evidence showing the effectiveness of several HIV prevention methods, social and political advocacy will be needed to overcome these barriers and integrate innovative HIV prevention approaches with addiction science to create effective drug policies.

Injection Drug Use Trajectories among Migrant Populations: A Narrative Review

BACKGROUND

Dual epidemics of injection drug use and blood-borne disease, characterized as "syndemics," are present in a range of settings. Behaviors that drive such syndemics are particularly prevalent among mobile drug-using populations, for whom cross-border migration may pose additional risks.

OBJECTIVES

This narrative review aims to characterize the risk factors for injection drug use initiation associated with migration, employing a risk environment framework and focusing on the San Diego-Tijuana border region as the most dynamic example of these phenomena.

METHODS

Based on previous literature, we divide migration streams into three classes: intra-urban, internal, and international. We synthesized existing literature on migration and drug use to characterize how mobility and migration drive the initiation of injection drug use, as well as the transmission of hepatitis and HIV, and to delineate how these might be addressed through public health intervention.

RESULTS

Population mixing between migrants and receiving communities and the consequent transmission of social norms about injection drug use create risk environments for injection drug use initiation. These risk environments have been characterized as a result of local policy environments, injection drug use norms in receiving communities, migration-related stressors, social dislocation, and infringement on the rights of undocumented migrants.

CONCLUSION

Policies that exacerbate risk environments for migrants may inadvertently contribute to the expansion of epidemics of injection-driven blood-borne disease. Successful interventions that address emerging syndemics in border regions may therefore need to be tailored to migrant populations and distinguish between the vulnerabilities experienced by different migration classes and border settings.

Prevalence and correlates of HIV infection among men who inject drugs in a remote area of Vietnam

Background

Lack of information on the HIV epidemic among men who inject drugs (MWID) in northwestern Vietnam, a remote area, may hamper national efforts to control the disease. We examined HIV prevalence, needle–syringe sharing behaviors, and associated factors among MWID in three areas of northwestern Vietnam.

Methods

We used descriptive analysis to report the characteristics, frequency of risk behaviors, and of access to healthcare services among the MWID. Univariable logistic regression was used to assess the associations between the HIV infection, needle–syringe sharing behaviors, and their independent variables. We further explored these associations in multivariable analyses where we included independent variables based on a priori knowledge and their associations with the dependent variables determined in univariable analyses (p <  0.25).

Results

The HIV prevalence was 37.9, 16.9, and 18.5% for Tuan Giao, Bat Xat, and Lao Cai City, respectively, and 25.4% overall. MWID of Thai minority ethnicity were more likely to be HIV-positive (adjusted odds ratio (AOR) 3.55; 95% confidence interval (CI) 1.84–6.87). The rate of needle–syringe sharing in the previous 6 months was approximately 9% among the MWID in Tuan Giao and Lao Cai City, and 27.8% in Bat Xat. Two thirds of the participants never underwent HIV testing before this study. Ever having been tested for HIV before this study was not associated with any needle–syringe sharing behaviors. Among the HIV-positive MWID, those who received free clean needles and syringes were less likely to give used needles and syringes to peers (AOR 0.21; 95% CI 0.06–0.79). Going to a “hotspot” in the previous week was associated with increased odds of needle–syringe sharing in multiple subgroups.

Conclusion

Our findings on HIV prevalence and testing participation among a subset of MWID in the northwestern Vietnam were corroborated with trend analysis results from the most recent HIV/STI Integrated Biological and Behavioral Surveillance report (data last collected in 2013.) We provided important insights into these MWID’s risky injection behaviors. We suggest heightened emphasis on HIV testing and needle and syringe provision for this population. Also, policymakers and program implementers should target hotspots as a main venue to tackle HIV epidemics.

Palliative Care in Vietnam: Long-Term Partnerships Yield Increasing Access

Palliative care began in Vietnam in 2001, but steady growth in palliative care services and education commenced several years later when partnerships for ongoing training and technical assistance by committed experts were created with the Ministry of Health, major public hospitals, and medical universities. An empirical analysis of palliative care need by the Ministry of Health in 2006 was followed by national palliative care clinical guidelines, initiation of clinical training for physicians and nurses, and revision of opioid prescribing regulations. As advanced and specialist training programs in palliative care became available, graduates of these programs began helping to establish palliative care services in their hospitals. However, community-based palliative care is not covered by government health insurance and thus is almost completely unavailable. Work is underway to test the hypothesis that insurance coverage of palliative home care not only can improve patient outcomes but also provide financial risk protection for patients' families and reduce costs for the health care system by decreasing hospital admissions near the end of life. A national palliative care policy and strategic plan are needed to maintain progress toward universally accessible cost-effective palliative care services.

Recreational drug use and risk of HIV infection among men who have sex with men: A cross-sectional study in Shenzhen, China

BACKGROUND

Recreational drug use has increased in recent years, especially among MSM, and has been found to be associated with higher risk of HIV infection. However, there is limited information about current recreational drug use among MSM in Shenzhen which is an international gateway city to China with a rapidly expanding MSM population.

METHODS

A cross-sectional survey among MSM in Shenzhen was conducted and was used to collected information on demographics, sexual behavior and drug use via questionnaires. Serologic results on HIV and syphilis were obtained from laboratory assays. We performed logistic regression analysis to evaluate correlates with drug use.

RESULTS

Among the 1935 MSM surveyed, 12.7% reported use of recreational drugs in the past six months. Rush poppers had become the most frequently used drug (10.6%). Risk factors associated with the use of recreational drugs included being unmarried, non-Han ethnicity, having high education level, seeking male sex partners via the internet, having multiple male sex partners, performing receptive role during anal sex, and having unprotected anal intercourse. Recreational drug use was significantly associated with higher risk of both HIV and syphilis infections (aOR:1.89, 95% CI:1.28-2.79; aOR:1.79, 95% CI:1.25-2.60, respectively).

CONCLUSIONS

Recreational drug use is associated with increased risk of HIV and syphilis infections among MSM in Shenzhen. Rush poppers were the most popular recreational drug. This finding suggests the need for targeted prevention and behavioral intervention programs to control the recreational drug use, and to reduce HIV and other sexually transmitted diseases among MSM in Shenzhen and internationally.

Intravenous heroin use in Haiphong, Vietnam: Need for comprehensive care including methamphetamine use-related interventions

BACKGROUND

The aim of this study was to describe patterns among people who inject drugs (PWID), risk-related behaviours and access to methadone treatment, in order to design a large-scale intervention aiming to end the HIV epidemic in Haiphong, Vietnam.

METHODS

A respondent-driven sampling (RDS) survey was first conducted to identify profiles of drug use and HIV risk-related behaviour among PWID. A sample of PWID was then included in a one-year cohort study to describe access to methadone treatment and associated factors.

RESULTS

Among the 603 patients enrolled in the RDS survey, 10% were female, all were injecting heroin and 24% were using methamphetamine, including 3 (0.5%) through injection. Different profiles of risk-related behaviours were identified, including one entailing high-risk sexual behaviour (n=37) and another involving drug-related high-risk practices (n=22). High-risk sexual activity was related to binge drinking and methamphetamine use. Among subjects with low sexual risk, sexual intercourse with a main partner with unknown serostatus was often unprotected. Among the 250 PWID included in the cohort, 55.2% initiated methadone treatment during the follow-up (versus 4.4% at RDS); methamphetamine use significantly increased. The factors associated with not being treated with methadone after 52 weeks were fewer injections per month and being a methamphetamine user at RDS.

CONCLUSION

Heroin is still the main drug injected in Haiphong. Methamphetamine use is increasing markedly and is associated with delay in methadone initiation. Drug-related risks are low but sexual risk behaviours are still present. Comprehensive approaches are needed in the short term.

Performance of the Bio-Rad Geenius HIV1/2 Supplemental Assay in Detecting "Recent" HIV Infection and Calculating Population Incidence

Objective:

HIV seroconversion biomarkers are being used in cross-sectional studies for HIV incidence estimation. Bio-Rad Geenius HIV-1/2 Supplemental Assay is an immunochromatographic single-use assay that measures antibodies (Ab) against multiple HIV-1/2 antigens. The objective of this study was to determine whether the Geenius assay could additionally be used for recency estimation.

Design:

This assay was developed for HIV-1/2 confirmation; however, quantitative data acquired give information on increasing concentration and diversity of antibody responses over time during seroconversion. A quantitative threshold of recent HIV infection was proposed to determine “recent” or “nonrecent” HIV infection; performance using this cutoff was evaluated.

Methods:

We tested 2500 highly characterized specimens from research subjects in the United States, Brazil, and Africa with well-defined durations of HIV infection. Regression and frequency estimation were used to estimate assay properties relevant to HIV incidence measurement: mean duration of recent infection (MDRI), false-recent rate, and assay reproducibility and robustness.

Results:

Using the manufacturer's proposed cutoff index of 1.5 to identify “recent” infection, the assay has an estimated false-recent rate of 4.1% (95% CI: 2.2 to 7.0) and MDRI of 179 days (155 to 201) in specimens from treatment-naive subjects, presenting performance challenges similar to other incidence assays. Lower index cutoffs associated with lower MDRI gave a lower rate of false-recent results.

Conclusions:

These data suggest that with additional interpretive analysis of the band intensities using an algorithm and cutoff, the Geenius HIV-1/2 Supplemental Assay can be used to identify recent HIV infection in addition to confirming the presence of HIV-1 and HIV-2 antibodies.

HIV infection among persons who inject drugs: ending old epidemics and addressing new outbreaks

AIDS among persons who inject drugs, first identified in December 1981, has become a global epidemic. Injecting drug use has been reported in 148 countries and HIV infection has been seen among persons who inject drugs in 61 countries. Many locations have experienced outbreaks of HIV infection among persons who inject drugs, under specific conditions that promote very rapid spread of the virus. In response to these HIV outbreaks, specific interventions for persons who inject drugs include needle/syringe exchange programs, medicated-assisted treatment (with methadone or buprenorphine) and antiretroviral therapy. Through a 'combined prevention' approach, these interventions significantly reduced new HIV infections among persons who inject drugs in several locations including New York City, Vancouver and France. The efforts effectively ended the HIV epidemic among persons who inject drugs in those locations. This review examines possible processes through which combined prevention programs may lead to ending HIV epidemics. However, notable outbreaks of HIV among persons who inject drugs have recently occurred in several countries, including in Athens, Greece; Tel-Aviv, Israel; Dublin, Ireland; as well as in Scott County, Indiana, USA. This review also considers different factors that may have led to these outbreaks. We conclude with addressing the remaining challenges for reducing HIV infection among persons who inject drugs.

Drug Abuse, HIV, and HCV in Asian Countries

Drug abuse and co-occurring infections are associated with significant morbidity and mortality. Asian countries are particularly vulnerable to the deleterious consequences of these risks/problems, as they have some of the highest rates of these diseases. This review describes drug abuse, HIV, and hepatitis C (HCV) in Asian countries. The most commonly used illicit drugs include opioids, amphetamine-type stimulants (ATS), cannabis, and ketamine. Among people who inject drugs, HIV rates range from 6.3 % in China to 19 % in Malaysia, and HCV ranges from 41 % in India and Taiwan to 74 % in Vietnam. In the face of the HIV epidemics, drug policies in these countries are slowly changing from the traditional punitive approach (e.g., incarcerating drug users or requiring registration as a drug user) to embrace public health approaches, including, for example, community-based treatment options as well as harm reduction approaches to reduce needle sharing and thus HIV transmission. HIV and HCV molecular epidemiology indicates limited geographic diffusion. While the HIV prevalence is declining in all five countries, use of new drugs (e.g., ATS, ketamine) continues to increase, as well as high-risk sexual behaviors associated with drug use-increasing the risk of sexual transmission of HIV, particularly among men who have sex with men. Screening, early intervention, and continued scaling up of therapeutic options (drug treatment and recovery support, ART, long-term HIV and HCV care for drug users) are critical for effective control or continued reduction of drug abuse and co-infections.

Prospects for ending the HIV epidemic among persons who inject drugs in Haiphong, Vietnam

BACKGROUND

To examine the prospects for "ending the HIV epidemic" among persons who inject drugs (PWID) in Haiphong, Vietnam. Reaching an incidence of <0.5/100 person-years at risk (PY) was used as an operational definition for "ending the epidemic."

METHODS

A respondent driven sampling study of 603 PWID was conducted from September to October 2014. Current heroin use (verified with urine testing and marks of injection) was an eligibility requirement. A structured questionnaire was administered by trained interviewers to obtain demographic, drug use, and risk behavior data; HIV counseling and testing and HCV testing was also conducted. Two methods (by assuming all new injectors were HIV negative at first injection and by slope of prevalence by years injecting) were used for estimating HIV among persons injecting for <5 years ("new injectors"). Comparisons were made to the HIV epidemic among PWID in New York City and modeling of the HIV epidemic in Can Tho province.

RESULTS

HIV prevalence was 25% in 2014, down from 68% in 2006 and 48% in 2009; overall HCV prevalence in the study was 67%. Among HIV seropositive PWID, 33% reported receiving antiretroviral treatment. The great majority (83%) of subjects reported pharmacies as their primary source of needles and syringes and self-reported receptive and distributive syringe sharing were quite low (<6%). Estimating HIV incidence among non-MSM male new injectors with the assumption that all were HIV negative at first injection gave a rate of 1.2/100 person-years (95% CI -0.24, 3.4). Estimating HIV incidence by the slope of prevalence by years injecting gave a rate of 0.8/100 person-years at risk (95% CI -0.9, 2.5).

CONCLUSIONS

The current HIV epidemic among PWID in Haiphong is in a declining phase, but estimated incidence among non-MSM new injectors is approximately 1/100 person-years and there is a substantial gap in provision of ART for HIV seropositives. Scaling up interventions, particularly HIV counseling and testing and antiretroviral treatment for all seropositive PWID, should accelerate the decline. Ending the epidemic is an attainable public health goal.

Genotypic distribution and hepatic fibrosis among HIV/HCV co-infected individuals in Southern China: a retrospective cross-sectional study

Background

End-stage liver disease and hepatocellular carcinoma due to hepatitis C virus (HCV) co-infection are increasingly common causes of death among HIV-infected individuals. However, there are few clinical investigations of HIV/HCV co-infected individuals from low and middle-income nations. Here, we compare the epidemiology of HCV-infected and HIV/HCV co-infected individuals in Southern China and examine hepatic fibrosis scores in co-infected individuals.

Methods

We conducted a retrospective cross-sectional study of treatment-naïve HIV/HCV co-infected and HCV mono-infected subjects. Bivariate and multivariate models were used to examine the association between demographics and HCV genotype. Among co-infected individuals, we also studied the relationship between fibrosis scores derived from non-invasive studies and HCV genotype.

Results

Data were collected from 175 HCV-infected individuals, including 89 (51 %) HIV/HCV co-infected individuals. HIV/HCV co-infection was correlated with intravenous drug use (AOR 46.25, p < 0.001) and not completing high school (AOR 17.39, p < 0.001) in a multivariate model. HIV/HCV co-infected individuals were more likely to be infected with HCV genotype 6a (p < 0.0001) or 3a (p < 0.023), whereas increased fibrosis (FIB-4 score) was associated with HCV genotype 3a infection (β 2.18, p < 0.001).

Discussion

Our results suggest that intravenous drug use is driving HIV/HCV co-infection in Southern China. While additional studies are needed, HCV genotype 6a is more common and genotype 3a appears to be associated with more severe hepatic fibrosis in co-infected individuals.

Conclusions

Future HIV/HCV co-infection research in China should focus on at risk populations, HCV testing uptake, and genotype-specific treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-1135-1) contains supplementary material, which is available to authorized users.

Barriers and Potential Improvements for Needle and Syringe Exchange Programs (NSPs) in China: A Qualitative Study from Perspectives of Both Health and Public Security Sectors

This study explores the acceptability, the barriers to the implementation of needle and syringe exchange programs (NSPs) and the potential improvement strategies in China from the perspectives of governmental health and public security officials. Purposive sampling was used for recruitment of participants who had been involved in NSPs implementation. Semi-Structured individual interviews were conducted in Mandarin to address three aspects of NSPs: (1) participants’ attitudes towards NSPs, (2) participants’ opinions on the effectiveness and barriers of NSPs, and (3) suggestions for improving the program. Content analysis was used to analyse the translated interview data. A total of 68 participants from 12 Hunan counties were interviewed (34 from each of the Bureau of Health and the Narcotic Division). Both groups recognised the importance and effectiveness of NSPs in HIV prevention, but public security officials regarded NSPs as a temporary intervention in place of punitive measures. Most health officials (32/34) regarded the main barriers to its implementation as administrative and structural, whereas participants from Narcotics Division (n=24) questioned the legitimacy of NSPs and concerned about the poor management of drug users’ risk behaviours. Close cooperation between the health and public security sectors, engagement of the drug user community and an enabling policy environment were reportedly to be critical for potential improvements of NSPs in China. Misconceptions about NSPs encourage drug users’ addictive behaviour, and an unclear leadership and insufficient support de-motivate the participants from the Bureau of Health and the Narcotics Division to actively support the program implementation.

Peering into the literature: A systematic review of the roles of people who inject drugs in harm reduction initiatives

BACKGROUND

People who inject drugs have been central to the development of harm reduction initiatives. Referred to as peer workers, peer helpers, or natural helpers, people with lived experience of drug use leverage their personal knowledge and skills to deliver harm reduction services. Addressing a gap in the literature, this systematic review focuses on the roles of people who inject drugs in harm reduction initiatives, how programs are organized, and obstacles and facilitators to engaging people with lived experience in harm reduction programs, in order to inform practice and future research.

METHODS

This systematic review included searches for both peer reviewed and gray literature. All titles and abstracts were screened by two reviewers. A structured data extraction tool was developed and utilized to systematically code information concerning peer roles and participation, program characteristics, obstacles, and facilitators.

RESULTS

On the basis of specific inclusion criteria 164 documents were selected, with 127 peer-reviewed and 37 gray literature references. Data extraction identified key harm reduction program characteristics and forms of participation including 36 peer roles grouped into five categories, as well as obstacles and facilitators at systemic, organizational, and individual levels.

CONCLUSIONS

Research on harm reduction programs that involve people with lived experience can help us better understand these approaches and demonstrate their value. Current evidence provides good descriptive content but the field lacks agreed-upon approaches to documenting the ways peer workers contribute to harm reduction initiatives. Implications and ten strategies to better support peer involvement in harm reduction programs are identified.

Prevalence and correlates of HCV monoinfection and HIV and HCV coinfection among persons who inject drugs in Vietnam

BACKGROUND

Vietnam bears a high burden of hepatitis C virus (HCV) and HIV infection among persons who inject drugs (PWID). The high prevalence of HCV and HIV occurs in a context of stigma and limited preventive interventions for PWID.

OBJECTIVES

This study aims to estimate the prevalence of HCV, HIV, and HIV/HCV coinfection among PWID and to explore their associations with lifetime injection behaviors.

METHODS

A total of 1434 PWID were recruited from the Thai Nguyen Province of Vietnam between 2005 and 2007. Participants responded to a structured questionnaire and provided blood samples at baseline. A cross-sectional analysis of data collected at baseline was carried out. Factors associated with HCV monoinfection and HIV/HCV coinfection were evaluated by multinomial logistic regression.

RESULTS

The prevalences of HIV and HCV were 35.1 and 88.8%, respectively, and the prevalences of HIV/HCV coinfection and HCV monoinfection were 34.8 and 53.9%, respectively. After adjusting for confounders in multivariate analysis, ever reusing a syringe and needle was found to be significantly associated with HIV monoinfection [adjusted odds ratio (AOR), 3.13; 95% confidence interval (CI), 1.99-4.94] and HIV/HCV coinfection (AOR, 3.34; 95% CI, 2.02-5.51). Ever sharing diazepam or novocaine was also found to be significantly associated with HIV monoinfection (AOR, 2.14; 95% CI, 1.38-3.32) and HIV/HCV coinfection (AOR, 2.47; 95% CI, 1.57-3.90).

CONCLUSION

Our findings demonstrate a high burden of HIV and HCV infection among PWID in Vietnam. Lifetime injection behaviors, including sharing of diazepam or novocaine, may account for the high prevalence of HIV and HCV. Improving prevention and ensuring access to care remain critically important for this vulnerable population.

Toward safe accessibility of opioid pain medicines in Vietnam and other developing countries: a balanced policy method

Moderate or severe pain is common among people with advanced cancer and other life-threatening illnesses. Yet despite agreement that pain relief is a human right, the poorest 80% of the world's population rarely have access to strong opioid analgesics. Excessively restrictive opioid policies, especially in developing countries, both stem from and propagate misguided fears about opioids, so-called opiophobia. Because opiophobia, like any norm, is historically, socially, and culturally situated, efforts to change opiophobic policies will be most effective if guided by awareness of their historical, social, and cultural determinants. We describe some of these determinants in Vietnam and report on results of an ongoing project there to allay opiophobia and improve safe access to opioids for medical uses. We used a method that entails working with committed local partners, including a high-level official from the Ministry of Health, to review all Vietnamese policies governing opioid accessibility to identify the barriers; devising an action plan to safely reduce or circumnavigate the barriers; obtaining buy-in for the plan from all stakeholders, including drug regulators and the police; and assisting the Ministry of Health to implement the plan. Since the start of the project, morphine consumption has increased each year and as of 2010 was ninefold greater than in 2003, and the number of hospitals offering palliative care has increased from three to 15. We conclude that this balanced policy method appears to be helping to reduce barriers to opioid access in Vietnam and should be used in other developing countries.

Drug use and sexual behavior: the multiple HIV vulnerabilities of men and women who inject drugs in Kumasi, Ghana

BACKGROUND

Recent evidence suggests that injecting drug use presents a new challenge to HIV prevention in West Africa. Very little is known about the HIV vulnerability of people who inject drugs (PWID) in Ghana, and no HIV prevention efforts are currently targeting PWID.

METHODS

Purposive sampling was used to recruit 30 (20 men and 10 women) PWID to participate in in-depth interviews in Kumasi, Ghana. Transcripts were coded and analyzed by theme.

RESULTS

Half the men and more than half the women in this study reported sharing needles/syringes (N/S); most shared a common mixing container; and all said they shared N/S with intimate partners. Some PWID who said that they do not share N/S with other PWID, also said they routinely use N/S that they find on the ground at injecting sites or in the hospital dumpster. Nearly, all the women (9/10) and more than half the men (12/20) were currently sexually active; most had more than 1 partner in the last 6 months, but very few reported condom use. Three women said they exchanged sex for money and 3 men reported buying sex in the last year. Several PWID had no knowledge of HIV transmission through injecting.

CONCLUSIONS

PWID in Kumasi are highly vulnerable to HIV because of N/S sharing and reuse, lack of condom use, low knowledge of HIV transmission, and lack of services. Program and policy recommendations include N/S and condom distribution, peer education, opioid substitution therapy, and training of health providers, police, and pharmacy staff.

HIV epidemic among drug users in China: 1995-2011

AIM

To describe trends in the HIV epidemic among drug users (DUs) in China from 1995 to 2011.

DESIGN, SETTING AND PARTICIPANTS

Data sets from China's national HIV/AIDS case reporting and sentinel surveillance systems as of December 2011 were used separately for descriptive analysis.

MEASURES

Changes in the geographic distribution of the number of HIV cases and HIV prevalence among injecting drug users (IDUs) and non-IDUs were examined. We also analysed changes in HIV prevalence among the broader DU population, and drug use-related behaviours including types of drugs used, recent injecting and recent needle sharing in the context of the rapid scale-up of DU sentinel sites and national harm reduction programmes.

FINDINGS

The HIV epidemic among China's DUs is still highly concentrated in five provinces. Here, HIV prevalence peaked at 30.3% [95% confidence interval (CI)=28.6, 32.1] among IDUs in 1999, and then gradually decreased to 10.9% (95% CI=10.6, 11.2) by 2011. We observed a rapid increase in the use of 'nightclub drugs' among DUs from 1.3% in 2004 to 24.4% in 2011. A decline in recent needle sharing among current IDU from 19.5% (95% CI=19.4, 19.6) in 2006 to 11.3% (95% CI=11.2, 11.4) in 2011 was found to be correlated with the rapid scale-up of methadone maintenance treatment (MMT; r(4)=-0.94, P=0.003) harm reduction efforts.

CONCLUSIONS

While HIV prevalence and needle sharing among current injecting drug users in China have declined dramatically and are correlated with the scale-up of national harm reduction efforts, the recent, rapid increased use of 'nightclub drugs' presents a new challenge.

Evaluating the impact of Mexico's drug policy reforms on people who inject drugs in Tijuana, B.C., Mexico, and San Diego, CA, United States: a binational mixed methods research agenda

Background

Policymakers and researchers seek answers to how liberalized drug policies affect people who inject drugs (PWID). In response to concerns about the failing “war on drugs,” Mexico recently implemented drug policy reforms that partially decriminalized possession of small amounts of drugs for personal use while promoting drug treatment. Recognizing important epidemiologic, policy, and socioeconomic differences between the United States—where possession of any psychoactive drugs without a prescription remains illegal—and Mexico—where possession of small quantities for personal use was partially decriminalized, we sought to assess changes over time in knowledge, attitudes, behaviors, and infectious disease profiles among PWID in the adjacent border cities of San Diego, CA, USA, and Tijuana, Baja California, Mexico.

Methods

Based on extensive binational experience and collaboration, from 2012–2014 we initiated two parallel, prospective, mixed methods studies: Proyecto El Cuete IV in Tijuana (n = 785) and the STAHR II Study in San Diego (n = 575). Methods for sampling, recruitment, and data collection were designed to be compatible in both studies. All participants completed quantitative behavioral and geographic assessments and serological testing (HIV in both studies; hepatitis C virus and tuberculosis in STAHR II) at baseline and four semi-annual follow-up visits. Between follow-up assessment visits, subsets of participants completed qualitative interviews to explore contextual factors relating to study aims and other emergent phenomena. Planned analyses include descriptive and inferential statistics for quantitative data, content analysis and other mixed-methods approaches for qualitative data, and phylogenetic analysis of HIV-positive samples to understand cross-border transmission dynamics.

Results

Investigators and research staff shared preliminary findings across studies to provide feedback on instruments and insights regarding local phenomena. As a result, recruitment and data collection procedures have been implemented successfully, demonstrating the importance of binational collaboration in evaluating the impact of structural-level drug policy reforms on the behaviors, health, and wellbeing of PWID across an international border.

Conclusions

Our prospective, mixed methods approach allows each study to be responsive to emerging phenomena within local contexts while regular collaboration promotes sharing insights across studies. The strengths and limitations of this approach may serve as a guide for other evaluations of harm reduction policies internationally.

Addressing injecting drug use in Asia and Eastern Europe

While the global HIV incidence dropped about 20 % in the past 10 years, HIV incidences among people who inject drugs (PWID) in Asia and Europe continue to increase and to account for high proportions of new HIV infections among PWID globally. Great changes have been observed in this region, such as progressing from rejection to acceptance of harm reduction strategies in Asian countries, but no such change has occurred in Eastern European countries. China has quickly scaled up harm reduction activities nationwide, resulting in the decline of HIV incidence and HIV prevalence among PWID since 2006. However, insufficient scaling up of harm reduction programs in other countries has failed to slow down their HIV epidemics. In Eastern European countries where the spread of HIV among PWID is the most severe, only about 15 % of funding for harm reduction programs are from domestic sources. Strong political and financial commitment from countries in this region is urgently needed to quickly scale up evidence-based harm reduction strategies in order to prevent the HIV epidemic from spreading rapidly from PWID to the heterosexual general population.

High coverage needle/syringe programs for people who inject drugs in low and middle income countries: a systematic review

BACKGROUND

Persons who inject drugs (PWID) are at an elevated risk for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection. In many high-income countries, needle and syringe exchange programs (NSP) have been associated with reductions in blood-borne infections. However, we do not have a good understanding of the effectiveness of NSP in low/middle-income and transitional-economy countries.

METHODS

A systematic literature review based on PRISMA guidelines was utilized to collect primary study data on coverage of NSP programs and changes in HIV and HCV infection over time among PWID in low-and middle-income and transitional countries (LMICs). Included studies reported laboratory measures of either HIV or HCV and at least 50% coverage of the local injecting population (through direct use or through secondary exchange). We also included national reports on newly reported HIV cases for countries that had national level data for PWID in conjunction with NSP scale-up and implementation.

RESULTS

Studies of 11 NSPs with high-coverage from Bangladesh, Brazil, China, Estonia, Iran, Lithuania, Taiwan, Thailand and Vietnam were included in the review. In five studies HIV prevalence decreased (range -3% to -15%) and in three studies HCV prevalence decreased (range -4.2% to -10.2%). In two studies HIV prevalence increased (range +5.6% to +14.8%). HCV incidence remained stable in one study. Of the four national reports of newly reported HIV cases, three reported decreases during NSP expansion, ranging from -30% to -93.3%, while one national report documented an increase in cases (+37.6%). Estimated incidence among new injectors decreased in three studies, with reductions ranging from -11/100 person years at risk to -16/100 person years at risk.

CONCLUSIONS

While not fully consistent, the data generally support the effectiveness of NSP in reducing HIV and HCV infection in low/middle-income and transitional-economy countries. If high coverage is achieved, NSP appear to be as effective in LMICs as in high-income countries. Additional monitoring and evaluation research is needed for NSPs where reductions in HIV/HCV infection among PWID are not occurring in order to identify and correct contributing problems.