A certain fate: spread of HIV among young injecting drug users in Manipur, north-east India

This study aimed to measure risk behaviours and seroprevalence of HIV and hepatitis C virus in IDUs in Manipur, North-East India, and evaluate the impact of the recently established Syringe and Needle Exchange Program (SNEP). Sampling strategy was based on social networks. Peer interviewers administered the study questionnaire and collected blood for anti-HCV and anti-HIV testing. One hundred and ninety-one IDUs (85% male) took part. Average age at first injection was 19 years and average length of time injecting was 3.7 years. The main drug currently injected was heroin (66%). Most (93%) reported having shared injecting equipment and only 42% had used the SNEP. Three-quarters (74.7%) were infected with HIV and almost all (98%) with HCV. Age (p < 0.001) and length of time injecting (p < 0.001) were significantly associated with being HIV-positive. Over two-thirds were sexually active, but only 3% consistently used condoms. Almost three-quarters of IDUs in this study were infected with HIV, most within the first two years of injecting, indicating infection continues to spread at very high rates. Unsafe sexual practices place partners of infected IDUs at risk of infection. The SNEP must increase its coverage to young and new IDUs before they are exposed to blood-borne viruses.

Sexual behaviour and infection rates for HIV, blood-borne and sexually transmitted infections among patients attending drug treatment centres in Rio de Janeiro, Brazil

A survey was carried out in 2 drug use treatment centres (TCs) in Rio de Janeiro, Brazil, to assess risk behaviours, HIV infection and other sexually transmitted infections/blood-borne infections (STIs/BBIs). Two hundred and twenty-five drug users (195 males and 30 females) were interviewed and clinically examined, and their blood and urine were tested for STIs/BBIs. Prevalences (%) for these infections were as follows--HIV: 0.9, hepatitis B virus (HBV): 14.7, hepatitis C virus (HCV): 5.8, syphilis: 5.3, gonorrhoea/chlamydia (CT/NG): 4.7. In bivariate analyses CT/NG infection was associated with younger age (P=0.003); current genitourinary symptoms (odds ratio [OR]=6.2) and a mainly illegal source of income (OR=9.1). Hepatitis C infection was associated with a history of ever having injected any drug (OR=19.6), and with each one of the injected drugs. After multiple logistic regression, lower educational level (adjusted odds ratio [AOR]=3.70) and 'ever having injected drugs' (AOR=3.69) remained as independent risk factors for hepatitis B infection. In conclusion, TCs must implement programmes directed towards the prevention of STIs/BBIs.

HIV infection associated with drug injecting in the newly independent states, eastern Europe: the social and economic context of epidemics

AIMS

We review recent trends in HIV associated with injecting drug use (IDU) in the Newly Independent States (NIS) in eastern Europe, including Belarus, Moldova, Russia, Ukraine, and Kazakhstan in central Asia. We aim to draw attention to the social and economic "risk environments" in which rapid HIV spread among IDUs has occurred.

METHODS

Findings draw on centrally registered HIV surveillance data, published research studies and assessment reports funded by international development agencies.

FINDINGS

Since 1995, there is evidence of rapid HIV spread in Belarus, Kazakhstan, Moldova, Russia and Ukraine, with estimates suggesting between 50% and 90% of new HIV infections among IDUs. At the same time, there have been rapid increases in the incidence of syphilis and declines in health and welfare status, including outbreaks of diphtheria, tuberculosis and cholera. Findings emphasize the potential influence of the social and economic context in creating the "risk environments" conducive to HIV and epidemic spread. Key factors include: rapid diffusions in IDU; population migration and mixing; economic transition and decline; increasing unemployment and impoverishment; the growth of informal economies; modes of drug production, distribution and consumption; declines in public health revenue and infrastructure; and political, ideological and cultural transition.

CONCLUSIONS

An understanding of the social and economic contexts mediating HIV spread is a prerequiste to identifying the environmental "pre-conditions" of epidemic outbreaks, and thus also, for predicting and preventing HIV transmission. The "risk environment" may influence the efficacy of individual and community-level HIV prevention and highlights the concomitant urgency for interventions targeting social and environmental change.

Co-infection with malaria and HIV in injecting drug users in Brazil: a new challenge to public health?

AIMS

To describe AIDS and malaria geography in Brazil, highlighting the role of injecting drug users (IDUs) in malaria outbreaks occurring in malaria-free regions, and the potential clinical and public health implications of malaria/HIV co-infection.

DESIGN

Review of the available literature and original analyses using geoprocessing and spatial analysis techniques.

FINDINGS

Both HIV/AIDS and malaria distribution are currently undergoing profound changes in Brazil, with mutual expansion to intersecting geographical regions and social networks. Very recent reports describe the first clinical case of AIDS in a remote Amazonian ethnic group, as well as malaria cases in Rio de Janeiro state (hitherto a malaria-free area for 20 years); in addition, two outbreaks of both infections occurred at the beginning of the 1990s in the most industrialized Brazilian state (São Paulo), due to the sharing of needles and syringes by drug users. Spatial data point to: (a) the expansion of HIV/AIDS towards malarigenic areas located in the centre-west and north of Brazil, along the main cocaine trafficking routes, with IDU networks apparently playing a core role; and (b) the possibility of new outbreaks of secondary malaria in urban settings where HIV/AIDS is still expanding, through the sharing of needles and syringes.

CONCLUSIONS

New outbreaks of cases of HIV and malaria are likely to occur among Brazilian IDUs, and might conceivably contribute to the development of treatment-resistant strains of malaria in this population. Health professionals should be alert to this possibility, which could also eventually occur in IDU networks in developed countries.

HIV-1 incidence among opiate users in northern Thailand

The incidence of human immunodeficiency virus type 1 (HIV-1) infection among opiate users was determined in a retrospective cohort of 436 patients with multiple admissions to the only inpatient drug treatment program in northern Thailand between October 1993 and September 1995. During 323.4 person-years of follow-up, 60 patients presenting for detoxification acquired HIV-1 infection, for a crude incidence rate of 18.6 per 100 person-years (95% confidence interval 14.4-23.9). All seroconverters were male. HIV-1 incidence varied by the current route of drug administration: 31.3 per 100 person-years for injectors and 2.8 per 100 person-years for noninjectors (smoking and ingestion). Significant differences were found by ethnicity: HIV-1 incidence was 29.3 per 100 person-years for Thai lowlanders and 8.5 per 100 person-years for hill tribes. Multivariate relative risk estimates showed that injecting opiates (vs. use by other routes), being unmarried, being under age 40 years, being a Thai lowlander, having a primary and secondary education, and being employed in the business sector were each independently associated with human immunodeficiency virus seroconversion. This HIV-1 incidence rate is double that reported for Bangkok and suggests that prevention and control programs for drug users need to be expanded throughout Thailand. Improved availability of more-effective treatment regimens and increased access to sterile injection equipment are needed to confront the HIV-1 epidemic among opiate users in northern Thailand.

Predictors of increased condom use following HIV intervention with heterosexually active drug users

Research with injection drug users (IDUs), at risk for acquiring and transmitting HIV, has focused primarily on their risky drug practices, with far less attention paid to their risky sex behaviors. The purpose of this study was to determine what variables were associated with an increase in condom use following an HIV intervention with 3357 IDUs in nine cities. Participants reported using condoms during 15% of their sexual encounters prior to the HIV intervention, and during 22% of their sexual encounters six months later. A logistic regression analysis indicated that individuals who increased their condom use were likely to be HIV seropositive (odds ratio OR = 2.49), to have received AIDS information prior to the intervention (OR = 1.28), to have multiple sex partners (OR = 2.14), to be single with multiple sex partners (OR = 1.34), or to have exchanged drugs or money for sex (OR = 1.33). Discussion focuses on the generally low incidence of condom use and the need for increased intervention, particularly among drug users in monogamous relationships and sex workers.

Condom use and HIV risk behaviors among U.S. adults: data from a national survey

CONTEXT

How much condom use among U.S. adults varies by type of partner or by risk behavior is unclear. Knowledge of such differentials would aid in evaluating the progress being made toward goals for levels of condom use as part of the Healthy People 2000 initiative.

METHODS

Data were analyzed from the 1996 National Household Survey of Drug Abuse, an annual household-based probability sample of the noninstitutionalized population aged 12 and older that measures the use of illicit drugs, alcohol and tobacco. The personal behaviors module included 25 questions covering sexual activity in the past year, frequency of condom use in the past year, circumstances of the last sexual encounter and HIV testing.

RESULTS

Sixty-two percent of adults reported using a condom at last intercourse outside of an ongoing relationship, while only 19% reported using condoms when the most recent intercourse occurred within a steady relationship. Within ongoing relationships, condom use was highest among respondents who were younger, black, of lower income and from large metropolitan areas. Forty percent of unmarried adults used a condom at last sex, compared with the health objective of 50% for the year 2000. Forty percent of injecting drug users used condoms at last intercourse, compared with the 60% condom use objective for high-risk individuals. Significantly, persons at increased risk for HIV because of their sexual behavior or drug use were not more likely to use condoms than were persons not at increased risk; only 22% used condoms during last intercourse within an ongoing relationship.

CONCLUSIONS

Substantial progress has been made toward national goals for increasing condom use. The rates of condom use by individuals at high risk of HIV need to be increased, however, particularly condom use with a steady partner.

Infection with HIV-1 subtypes B and E in injecting drug users screened for enrollment into a prospective cohort in Bangkok, Thailand

From May through August 1995, a cross-sectional survey was conducted among injecting drug users (IDUs) drawn from 15 drug treatment clinics in Bangkok and who were not known to be HIV-seropositive, to determine the prevalence of HIV-1 subtypes B and E and related risk behaviors, and to offer enrollment in a prospective cohort study. IDUs who voluntarily consented were interviewed, and blood specimens were tested for the presence of HIV antibodies. HIV-1-seropositive specimens were tested for subtypes B' (Thai B) and E by using V3 loop peptide enzyme immunoassays specific for these HIV-1 genetic subtypes. Of 1674 IDUs studied, the mean age was 31.2 years (interquartile range, 25-37 years), 94.8% were men, and 29.3% were HIV-1-seropositive. On multiple logistic regression analysis, HIV-1 seropositivity was associated with older age, not being married, less education, needle sharing, and incarceration. HIV-1 subtype B' accounted for 65% of prevalent infections and subtype E, 35%. Infection with subtype E was associated with younger age and did not seem to be associated with sexual risk behaviors, which were uncommon in general. Bangkok IDUs continue to be at high risk for HIV-1 infection related to needle sharing and incarceration. Although HIV-1 subtype B' accounts for most prevalent infections, subtype E seems to be more prevalent among younger IDUs, and most infections seem likely to result from parenteral transmission.

Factors associated with changes in sex behaviour among drug users in Puerto Rico

Despite available strategies to prevent sex risk behaviours in Puerto Rico, heterosexual transmission of HIV continues to increase. Since 1990, heterosexual contact has been the fastest growing infection risk category among the island's general population, and the primary transmission route for women and children. To understand change in sex risk behaviours and factors related to change, 911 drug injectors and 359 crack smokers were recruited from the San Juan metropolitan area following a stratified cluster design. This study comprised a total of 1,004 (79.1%) drug users who were assessed at follow-up. Abstinence from sex behaviour increased from 54.6% to 61.1% (p < 0.01), use of condoms during vaginal sex also increased from 26.4% to 36.9% (p < 0.01). In multivariate analysis, significant predictors of abstinence were gender, injection drug use, HIV seropositivity and not having a steady partner. Predictors of using condoms during vaginal sex were HIV seropositivity, STD diagnosis and participation in an HIV preventive programme. These findings indicate that additional HIV preventive efforts are needed to reduce sex risk behaviours among drug users who have a steady sex partner, as well as among drug users who are HIV-negative.

Long-term trends in self-reported HIV risk behavior: injection drug users in Los Angeles, 1987 through 1995

This article reviews trends in self-reported HIV risk behaviors across serial samples of injection drug-using (IDU) arrestees interviewed in Los Angeles. Between 1987 and 1995, a gradual decrease occurred in the percentage who share needles. However, measured over a past-year recall period, the prevalence of needle sharing remained high until 1994 to 1995, when it abruptly declined. Needle sharing with strangers and needle sharing at shooting galleries declined gradually throughout the study period. Among IDUs who shared needles, bleach use increased rapidly until 1991 but leveled off thereafter. No change occurred in number of sex partners, but condom use gradually increased among IDUs with 2 or more partners. Concurrent change in local needle exchange policy and practice may explain the abrupt decline in past-year needle sharing. New strategies may be needed to promote further increases in bleach use and condom use.

HIV antibody seroprevalence and associated risk factors in sex workers, drug users, and prisoners in Sindh, Pakistan

OBJECTIVE

To determine prevalence of HIV infection and risk behaviors in commercial sex workers (CSWs), drug users, and prisoners in Sindh, Pakistan.

METHODS

A medical clinic was established in a "red-light" district of Karachi. Eighty-one CSWs who registered at the clinic between November 1993 and June 1994 were provided HIV counseling and testing and administered a risk factor questionnaire. Next, 316 male drug users were tested for HIV-1 antibody from April to July 1994. Finally, a voluntary serosurvey of HIV-1 and HIV-2 and risk behaviors of 3525 prisoners in Sindh was conducted between July 1994 and December 1994. Abbott Recombinant HIV third-generation enzyme-linked immunosorbent assay (ELISA) and confirmatory testing with Western blot analysis were used in all three groups.

RESULTS

None of 81 CSWs tested for HIV-1 antibody were positive. None of 316 drug users tested positive for HIV-1 antibody. Of 3441 male prisoners, 1 was HIV-1 infected, and of 84 female prisoners, 1 was HIV-1 infected. No prisoner was positive for HIV-2 antibody.

DISCUSSION

The prevalence of HIV in CSWs, drug users, and prisoners in Sindh is low at present. Intervention programs implemented at this stage can make an impact in HIV prevention.

Risk behaviors, HIV seropositivity, and tuberculosis infection in injecting drug users who operate shooting galleries in Puerto Rico

This study was designed to assess HIV risk behaviors, HIV seroprevalence, and tuberculosis (TB) infection in shooting gallery managers in Puerto Rico. The subjects were 464 injection drug users (IDUs), of whom 12.5% reported managing shooting galleries. The median frequency of drug injection was higher in shooting gallery managers than in nonmanagers. A trend was observed for purified protein derivative (PPD) reactivity to increase according to the length of time spent as a gallery manager, but this trend was not statistically significant. However, anergy rates increased significantly with increase in the number of months spent as shooting gallery manager (p = .021). Multivariate analyses showed that IDUs reporting shooting gallery management experience of > or = 25 months were more likely to be infected with HIV. Prevention programs need to emphasize strategies to protect the health of shooting gallery clients and, in particular, shooting gallery managers. Additional studies are required to determine effective strategies for reducing the risk of HIV and TB infection in shooting galleries.

Clinical and immunological features of human immunodeficiency virus infection in patients from Bangkok, Thailand

BACKGROUND

To assess the association between the CD4 count and clinical diseases in a cohort of Thai patients.

METHODS

In all, 1902 patients who presented with human immunodeficiency virus (HIV) infection at the Chulalongkorn University Hospital in Bangkok were investigated.

RESULTS

At the time of presentation 295 (15.5%) patients had acquired immunodeficiency syndrome (AIDS) and there was a highly significant tendency for lower CD4 counts in this group (median 67/mm3) than in patients free of AIDS (median 369/mm3). A total of 757 patients had data available on follow-up and were free of AIDS at the first visit. During a median follow-up of 0.9 years, 110 developed AIDS or AIDS-related death (12.2/100 person years). Subjects with CD4 count < 200/mm3 at initial visit showed over a ninefold increase in risk of developing AIDS compared to subjects with levels > or = 500/mm3 (relative risk [RR] = 9.1; 95% CI: 5.4-16.0). The rate/100 person years was 47.1 compared with 6.0 in subjects with levels > or = 500/mm3. After adjusting for initial CD4 count, homosexual men showed over a twofold increase in risk of developing AIDS compared to heterosexuals (RR = 2.4; 95% CI: 1.6-4.4) and intravenous drug users (IVDU) showed nearly a twofold increase (RR = 1.8; 95% CI: 0.9-3.9). The increased risk in homosexual men persisted even after further adjustment for clinical stage (RR = 2.2; 95% CI: 1.3-3.7) but the increased risk in IVDU was attenuated (RR = 1.5; 95% CI: 0.7-3.2) although it remained increased albeit non-significantly. Men tended to progress faster to AIDS than women but the difference was not significant. However, the faster progression in homosexual men was seen even when compared to heterosexual men only.

CONCLUSION

The rate of progression of AIDS according to CD4 count group at baseline in this Thai cohort is broadly comparable with Western cohorts. It appears that heterosexuals in Thailand show slower progression to AIDS than homosexual men.

HIV, hepatitis B and sexual practices in the street-recruited injecting drug users of Calcutta: risk perception versus observed risks

Injecting drug users (IDUs) were recruited from the streets of Calcutta to obtain a baseline biological and behavioural data on risk practices. One-fifth of them (mostly using buprenorphine) tested positive for hepatitis B surface antigen (HBsAg); 4% were reactive to serologic test for syphilis (VDRL: Venereal Disease Research Laboratory). Condom use was insignificant while 74% reported sex with female sex workers and 15% of male IDUs also reported having sex with men. Although, sharing of injecting equipment ('works') was perceived as dangerous by the IDUs, majority of them (90/103) reportedly shared it; cleaning of works before sharing was a concern for intravenous but not for intramuscular drug injecting. Half of the IDUs reported suffering ever from abscess; a proportion (12%) of which had had superadded attack of maggots in it. They were also found to be infected with HIV (1%, 95% CI 0.028-5.97%) at a low prevalence that prompted subsequent launching of needle syringe exchange programme, establishment of cleaning norms before sharing of works, cleaning of injecting site on the body and condom promotion.

Risk factors for HIV seropositivity in a sample of drug users in drug treatment in Ho Chi Minh City, Vietnam

The article describes drug use behaviors, AIDS knowledge, risks for HIV infection, and HIV seroprevalence in drug users entering rehabilitation in Ho Chi Minh City, Vietnam. A cross-sectional, descriptive survey of all new entrants to a residential drug treatment center was conducted with linked HIV serology between July 1 and July 14, 1995. A total of 105 subjects participated: 101 men and 4 women. HIV serostatus was available for 88 subjects. Forty-seven percent (41 of 88 subjects) were HIV-positive. Median age of the subjects was 38 years. Mean length of injection drug use was 13.2 years (range, 1-27 years). The primary drug of injection was opium (96%), although 59% of subjects also injected "Western" drugs such as sedatives or tranquilizers. Eighty-two percent (86 of 105 subjects) correctly answered at least 7 of 10 AIDS knowledge questions, and only 28% (27 of 97 subjects) reported any needle sharing in the last 5 years. Seropositivity was associated with a history of previous treatment for drug abuse (p = 0.002), longer history of injecting drugs (p = 0.003), use of Western drugs (p = 0.03), and higher educational level (p = 0.05). Multivariate analysis found that the independent predictors of HIV seropositivity were history of previous treatment for drug abuse (p = 0.06) and longer history of injecting drugs (p = 0.05). Despite low levels of self-reported needle sharing and high levels of AIDS knowledge, HIV seroprevalence was high in this sample. The potential for epidemic spread of HIV in Vietnamese drug users is substantial. Risk-reduction programs and intense AIDS education projects targeting the population of drug users are necessary to control the AIDS epidemic in Vietnam.

[Risk reduction and intravenous drug use abstinence in patients with HIV infection. The SEROCO group]

BACKGROUND

Little is known about the complex stepwise process of giving up intravenous (i.v.) drugs. However, HIV risk reduction programs directed towards i.v. drug users have been accused by some opponents to encourage users to continue. In order to better assess the relationships between risk reduction and abstinence, we studied factors associated with abstinence in HIV-infected patients using i.v. drugs at enrollment in the SEROCO cohort (1988-1994).

METHODS

63 HIV-infected patients injecting i.v. drugs at enrollment were followed-up every 6 months with a clinical examination and a questionnaire concerning sexual and drugs practices since last consultation. Abstinence was defined as non injecting for at least 6 months. The 30 patients who became abstinent during a follow-up period of 3 years were compared to the 33 remaining.

RESULTS

Abstinence during follow-up was not related to age at inclusion, duration of i.v. drug use, gender or marital status. However, patients who became abstinent were more likely to have a professional activity at inclusion than the remaining (70% vs 42%, p = 0.03). Before knowledge of HIV infection, frequency of injections, needle sharing and use of condoms did not differ between the 2 groups. During follow-up, behavioural changes occurred in the two groups, but were more marked in those who lately became abstinent. These latter were more likely to always inject with new needles/syringes (57% vs 18%, p = 0.003), and to use condoms with HIV-negative partners or of unknown status (73% vs 39%, p = 0.06). Professional activity and systematic use of new needles/syringes remained independently associated with abstinence in multivariate analysis.

CONCLUSION

In this cohort, abstinence appeared as a stepwise process in which risk reduction preceded abstinence. This confirms that risk reduction programs do not work against those messages aimed at stopping i.v. drug use. Since this analysis selected particular subjects, enrolled in a cohort of HIV-infected patients, results should be confirmed in other samples of i.v. drugs users.

Epidemiology of HIV-1 infection in opiate users in Northern Thailand

Characterizing the epidemiology of HIV-1 infection in Northern Thai opiate users is important in developing control strategies in this ethnically diverse and culturally distinct region. A cross-sectional survey of drug users first admitted between 1993 and 1995 at the Northern Drug Dependence Treatment Center, Mae Rim, Thailand, was conducted. Patients (n = 4197) were interviewed at intake about their history of drug use when they provided serum specimens for HIV-1 antibody testing. The HIV-1 prevalence was 18.6%, with men having a fourfold higher prevalence than women. Wide diversity in HIV-1 prevalence was seen by ethnicity; the HIV-1 prevalence among Thai lowlanders was four times greater than that among ethnic minorities (hill tribes). Differences in HIV-1 prevalence were the result of differences in opiate use; hill tribes frequently smoked or ingested opium, whereas Thai lowlanders injected heroin. The high HIV-1 prevalence suggests that preventive interventions for risk reduction are urgently needed in these populations. Education about the risks of injection drug use (IDU) as well as information concerning needle disinfection and expansion of drug treatment are required to reduce the risk of HIV-1 transmission associated with sharing injection equipment. Further, increasing sources of sterile needles should be considered for active users, especially for those in more remote settings.

"Why I am not infected with HIV": implications for long-term HIV risk reduction and HIV vaccine trials

OBJECTIVE

To describe beliefs about remaining HIV-seronegative in injecting drug users in two high-seroprevalence cities, and to consider implications of these beliefs for ongoing risk reduction efforts and for HIV vaccine efficacy trials.

DESIGN

Cross-sectional survey with open- and closed-ended questions.

SUBJECTS

58 HIV-seronegative injecting drug users participating in HIV vaccine preparation cohort studies in New York City, New York, U.S.A., and Bangkok, Thailand.

MAJOR FINDINGS

Large majorities of subjects in Bangkok (90%) and in New York (89%) believed their "own efforts" to practice safer injection methods and safer sex were very important in avoiding HIV infection. More Bangkok subjects (30%) believed that they would "probably" become infected with HIV in the future than New York subjects (4%). Three percent of Bangkok subjects and 70% of New York subjects believed "having an immune system strong enough to avoid becoming infected with HIV despite exposure to the virus" was very important in avoiding HIV infection. This belief in New York subjects was associated with having previously engaged in high-risk behaviors (i.e., sharing injection equipment, unprotected sex, or both) with partners known to be HIV-seropositive.

CONCLUSIONS

Risk reduction programming for high-HIV-seroprevalence populations and within HIV vaccine trials should address not only specific HIV risk behaviors, but also the complex belief systems about avoiding HIV infection that develop within such groups. The person's "own efforts/self-efficacy" appears to be central in the psychology of risk reduction. Members of some high-risk populations may overestimate greatly the frequency of any possible natural immunity to becoming infected with HIV. Prevention programs for these populations will need to address explicitly the probabilistic nature of HIV transmission.

Infection with human immunodeficiency virus and hepatitis viruses in Chinese drug addicts

The prevalence of antibody against hepatitis C virus (anti-HCV) and five hepatitis B virus markers (HBVM) was measured in 176 Chinese drug addicts, of whom 23 were AIDS patients. Of 176 drug addicts, 147 were members of ethnic minorities while 29 were Han, the majority ethnic group. The total prevalence rates of anti-HCV and HBVM were 35.8% and 50.6% respectively, significantly different (P < 0.01). Anti-HCV and HBVM were together found in 22.7%. Similar prevalence rates were found among the different ethnic groups. Among the ethnic minorities, there was a significantly higher prevalence rate of anti-HCV in intravenous drug addicts (IVDA, 51.1%) than in oral drug addicts (20.3%). Furthermore, the prevalence of anti-HCV was significantly higher in needle-sharing abusers (60.4%) than in non-needle sharing ones (37.1%, P < 0.05). The prevalence of HBVM was also significantly higher in needle-sharing abusers (69.8%) than in non-needle sharing ones (34.3%). Prevalence of HBsAg was significantly higher in drug abusers with AIDS (47.8%) than in IVDA only (16.1%). The anti-HCV positive rates among ethnic minority people were: for the Yi people 69.2%, the Hui 55.6%, the Bai 53.9%, the Dai 26.8% and the Wa 23.1%. No obvious difference was identified for HBVM. The prevalence rates of HCV, HBV and HCV + HBV in IVDA showed no significant difference (P > 0.05) between the two regions. HIV, HCV and HBV infections may promote each other and be related to needle-sharing behaviour in drug abuse and to different subcultures and living habits.

An HIV type 1 epidemic among injecting drug users in the former Soviet Union caused by a homogeneous subtype A strain

Epidemiological data have demonstrated rapid growth of HIV-1 infections among injecting drug users (IDUs) in the Ukraine and Russia, during 1996. Here we describe the results of genetic analysis of isolates derived from 12 HIV-1-infected IDUs in different sites of Russia and the Ukraine. The blood samples were taken within a 1- to 2-month period after the first HIV-1-positive test. The results of the heteroduplex mobility assay as well as gag/env phylogenetic analysis reveal that all sequences belong to gag/env genetic subtype A. Moreover, interpatient genetic distances between the nucleotide sequences encompassing the C2-V3, the V4-V5, and p17-encoding regions within this group were low (the average means were 0.9, 1.3, and 0.4%, respectively). These data show a marked homogeneity of HIV-1, probably spreading during primary infection. It is possible that the current epidemic of subtype A HIV-1 among IDUs in the former Soviet Union is caused by a point source exposure.

Dominican, Mexican, and Puerto Rican prostitutes: drug use and sexual behaviors

Although Hispanics are overrepresented in AIDS cases in the United States, little information is available to help understand differences in drug and sex risk behaviors in Hispanic subgroups, needed to develop appropriate prevention programs. This study reports on HIV-related risk behaviors in three groups of Hispanic prostitutes recruited in the United States: Dominican (77), recruited in Washington Heights, NY, Mexican (151), recruited in El Paso, 7X; and Puerto Rican (48), recruited in East Harlem, NY Ethnographic interviews were conducted with a subsample of subjects to examine cultural meaning of risk behaviors; structured interviews were conducted with subjects to describe demographic characteristics and summarize levels of risk behaviors. Results indicated that the labels Hispanic and prostitute obfuscated important differences related to geographic and cultural factors. To be effective for diverse Hispanic groups, HIV prevention efforts and interventions must be based on knowledge of these differences.

The prevalence of human immunodeficiency virus among drug-dependent patients in Jeddah, Saudi Arabia

This study was carried out to determine the prevalence of HIV among drug-dependent patients in Jeddah. Between January 1 1995 and May 31 1996, all the patients admitted into the Al Amal Hospital for drug dependence were screened for HIV by Enzyme Immunoassay (EIA) and confirmed by Western blot. Those positive by the two tests were questioned about exposure to the risk factors for HIV infection and examined for clinical evidence of Acquired Immunodeficiency Syndrome (AIDS). Of 2628 admitted, 5 tested positive by EIA but only 4 were confirmed by Western blot, giving an overall prevalence of 0.15%. Three of the four HIV carriers used the intravenous route for drug use and the calculated prevalence for 2102 intravenous drug users was 0.14%. None of the patients showed any clinical evidence of AIDS. In view of the known preference by drug-dependent patients in Jeddah for the parenteral route and their sharing of needles and syringes, recommendations are made to prevent the spread of HIV through this group and into the community.

Risk behavior and HIV seroprevalence among injecting drug users in Rio de Janeiro, Brazil

OBJECTIVE

To characterize HIV seroprevalence and risk behavior among injecting drug users (IDUs) in Rio de Janeiro, Brazil, between 1990 and 1996.

DESIGN

We report data from three separate cross-sectional samples of IDUs in Rio de Janeiro: the World Health Organization (WHO) sample (n = 479), the Proviva sample (n = 138) and the Brasil sample (n = 110). These data provide the most comprehensive view available, to date, of this understudied population in Rio.

METHODS

Demographic characteristics, HIV/AIDS risk behavior and HIV seroprevalence were compared across the three samples and combined analyses were performed to determine the factors associated with injecting risk behavior, sexual risk behavior and HIV seropositivity.

RESULTS

The overall HIV seroprevalence among IDUs was 25%. Two encouraging findings of the present analysis were the lower levels of needle-sharing among participants recruited in the latest years (1995-1996) and the lower HIV seroprevalence in the Proviva sample composed mainly of less educated, poorer IDUs living in deprived neighborhoods. No trends toward safer behavior were found for sexual risk, younger age being the principal factor associated with high risk.

CONCLUSIONS

Levels of needle-sharing and sexual risk among IDUs in Rio remain high, demonstrating the urgent need to increase the limited preventive measures undertaken so far. Seroprevalence levels for HIV remain significantly lower in the most deprived sample, arguing for the fundamental importance of prompt and effective prevention strategies to keep infection rates from rising among the poorest and largest strata of Rio's IDUs.

Rising HIV infection rates in Ho Chi Minh City herald emerging AIDS epidemic in Vietnam

OBJECTIVE

To describe the epidemiology of HIV in Ho Chi Minh City in the context of current surveillance data from Vietnam.

METHODS

Since the late 1980s, HIV surveillance data have been collected in Ho Chi Minh City from centers for the treatment of venereal disease and tuberculosis, centers for the rehabilitation of injecting drug users and sex workers, prenatal clinics, blood banks and other sites.

RESULTS

The first case of HIV infection in Vietnam was identified in 1990 in Ho Chi Minh City. The cumulative number of reported HIV infections in this city at the end of 1996 was 2774, about half of the number of cases in the country; 86% of infections were among men, 86% among injecting drug users, 2.5% among patients with sexually transmitted diseases and 2.5% among sex workers. The first HIV infection among antenatal women was detected in 1994. The prevalence of HIV among injecting drug users rose dramatically from 1% in 1992 to 39% in 1996, compared with 1.2% among sex workers, 0.3% among blood donors and 1.3% among tuberculosis patients in 1996. The populations of injecting drug users and sex workers in Ho Chi Minh City are estimated to be 30000 and 80000, respectively, and rates of sexually transmitted diseases are 2-3 per 1000 persons per year. By the end of December 1996, 42 out of 53 provinces had reported HIV infections, and border areas near China and Cambodia began identifying large numbers of HIV-seropositive people.

CONCLUSIONS

Ho Chi Minh City is at the forefront of a new HIV epidemic in Vietnam. This epidemic shows similarities to that in Thailand nearly a decade ago, with rapidly rising HIV rates among injecting drug users and infection already established among sex workers. Prevention efforts should include the targeting of injecting drug users and sex workers outside rehabilitation centers, the availability of sterile needles and condoms, the establishment of anonymous testing sites, the control of sexually transmitted diseases and the coordination of programs within southeast Asia.

Impact of a longitudinal community HIV intervention targeting injecting drug users' stage of change for condom and bleach use

PURPOSE

To evaluate the impact of the Long Beach AIDS Community Demonstration Project, a community-based HIV-prevention intervention incorporating principles from the Transtheoretical model in its design and evaluation.

DESIGN

Repeated cross-sectional sampling with matched intervention and comparison communities.

SETTING

Neighborhoods in Long Beach, California, having a high prevalence of drug abuse and prostitution.

SUBJECTS

3081 injecting drug users who were sexually active and/or shared injection equipment.

INTERVENTION

Trained peer volunteers distributed fliers featuring role model stories targeted to the population's stage of change. Fliers were packaged with bleaching kits and/or condoms.

MEASURES

Primary outcome measures were exposure to the intervention, condom carrying, and stage of change for disinfecting injection equipment with bleach and for using condoms with main and other partners.

RESULTS

Toward the end of the study, 77% of injection drug users in the intervention area reported being exposed to the intervention. In the intervention area, rates of condom carrying increased from 10 to 27% (p < .001), and there was an increase from 2.32 to 3.11 in mean stage of change for using condoms with other partners, while stage of change decreased in the comparison area (p < .01). Mean stage of change for using condoms with a main partner also increased in the intervention area, but the difference was not significant after controlling for change in the comparison area. Subjects with recent project exposure had higher stage-of-change scores for using condoms with a main partner (p < .05) and other partners (p < .01) and for cleaning injection equipment with bleach (p < .05).

CONCLUSIONS

The results demonstrate the effectiveness of the AIDS Community Demonstration Project intervention for reaching injecting drug users in the community and for motivating the adoption of risk-reducing practices.

Reaching out beyond the hills: HIV prevention among injecting drug users in Manipur, India

Outreach interventions using ex-IDUs to inform and educate their peers about HIV/AIDS prevention measures have been found to be effective in the United States and other developed countries. While HIV/AIDS prevention programmes targeting IDUs have also been implemented in a number of developing countries, very little information is available on the process of implementation of these programmes. This paper attempts to document some of this knowledge by describing the implementation process of an outreach intervention targeting IDUs in a small town--Churachandpur--with high injection drug use and high HIV infection rates, in the north-eastern state of Manipur. The paper describes the barriers encountered in implementing the outreach and how these barriers were minimized. In conclusion, the paper makes the case for targeting outreach to the larger community before targeting the IDUs.

The AIDS epidemic among Spanish drug users: a birth cohort-associated phenomenon

OBJECTIVES

In Spain the number of new acquired immunodeficiency syndrome (AIDS) cases among injection drug users continues to rise. The time trend up to 1994 has been analyzed, with special attention paid to the different generations.

METHODS

The source for injection drug use-related cases was the Spanish AIDS Register. Independent analyses of annual specific rates were run for each sex with the use of an age-period-cohort log-linear model.

RESULTS

After adjustment for age and year of diagnosis, AIDS incidence related to injection drug use is associated with specific birth cohorts. Rising values are observed in the successive generations born during the 1950s, peaking in men born in 1962 and women born in 1964. In subsequent cohorts, there is a marked falloff in incidence for both sexes, but this decline is seen to halt in men from the 1972 birth cohort onwards. The overall period effect is upward, yet the trend flattens in the last years. There is a pronounced age effect with maximum values in men and women at ages 29 and 27, respectively.

CONCLUSIONS

It is essential to urge avoidance of risk behaviors in new generations.

[Current status of HIV infection in Yunnan Province of China]

In cooperation with the Chinese Academy of Preventive Medicine and Yunnan Province Provincial Office for AIDS Control and Prevention, we studied the current status of HIV infection intravenous drug users (IVDUs) and other high risk groups in Yunnan province of China. As of the end of 1995, 1,807 HIV cases were officially reported (Positive rate was 0.6%), of which 1,278 (77.9%) were IVDUs, and 24 were their spouses. The majority of cases were found among the Dai minority male farmers near Ruili which borders on Myammar, but HIV also appears to be spreading among the Han people. HIV antibody positive rates among commercial sex workers, pregnant women and blood donors were 0.2%, 0.07% and 0.04%, respectively. A system for surveillance of HIV has been developed, but preventive strategies to cope with HIV epidemic are not sufficient. As HIV/AIDS is now a global issue, (1) the integration and coordination of such preventive strategies in cooperation with community health workers, (2) general health education for condom use promotion and (3) care of psychological vulnerable person such as IVDUs, should be developed.

Factors influencing condom use among heterosexual users of injection drugs and crack cocaine

OBJECTIVES

To study factors that influence the self-reported use of condoms among injection drug users and crack smokers.

STUDY DESIGN

A cross-sectional design was used to collect data from drug-using heterosexual men (n = 247) and women (n = 107).

RESULTS

Participants were largely African American (79.4%), male (69.8%), and unmarried (90.1%). The mean age for men was 39.9 years, 35.5 years for women. Drug user groups consisted of individuals who used both crack cocaine and injection drugs (40.1%), noninjecting crack smokers (33.1%), and non-crack-smoking injection drug users (26.8%). Daily injection drug or crack use was reported by 62.9% of the sample. One third of the sample reported recent vaginal sex with more than one partner. More than 70% of the participants frequently used drugs when having sex. Logistic regression showed that individuals who were high when having vaginal sex were less likely to use condoms than people who were not high (odds ratio [OR] 0.82; 95% confidence interval [CI], 0.68-0.99); individuals whose partners got high when having sex were more likely to report condom use (OR 1.20; 95% CI, 1.01-1.42); individuals were less likely to use condoms when having sex with a main partner (OR 0.40; 95% CI, 0.20-0.80); individuals who believed it was important to use condoms were more likely to use condoms (beta = 0.57, P < 0.00); and people who believed condoms reduced sexual pleasure were less likely to use condoms (beta = -0.53, P < 0.00).

CONCLUSIONS

In addition to being sensitive to partner characteristics, sex risk-reduction interventions targeting users of injection drugs or crack must address the widespread use of psychoactive drugs that occurs immediately before and during sex because such use presents a significant impediment to the employment of safer-sex techniques that rely on condoms. Until such interventions are in place, access to drug abuse treatment is a critical dimension of human immunodeficiency virus and other sexually transmitted disease prevention.