Time Since Migration and HIV Risk Behaviors Among Puerto Ricans Who Inject Drugs in New York City

BACKGROUND

Among people who inject drugs (PWID) in the United States, those who initiated drug injection in Puerto Rico (immigrant Puerto Rican PWID) engage in more injection and sexual risk behaviors, and have higher HIV incidence than non-Hispanic whites.

OBJECTIVE

Understand the persistence of these HIV behaviors.

METHODS

In a cross-sectional study conducted in New York City (NYC) in 2012 (National HIV Behavioral Surveillance), PWID aged ≥18 years were recruited using Respondent-Driven Sampling, interviewed, and tested for HIV. Participants were categorized into 5 different groups: (1) US-born non-Hispanic PWID, (2) US-born Puerto Rican PWID, (3) recent immigrant Puerto Rican PWID (≤3 years in NYC), (4) medium-term immigrant Puerto Rican PWID (>3 and ≤10 years in NYC), and (5) long-term immigrant Puerto Rican PWID (>10 years in NYC). We examined the relationship between time since migrating on sexual and injection risk behaviors among immigrant Puerto Rican PWID, compared with U.S.-born Puerto Rican PWID and US-born non-Hispanic PWID. Adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were estimated using logistic regression.

RESULTS

A total of 481 PWID were recruited. In adjusted analyses using US-born non-Hispanic PWID as the comparison group, syringe sharing was significantly more likely among medium-term immigrants; and unprotected sex with casual partners was more likely among recent and long-term immigrants.

CONCLUSIONS

The risk-acculturation process for immigrant Puerto Rican PWID may be nonlinear and may not necessarily lead to risk reduction over time. Research is needed to better understand this process.

Factors associated with recent HIV testing among men who have sex with men in New York City

Understanding factors associated with recent HIV testing among men who have sex with men (MSM) is important for designing interventions to increase testing rates and link cases to care. A cross-sectional study of MSM was conducted in NYC in 2011 using venue-based sampling. Associations between HIV testing in the past 12 months and relevant variables were examined through the estimation of prevalence ratios (PR) and 95 % confidence intervals (CI). Of 448 participants, 107 (23.9 %) had not been tested in the past 12 months. Factors independently associated with not testing in the previous 12 months were: lack of a visit to a healthcare provider in the past 12 months (aPR: 2.5; 95 % CI: 1.9, 3.2); age ≥30 (adjusted PR: 1.9; 95 % CI: 1.4, 2.7); not having completed a bachelor's degree (aPR: 1.6; 95 % CI: 1.0, 2.4); and non-gay sexual identity (aPR: 1.4; 95 % CI: 1.0, 1.8); such MSM may be less aware of the need for frequent HIV testing.

Combined HIV prevention, the New York City condom distribution program, and the evolution of safer sex behavior among persons who inject drugs in New York City

Examine long term sexual risk behaviors among persons who inject drugs (PWID) in New York City following implementation of "combined" prevention programming, including condom social marketing. Quantitative interviews and human immunodeficiency virus (HIV) testing were conducted among PWID entering Beth Israel Medical Center drug treatment programs 1990-2012. Data were analyzed by four time periods corresponding to the cumulative implementation of HIV prevention interventions. 7,132 subjects were recruited from 1990 to 2012; little change in sexual behavior occurred among HIV seronegative subjects, while HIV seropositive subjects reported significant decreases in being sexually active and significant increases in consistent condom use. HIV transmission risk (being HIV positive and engaging in unprotected sex) declined from 14 % in 1990-1995 to 2 % in 2007-2012 for primary sexual partners and from 6 to 1 % for casual partners. Cumulative implementation of combined prevention programming for PWID was associated with substantial decreases in sexual risk behavior among HIV seropositives.

Herpes simplex virus type 2 associated with HIV infection among New York heterosexuals living in high-risk areas

Herpes simplex virus type 2 (HSV-2) has been shown to increase the risk of sexual human immunodeficiency virus (HIV) transmission. A matched case-control design was used to examine the association between HSV-2 and HIV infection among heterosexuals in 'high-risk areas' (HRAs) in New York City (NYC). We identified NYC HRAs using HIV surveillance data on heterosexual-related adult HIV diagnoses and USA census data on household poverty. Heterosexuals who were socially or geographically linked to an HRA were recruited using respondent-driven sampling. HIV prevalence was 8.6% and HSV-2 prevalence was 80.1%. Only 6% of HIV-positives knew they were infected. HIV-positive cases were matched to HIV-negative controls on gender, race/ethnicity and age, and tested for antibody to HSV-2. In a multivariate model, HIV infection was associated with HSV-2 infection (adjusted odds ratio [AOR] = 3.5, 95% confidence interval 1.1-11.7) and non-HSV-related sexually transmitted infection diagnosis in the previous year (AOR = 2.6, 1.1-6.2). Effective approaches to HIV risk reduction for individuals with HSV-2 remain uncertain, and these are urgently needed in high-risk communities where multiple social, behavioural and biological factors that facilitate HIV infection coexist.

Evaluation of a patient referral contact tracing programme for hepatitis B and C virus infection in drug injectors

Binary file ES_Abstracts_Final_ECDC.txt matches

Evaluation of a patient referral contact tracing programme for hepatitis B and C virus infection in drug injectors

Effective contact tracing for hepatitis B virus (HBV) and hepatitis C virus (HCV) infection could enhance disease control, especially in populations with low HBV vaccination rates and high prevalence of untreated HCV infection. We evaluated a low-cost approach to HBV/HCV contact tracing in injection drug users (IDUs). Index cases (n=26) were IDUs who seroconverted to HBV and/or HCV during a prospective cohort study in Seattle. Interviewers elicited index cases' recent injection partners and administered recall cues and other techniques to boost recall. Index cases received vouchers for free hepatitis testing, which they were to give to locatable partners. Persons redeeming vouchers also received small monetary incentives. Most (26/40) seroconverters participated in the paid contact interviews. Index cases reported many partners (mean=17), and in the aggregate, index cases indicated they could refer more than one third of their elicited partners for testing. Overall, only 17 persons were ultimately referred and just eight of these were confirmed as partners sought for referral. The supplementary elicitation techniques, and especially the recall cues, increased reporting of injection partners substantially. The injection network constructed from reported partnerships was mostly connected and cyclic. Successful contact tracing in IDUs likely requires active involvement by public health staff to locate and notify exposed injection partners.

Needle exchange use, sexual risk behaviour, and the prevalence of HIV, hepatitis B virus, and hepatitis C virus infections among Bulgarian injection drug users

At a time when the rates of HIV, hepatitis C virus (HCV), and hepatitis B virus (HBV) infections have risen among injection drug users (IDUs) in other countries in the region, little is known about the prevalence of these infections among Bulgarian injectors and about their sexual risk behaviours. IDUs (n = 773) in a community-based needle exchange programme (NEP) and two major drug treatment facilities in Sofia completed a structured interview and were tested for HIV, HBV, and HCV antibodies. While HCV prevalence in the sample was 73.9%, HBV and HIV prevalence was low -6% and 0.5%, respectively. Having more than 10 sexual partners, having sex with someone with hepatitis C or another IDU, and never using a condom with another IDU were common among those who were recruited through NEP. As 40% of the IDUs reported using NEP, it appears that needle exchange provides an opportunity to reach high-risk populations and prevent sexual transmission of blood-borne pathogens.

Factors associated with interest in initiating treatment for hepatitis C Virus (HCV) infection among young HCV-infected injection drug users

OBJECTIVE

We sought to identify factors associated with interest in receiving therapy for hepatitis C virus (HCV) infection among HCV-infected injection drug users (IDUs) in 3 United States cities.

METHODS

IDUs aged 18-35 years who were HCV-infected and seronegative for human immunodeficiency virus underwent surveys on behaviors, experience, and interest in treatment for HCV infection and readiness to quit drug use.

RESULTS

Among treatment-naive IDUs (n=216), 81.5% were interested in treatment for HCV infection, but only 27.3% had seen a health-care provider since receiving a diagnosis of HCV infection. Interest in treatment for HCV infection was greater among IDUs with a high perceived threat of progressive liver disease, those with a usual source of care, those without evidence of alcohol dependence, and those with higher readiness scores for quitting drug use. Interest in treatment for HCV infection was 7-fold higher among IDUs who were told by their health-care provider that they were at risk for cirrhosis or liver cancer.

CONCLUSIONS

Improving provider-patient communication and integrating treatments for substance abuse and HCV may increase the proportion of IDUs who initiate treatment for HCV infection.

Hepatitis B virus genotypes and HBsAg subtypes in refugees and injection drug users in the United States determined by LiPA and monoclonal EIA

Hepatitis B virus (HBV) genotyping and hepatitis B surface antigen (HBsAg) subtyping were carried out on sera from 196 HBsAg-positive patients, including 151 refugees entering the United States and 45 injection drug users in Seattle. HBsAg subtyping was performed by enzyme immunoassay (EIA) using a panel of monoclonal antibodies and the HBV genotype was determined by polymerase chain reaction (PCR) followed by detection of amplified HBV DNA by a reverse-phase hybridization line probe assay (LiPA) using genotype-specific probes. HBV DNA was detected by PCR in 155 (79%) of the 196 sera and all 155 were genotyped by LiPA. Samples from Southeast Asia were predominantly genotype B/subtype ayw1 and genotype C/adr; samples from the former Soviet Union and eastern Europe were mostly genotype D/ayw2 and genotype D/ayw3; samples from east Africa were mainly genotype A/adw2 and genotype D/ayw2; and samples from injection drug users were mostly genotype D/ayw3 and genotype A/adw2. Some strains of ayw3 gave atypical monoclonal antibody reactivity patterns in the subtyping assay due to a Val/Ala instead of a Thr at amino acid residue 118 and a Thr instead of a Met at residue 125. A strain of ayw2 also gave an atypical monoclonal antibody reactivity pattern due to an Ala instead of a Thr at amino acid residue 123. LiPA genotyping and monoclonal EIA subtyping can provide useful information for epidemiological studies.

Functional analysis of the yeast Ran exchange factor Prp20p: in vivo evidence for the RanGTP gradient model

Numerous cellular processes rely on the movement of macromolecules into and out of the nucleus. The primary regulator of this movement is the small GTPase Ran. Like other small GTPases, the nucleotide-bound state of Ran is regulated by effectors that enhance the rate of nucleotide exchange or hydrolysis. Current models for vectorial nuclear transport suggest that it is the strict compartmentalization of these Ran effector molecules that generates a gradient of RanGTP between the nucleus and the cytoplasm to impart directionality to the transport process. Here we investigate the mechanism by which the Ran exchange factor is targeted to the nucleus, and test the impact of disrupting this nuclear compartmentalization on nucleocytoplasmic transport in vivo. Our results indicate that in Saccharomycces cerevisiae the nucleotide exchange factor Prp20p can be targeted to the nucleus via a classical nuclear localization sequence. This transport mechanism is dependent both on Ran and the receptor that recognizes the nuclear localization sequence, importin alpha. Mutations in the evolutionarily conserved nuclear localization sequence only partially inhibit nuclear import of Prp20p, suggesting the existence of a secondary mechanism for this critical nuclear targeting. In an in vivo test of the RanGTP gradient model, we demonstrate that overexpression of a functional cytoplasmic exchange factor inhibits cell growth and blocks both protein import and RNA export in wild-type cells that contain the endogenous nuclear Prp20 protein. Taken together, our results provide in vivo evidence for the idea that the compartmentalization of the exchange factor serves as a mechanism for establishing directional nuclear transport.

Using a jail-based survey to monitor HIV and risk behaviors among Seattle area injection drug users

Routine monitoring of human immunodeficiency virus (HIV) and risk behaviors among injection drug users (IDUs) is difficult outside drug treatment settings. We developed and implemented a survey of recently arrested IDUs to describe the prevalence of HIV, drug use, and sexual behaviors among them. A probability sampling survey was instituted in the King County Correctional Facility in Seattle, Washington, to sample recently arrested IDUs at the time of booking and in the jail health clinic between 1998 and 1999. Following HIV risk assessment and blood draw, additional information on drug use practices was gathered using a standardized questionnaire. Potential participants who were released from jail early could complete the study at a nearby research storefront office. Of the 4,344 persons intercepted at booking, 503 (12%) reported injection drug use, and 201 of the IDUs (40%) participated in the study. An additional 161 IDUs were enrolled in the study from the jail health clinic. Among the 348 unduplicated subjects, HIV prevalence was 2%; in the past 6 months, 69% reported two or more shooting partners, 72% used a cooker after someone else, 60% shared a syringe to divide up drugs, and 62% injected with used needles. Only 37% reported being hepatitis C seropositive, and 8% reported hepatitis B vaccination. It was feasible to conduct a jail-based survey of recently arrested IDUs that yielded useful information. The high prevalence of reported risky drug use practices warrants ongoing monitoring and illustrates the need for improving prevention programs for HIV and hepatitis B and C in this population, including expansion of hepatitis C screening and provision of hepatitis B vaccination at the jail health clinic.

Predictors of accidental fatal drug overdose among a cohort of injection drug users

OBJECTIVES

This study evaluated factors associated with accidental fatal drug overdose among a cohort of injection drug users (IDUs).

METHODS

In a prospective cohort study of 2849 IDUs in King County, Washington, deaths were identified by electronically merging subject identifiers with death certificate records. Univariate and multivariate Cox regression analyses were performed to identify predictors of overdose mortality.

RESULTS

Thirty-two overdoses were observed. Independent predictors of overdose mortality were bisexual sexual orientation (relative risk [RR] = 4.86; 95% confidence interval [CI] = 2.30, 13.2), homelessness (RR = 2.30; 95% CI = 1.06, 5.01), infrequent injection of speedballs (RR = 5.36; 95% CI = 1.58, 18.1), daily use of powdered cocaine (RR = 4.84; 95% CI = 1.13, 20.8), and daily use of poppers (RR = 22.0; 95% CI = 1.74, 278).

CONCLUSIONS

Sexual orientation, homelessness, and drug use identify IDUs who may benefit from targeted interventions.

Sharing of drug preparation equipment as a risk factor for hepatitis C

OBJECTIVES

This study investigated the sharing of drug preparation equipment as a possible route of hepatitis C virus (HCV) transmission.

METHODS

HCV seroconversion was measured in a cohort of 317 injection drug users who tested negative for HCV antibody at recruitment.

RESULTS

Cumulative HCV incidence was 16.7% per year. Among those who did not share syringes, HCV seroconversion was associated with sharing drug cookers and filtration cotton (adjusted risk ratio = 5.9; 95% confidence interval = 1.1, 31.7); 54% of HCV infections in injection drug users who did not share syringes were attributable to cooker/cotton sharing.

CONCLUSIONS

Among injection drug users who do not share syringes, an important proportion of HCV infections may be attributed to cooker/cotton sharing.

Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors

The association between needle exchange, change in drug use frequency and enrollment and retention in methadone drug treatment was studied in a cohort of Seattle injection drug users (IDUs). Participants included IDUs classified according to whether they had used a needle exchange by study enrollment and during the 12-month follow-up period. The relative risk (RR) and the adjusted RR (ARR) were estimated as measures of the association. It was found that IDUs who had formerly been exchange users were more likely than never-exchangers to report a substantial (> or= 75%) reduction in injection (ARR = 2.85, 95% confidence limit [CL] 1.47-5.51), to stop injecting altogether (ARR = 3.5, 95% CL 2.1-5.9), and to remain in drug treatment. New users of the exchange were five times more likely to enter drug treatment than never-exchangers. We conclude that reduced drug use and increased drug treatment enrollment associated with needle exchange participation may have many public health benefits, including prevention of blood-borne viral transmission.

HIV and HCV infection among injecting drug users

BACKGROUND

Human immunodeficiency virus (HIV) and hepatitis C virus (HCV) are the two blood-borne pathogens most commonly transmitted among injection drug users via multi-person use of syringes and other injection equipment. However, important differences exist in the epidemiology of HIV and HCV within different populations of intravenous drug users.

METHOD

A literature review was carried out to summarize publications describing the epidemiology and natural history of HIV and HCV in injection drug users.

RESULTS

Among injection drug users worldwide, HIV prevalence varies from <5% to >80%, with annual HIV incidence between <1% and 50%. More consistency is shown in HCV prevalence (50-90%) and incidence (10-30% per year). Host, environmental and viral factors that favor rapid spread of HCV among IDUs suggest that HCV infection in a population of injection drug users may become endemic over a relatively short period of time. Lower transmission efficiency for HIV also indicates that its spread among injection drug users may be somewhat slower.

CONCLUSIONS

Successful efforts to prevent transmission of blood-borne viruses among IDUs typically result in risk reduction; however, no intervention has resulted in elimination of risk behavior. To reduce HIV transmission, risk reduction may be sufficient, whereas control of HCV may necessitate the use of injection practices that guarantee elimination of exposure to equipment contaminated with even small amounts of blood.

Methadone treatment and HIV and hepatitis B and C risk reduction among injectors in the Seattle area

Drug treatment has the potential to reduce incidence of blood-borne infections by helping injection drug users (IDUs) achieve abstinence or by decreasing the frequency of injection and sharing practices. We studied the associations between retention in methadone treatment and drug use behaviors and incidence of hepatitis B and C in a cohort of IDUs in the Seattle, Washington, area. Data on IDUs entering methadone treatment at four centers in King County, Washington, were collected through face-to-face interviews using a standardized questionnaire at baseline and 12-month follow-up between October 1994 and January 1998. Blood specimens were obtained and tested for human immunodeficiency virus (HIV) and hepatitis B and C. Drug treatment status at follow-up was analyzed in relation to study enrollment characteristics and potential treatment outcomes, including injection risk behaviors, cessation or reduced frequency of injection, and incidence of hepatitis B and C. Of 716 IDUs, 292 (41%) left treatment, 198 (28%) disrupted (left and returned) treatment, and 226 (32%) continued treatment throughout the 1-year follow-up period. Compared to those who left treatment, subjects who disrupted or continued were less likely to inject at follow-up (odds ratio [OR] = 0.5, 95% CI 0.3-0.7; and OR = 0.1, 95% CI 0.1-0.2, respectively). Among the 468 (65%) subjects who continued injecting, those who continued treatment injected less frequently, were less likely to pool money to buy drugs (OR = 0.5, 95% CI 0.3-0.8) and inject with used needles (OR = 0.5, 95% CI 0.2-0.8) compared to those who left treatment. Cooker or cotton sharing was not associated with retention in treatment, but hepatitis B incidence was lowest among those who continued treatment. The results of this study suggest drug use risk reduction is more likely to be achieved by those who remain in drug treatment and by those who stop injecting, but that those who drop out and return and those who continue to inject while in treatment may also benefit. This supports the role of consistent drug treatment in an overall harm-reduction strategy.

Changes in injection risk behavior associated with participation in the Seattle needle-exchange program

We studied the influence of the Seattle, Washington, needle-exchange program on sharing of drug injection equipment (syringes, drug cookers, filtration cotton) to identify potential gaps in risk reduction and to understand in greater detail the lack of an association between exchange use and risk of hepatitis B or C virus transmission. In a cohort of 2,208 injection drug users who completed a 1-year follow-up visit, we measured the association between needle-exchange use at study enrollment (ever vs. never) and injection risk behavior at the follow-up. Control for confounding was carried out using both logistic regression and propensity score analytic methods to estimate the adjusted odds ratio (AOR). In both univariate and multivariate analyses, needle-exchange use was associated with a lower likelihood of injection with a used syringe (AOR = 0.7, 95% confidence limit 0.5, 0.9). There was no association between exchange use and cooker or cotton sharing (AOR = 0.8, 95% confidence limit 0.6, 1.1) or between exchange use and use of a common syringe to divide drugs (AOR = 0.9). This analysis suggests that risk reduction measures adopted by users of the Seattle exchange may not be sufficient to prevent transmission of all blood-borne viruses, including hepatitis C virus. Greater awareness of the infection risk associated with these practices may help curb this type of equipment sharing and ultimately prevent disease transmission.

Volunteer bias in nonrandomized evaluations of the efficacy of needle-exchange programs

OBJECTIVE

Nonrandomized comparisons of the incidence of HIV and hepatitis B and C between injection drug users (IDUs) who do and do not attend voluntary needle-exchange programs may be subject to bias. To explore possible sources of bias, we examined characteristics associated with voluntarily beginning or ceasing to participate in the Seattle needle exchange.

METHODS

In a cohort of 2,879 IDUs, a standardized questionnaire measured characteristics present at enrollment. We examined the relation of these characteristics to the proportion of IDUs who began to use the program during the ensuing 12-month follow-up period and to the proportion of current exchangers who dropped out during that period of time.

RESULTS

Of the 494 never-exchangers at baseline, 32% attended the exchange program during follow-up; those who reported sharing syringes or who were homeless at enrollment were more likely to become new exchange users (adjusted risk ratio [ARR] for becoming an exchange user = 1.8 for those who shared syringes, and ARR = 2.2 for those who were homeless). Of 1,274 current exchangers, 16% stopped using the exchange during followup, with daily injectors (ARR = 0.6) and those who reported backloading (ARR = 0.6) being relatively less likely to drop out of the exchange.

CONCLUSIONS

The analysis suggests that IDUs participating in needle-exchange programs at a given point in time may include a particularly high proportion of those injectors whose pattern of drug use puts them at elevated risk of blood-borne viral infections.

Audio-computer interviewing to measure risk behaviour for HIV among injecting drug users: a quasi-randomised trial

BACKGROUND

We aimed to assess audio-computer-assisted self-interviewing (audio-CASI) as a method of reducing under-reporting of HIV risk behaviour among injecting drug users.

METHODS

Injecting drug users were interviewed at syringe-exchange programmes in four US cities. Potential respondents were randomly selected from participants in the syringe exchanges, with weekly alternate assignment to either traditional face-to-face interviews or audio-CASI. The questionnaire included items on sociodemographic characteristics, drug use, and HIV risk behaviours for 30 days preceding the interview. We calculated odds ratios for the difference in reporting of HIV risk behaviours between interview methods.

FINDINGS

757 respondents were interviewed face-to-face, and 724 were interviewed by audio-CASI. More respondents reported HIV risk behaviours and other sensitive behaviours in audio-CASI than in face-to-face interviews (odds ratios for reporting of rented or bought used injection equipment in audio-CASI vs face-to-face interview 2.1 [95% CI 1.4-3.3] p=0.001; for injection with borrowed used injection equipment 1.5 [1.1-2.2] p=0.02; for renting or selling used equipment 2.3 [1.3-4.0] p=0.003).

INTERPRETATION

Although validation of these self-reported behaviours was not possible, we propose that audio-CASI enables substantially more complete reporting of HIV risk behaviour. More complete reporting might increase understanding of the dynamics of HIV transmission and make the assessment of HIV-prevention efforts easier.

Syringe exchange and risk of infection with hepatitis B and C viruses

The authors utilized a cohort study among Seattle injection drug users (IDUs) to assess whether participation in a syringe exchange program was associated with incidence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection. Susceptible IDU subjects (187 seronegative for antibody to HCV, and 460 seronegative for core antibody to HBV) were identified in drug treatment, corrections, and social service agencies from June 1994 to January 1996, and followed for seroconversion one year later. The subjects included in the analysis were Seattle-King County (Washington State) area IDUs enrolled in a larger multipurpose cohort study, the Risk Activity Variables, Epidemiology, and Network Study (RAVEN Study). There were 39 HCV infections (20.9/100/year) and 46 HBV infections (10.0/100/year). There was no apparent protective effect of syringe exchange against HBV (former exchange users, relative risk (RR) = 0.68, 95% confidence interval (CI) 0.2-2.5; sporadic exchange users, RR = 2.4, 95% CI 0.9-6.5; regular users, RR = 1.81, 95% CI 0.7-4.8; vs. RR = 1.0 for nonusers of the exchange; adjusted for daily drug injection). Neither did the exchange protect against HCV infection (sporadic users, RR = 2.6, 95% CI 0.8-8.5; regular users, RR = 1.3, 95% CI 0.8-2.2; vs. RR = 1.0 for nonusers; adjusted for recent onset of injection and syringe sharing prior to enrollment). While it is possible that uncontrolled confounding or other bias obscured a true beneficial impact of exchange use, these data suggest that no such benefit occurred during the period of the study.

Hepatitis C virus transmission dynamics in injection drug users

Hepatitis C virus (HCV) presents several challenges to the development of prevention programs. HCV infection is persistent in up to 80% of cases, and viremic individuals may transmit infection to others. With 65-90% of injection drug users anti-HCV positive, a large reservoir of infection exists in most drug-injector populations. Studying the genetic variability of HCV infections could permit researchers to reconstruct chains of viral transmission in IDUs. However, the relationship of HCV to HIV epidemiology remains unclear and may depend on whether the proportions of infectious persons in the population are similar for both viruses.

The protective effect of AIDS-related behavioral change among injection drug users: a cross-national study. WHO Multi-Centre Study of AIDS and Injecting Drug Use

OBJECTIVE

This study assessed the relationship between self-reported acquired immunodeficiency syndrome (AIDS) behavioral change and human immunodeficiency virus (HIV) serostatus among injection drug users.

METHODS

The study sample involved 4419 injection drug users recruited from drug abuse treatment and nontreatment settings in 11 cities in North America, South America, Europe, Asia, and Australia. The World Health Organization multisite risk behavior questionnaire was used, and either blood or saliva samples for HIV testing were obtained. Subjects were asked, "Since you first heard about AIDS, have you done anything to avoid getting AIDS?"

RESULTS

The protective odds ratio for behavioral change against being infected with HIV was 0.50 (95% confidence interval = 0.42, 0.59). While there was important variation across sites, the relationship remained consistent across both demographic and drug use history subgroups.

CONCLUSIONS

Injection drug users are capable of modifying their HIV risk behaviors and reporting accurately on behavioral changes. These behavioral changes are associated with their avoidance of HIV infection.

Reduced risk of hepatitis B and hepatitis C among injection drug users in the Tacoma syringe exchange program

OBJECTIVES

This case-control study examined the association between syringe exchange use and hepatitis B and C in injection drug users.

METHODS

Case patients included 28 injection drug users with acute hepatitis B and 20 with acute hepatitis C reported to the health department in a sentinel hepatitis surveillance county; control subjects were injection drug users with no markers of exposure to hepatitis B or C (n = 38 and 26, respectively) attending health department services during the same period. Data were abstracted from clinic records.

RESULTS

Seventy-five percent of case patients with hepatitis B and 26% of control subjects had never used the exchange; similar proportions were found for the hepatitis C case and control groups. After adjustment for demographic characteristics and duration of injecting drugs, nonuse of the exchange was associated with a sixfold greater risk of hepatitis B (odds ratio [OR] = 5.5; 95% confidence interval [CI] = 1.5, 20.4) and a sevenfold greater risk of hepatitis C (OR = 7.3; 95% CI = 1.6, 32.8).

CONCLUSIONS

The results suggest that use of the exchange led to a significant reduction in hepatitis B and hepatitis C in the county and may have also prevented a substantial proportion of human immunodeficiency virus infections in injection drug users.

Maintaining low HIV seroprevalence in populations of injecting drug users

OBJECTIVES

To describe prevention activities and risk behavior in cities where human immunodeficiency virus (HIV) was introduced into the local population of injecting drug users (IDUs), but where seroprevalence has nevertheless remained low (< 5%) during at least 5 years.

DESIGN AND SETTING

A literature search identified five such cities: Glasgow, Scotland; Lund, Sweden; Sydney, New South Wales, Australia; Tacoma, Wash; and Toronto, Ontario. Case histories were prepared for each city, including data on prevention activities and current levels of risk behavior among IDUs.

PARTICIPANTS

Injecting drug users recruited from both drug treatment and non-treatment settings in each city.

INTERVENTIONS

A variety of HIV prevention activities for IDUs had been implemented in each of the five cities.

RESULTS

There were three common prevention components present in all five cities: (1) implementation of prevention activities when HIV seroprevalence was still low, (2) provision of sterile injection equipment, and (3) community outreach to IDUs. Moderate levels of risk behavior continued with one third or more of the IDUs reporting recent unsafe injections.

CONCLUSIONS

In low-seroprevalence areas, it appears possible to severely limit transmission of HIV among populations of IDUs, despite continuing risk behavior among a substantial proportion of the population. Pending further studies, the common prevention components (beginning early, community outreach, and access to sterile injection equipment) should be implemented wherever populations of IDUs are at risk for rapid spread of HIV.

An interview study of participants in the Tacoma, Washington, syringe exchange

Although European and Australian studies of syringe exchange programs have reported safer injection among participants and no increase in drug use, the generalizability of these findings to the US is uncertain. We report on the operations and potential effectiveness of the longest-operating syringe exchange in the US and compare our results to studies of exchange programs outside the US. The sample of 204 study subjects reported no change in the frequency of injection, from 155 to 152 injections per month, and a decline in the frequency of unsafe injections, from 56 to 30 times per month, while participating in the program. In all studies, participants report reduction in unsafe injections, and no increase in illicit drug use. However, the comparison also suggests that a high proportion of Tacoma exchangers have higher initial rates of drug injection, unsafe injection and homelessness, all of which were associated with unsafe injection while using the exchange. These indicate a need for additional services but that the Tacoma program is no less effective than European and Australian programs.

The Tacoma Syringe Exchange

For over a year, the Tacoma Syringe Exchange has been operating in spite of existing drug paraphernalia laws. One hundred fifty-four subjects have been interviewed regarding drug injection practices for the month prior to first use of the exchange and for the most recent month since using the exchange. Statistically significant reductions in mean frequency of obtaining used syringes, and in mean rate of passing on used syringes, have been reported. Mean number of times bleach was used to disinfect contaminated syringes has risen. The exchange continues to attract mainly men, median age 35, with a long history of injection. No differences have been observed in mean number of injections per month. In order to increase utilization, new sites are planned, but expansion has been hampered by a series of legal problems. Since the exchange draws many difficult to reach individuals, it is an important location for STD screening and drug treatment recruitment. Documentation of participation patterns and barriers to exchange use, and effects upon HIV serological status are recommended.

Dermoid cyst of the spine in childhood

A 1 year, 10-month-old boy presented with a history of meningitis, a recent neurologic deficit, and myelographic evidence of a thoracic, extradural compressive lesion. The lesion was subtotally totally excised at surgery and found to be a dermoid cyst. Treatment of this uncommon tumor is facilitated by its early recognition and excision before onset of infection. Incomplete removal can result in regrowth.