Articles tagged as "Injecting drug use and HIV prevention"

HIV testing and the HIV epidemic –vitally important to prevent HIV becoming endemic

Editor’s notes: Epidemics refer to situations where the number of infections rises (and subsequently falls) more quickly than might be expected compared to a disease that is endemic.  Endemic implies a stable situation, with natural fluctuations in the number of cases.  Medley and Vassal have written a provocative article in Science that considers how differently individuals, communities and society react to epidemic rather than endemic diseases.  They choose to call HIV in 2017 endemic, which carries a serious risk. As the authors state, “The contained public response, and the concurrent shift of responsibility to individuals to protect themselves from risk, means that endemic disease embeds itself further, as those at risk are often the very same people who do not have the private resources to avoid risk or access treatment.”  There are in fact multiple separate epidemics of HIV in different regions and in different populations.  Some are rising and some are falling. The latest UNAIDS’ report emphasizes the heterogeneity of HIV infections in the world.  New HIV infections have fallen by 29% since 2010 in East and Southern Africa, the region with the highest rates.  On the other hand, new HIV infections have risen by an alarming 60% in Eastern Europe and Central Asia over the same period, albeit from a much lower baseline.  There is widespread political consensus to pursue the UN agenda endorsed at the High Level Meeting on Ending AIDS in New York last year.  Let’s not throw in the towel too soon!

HIV testing services remain central to the HIV strategy and, as usual, this month there are several important papers on aspects of HIV testing, many of which illustrate challenges that need to be overcome.

There are several reasons to encourage people living with HIV to know their status.  First and foremost, we know that the earlier treatment is started in the course of HIV, the better the outlook for the individual.  People who start treatment become much less likely to transmit HIV infection to sexual partners. People who know their HIV status are also able to make informed decisions about their lives and their partnerships.  A study this month by Escudero et al. from New York City used agent-based modelling to understand the testing and care continuum for people who inject drugs. Their results remind us of the key role of HIV testing.  They estimated that 53% of the HIV transmission events from people who inject drugs arose from people who did not know their status, and a further 37% from people who had not been started ART.  In other words, they estimate that only 10-11% of infections from people who inject drugs could be prevented by improving quality of care for people on treatment.  The need to find effective ways to encourage people at risk to know their status and start treatment is stark.

Guanzhou is one of the largest cities in China, with a high population of migrants both national and international.  It is among the most prosperous regions of Guangdong province and has the highest rates of HIV.   Chen et al. added some HIV testing related questions to a wider population based health survey in two districts and showed that approximately a quarter of adults had previously been tested for HIV.  HIV testing was almost all provided through free government facilities or blood transfusion centres.  Despite early steps to make HIV self-testing more available, none of the 666 participants who answered the relevant questions in the survey had used a self-test.  Distance from an HIV testing site was a key determinant of the likelihood of getting tested.  It was not clear that people who might be at higher risk were more likely to be tested, although the numbers and sampling focused on the general population rather than people at special risk.

Wang et al. explored the different HIV test kits used in the first line screening in Xi’an.  In line with Chinese guidelines, but not in line with WHO guidance on HIV testing algorithms for low prevalence settings, they used third- or fourth-generation rapid tests and repeated the positive tests.  WHO’s algorithm for low prevalence settings includes three different rapid tests based on different antigens.   Among 665 people found to be positive on rapid tests, only 559 were confirmed to be HIV-positive by Western blotting.  Subsequent follow up with additional Western blots showed that two of the individuals in whom the first Western blot was indeterminate were seroconverting but the other 104 were HIV-negative and had had false-positive results on the original rapid tests.  False positives were more likely with the fourth-generation test (22% of positive tests) compared to the various third-generation tests used (9-11% of positive tests).  Fourth-generation assays are known to be more sensitive, detecting people with HIV around a week or two earlier in the window period than third-generation assays.  However, the authors point out that in low prevalence settings like Xi’an, the known lack of specificity of fourth-generation assays means that they may not provide sufficient advantages to be used as the first line test.  Overall, the paper emphasizes the importance of using clearly defined algorithms.  The WHO algorithms no longer use Western blots, but do recommend using multiple tests based on different antigens for testing people at low risk of infection, and at least two different tests with different antigens for testing people at high risk of infection.  Everyone should have additional confirmatory tests done prior to starting ART.

Harbertson et al. also focused on the accuracy of rapid diagnostic tests.  They screened samples from 459 military personnel in seven African countries who had reported that they were HIV-positive.  Using the WHO algorithm, they compared the results of quality assured HIV testing to the self-reported HIV status of the participants.  They found that, in different country surveys, between three and 91% of people who said that they were living with HIV were in fact HIV-negative.  The authors point out that several studies have demonstrated the importance of following the WHO guidance, and that the positive predictive value of a test (or algorithm) will always fall as the overall prevalence falls.  They discuss possible limitations such as misunderstanding the question or the terminology used, but discount these possibilities as causing many of the false-positive reports, particularly given the highly variable results across different countries.  There was a strong association between the likelihood of a false positive report and lower education level. People whose understanding of HIV was less good were also more likely to report themselves to be positive falsely.  Overall, the authors assume that quality of testing services needs to be an important priority, while not discounting the challenges of using self-reports to collect information about HIV status.

As more and more people chose to know their HIV status, it may be possible to use routine data from the health service to track the epidemiology of HIV, rather than to use special surveys. Traditionally surveys of antenatal mothers have been used to monitor trends in the HIV epidemic over time.  With the widespread adoption of routine testing for mothers, a large proportion of women have an HIV test.  However, the assays used vary.  For surveillance purposes, samples are often stored and transported as dried blood spots and assays are run in batches using automated ELISA technology.  Routine testing (as discussed above) is often done using an algorithm based on a number of different rapid tests.   Pereira et al. have explored the differences between these approaches among almost 40 000 Brazilian mothers who participated in the antenatal surveillance exercise.  They interviewed mothers and linked their routine ANC results to the surveillance database.  Overall the prevalence of HIV among expectant mothers in Brazil was similar whichever approach was used (0.36% or 0.38%).  However, there were interesting differences.  The performance accuracy in those found positive in the surveillance exercise (which was taken as the gold standard) was only 84% overall and varied between regions from 43% to 100%.  So these 14 false negative results among the 88 individuals who were truly positive were compensated for in the overall prevalence estimates by a similar number (18) of false positive results among around 30 000 individuals who were truly negative. This highlights the challenges of providing accurate results to people in low prevalence settings. The 13% of mothers who slipped through the routine services and were not tested or refused to be tested were significantly more likely to be HIV-positive (0.56%), reinforcing the potential biases involved.  Finding 90% of people living with HIV will require considerable attention to the detail and the quality of HIV testing services.

Adolescents are often a population left behind, and regular reports show that adolescents living with HIV are less likely to know their status or to be on treatment or virally supressed.  Simms et al. used provider initiated testing and counselling (PITC) in primary care clinics in Harare, Zimbabwe.  For two years, the research team supported the routine offer of HIV testing to all six to 15 year olds presenting to seven clinics in a well-defined area of Harare.  The authors then conducted a population-based survey to find out how many eight to 17 year olds (who had had two years of exposure to the intervention) were aware of their status. 141 (2.6%) were living with HIV and more than one-third of these were undiagnosed.  Some had rarely been to the clinic, and others had been taken to the clinic by a guardian who was unable to consent to HIV testing on behalf of the child or the child’s parents.  Others had slipped through the PITC net, possibly because, as Lightfoot et al. in an accompanying comment suggest, providers still find it hard to offer HIV tests to everyone, as they assume that people living with HIV will not appear healthy.  This fits with the researchers’ findings that adolescents living with HIV who were currently healthy, had no skin or other problems and had parents who were alive were less likely to be diagnosed.  Both papers suggest that community based testing is needed to find adolescents. However, this also raises challenges in settings with lower prevalence than the high-density suburbs of Harare chosen for this project.  As prevalence falls lower than the 2.6% observed, a huge testing effort is needed, with attendant costs, but also (as explored above) with the risks of inaccurate results and of the very people that we want to find most, not being around for testing at the right moment. 

 

When an emerging disease becomes endemic.

Medley GF, Vassall A. Science. 2017 Jul 14;357(6347):156-158. doi: 10.1126/science.aam8333.

Epidemics, such as HIV in the early 1980s and Ebola in 2014, inspire decisive government investment and action, and individual and societal concern, sometimes bordering on panic. By contrast, endemic diseases, such as HIV in 2017 and tuberculosis, struggle to maintain the same attention. For many, the paradox is that endemic disease, in its totality, continues to impose a far higher public health burden than epidemic disease. Overall, the swift political response to epidemics has resulted in success. It has proven possible to eradicate epidemic diseases, often without the availability of vaccines and other biomedical technologies. In recent times, only HIV has made the transition from epidemic to endemic, but diseases that have existed for centuries continue to cause most of the infectious disease burden.

Abstract access

 

The risk of HIV transmission at each step of the HIV care continuum among people who inject drugs: a modeling study.

Escudero DJ, Lurie MN, Mayer KH, King M, Galea S, Friedman SR, Marshall BL. BMC Public Health. 2017 Jul 25;17(1):614. doi: 10.1186/s12889-017-4528-9.

Background: People who inject drugs (PWID) are at continued risk for HIV in the U.S., and experience disparities across the HIV care continuum compared to other high-risk groups. Estimates of the risk of HIV transmission at each stage of the care continuum may assist in identifying public health priorities for averting incident infections among PWID, in addition to transmissions to sexual partners of PWID.

Methods: We created an agent-based model simulating HIV transmission and the HIV care continuum for PWID in New York City (NYC) in 2012. To account for sexual transmission arising from PWID to non-PWID, the simulation included the entire adult NYC population. Using surveillance data and estimates from the National HIV Behavioral Surveillance system, we simulated a dynamic sexual and injecting network. We estimated the proportion of HIV transmission events attributable to PWID in the following categories, those: without an HIV diagnosis ('Undiagnosed'); diagnosed but not on antiretroviral therapy (ART) ('Diagnosed - not on ART'); those who initiated ART but were not virally suppressed ('Unsuppressed'); and, those who achieved viral suppression ('Suppressed').

Results: We estimated HIV incidence among PWID to be 113 per 100 000 person-years in 2012, with an overall incidence rate for the entire adult NYC population of 33 per 100 000 person-years. Despite accounting for only 33% of the HIV-infected PWID population, the Undiagnosed were associated with 52.6% (95% simulation interval [95% SI]: 47.1-57.0%) of total transmission events. The Diagnosed - not on ART population contributed the second-largest proportion of HIV transmissions, with 36.6% (95% SI: 32.2-41.5%). The Unsuppressed population contributed 8.7% (95% SI: 5.6-11.8%), and Suppressed 2.1% (95% SI: 1.1-3.9%), relatively little of overall transmission.

Conclusion: Among PWID in NYC, more than half (53%) of transmissions were from those who were unaware of their infection status and more than 36% were due to PWID who knew their status, but were not on treatment. Our results indicate the importance of early diagnosis and interventions to engage diagnosed PWID on treatment to further suppress population-level HIV transmission. Future HIV prevention research should focus on the elimination of identified and potential barriers to the testing, diagnosis, and retention of PWID on HIV treatment.

Abstract  Full-text [free] access

 

Is there a relationship between geographic distance and uptake of HIV testing services? A representative population-based study of Chinese adults in Guangzhou, China.

Chen W, Zhou F, Hall BJ, Tucker JD, Latkin C, Renzaho AMN, Ling L. PLoS One. 2017 Jul 20;12(7):e0180801. doi: 10.1371/journal.pone.0180801. eCollection 2017.

Achieving high coverage of HIV testing services is critical in many health systems, especially where HIV testing services remain centralized and inconvenient for many. As a result, planning the optimal spatial distribution of HIV testing sites is increasingly important. We aimed to assess the relationship between geographic distance and uptake of HIV testing services among the general population in Guangzhou, China. Utilizing spatial epidemiological methods and stratified household random sampling, we studied 666 adults aged 18-59. Computer-assisted interviews assessed self-reported HIV testing history. Spatial scan statistic assessed the clustering of participants who have ever been tested for HIV, and two-level logistic regression models assessed the association between uptake of HIV testing and the mean driving distance from the participant's residence to all HIV testing sites in the research sites. The percentage of participants who have ever been tested for HIV was 25.2% (168/666, 95%CI: 21.9%, 28.5%), and the majority (82.7%) of participants tested for HIV in Centres for Disease Control and Prevention, public hospitals or STIs clinics. None reported using self-testing. Spatial clustering analyses found a hotspot included 48 participants who have ever been tested for HIV and 25.8 expected cases (Rate Ratio = 1.86, P = 0.002). Adjusted two-level logistic regression found an inverse relationship between geographic distance (kilometers) and ever being tested for HIV (aOR = 0.90, 95%CI: 0.84, 0.96). Married or cohabiting participants (aOR = 2.14, 95%CI: 1.09, 4.20) and those with greater social support (aOR = 1.04, 95%CI: 1.01, 1.07) were more likely to be tested for HIV. Our findings underscore the importance of considering the geographical distribution of HIV testing sites to increase testing. In addition, expanding HIV testing coverage by introducing non-facility based HIV testing services and self-testing might be useful to achieve the goal that 90% of people living with HIV knowing their HIV status by the year 2020.

Abstract  Full-text [free] access

 

The characteristics of screening and confirmatory test results for HIV in Xi'an, China.

Wang L, Zhou KH, Zhao HP, Wang JH, Zheng HC, Yu Y, Chen W. PLoS One. 2017 Jul 7;12(7):e0180071. doi: 10.1371/journal.pone.0180071. eCollection 2017.

Objectives: Individuals with recent or acute HIV infection are more infectious than those with established infection. Our objective was to analyze the characteristics of detection among HIV infections in Xi'an.

Methods: A 4th-generation kit (Architect HIV Ag/Ab Combo) and three 3rd-generationEIA kits (WanTai, XinChuang and Livzon) were used for HIV screening. Overall, 665 individuals were identified as positive and were tested by western blotting (WB). The characteristics of the screening and confirmatory tests were analyzed, including the band patterns, the early detection performance and the false-positive rates.

Results: In total, 561 of the 665 patients were confirmed as having HIV-1 infection, and no HIV-2 specific band was observed. Among these 561 WB-positive cases, reactivity to greater than or equal to 9 antigens was the most commonly observed pattern (83.18%), and the absence of reactivity to p17, p31 and gp41 was detected in 6.44%, 5.9% and 2.86% of the cases, respectively. Two cases were positive by the 4th-generation assay but negative by the 3rd-generation assay for HIV screening and had seroconversion. The false-positive rate of the Architect HIV Ag/Ab Combo (22.01%) was significantly higher than those of WanTai (9.88%), XinChuang (10.87%) and Livzon (8.93%), p<0.05

Conclusion: HIV infection in Xi'an is mainly caused by HIV-1, and individuals are rarely identified at the early phase. Although the false-positive rate of the 4th-generation assay was higher than that of the 3rd-generation assay, it is still recommended for use as the initial HIV screening test for high-risk individuals. In Xi'an, a 3rd-generation assay for screening could be considered.

Abstract  Full-text [free] access

 

Self-reported HIV-positive status but subsequent HIV-negative test result using rapid diagnostic testing algorithms among seven sub-Saharan African military populations.

Harbertson J, Hale BR, Tran BR, Thomas AG, Grillo M, Jacobs MB, McAnany J, Shaffer RA. PLoS One. 2017 Jul 7;12(7):e0180796. doi: 10.1371/journal.pone.0180796. eCollection 2017.

HIV rapid diagnostic tests (RDTs) combined in an algorithm are the current standard for HIV diagnosis in many sub-Saharan African countries, and extensive laboratory testing has confirmed HIV RDTs have excellent sensitivity and specificity. However, false-positive RDT algorithm results have been reported due to a variety of factors, such as suboptimal quality assurance procedures and inaccurate interpretation of results. We conducted HIV serosurveys in seven sub-Saharan African military populations and recorded the frequency of personnel self-reporting HIV positivity, but subsequently testing HIV-negative during the serosurvey. The frequency of individuals who reported they were HIV-positive but subsequently tested HIV-negative using RDT algorithms ranged from 3.3 to 91.1%, suggesting significant rates of prior false-positive HIV RDT algorithm results, which should be confirmed using biological testing across time in future studies. Simple measures could substantially reduce false-positive results, such as greater adherence to quality assurance guidelines and prevalence-specific HIV testing algorithms as described in the World Health Organization's HIV testing guidelines. Other measures to improve RDT algorithm specificity include classifying individuals with weakly positive test lines as HIV indeterminate and retesting. While expansion of HIV testing in resource-limited countries is critical to identifying HIV-infected individuals for appropriate care and treatment, careful attention to potential causes of false HIV-positive results are needed to prevent the significant medical, psychological, and fiscal costs resulting from individuals receiving a false-positive HIV diagnosis.

Abstract  Full-text [free] access

 

Transitioning from antenatal surveillance surveys to routine HIV testing: a turning point in the mother-to-child transmission prevention programme for HIV surveillance in Brazil.

Pereira GFM, Sabidó M, Caruso A, Benzaken AS. BMC Infect Dis. 2017 Jul 5;17(1):469. doi: 10.1186/s12879-017-2540-4.

Background: In Brazil, due to the rapid increase in programmes for the prevention of mother-to-child transmission (PMTCT), routine programme data are widely available. The objective of this study was to assess the utility of programmatic data to replace HIV surveillance based on the antenatal care (ANC) surveillance survey (SS).

Methods: We analysed ANC SS data from 219 maternity service clinics. PMTCT variables were extracted from the ANC SS data collection form, which allowed us to capture and compare the ANC SS data and PMTCT HIV test results for each pregnant woman who completed the ANC SS. Both the PMTCT programme and the ANC SS tested for HIV using sequential ELISA and western blot for confirmation. We assessed the completeness (% missing) of the PMTC data included in the ANC SS.

Results: Of the 36 713 pregnant women who had ANC SS HIV tests performed, 30 588 also underwent PMTCT HIV testing. The HIV prevalence rate from routine PMTCT testing was 0.36%, compared to 0.38% from the ANC SS testing (relative difference -0.05%; absolute difference -0.02%). The relative difference in prevalence rates between pregnant women in northern Brazil and pregnant women central-west Brazil was -0.98 and 0.66, respectively. Of the 29 856 women who had HIV test results from both the PMTCT and ANC SS, the positive percent agreement of the PMTCT versus the surveillance test was 84.1% (95% confidence interval [CI]: 74.8-91.0), and the negative percent agreement was 99.9% (95% CI: 99.9-100.0). The PMTCT HIV testing uptake was 86.4%. The ANC SS HIV prevalence was 0.33% among PMTCT non-refusers and 0.59% among refusers, with a percent bias of -10.80% and a differential prevalence ratio of 0.56. Syphilis and HIV testing results were complete in 98% and 97.6% of PMTCT reports, respectively. The reported HIV status for the women at clinic entry was missing.

Conclusion: Although there were consistent HIV prevalence estimates from the PMTCT data and the ANC SS, the overall positive percent agreement of 84.1% falls below the World Health Organization benchmark of 94.7%. Therefore, Brazil must continue to reinforce data collection practices and ensure the quality of recently introduced rapid HIV testing before replacing the PMTCT data with surveillance techniques. However, some regions with better results could be prioritized to pilot the use of PMTCT data for surveillance.

Abstract  Full-text [free] access

 

Community burden of undiagnosed HIV infection among adolescents in Zimbabwe following primary healthcare-based provider-initiated HIV testing and counselling: A cross-sectional survey.

Simms V, Dauya E, Dakshina S, Bandason T, McHugh G, Munyati S, Chonzi P, Kranzer K, Ncube G, Masimirembwa C, Thelingwani R, Apollo T, Hayes R, Weiss HA, Ferrand RA. PLoS Med. 2017 Jul 25;14(7):e1002360. doi: 10.1371/journal.pmed.1002360. eCollection 2017 Jul.

Background: Children living with HIV who are not diagnosed in infancy often remain undiagnosed until they present with advanced disease. Provider-initiated testing and counselling (PITC) in health facilities is recommended for high-HIV-prevalence settings, but it is unclear whether this approach is sufficient to achieve universal coverage of HIV testing. We aimed to investigate the change in community burden of undiagnosed HIV infection among older children and adolescents following implementation of PITC in Harare, Zimbabwe.

Methods and Findings: Over the course of 2 years (January 2013-January 2015), 7 primary health clinics (PHCs) in southwestern Harare implemented optimised, opt-out PITC for all attendees aged 6-15 years. In February 2015-December 2015, we conducted a representative cross-sectional survey of 8-17-year-olds living in the 7 communities served by the study PHCs, who would have had 2 years of exposure to PITC. Knowledge of HIV status was ascertained through a caregiver questionnaire, and anonymised HIV testing was carried out using oral mucosal transudate (OMT) tests. After 1 participant taking antiretroviral therapy was observed to have a false negative OMT result, from July 2015 urine samples were obtained from all participants providing OMTs and tested for antiretroviral drugs to confirm HIV status. Children who tested positive through PITC were identified from among survey participants using gender, birthdate, and location. Of 7146 children in 4251 eligible households, 5486 (76.8%) children in 3397 households agreed to participate in the survey, and 141 were HIV positive. HIV prevalence was 2.6% (95% CI 2.2%-3.1%), and over a third of participants with HIV were undiagnosed (37.7%; 95% CI 29.8%-46.2%). Similarly, among the subsample of 2643 (48.2%) participants with a urine test result, 34.7% of those living with HIV were undiagnosed (95% CI 23.5%-47.9%). Based on extrapolation from the survey sample to the community, we estimated that PITC over 2 years identified between 18% and 42% of previously undiagnosed children in the community. The main limitation is that prevalence of undiagnosed HIV was defined using a combination of 3 measures (OMT, self-report, and urine test), none of which were perfect.

Conclusions: Facility-based approaches are inadequate in achieving universal coverage of HIV testing among older children and adolescents. Alternative, community-based approaches are required to meet the Joint United Nations Programme on HIV/AIDS (UNAIDS) target of diagnosing 90% of those living with HIV by 2020 in this age group.

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Key populations need so much more than HIV-specific services – involve them at every stage of planning and programming

Editor’s notes: This month sees a welcome set of papers covering female sex workers in West Africa; gay men and other men who have sex with men in the Middle East and in East Africa; people who inject drugs in the USA and eastern Europe.

Sex work is legal in Cote d’Ivoire although soliciting and pandering are criminalized, which creates legal barriers to practicing sex work.  Legalization does not necessarily prevent widespread abuse of power. Lyons and colleagues recruited 466 female sex workers in Abidjan through a respondent driven sampling approach.  A structured interview and rapid HIV test was performed.  Around 11% of the women were found to be living with HIV and it is clear that there are large unmet needs for HIV-specific services.  Only one quarter of those living with HIV reported that they knew their status and of these, only a few were already taking ART.  However, the focus of this study was on violence, both physical and sexual, which was alarmingly common, with around 54% of women reporting physical violence and 43% sexual violence.  The violence was most often perpetrated by spouses and boyfriends as well as by paying customers.  Other sex workers, pimps or managers and uniformed officers were also responsible for violence, both physical and sexual.  16% of women said that they had been tortured.  Collecting reliable data on sensitive areas with vulnerable populations is challenging.  The sampling method may introduce biases, and the interviews may lead to reported behaviours to “please” the interviewer.  However, this study included major efforts to work with the community of sex workers and their networks, and considerable trust has been built, so the results seem credible.  The authors call for structural interventions and policy reforms that have little to do with HIV directly, but would lead to an environment where HIV and other harms were greatly reduced.  There is also a direct need to ensure that sex workers have good access to HIV and other sexual and reproductive health services.

People who inject drugs also have many needs besides HIV services.  In the USA, the number of people who inject drugs is increasing.  This has led to a rising number of deaths from opioid overdose (around 30 000 in 2014), as well as increased HIV transmission, which makes the headlines of the news, when it occurs in settings where HIV is otherwise rare.  Cost-effective HIV prevention programmes for people who inject drugs are essential to the long-term health outcomes for this population and other high-risk groups in the USA.  Bernard and colleagues used a mathematical model and economic analysis to identify the most cost-effective interventions for HIV prevention programmes for people who inject drugs in the USA.

The authors found that under many likely assumptions about potential scale up, the best buy was always to provide opioid agonist therapy, which reduces injecting frequency and results in multiple, immediate quality-of-life improvements.  Needle and syringe exchange programmes are less expensive, but in these models produced fewer benefits, making them the next most cost-effective intervention, alone or in combination. PrEP was not likely to be cost-effective in this population except in the very highest risk settings.  This is in line with the values and preference expressed by many people who use drugs around the world.  The priority should be for “standard” harm reduction approaches, which will reduce HIV transmission, but have far wider benefits on the health and well-being of drug users and their communities.

Relatively little research is carried out with key populations in the Middle East.  Heimer and colleagues also used respondent driven sampling (with the same potential biases as above) to recruit 292 men who have sex with men in Beirut.  Although one quarter of the participants had been born in Syria and moved recently to Lebanon, the sampling method does reduce the precision of this estimate.  Of 36 people living with HIV identified, 32 were on HIV treatment, which is encouraging.  If the 32 on treatment were virally suppressed, the prevalence of “infectious HIV” in the survey was around 1.4%.  As we move forward into the viral load era, notions of risk for sexual behaviour will change, and we need to think about explicit descriptions such as “condomless sex” rather than simply referring to “unprotected sex”.  As stated above, the benefits of condoms for other sexually transmitted infections as well as for HIV need to be emphasized and the full range of ARV-based prevention made available in order to minimize the epidemic of HIV among gay men and other men who have sex with men in Lebanon and beyond.

The dynamics of the HIV epidemic in Ukraine are shifting.  Increasingly sexual transmission is becoming more common, and transmission through injecting drug use reducing.  Fearnhill and colleagues’ study of phylogenetics and recent infections among 876 newly diagnosed people living with HIV in Kiev highlights these trends.  The study also demonstrates plenty of uncertainty and suggests that the stigma associated with both injecting drug use and with gay men and other men having sex with men may lead to significant under-reporting of both in traditional epidemiological surveillance.  Although phylogenetics cannot prove misclassification, it is highly suggestive when large clusters of HIV from known gay men and other men who have sex with men include no women, but do include other men, who self-report to be heterosexual.  Transmission was most common among gay men and other men who have sex with men, and from those with recent infections.  HIV strains from women often cluster with those from people who inject drugs.  In a complex and dynamic environment with overlapping risk factors for HIV infection, phylogenetics adds a useful lens through which to examine what is happening.  Yet again, the challenge is to translate more granular understanding of the epidemics into clear public health policy and practice.

What do men who have sex with men in Kenya think about participating in HIV prevention research, such as a vaccine trial?  Doshi and colleagues used a social network-based approach to conduct in-depth interviews with 70 gay men and other men who have sex with men.  Here is what some of them said:

“He [the potential study participant] keeps hearing there is a research [study] that is starting, that there is money – one thousand or two, three thousand – he will run for the money…because it is someone’s life you have to be sure of what is going on…. You run for the better option because research comes in every type and researchers are everywhere in town.”

“Ok, you know most of the research coming to Kenya starts with MSM. Those are the ones that are tested on first so if there are side effects, those will be the first victims”

“It will benefit many of us…on my side…because sometimes I’m drunk I go out and meet people and they tell me they do not use condom…or… I’m drunk, I don’t know myself and I have already come to the bed with someone. Even I don’t know what he will do to me, if he will do me with a condom or if he will do me without a condom. Now the [HIV] vaccine…will be beneficial to me and the whole community”

This is a rich paper, giving insights into the reasons that people do or do not want to participate in vaccine trials.  It raises plenty of ethical questions about the balance between self-interest, altruism, coercion and consent.  It is encouraging that on the whole most participants saw the potential benefits to the wider community and would consider volunteering their time despite the associated risks.  Their perceptions were also coloured by previous research studies and how researchers had met their responsibilities for the care and well-being of their participants.  A good advertisement for the UNAIDS-AVAC Good Participatory Practice guidance!

Physical and sexual violence affecting female sex workers in Abidjan, Côte d'Ivoire: prevalence, and the relationship with the work environment, HIV, and access to health services

Lyons CE, Grosso A, Drame FM, Ketende S, Diouf D, Ba I, Shannon K, Ezouatchi R, Bamba A, Kouame A, Baral S. J Acquir Immune Defic Syndr. 2017 May 1;75(1):9-17. doi: 10.1097/QAI.0000000000001310.

Background: Violence is a human rights violation, and an important measure in understanding HIV among female sex workers (FSW). However, limited data exist regarding correlates of violence among FSW in Côte d'Ivoire. Characterizing prevalence and determinants of violence and the relationship with structural risks for HIV can inform development and implementation of comprehensive HIV prevention and treatment programs.

Methods: FSW > 18 years were recruited through respondent driven sampling (RDS) in Abidjan, Côte d'Ivoire. In total, 466 participants completed a socio-behavioral questionnaire and HIV testing. Prevalence estimates of violence were calculated using crude and RDS-adjusted estimates. Relationships between structural risk factors and violence were analyzed using χ2 tests and multivariable logistic regression.

Results: The prevalence of physical violence was 53.6% (250/466), and sexual violence was 43.2% (201/465) among FSW in this study. Police refusal of protection was associated with physical (adjusted Odds Ratio [aOR]: 2.8; 95% confidence interval [CI]: 1.7 to 4.4) and sexual violence (aOR: 3.0; 95% CI: 1.9 to 4.8). Blackmail was associated with physical (aOR: 2.5; 95% CI: 1.5 to 4.2) and sexual violence (aOR: 2.4; 95% CI: 1.5 to 4.0). Physical violence was associated with fear (aOR: 2.2; 95% CI: 1.3 to 3.1) and avoidance of seeking health services (aOR: 2.3; 95% CI: 1.5 to 3.8).

Conclusions: Violence is prevalent among FSW in Abidjan and associated with features of the work environment and access to care. These relationships highlight layers of rights violations affecting FSW, underscoring the need for structural interventions and policy reforms to improve work environments, and to address police harassment, stigma, and rights violations to reduce violence and improve access to HIV interventions.

Abstract

Estimation of the cost-effectiveness of HIV prevention portfolios for people who inject drugs in the United States: a model-based analysis

Bernard CL, Owens DK, Goldhaber-Fiebert JD, Brandeau ML. PLoS Med. 2017 May 24;14(5):e1002312 doi: 10.1371/journal.pmed.1002312. eCollection 2017 May.

Background: The risks of HIV transmission associated with the opioid epidemic make cost-effective programs for people who inject drugs (PWID) a public health priority. Some of these programs have benefits beyond prevention of HIV-a critical consideration given that injection drug use is increasing across most United States demographic groups. To identify high-value HIV prevention program portfolios for US PWID, we consider combinations of four interventions with demonstrated efficacy: opioid agonist therapy (OAT), needle and syringe programs (NSPs), HIV testing and treatment (Test & Treat), and oral HIV pre-exposure prophylaxis (PrEP).

Methods and Findings: We adapted an empirically calibrated dynamic compartmental model and used it to assess the discounted costs (in 2015 US dollars), health outcomes (HIV infections averted, change in HIV prevalence, and discounted quality-adjusted life years [QALYs]), and incremental cost-effectiveness ratios (ICERs) of the four prevention programs, considered singly and in combination over a 20-y time horizon. We obtained epidemiologic, economic, and health utility parameter estimates from the literature, previously published models, and expert opinion. We estimate that expansions of OAT, NSPs, and Test & Treat implemented singly up to 50% coverage levels can be cost-effective relative to the next highest coverage level (low, medium, and high at 40%, 45%, and 50%, respectively) and that OAT, which we assume to have immediate and direct health benefits for the individual, has the potential to be the highest value investment, even under scenarios where it prevents fewer infections than other programs. Although a model-based analysis can provide only estimates of health outcomes, we project that, over 20 y, 50% coverage with OAT could avert up to 22 000 (95% CI: 5200, 46 000) infections and cost US$18 000 (95% CI: US$14 000, US$24 000) per QALY gained, 50% NSP coverage could avert up to 35 000 (95% CI: 8900, 43 000) infections and cost US$25 000 (95% CI: US$7000, US$76 000) per QALY gained, 50% Test & Treat coverage could avert up to 6700 (95% CI: 1200, 16 000) infections and cost US$27 000 (95% CI: US$15 000, US$48 000) per QALY gained, and 50% PrEP coverage could avert up to 37 000 (22 000, 58 000) infections and cost US$300 000 (95% CI: US$162 000, US$667 000) per QALY gained. When coverage expansions are allowed to include combined investment with other programs and are compared to the next best intervention, the model projects that scaling OAT coverage up to 50%, then scaling NSP coverage to 50%, then scaling Test & Treat coverage to 50% can be cost-effective, with each coverage expansion having the potential to cost less than US$50 000 per QALY gained relative to the next best portfolio. In probabilistic sensitivity analyses, 59% of portfolios prioritized the addition of OAT and 41% prioritized the addition of NSPs, while PrEP was not likely to be a priority nor a cost-effective addition. Our findings are intended to be illustrative, as data on achievable coverage are limited and, in practice, the expansion scenarios considered may exceed feasible levels. We assumed independence of interventions and constant returns to scale. Extensive sensitivity analyses allowed us to assess parameter sensitivity, but the use of a dynamic compartmental model limited the exploration of structural sensitivities.

Conclusions: We estimate that OAT, NSPs, and Test & Treat, implemented singly or in combination, have the potential to effectively and cost-effectively prevent HIV in US PWID. PrEP is not likely to be cost-effective in this population, based on the scenarios we evaluated. While local budgets or policy may constrain feasible coverage levels for the various interventions, our findings suggest that investments in combined prevention programs can substantially reduce HIV transmission and improve health outcomes among PWID.

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HIV risk, prevalence, and access to care among men who have sex with men in Lebanon

Heimer R, Barbour R, Khoury D, Crawford FW, Shebl FM, Aaraj E, Khoshnood K. AIDS Res Hum Retroviruses. 2017 Jun 29 doi: 10.1089/AID.2016.0326. [Epub ahead of print].

Objective: Little is known about HIV prevalence and risk among men who have sex with men in much of the Middle East, including Lebanon. Recent national level surveillance has suggested an increase in HIV prevalence concentrated among men in Lebanon. We undertook a biobehavioral study to provide direct evidence for the spread of HIV.

Design: MSM were recruited by respondent driven sampling, interviewed, and offered HIV testing anonymously at sites located in Beirut, Lebanon from October 2014 through February 2015. The interview questionnaire was designed to obtain information on participants' sociodemographic situation, sexual behaviors, alcohol and drug use, health, HIV testing and care, experiences of stigma and discrimination. Individuals not reporting an HIV diagnosis were offered optional, anonymous HIV testing.

Results: Among the 292 MSM recruited, we identified 36 cases of HIV (12.3%). A quarter of the MSM were born in Syria and recently arrived in Lebanon. Condom use was uncommon; 65% reported unprotected sex with other men. Group sex encounters were reported by 22% of participants. Among the 32 individuals already aware of their infection, 30 were in treatment and receiving antiretroviral therapy.

Conclusions: HIV prevalence was substantially increased over past estimates. Efforts to control future increases will have to focus on reducing specific risk behaviors and experienced stigma and abuse, especially among Syrian refugees.

Abstract

A phylogenetic analysis of HIV-1 sequences in Kiev: findings among key populations

Fearnhill E, Gourlay A, Malyuta R, Simmons R, Ferns RB, Grant P, Nastouli E, Karnets I, Murphy G, Medoeva A, Kruglov Y, Yurchenko A, Porter K; CASCADE Collaboration in EuroCoord. Clin Infec Dis 2017 May 29: doi: 10.1093/cid/cix499. [Epub ahead of print].

Background: The HIV epidemic in Ukraine has been driven by a rapid rise among people who inject drugs, but recent studies have shown an increase through sexual transmission.

Methods: Protease and RT sequences from 876 new HIV diagnoses (April 2013 - March 2015) in Kiev were linked to demographic data. We constructed phylogenetic trees for 794 subtype A1 and 64 subtype B sequences and identified factors associated with transmission clustering. Clusters were defined as ≥ 2 sequences, ≥ 80% local branch support and maximum genetic distance of all sequence pairs in the cluster ≤ 2.5%. Recent infection was determined through the LAg avidity EIA assay. Sequences were analysed for transmitted drug resistance (TDR) mutations.

Results: 30% of subtype A1 and 66% of subtype B sequences clustered. Large clusters (maximum 11 sequences) contained mixed risk groups. In univariate analysis, clustering was significantly associated with subtype B compared to A1 (OR 4.38 [95% CI 2.56-7.50]), risk group (OR 5.65 [3.27-9.75]) for men who have sex with men compared to heterosexual males, recent, compared to long-standing, infection (OR 2.72 [1.64-4.52]), reported sex work contact (OR 1.93 [1.07-3.47]) and younger age groups compared to age ≥36 (OR 1.83 [1.10-3.05] for age ≤25). Females were associated with lower odds of clustering than heterosexual males (OR 0.49 [0.31-0.77]). In multivariate analysis, risk group, subtype and age group were independently associated with clustering (p<0.001, p=0.007 and p=0.033). 18 sequences (2.1%) indicated evidence of TDR.

Conclusions: Our findings suggest high levels of transmission and bridging between risk groups.

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Contextualizing willingness to participate: recommendations for engagement, recruitment & enrolment of Kenyan MSM in future HIV prevention trials

Doshi M, Avery L, Kaddu RP, Gichuhi M, Gakii G, du Plessis E, Dutta S, Khan S, Kimani J, Lorway RR. BMC Public Health. 2017 May 18;17(1):469 doi: 10.1186/s12889-017-4395-4.

Background: The HIV epidemic among men who have sex with men (MSM) continues to expand globally. The addition of an efficacious, prophylactic vaccine to combination prevention offers immense hope, particularly in low- and middle- income countries which bear the greatest global impact. However, in these settings, there is a paucity of vaccine preparedness studies that specifically pertain to MSM. Our study is the first vaccine preparedness study among MSM and female sex workers (FSWs) in Kenya. In this paper, we explore willingness of Kenyan MSM to participate in HIV vaccine efficacy trials. In addition to individual and socio-cultural motivators and barriers that influence willingness to participate (WTP), we explore the associations or linkages that participants draw between their experiences with or knowledge of medical research both generally and within the context of HIV/AIDS, their perceptions of a future HIV vaccine and their willingness to participate in HIV vaccine trials.

Methods: Using a social network-based approach, we employed snowball sampling to recruit MSM into the study from Kisumu, Mombasa, and Nairobi. A field team consisting of seven community researchers conducted in-depth interviews with a total of 70 study participants. A coding scheme for transcribed and translated data was developed and the data was then analysed thematically.

Results: Most participants felt that an HIV vaccine would bring a number of benefits to self, as well as to MSM communities, including quelling personal fears related to HIV acquisition and reducing/eliminating stigma and discrimination shouldered by their community. Willingness to participate in HIV vaccine efficacy trials was highly motivated by various forms of altruism. Specific researcher responsibilities centred on safe-guarding the rights and well-being of participants were also found to govern WTP, as were reflections on the acceptability of a future preventive HIV vaccine.

Conclusion: Strategies for engagement of communities and recruitment of trial volunteers for HIV vaccine efficacy trials should not only be grounded in and informed by investigations into individual and socio-cultural factors that impact WTP, but also by explorations of participants' existing experiences with or knowledge of medical research as well as attitudes and acceptance towards a future HIV vaccine.

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Africa, Asia, Northern America
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H*V – can we do better for HIV, HBV and HCV if we all work together?

Editor’s notes: The Sustainable Development Goals (SDGs) signal a major shift in the way that the United Nations and her development partners aim to shape the next decades.  Whereas the Millennium Development Goals reinforced specific programmes for HIV, tuberculosis and malaria, the SDGs call for a more integrated approach to health and well-being and encourage integration and synergy wherever it makes sense.  Hepatitis is one obvious area in which better collaboration and coordination could yield benefits.  Hepatitis B (HBV) and C (HCV) viruses are both more common in some of the populations most affected by HIV.  HCV can now be cured with drugs that derive directly from the HIV portfolio, while some ARVs have a direct effect on HBV.

Rwanda is one of the first countries in sub-Saharan Africa to set up a control programme for viral hepatitis, building on the infrastructure established for HIV. Umutesi and colleagues report on results of screening almost 120 000 people living with HIV who entered care for markers of HBV and HCV.  Around 5000 people (4.3%) were identified with a positive Hepatitis B surface antigen and a similar number (4.6%) were found to have antibodies against HCV.  There was marked variation geographically with a range by district from 2%-11% for HBV, higher in more urban areas and in men.  For HCV the range was from 3%-8% and was higher in more rural areas, and also in men.  This study provides a good platform to estimate numbers of people who might need treatment and to plan the next steps in an integrated programme.

People who inject drugs are particularly severely affected by HCV, and so co-infection with both HIV and HCV is common in areas where both viruses circulate.  Some estimates from Ho Chi Minh City in Viet Nam suggest that more than 40% of people who inject drugs are living with HIV and that essentially all of these people are also co-infected with HCV.  Birger R and colleagues developed a mathematical model to explore the likely impact of interventions aimed at HIV, HCV or broad harm reduction [with methadone maintenance treatment (MMT)] on future mortality and incidence of both infections.  While ART scale up reduces HIV incidence and mortality, it has no effect on HCV.  MMT is effective at reducing incidence of both HIV and HCV (and has morbidity and mortality benefits beyond these viruses).  However, MMT does not help the many people already living with HCV and so has little effect on HCV related mortality. So the model is clear that treatment for HCV needs to be an important part of a combined programme and that we urgently need to find ways to reduce the price of directly acting antivirals if we are to save more Vietnamese lives.

Haldane and colleagues have also focused on this intersection between HIV and substance use services.  They carried out a systematic review to understand the models and implications of integration of service delivery.  The authors expand their typology of integration models considering the point of entry of the client, and the degree to which services are co-located and delivered.  Integration can be considered as “clinical”, “service” or “systems”.  The first two can operate at the micro or meso level meaning that individual staff can deal with both situations, or that staff are trained to provide appropriate referrals.  Systems level integration operates at a macro level and implies that programmes for each service make collaborations and coordinate in ways that may affect staffing, funding and fragmentation of services. Although there are theoretical advantages to coordination and integration (as shown by the mathematical model above), there are few good empirical studies of integrated service delivery reported outside the USA.  The authors considered that most of the intervention studies had a risk of bias in the interpretation of their impact, although all demonstrated positive changes in outcomes.  Furthermore, almost all the studies focussed on integration at the clinic or individual provider level (meso or micro) rather than addressing the larger systemic challenges that we need to consider.  If we are to achieve the ideals laid out in the Sustainable Development Goals, we will need to overcome some of these systemic challenges, particularly for populations that are criminalized and marginalized by many of the public services.

Prevalence of hepatitis B and C infection in persons living with HIV enrolled in care in Rwanda.

Umutesi J, Simmons B, Makuza JD, Dushimiyimana D, Mbituyumuremyi A, Uwimana JM, Ford N, Mills EJ, Nsanzimana S. BMC Infect Dis. 2017 May 2;17(1):315. doi: 10.1186/s12879-017-2422-9.

Background: Hepatitis B (HBV) and C (HCV) are important causes of morbidity and mortality in people living with human immunodeficiency virus (HIV). The burden of these co-infections in sub-Saharan Africa is still unclear. We estimated the prevalence of the hepatitis B surface antigen (HBsAg) and hepatitis C antibody (HCVAb) among HIV-infected individuals in Rwanda and identified factors associated with infection.

Methods: Between January 2016 and June 2016, we performed systematic screening for HBsAg and HCVAb among HIV-positive individuals enrolled at public and private HIV facilities across Rwanda. Results were analyzed to determine marker prevalence and variability by demographic factors.

Results: Overall, among 117 258 individuals tested, the prevalence of HBsAg and HCVAb was 4.3% (95% confidence interval [CI] (4.2-4.4) and 4.6% (95% CI 4.5-4.7) respectively; 182 (0.2%) HIV+ individuals were co-infected with HBsAg and HCVAb. Prevalence was higher in males (HBsAg, 5.4% [5.1-5.6] vs. 3.7% [3.5-3.8]; HCVAb, 5.0% [4.8-5.2] vs. 4.4% [4.3-4.6]) and increased with age; HCVAb prevalence was significantly higher in people aged ≥65 years (17.8% [16.4-19.2]). Prevalence varied geographically.

Conclusion: HBV and HCV co-infections are common among HIV-infected individuals in Rwanda. It is important that viral hepatitis prevention and treatment activities are scaled-up to control further transmission and reduce the burden in this population. Particular efforts should be made to conduct targeted screening of males and the older population. Further assessment is required to determine rates of HBV and HCV chronicity among HIV-infected individuals and identify effective strategies to link individuals to care and treatment.

Abstract  Full-text [free] access

The impact of HCV therapy in a high HIV-HCV prevalence population: A modeling study on people who inject drugs in Ho Chi Minh City, Vietnam.

Birger RB, Le T, Kouyos RD, Grenfell BT, Hallett TB. PLoS One. 2017 May 11;12(5):e0177195. doi: 10.1371/journal.pone.0177195. eCollection 2017.

Background: Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (HCV) coinfection is a major global health problem especially among people who inject drugs (PWID), with significant clinical implications. Mathematical models have been used to great effect to shape HIV care, but few have been proposed for HIV/HCV.

Methods: We constructed a deterministic compartmental ODE model that incorporated layers for HIV disease progression, HCV disease progression and PWID demography. Antiretroviral therapy (ART) and Methadone Maintenance Therapy (MMT) scale-ups were modeled as from 2016 and projected forward 10 years. HCV treatment roll-out was modeled beginning in 2026, after a variety of MMT scale-up scenarios, and projected forward 10 years.

Results: Our results indicate that scale-up of ART has a major impact on HIV though not on HCV burden. MMT scale-up has an impact on incidence of both infections. HCV treatment roll-out has a measurable impact on reductions of deaths, increasing multifold the mortality reductions afforded by just ART/MMT scale-ups.

Conclusion: HCV treatment roll-out can have major and long-lasting effects on averting PWID deaths on top of those averted by ART/MMT scale-up. Efficient intervention scale-up of HCV alongside HIV interventions is critical in Vietnam.

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Integrating HIV and substance use services: a systematic review

Haldane V, Cervero-Liceras F, Chuah FL, Ong SE, Murphy G, Sigfrid L, Watt N, Balabanova D, Hogarth S, Maimaris W, Buse K, Piot P, McKee M, Perel P, Legido-Quigley H. Journal of the International AIDS Society. 2017 May 30;20(1).http://dx.doi.org/10.7448/IAS.20.1.21585.

Introduction: Substance use is an important risk factor for HIV, with both concentrated in certain vulnerable and marginalized populations. Although their management differs, there may be opportunities to integrate services for substance use and HIV. In this paper we systematically review evidence from studies that sought to integrate care for people living with HIV and substance use problems.

Methods: Studies were included if they evaluated service integration for substance use and HIV. We searched multiple databases from inception until October 2015. Articles were screened independently by two reviewers and assessed for risk of bias.

Results and discussion: 11 057 records were identified, with 7616 after removal of duplicates. After screening titles and abstracts, 51 met the inclusion criteria. Integration models were categorized by location (HIV, substance use and other facilities), level of integration from micro (integrated care delivered to individuals) to macro (system level integrations) and degree of integration from least (screening and counselling only) to most (care for HIV, substance use and/or other illnesses at the same facility). Most reported descriptive or cohort studies; in four randomized control trials integrated activities improved patient outcomes. There is potential for integrating services at all facility types, including mobile health services. While services offering screening only can achieve synergies, there are benefits from delivering integrated treatment for HIV and substance use, including ease of referral to other mental health and social services.

Conclusions: Our review used a wide range of databases and conference archives to increase representation of papers from low- and middle-income countries. Limitations include the overrepresentation of studies from the United States, and the descriptive nature of the majority of papers. The evidence reviewed shows that greater integration offers important benefits in both patient and service outcomes but further research and outcome reporting is needed to better understand innovative and holistic care models at the complex intersection of substance use and HIV services.

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Africa, Asia, Europe, Northern America
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People who inject drugs living with HIV in Russia face more mental health issues and diminished quality of life

Psychiatric symptoms, quality of life, and HIV status among people using opioids in Saint Petersburg, Russia.

Desrosiers A, Blokhina E, Krupitsky E, Zvartau E, Schottenfeld R, Chawarski M. Drug Alcohol Depend. 2017 Mar 1;172:60-65. doi: 10.1016/j.drugalcdep.2016.12.007. Epub 2017 Jan 23.

Background: The Russian Federation is experiencing a very high rate of HIV infection among people who inject drugs (PWID). However, few studies have explored characteristics of people with co-occurring opioid use disorders and HIV, including psychiatric symptom presentations and how these symptoms might relate to quality of life. The current study therefore explored a.) differences in baseline psychiatric symptoms among HIV+ and HIV- individuals with opioid use disorder seeking naltrexone treatment at two treatment centers in Saint Petersburg, Russia and b.) associations between psychiatric symptom constellations and quality of life.

Methods: Participants were 328 adults enrolling in a randomized clinical trial evaluating outpatient treatments combining naltrexone with different drug counseling models. Psychiatric symptoms and quality of life were assessed using the Brief Symptom Inventory and The World Health Organization Quality of Life-BREF, respectively.

Results: Approximately 60% of participants were HIV+. Those who were HIV+ scored significantly higher on BSI anxiety, depression, psychoticism, somatization, paranoid ideation, phobic anxiety, obsessive-compulsive, and GSI indexes (all p<0.05) than those HIV-. A K-means cluster analysis identified three distinct psychiatric symptom profiles; the proportion of HIV+ was significantly greater and quality of life indicators were significantly lower in the cluster with the highest psychiatric symptom levels.

Conclusion: Higher levels of psychiatric symptoms and lower quality of life indicators among HIV+ (compared to HIV-) individuals injecting drugs support the potential importance of combining interventions that target improving psychiatric symptoms with drug treatment, particularly for HIV+ patients.

Abstract access 

Editor’s notes: The higher prevalence of mental health disorders among people living with HIV is well known. This paper focuses on the association of mental health disorders and HIV among people who inject drugs, in St Petersburg, Russian Federation – the city with the highest prevalence of HIV and drug use in the Russian Federation. HIV positive people who inject drugs had significantly higher prevalence of mental health problems than HIV negative people who inject drugs. They had a lower quality of life according to a validated scale, underscoring the need for strong, combination public health programmes to support this vulnerable group. The population studied was selected through existing service provision. Since these individuals were already seeking treatment on their own, there could be many more who are not engaged in care either for HIV treatment or drug use support. This suggests the need to strengthen awareness and services, especially in areas where clean needles and other risk management methods are not yet available.

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Russian Federation
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The hope and reality of injecting drug use among people living with HIV in Ukraine

Attitudes toward addiction, methadone treatment, and recovery among HIV-infected Ukrainian prisoners who inject drugs: incarceration effects and exploration of mediators.  

Polonsky M, Rozanova J, Azbel L, Bachireddy C, Izenberg J, Kiriazova T, Dvoryak S, Altice FL. AIDS Behav. 2016 Dec;20(12):2950-2960.

In this study, we use data from a survey conducted in Ukraine among 196 HIV-infected people who inject drugs, to explore attitudes toward drug addiction and methadone maintenance therapy (MMT), and intentions to change drug use during incarceration and after release from prison. Two groups were recruited: Group 1 (n = 99) was currently incarcerated and Group 2 (n = 97) had been recently released from prison. This paper's key finding is that MMT treatment and addiction recovery were predominantly viewed as mutually exclusive processes. Group comparisons showed that participants in Group 1 (pre-release) exhibited higher optimism about changing their drug use, were less likely to endorse methadone, and reported higher intention to recover from their addiction. Group 2 participants (post-release), however, reported higher rates of HIV stigma. Structural equation modeling revealed that in both groups, optimism about recovery and awareness of addiction mediated the effect of drug addiction severity on intentions to recover from their addiction.

Abstract access 

Editor’s notes: Despite reductions in HIV incidence and mortality globally, the epidemic in Ukraine remains volatile and continues to expand, especially among people who inject drugs.  People who inject drugs account for more than 40% of people living with HIV.  At 20%, HIV prevalence among Ukrainian people living in prisons is the highest in Europe, with drug injection of opioids being the major driver of transmission. This is due to a concentration of people who inject drugs among prisoners and other incarcerated people, especially people living with HIV. Programmes focusing on prisoners and other incrcerated people may play a central role in HIV prevention since nearly all of them transition back to the community. Opioid agonist therapies including methadone maintenance therapy have been shown to have many benefits including reducing HIV transmission by over 50% among people who inject drugs.  Despite these benefits, moral biases, stigma and ideological prejudices are barriers to opioid agonist therapies scale-up globally including in Ukraine.  Opioid agonist therapies are available free of charge through national and external Global Fund support. However, scale up of opioid agonist therapies and treatment retention in Ukraine have been low, with only about 2.7% of people who inject drugs enrolled. This has constrained HIV prevention efforts.  Adoption of opioid agonist therapies has been especially slow among criminal justice populations. This study compares attitudes towards opioid agonist therapies among currently and previously incarcerated opioid-dependent people living with HIV in Ukraine.

The study uses data from a survey of people living with HIV conducted in Ukraine to explore attitudes to methadone treatment and intentions to change drug use behaviour before and after release from prison.

This study has important implications for future management of people who inject drugs who are living with HIV.  While staff attitudes may undermine the successful opioid agonist therapies delivery in prisons, the findings of this study suggest that prisoners and other incarcerated people are important foci for programmes that should be done in parallel with staff-based activities. The findings also suggest that optimism about recovery while in prison is falsely elevated. This may contribute to individual inability to comprehend addiction as a chronic relapsing condition, which in the absence of treatment, results in 85% relapsing within 12 months of release. Future programmes should take advantage of individuals’ sobriety while in prison and cultivate their ability to recognise the cycle of addiction and incarceration. This optimism should also be channelled to focus on evidence-based programmes, e.g., methadone maintenance therapy that has been associated with reduced illicit drug relapse, HIV risk-taking and reincarceration. Considerable health marketing work also needs to be done to focus on negative attitudes and prejudices about methadone maintenance therapy at both individual and societal level. This would importantly involve rebranding methadone maintenance therapy as a medical treatment for a chronic relapsing condition.

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Ukraine
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Needle-syringe programmes and treatment will dramatically reduce HIV epidemic among people who inject drugs in Russia and Ukraine

Reducing HIV infection in people who inject drugs is impossible without targeting recently-infected subjects.

Vasylyeva TI, Friedman SR, Lourenco J, Gupta S, Hatzakis A, Pybus OG, Katzourakis A, Smyrnov P, Karamitros T, Paraskevis D, Magiorkinis G. AIDS. 2016 Nov 28;30(18):2885-2890.

Objective: Although our understanding of viral transmission among people who inject drugs (PWID) has improved, we still know little about when and how many times each injector transmits HIV throughout the duration of infection. We describe HIV dynamics in PWID to evaluate which preventive strategies can be efficient.

Design: Due to the notably scarce interventions, HIV-1 spread explosively in Russia and Ukraine in 1990s. By studying this epidemic between 1995 and 2005, we characterized naturally occurring transmission dynamics of HIV among PWID.

Method: We combined publicly available HIV pol and env sequences with prevalence estimates from Russia and Ukraine under an evolutionary epidemiology framework to characterize HIV transmissibility between PWID. We then constructed compartmental models to simulate HIV spread among PWID.

Results: In the absence of interventions, each injector transmits on average to 10 others. Half of the transmissions take place within 1 month after primary infection, suggesting that the epidemic will expand even after blocking all the post-first month transmissions. Primary prevention can realistically target the first month of infection, and we show that it is very efficient to control the spread of HIV-1 in PWID. Treating acutely infected on top of primary prevention is notably effective.

Conclusion: As a large proportion of transmissions among PWID occur within 1 month after infection, reducing and delaying transmissions through scale-up of harm reduction programmes should always form the backbone of HIV control strategies in PWID. Growing PWID populations in the developing world, where primary prevention is scarce, constitutes a public health time bomb

Abstract  Full-text [free] access 

Editor’s notes: This paper presents powerful findings from a mathematical model that sought to estimate how much prevalence of HIV will increase among people who inject drugs in 10-20 years’ time in the absence of HIV treatment and needle-syringe programmes. Findings suggest HIV prevalence will reach 86% in 20 years in the absence of programmes. The paper provides important new information to the growing body of evidence that estimates the impact of needle-syringe programmes and opioid substitution therapy in reducing HIV transmission among people who inject drugs, in the region. The authors focus on the impact of needle-syringe programmes and of the prevention benefits of treatment, reducing transmission among individuals recently acquiring HIV where infectivity is higher in the first month of infection. The estimates provide projections of programme impact in the realities of the current policy environment, given the prohibition of opioid substitution therapy in the Russian Federation. The model focusses on injection transmission routes only and does not consider sexual transmission among people who inject drugs. Therefore, projected estimates of HIV are likely to be underestimates. The paper is important in highlighting the urgent need for needle-syringe programmes and treatment among people who inject drugs in the region and highlighting the crisis in relation to HIV among people who inject drugs in Russia and Ukraine. Modelling estimates such as these are powerful tools to persuade policy makers of the urgent need for programmes.  Importantly the authors recognize the need for structural programmes. They highlight the need to create an enabling environment in which needle-syringe programmes can operate. This environment needs to include supportive policing practices and reducing stigma. 

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Russian Federation, Ukraine
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HIV incidence halved among injecting drugs users in network outreach programme - Ukraine

HIV incidence among people who inject drugs (PWIDs) in Ukraine: results from a clustered randomised trial.

Booth RE, Davis JM, Dvoryak S, Brewster JT, Lisovska O, Strathdee SA, Latkin CA. Lancet HIV. 2016 Oct;3(10):e482-9. doi: 10.1016/S2352-3018(16)30040-6. Epub 2016 Jul 29.

Background: HIV prevalence among people who inject drugs (PWID) in Ukraine is among the highest in the world. In this study, we aimed to assess whether a social network intervention was superior to HIV testing and counselling in affecting HIV incidence among PWID. Although this was not the primary aim of the study, it is associated with reducing drug and sex risk behaviours, which were primary aims.

Methods: In this clustered randomised trial, PWID who were 16 years of age or older, had used self-reported drug injection in the past 30 days, were willing to be interviewed for about 1 hour and tested for HIV, were not too impaired to comprehend and provide informed consent, and, for this paper, who tested HIV negative at baseline were recruited from the streets by project outreach workers in three cities in southern and eastern Ukraine: Odessa, Donetsk, and Nikolayev. Index or peer leaders, along with two of their network members, were randomly assigned (1:1) by the study statistician to the testing and counselling block (control group) or the testing and counselling plus a social network intervention block (intervention group). No stratification or minimisation was done. Participants in the network intervention received five sessions to train their network members in risk reduction. Those participants assigned to the control group received no further intervention after counselling. The main outcome of this study was HIV seroconversion in the intent-to-treat population as estimated with Cox regression and incorporating a gamma frailty term to account for clustering. This trial is registered with ClinicalTrial.gov, number NCT01159704.

Findings: Between July 12, 2010, and Nov 23, 2012, 2304 PWIDs were recruited, 1200 of whom were HIV negative and are included in the present study. 589 index or peer leaders were randomly assigned to the control group and 611 were assigned to the intervention group. Of the 1200 HIV-negative participants, 1085 (90%) were retained at 12 months. In 553.0 person-years in the intervention group, 102 participants had seroconversion (incidence density 18.45 per 100 person-years; 95% CI 14.87-22.03); in 497.1 person-years in the control group 158 participants seroconverted (31.78 per 100 person-years; 26.83-36.74). This corresponded to a reduced hazard in the intervention group (hazard ratio 0.53, 95% CI 0.38-0.76, p=0.0003). No study-related adverse events were reported.

Interpretation: These data provide strong support for integrating peer education into comprehensive HIV prevention programmes for PWID and suggest the value in developing and testing peer-led interventions to improve access and adherence to pre-exposure prophylaxis and antiretroviral therapy.

Abstract  Full-text [free] access 

Editor’s notes: People who inject drugs are at high risk of HIV infection, and, in many settings, are unlikely to have appropriate access to HIV prevention programmes. This study is a secondary, subgroup analysis of a randomised control of a social network programme for people who inject drugs in Ukraine (the primary outcome was HIV risk taking behaviour). The investigators recruited 256 index users, who subsequently recruited fellow members of their injection network to the study. Half (n=128) of the index participants were randomized to a two-week training programme in risk reduction education. These “peer leaders” were trained with the intention that they would disseminate these skills within their injection networks. The HIV incidence was alarmingly high. After 12 months, for the sub-group of participants who were initially HIV-negative, the incidence of seroconversion was 31.9/100 person-years in the control networks and 18.4/100 person-years in the programme networks, representing a 47% reduction in incidence associated with the programme. This study is notable for its randomized design, low attrition, close collaboration with local non-governmental organizations, a study protocol adaptation process which engaged drugs users and dealers, and a biological outcome measure. Further research can consider the economic costs for each averted HIV infection, whether the programme effects varied by other factors, and assessment of the extent to which the risk reduction skills were shared beyond study participants. The very high incidence, even among those receiving the intervention, emphasize the need for much greater investment in harm reduction approaches.

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Ukraine
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New evidence in support of opioid substitution therapy as a key HIV programme for people who inject drugs

Impact of opioid substitution therapy on antiretroviral therapy outcomes: a systematic review and meta-analysis.

Low AJ, Mburu G, Welton NJ, May MT, Davies CF, French C, Turner K, Looker KJ, Christensen H, McLean S, Rhodes T, Platt L, Hickman M, Guise A, Vickerman P. Clin Infect Dis. 2016 Jun 25. pii: ciw416. [Epub ahead of print]

Background: HIV-positive people who inject drugs (PWID) frequently encounter barriers accessing and remaining on antiretroviral treatment (ART). Some studies have suggested that opioid substitution therapy (OST) could facilitate PWID's engagement with HIV services. We conducted a systematic review and meta-analysis to evaluate the impact of concurrent OST use on ART-related outcomes among HIV-positive PWID.

Methods: We searched Medline, PsycInfo, Embase, Global Health, Cochrane, Web of Science, and Social Policy and Practice databases for studies between 1996 to November 2014 documenting the impact of OST, compared to no OST, on ART outcomes. Outcomes considered were: coverage and recruitment onto ART, adherence, viral suppression, attrition from ART, and mortality. Meta-analyses were conducted using random effects modelling, and heterogeneity assessed using Cochran's Q test and I2 statistic.

Results: We identified 4685 articles, and 32 studies conducted in North America, Europe, Indonesia and China were included. OST was associated with a 69% increase in recruitment onto ART (HR=1.69, 95% confidence interval (CI): 1.32-2.15), a 54% increase in ART coverage (OR=1.54; 95% CI: 1.17-2.03), a two-fold increase in adherence (OR=2.14, 95% CI: 1.41-3.26), and a 23% decrease in the odds of attrition (OR=0.77, 95% CI:0.63-0.95). OST was associated with a 45% increase in odds of viral suppression (OR=1.45, 95%CI:1.21-1.73), but there was limited evidence from six studies for OST decreasing mortality for PWID on ART (HR=0.91, 95% CI:0.65-1.25).

Conclusions: These findings support the use of OST, and its integration with HIV services, to improve the HIV treatment and care continuum amongst HIV-positive PWID.

Abstract access

Editor’s notes: This is a very important study contributing new evidence on how opioid substitution therapy can help in the treatment and prevention of HIV among people who inject drugs. This review provides key evidence in support of opioid substitution therapy as a cornerstone HIV treatment and prevention programme. This evidence is essential given the growing number of HIV infections among people who inject drugs globally, particularly in eastern Europe and sub-Saharan Africa. There is a wealth of evidence from systematic reviews and mathematical modelling to illustrate how the use of opioid substitution therapy decreases risk of HIV acquisition at an individual-level.  It can also reduce HIV prevalence and incidence at the population level. This review is important in that it illustrates how opioid substitution therapy can facilitate HIV treatment.  Findings illustrate that opioid substitution therapy works by increasing adherence to HIV treatment, decreasing attrition from treatment and increasing odds of viral suppression reducing the odds of onwards HIV transmission. In addition to this important review, there is also a need to understand the role opioid substitution therapy might have in increasing uptake of HIV testing. This review does not address that question. It is notable that few studies on impact of opioid substitution therapy on HIV treatment outcomes and uptake included in the review were identified in low-income countries or eastern Europe where need is greatest. This partly reflects the lack of opioid substitution therapy programmes in that region, particularly the Russian Federation. This is also the case in sub-Saharan Africa where opioid substitution therapy programmes are newly established and yet to be evaluated. Future research is necessary to understand how opioid substitution therapy might work: (1) where transmission of HIV is predominantly sexual and (2) where injecting drug use occurs within very different social and economic contexts.

Asia, Europe, Northern America
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Fishing, injection drug use and HIV risk

The association between psychosocial and structural-level stressors and HIV injection drug risk behavior among Malaysian fishermen: a cross-sectional study.

Michalopoulos LM, Jiwatram-Negron T, Choo MK, Kamarulzaman A, El-Bassel N. BMC Public Health. 2016 Jun 2;16(1):464. doi: 10.1186/s12889-016-3125-7.

Background: Malaysian fishermen have been identified as a key-affected HIV population with HIV rates 10 times higher than national rates. A number of studies have identified that psychosocial and structural-level stressors increase HIV injection drug risk behaviors. The purpose of this paper is to examine psychosocial and structural-level stressors of injection drug use and HIV injection drug risk behaviors among Malaysian fishermen.

Methods: The study employs a cross-sectional design using respondent driven sampling methods. The sample includes 406 fishermen from Pahang state, Malaysia. Using multivariate logistic regressions, we examined the relationship between individual (depression), social (adverse interactions with the police), and structural (poverty-related) stressors and injection drug use and risky injection drug use (e.g.., receptive and non-receptive needle sharing, frontloading and back-loading, or sharing drugs from a common container).

Results: Participants below the poverty line had significantly lower odds of injection drug use (OR 0.52, 95 % CI: 0.27-0.99, p = 0.047) and risky injection drug use behavior (OR 0.48, 95 % CI: 0.25-0.93, p = 0.030). In addition, participants with an arrest history had higher odds of injection use (OR 19.58, 95 % CI: 9.81-39.10, p < 0.001) and risky injection drug use (OR 16.25, 95 % CI: 4.73-55.85, p < 0.001). Participants with depression had significantly higher odds of engaging in risky injection drug use behavior (OR 3.26, 95 % 1.39-7.67, p = 0.007). Focusing on participants with a history of injection drug use, we found that participants with depression were significantly more likely to engage in risky drug use compared to participants below the depression cutoff (OR 3.45, 95 % CI: 1.23-9.66, p < 0.02).

Conclusions: Findings underscore the need to address psychosocial and structural-level stressors among Malaysian fishermen to reduce HIV injection drug risk behaviors.

Abstract  Full-text [free] access 

Editor’s notes: There is an increasing amount of research on high rates of HIV infection among people living in fishing communities in parts of Africa and Asia. There is also a lot of information on factors which put people in these fishing communities at risk of HIV infection. This paper is, however, the first study to look in detail at the association between risky injection drug use behaviours and HIV among fishermen. The authors of this fascinating and important paper provide a detailed analysis on the association between, what they call, individual, social and structural factors which contribute to risk. Interestingly, poorer fishermen were at less risk than fishermen who were better off, perhaps because poorer men could not afford the costs of injection drugs. However, the fear of the police, and the risk of arrest, resulted in injection practices which increased the risk of HIV infection. The authors note that the association between symptoms of depression and risky injection drug use may be an outcome of this behaviour rather than the cause. The authors highlight how fishermen using injection drugs to manage stress and risk in their lives, may compound the stress they face by this behaviour. The paper illustrates, very clearly, the complex relationship there often is between individual behaviours and the structural and social context. The authors provide very useful pointers for unpacking risk and HIV-infection in other similar populations. 

Asia
Malaysia
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How research can both provide evidence of burden of disease and facilitate access to services

Integrated respondent-driven sampling and peer support for persons who inject drugs in Haiphong, Vietnam: a case study with implications for interventions.

Des Jarlais D, Duong HT, Pham Minh K, Khuat OH, Nham TT, Arasteh K, Feelemyer J, Heckathorn DD, Peries M, Moles JP, Laureillard D, Nagot N. AIDS Care. 2016 May 13:1-4. [Epub ahead of print]

Combined prevention for HIV among persons who inject drugs (PWID) has led to greatly reduced HIV transmission among PWID in many high-income settings, but these successes have not yet been replicated in resource-limited settings. Haiphong, Vietnam experienced a large HIV epidemic among PWID, with 68% prevalence in 2006. Haiphong has implemented needle/syringe programs, methadone maintenance treatment (MMT), and anti-retroviral treatment (ART), but there is an urgent need to identify high-risk PWID and link them to services. We examined integration of respondent-driven sampling (RDS) and strong peer support groups as a mechanism for identifying high-risk PWID and linking them to services. The peer support staff performed the key tasks that required building and maintaining trust with the participants, including recruiting the RDS seeds, greeting and registering participants at the research site, taking electronic copies of participant fingerprints (to prevent multiple participation in the study), and conducting urinalyses. A 6-month cohort study with 250 participants followed the RDS cross-sectional study. The peer support staff maintained contact with these participants, tracking them if they missed appointments, and providing assistance in accessing methadone and ART. The RDS recruitment was quite rapid, with 603 participants recruited in three weeks. HIV prevalence was 25%, Hepatitis C (HCV) prevalence 67%, and participants reported an average of 2.7 heroin injections per day. Retention in the cohort study was high, with 86% of participants re-interviewed at 6-month follow-up. Assistance in accessing services led to half of the participants in need of methadone enrolled in methadone clinics, and half of HIV-positive participants in need of ART enrolled in HIV clinics by the 6-month follow-up. This study suggests that integrating large-scale RDS and strong peer support may provide a method for rapidly linking high-risk PWID to combined prevention and care, and greatly reducing HIV transmission among PWID in resource-limited settings.

Abstract access

Editor’s notes: This paper highlights that evidence on the effectiveness of harm reduction programmes including opioid substitution therapy, needle-syringe programmes and antiretroviral therapy, alone, and in combination have been shown to be effective in reducing incidence of HIV and hepatitis C in Europe, northern America and Australia. But evidence is lacking in countries with the largest or growing populations of people who inject drugs and high prevalence of HIV and hepatitis C. This is particularly true in low-income settings including South-East Asia and East Africa. But this is also true in high income countries such as the Russian Federation which has the fastest growing epidemic of HIV in the world, primarily among people who inject drugs. But opioid substitution therapy is prohibited. The paper is methodologically interesting. It demonstrates the feasibility of following-up a cohort of people who inject drugs over six months. More importantly, it illustrates how research can be used to link the most vulnerable members of the population, including people who inject frequently and people living with HIV who are not on treatment, into opioid substitution therapy and HIV treatment services. As well as demonstrating the practical use of research in increasing access to services, the research is also important for advocacy purposes. The authors illustrate the burden of HIV and hepatitis C among the population, further highlighting the need for harm reduction services and HIV/hepatitis C treatment. 

Asia
Viet Nam
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