Articles tagged as "Injecting drug use and HIV prevention"

Comparing the performance of different community-based measures of viral load as correlates for HIV incidence

Community viral load, antiretroviral therapy coverage, and HIV incidence in India: a cross-sectional, comparative study.

Solomon SS, Mehta SH, McFall AM, Srikrishnan AK, Saravanan S, Laeyendecker O, Balakrishnan P, Celentano DD, Solomon S, Lucas GM. Lancet HIV. 2016 Apr;3(4):e183-90. doi: 10.1016/S2352-3018(16)00019-9. Epub 2016 Mar 11.

Background: HIV incidence is the best measure of treatment-programme effectiveness, but its measurement is difficult and expensive. The concept of community viral load as a modifiable driver of new HIV infections has attracted substantial attention. We set out to compare several measures of community viral load and antiretroviral therapy (ART) coverage as correlates of HIV incidence in high-risk populations.

Methods: We analysed data from a sample of people who inject drugs and men who have sex with men, who were participants of the baseline assessment of a cluster-randomised trial in progress across 22 cities in India ( number NCT01686750). We recruited the study population by use of respondent-driven sampling and did the baseline assessment at 27 community-based sites (12 for men who have sex with men and 15 for people who inject drugs). We estimated HIV incidence with a multiassay algorithm and calculated five community-based measures of HIV control: mean log10 HIV RNA in participants with HIV in a community either engaged in care (in-care viral load), aware of their status but not necessarily in care (aware viral load), or all HIV-positive individuals whether they were aware, in care, or not (population viral load); participants with HIV in a community with HIV RNA more than 150 copies per mL (prevalence of viraemia); and the proportion of participants with HIV who self-reported ART use in the previous 30 days (population ART coverage). All participants were tested for HIV, with additional testing in HIV-positive individuals. We assessed correlations between the measures and HIV incidence with Spearman correlation coefficients and linear regression analysis.

Findings: Between Oct 1, 2012, and Dec 19, 2013, we recruited 26 503 participants, 12 022 men who have sex with men and 14 481 people who inject drugs. Median incidence of HIV was 0.87% (IQR 0.40-1.17) in men who have sex with men and 1.43% (0.60-4.00) in people who inject drugs. Prevalence of viraemia was more strongly correlated with HIV incidence (correlation 0.81, 95% CI 0.62-0.91; p<0.0001) than all other measures, although correlation was significant with aware viral load (0.59, 0.27-0.79; p=0.001), population viral load (0.51, 0.16-0.74; p=0.007), and population ART coverage (-0.54, -0.76 to -0.20; p=0.004). In-care viral load was not correlated with HIV incidence (0.29, -0.10 to 0.60; p=0.14). With regression analysis, we estimated that to reduce HIV incidence by 1 percentage point in a community, prevalence of viraemia would need to be reduced by 4.34%, and ART use in HIV-positive individuals would need to increase by 19.5%.

Interpretation: Prevalence of viraemia had the strongest correlation with HIV incidence in this sample and might be a useful measure of the effectiveness of a treatment programme.

Abstract access    

Editor’s notes: The ideal metric of impact for a programme looking at the prevention benefits of treatment would be the reduction in HIV incidence in the target population. Incidence is however very difficult to measure. ‘Community viral load’ has been proposed as an alternative. However its estimation using data collected either in a routine clinical setting or from a cohort study can suffer from bias, due to the population included not being representative of the wider population of people living with HIV.

This paper describes a study among gay men and other men who have sex with men and people who inject drugs carried out at 27 sites in India. Participants were recruited using respondent-driven sampling (in which respondents recruit their peers to produce a generally representative sample of hard-to-reach populations). At each site incidence was estimated using a multi-assay algorithm designed to identify seroconversion occurring approximately within the last six months. Five community-based measures of viral load were measured at each site. Of these, the prevalence of HIV viraemia (i.e. the proportion of the population with a viral load greater than 150 copies per mL), was most strongly associated with HIV incidence, while mean viral load among people in-care was not associated. This latter finding is important if a case-based surveillance approach using only data collected at clinics is to be used to estimate incidence. Population ART coverage, a measure of the proportion of the site participants on ART was also strongly correlated with incidence. As this can be measured through a simple questionnaire, rather than lab-based assays, it could be an easily and cheaply obtainable correlate for incidence, albeit one potentially prone to response bias.

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Programme planning must take into account diversity of sex worker populations - Pakistan

Heterogeneity among sex workers in overlapping HIV risk interactions with people who inject drugs: a cross-sectional study from 8 major cities in Pakistan. 

Melesse DY, Shafer LA, Shaw SY, Thompson LH, Achakzai BK, Furqan S, Reza T, Emmanuel F, Blanchard JF. Medicine (Baltimore). 2016 Mar;95(12):e3085. doi: 10.1097/MD.0000000000003085.

Concerns remain regarding the heterogeneity in overlapping human immunodeficiency virus (HIV) risk behaviors among sex workers (SWs) in Pakistan; specifically, the degree to which SWs interact with people who inject drugs (PWID) through sex and/or needle sharing. Following an in-depth mapping performed in 2011 to determine the size and distribution of key populations at highest risk of HIV acquisition in Pakistan, a cross-sectional biological and behavioral survey was conducted among PWID, female (FSWs), male (MSWs), and hijra/transgender (HSWs) sex workers, and data from 8 major cities were used for analyses. Logistic regression was used to identify factors, including city of residence and mode of SW-client solicitation, contributing to the overlapping risks of drug injection and sexual interaction with PWID. The study comprised 8483 SWs (34.5% FSWs, 32.4% HSWs, and 33.1% MSWs). Among SWs who had sex with PWID, HSWs were 2.61 (95% confidence interval [CI], 1.19-5.74) and 1.99 (95% CI, 0.94-4.22) times more likely to inject drugs than MSWs and FSWs, respectively. There was up to a 3-fold difference in drug injecting probability, dependent on where and/or how the SW solicited clients. Compared with SWs in Larkana, the highest likelihood of drug injection use was among SWs in Multan (OR = 4.52; 95% CI: 3.27-6.26), followed by those in Lahore, Quetta, and Faisalabad. Heterogeneity exists in the overlapping patterns of HIV risk behaviors of SWs. The risk of drug injection among SWs also varies by city. Some means of sexual client solicitation may be along the pathway to overlapping HIV risk vulnerability due to increased likelihood of drug injection among SWs. There is a need to closely monitor the mixing patterns between SWs and PWID and underlying structural factors, such as means of sexual client solicitation, that mediate HIV risk, and implement prevention programs customized to local sub-epidemics.

Abstract  Full-text [free] access

Editor’s notes: This is an important paper reporting findings of an HIV prevalence and risk behaviour survey among sex workers and people who inject drugs. The paper describes the diversity of sex work, including male and transgender sex workers that are often neglected in research and service planning. It also examines injecting drug use among sex workers, a behaviour that can increase sex workers’ vulnerability to HIV, violence and other health harms. The finding that among sex workers who had a sex partner who also injected drugs, transgender sex workers had higher odds of injecting than male or female sex workers is important. This finding highlights the differences in vulnerability among the three sex worker populations, whose diversity is often not taken into account in programme planning. Other international evidence suggests increased stigma experienced by transgender sex workers on account of their gender. For example, with increased arrest and harassment administered by police and higher levels of poor emotional health. These are factors that might explain use of injecting drugs as a coping strategy. The study illustrates a clear need to target harm reduction services among this population, to ensure they have access to needle-syringe programmes.  Advice on safe injecting practices and how to manage injecting drug use alongside sex work are also necessary. Findings also clearly illustrate the need to understand better the underlying determinants of drug use and address those. Understanding why prevalence of drug use varies by city is vital. So too, is understanding how the way in which clients are engaged increases risk of injecting, in order to create enabling environments to minimise harms associated with injecting. 

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Sex and drugs: cost-effectiveness of risk reduction programmes for female sex workers who inject drugs in Mexico

Cost-effectiveness of combined sexual and injection risk reduction interventions among female sex workers who inject drugs in two very distinct Mexican border cities.

Burgos JL, Patterson TL, Graff-Zivin JS, Kahn JG, Rangel MG, Lozada MR, Staines H, Strathdee SA. PLoS One. 2016 Feb 18;11(2):e0147719. doi: 10.1371/journal.pone.0147719. eCollection 2016.

Background: We evaluated the cost-effectiveness of combined single session brief behavioral intervention, either didactic or interactive (Mujer Mas Segura, MMS) to promote safer-sex and safer-injection practices among female sex workers who inject drugs (FSW-IDUs) in Tijuana (TJ) and Ciudad-Juarez (CJ) Mexico. Data for this analysis was obtained from a factorial RCT in 2008-2010 coinciding with expansion of needle exchange programs (NEP) in TJ, but not in CJ.

Methods: A Markov model was developed to estimate the incremental cost per quality adjusted life year gained (QALY) over a lifetime time frame among a hypothetical cohort of 1000 FSW-IDUs comparing a less intensive didactic vs. a more intensive interactive format of the MMS, separately for safer sex and safer injection combined behavioral interventions. The cost for antiretroviral therapy was not included in the model. We applied a societal perspective, a discount rate of 3% per year and currency adjusted to US$2014. A multivariate sensitivity analysis was performed. The combined and individual components of the MMS interactive behavioral intervention were compared with the didactic formats by calculating the incremental cost-effectiveness ratios (ICER), defined as incremental unit of cost per additional health benefit (e.g., HIV/STI cases averted, QALYs) compared to the next least costly strategy. Following guidelines from the World Health Organization, a combined strategy was considered highly cost-effective if the incremental cost per QALY gained fell below the gross domestic product per capita (GDP) in Mexico (equivalent to US$ 10 300).

Findings: For CJ, the mixed intervention approach of interactive safer sex/didactic safer injection had an incremental cost-effectiveness ratio (ICER) of US$4360 ($310-$7200) per QALY gained compared with a dually didactic strategy. Using the dually interactive strategy had an ICER of US$5874 ($310-$7200) compared with the mixed approach. For TJ, the combination of interactive safer sex/didactic safer injection had an ICER of US$5921 ($104-$9500) per QALY compared with dually didactic. Strategies using the interactive safe injection intervention were dominated due to lack of efficacy advantage. The multivariate sensitivity analysis showed a 95% certainty that in both CJ and TJ the ICER for the mixed approach (interactive safer sex didactic safer injection intervention) was less than the GDP per capita for Mexico. The dual interactive approach met this threshold consistently in CJ, but not in TJ.

Interpretation: In the absence of an expanded NEP in CJ, the combined-interactive formats of the MMS behavioral intervention is highly cost-effective. In contrast, in TJ where NEP expansion suggests that improved access to sterile syringes significantly reduced injection-related risks, the interactive safer-sex combined didactic safer-injection was highly cost-effective compared with the combined didactic versions of the safer-sex and safer-injection formats of the MMS, with no added benefit from the interactive safer-injection component.

Abstract  Full-text [free] access 

Editor’s notes: Female sex workers who inject drugs are a particularly vulnerable group with potential risks of HIV infection stemming from both condomless sex and use of contaminated injecting equipment. In the northern border towns of Mexico, which are on major drug trafficking routes into the United States, the prevalence of HIV among female sex workers who inject drugs is 12%. This is in comparison with 6% among female sex workers who do not inject drugs and 0.3% among the general population. In this context, the authors conducted a cost-effectiveness analysis of a combined single-session brief behavioural programme. It was either didactic or interactive, to promote safer sexual and injection practices among female sex workers who inject drugs in two Mexican cities: Ciudad Juarez and Tijuana.

The authors found that the programme can be highly cost-effective in reducing HIV risky behaviours, although with varying results. Sensitivity analyses suggested that in both cities, the mixed approach (interactive safer sex/didactic safer injection intervention) was highly cost-effective. The dual interactive approach was highly cost-effective in Ciudad Juarez but not in Tijuana.

This article illustrates the importance of targeting programmes that take into consideration city-level contexts. Although the cities are similar in many ways, the double interactive approach was not highly cost-effective in the Tijuana setting. This is likely to be due to the fact that needle syringe distribution at the community level expanded at the same time, making the interactive safer injection practice component redundant. This supports previous research that community-level programmes, such as needle-exchange programmes, could be potentially more cost-effective than individual-level activities. Individual-level activities may then be best suited for settings where needle-syringe programmes are not available, such as in prisons. 

Latin America
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HIV and injecting ‘krokodile’

Krokodile Injectors in Ukraine: fueling the HIV Epidemic?

Booth RE, Davis JM, Brewster JT, Lisovska O, Dvoryak S. AIDS Behav. 2016 Feb;20(2):369-76. doi: 10.1007/s10461-015-1008-z.

This study was designed to assess the characteristics of krokodile injectors, a recent phenomenon in Ukraine, and HIV-related risk factors among people who inject drugs (PWID). In three Ukraine cities, Odessa, Donetsk and Nikolayev, 550 PWID were recruited between December 2012 and October 2013 using modified targeted sampling methods. The sample averaged 31 years of age and they had been injecting for over 12 years. Overall, 39% tested positive for HIV, including 45% of krokodile injectors. In the past 30 days, 25% reported injecting krokodile. Those who injected krokodile injected more frequently (p < 0.001) and they injected more often with others (p = 0.005). Despite knowing their HIV status to be positive, krokodile users did not reduce their injection frequency, indeed, they injected as much as 85% (p = 0.016) more frequently than those who did not know their HIV status or thought they were negative. This behavior was not seen in non-krokodile using PWID. Although only a small sample of knowledgeable HIV positive krokodile users was available (N = 12), this suggests that krokodile users may disregard their HIV status more so than non-krokodile users. In spite of widespread knowledge of its harmful physical consequences, a growing number of PWID are turning to injecting krokodile in Ukraine. Given the recency of krokodile use in the country, the associated higher frequency of injecting, a propensity to inject more often with others, and what could be a unique level of disregard of HIV among krokodile users, HIV incidence could increase in future years.

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Editor’s notes: This is an important study among a highly vulnerable population of people who inject drugs where HIV prevalence has been consistently high over the last decade. This is one of the first empirical studies to examine the role of krokodile use on HIV risk acquisition. Krokodile is a home produced drug that has become more popular among people who inject drugs in Ukraine and the Russian Federation over the last five years. There is a long history of injection with home-produced opioids and amphetamines in these countries. The key component of krokodile is codeine, an opioid, but severe side effects have been associated with its injection including tissue damage, gangrene and organ failure. This study highlights some of the characteristics and HIV risk behaviours associated with krokodile injection to inform appropriate HIV prevention programming. Findings note that people who inject krokodile are more likely to inject with others. This reflects the home-produced nature of the drug that facilitates more group injecting as people congregate at places where it is produced to buy and inject. Programmes need to focus on strategies to avoid injecting with other people’s used injecting equipment, such as marking equipment, as can happen in group injecting scenarios. This programme would ensure there are sufficient numbers of clean needles/syringes in circulation. Worryingly, a higher prevalence of HIV was observed among people who inject krokodile, most likely associated with their older age and more frequent injecting. Targeted harm reduction information is urgently needed for krokodile users to prevent further HIV transmission and prevent soft tissue damage. There is already a large network of needle-syringe programmes and opioid substitution therapy available for people who inject drugs in Ukraine. However, access is often reduced since people who inject drugs are concerned about being arrested. Registration as a person who injects drugs causes problems with employment, families and police. Collaboration with the police is necessary to increase access to opioid substitution and needle and syringe programmes. Programmes are also required to reduce the stigma associated with injection in order to address the health needs of this population. 

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Increased heroin use puts Colombia at risk of HIV epidemic among people who inject drugs

Heroin use and injection risk behaviors in Colombia: implications for HIV/AIDS prevention.

Mateu-Gelabert P, Harris S, Berbesi D, Cardona AM, Velez LP, Motta IE, Jessell L, Guarino H, Friedman SR.Subst Use Misuse. 2016 Jan 22:1-11. [Epub ahead of print]

Background: Heroin production in Colombia has increased dramatically in recent decades, and some studies point to an increase in local heroin use since the mid-1990s. Despite this rapid increase, little is known about the effects of these activities on heroin injection within Colombia. One of the biggest concerns surrounding heroin injection is the potential spread of HIV through drug user networks.

Objectives: This article examines injection risk behaviors among heroin injectors in the Colombian cities of Medellin and Pereira to explore the implications for possible increased HIV transmission within this group.

Methods: A cross-sectional study used respondent-driving sampling to recruit a sample of 540 people who inject drugs (PWID) over 18 years of age (Medellin: n = 242, Pereira: n = 298). Structured interviews with each participant were conducted using the World Health Organization Drug Injection Study Phase II Survey. An HIV test was also administered.

Results: Information regarding the socio-demographics, injection drug use, HIV risk and transmission behaviors, injection risk management, and HIV knowledge and prevalence of participants are reported. The study identified many young, newly initiated injectors who engage in risky injection practices. The study also found that HIV prevalence is fairly low among participants (2.7%).

Conclusions/Importance: Findings indicate a potential risk for the spread of HIV among PWID in Colombia given their widespread sharing practices, high rate of new injector initiation, and unsafe syringe cleaning practices. Colombia has a possibly time-limited opportunity to prevent an HIV epidemic by implementing harm reduction interventions among young, newly initiated PWID.

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Editor’s notes: Little is known about the prevalence of HIV or of HIV transmission risk factors among people who inject drugs in Colombia. There is evidence that the size of this key population has increased in recent years, coinciding with an increase in domestic production of heroin. This study used a novel sampling method to recruit 540 people who inject heroin from two cities in Colombia in 2010. Key findings are that the prevalence of HIV was 2.7% and that multi-person use of contaminated injecting equipment was common. Without imminent implementation of a needle-syringe programme, rapid transmission of HIV within this population – and to sexual partners in the general population - is to be expected. As injection drug use continues to expand in low- and middle-income countries, this study provides a template for researchers to collect data which can directly inform a policy response.

Latin America
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Why get tested for HIV in Russia?

Motivators and barriers to HIV testing among street-based female sex workers in St. Petersburg, Russia.

King EJ, Maman S, Dudina VI, Moracco KE, Bowling JM. Glob Public Health. 2015 Dec 28:1-16. [Epub ahead of print]

Female sex workers are particularly susceptible to HIV-infection in Russia. However, a dearth of information exists on their utilisation of HIV services. A mixed-methods, cross-sectional study was conducted to examine motivators and barriers to HIV testing among street-based sex workers in St. Petersburg, Russia. The health belief model was the theoretical framework for the study. Twenty-nine sex workers participated in in-depth interviews, and 139 sex workers completed interviewer-administered surveys between February and September 2009. Barriers to getting an HIV test were fear of learning the results, worrying that other people would think they were sick, and the distance needed to travel to obtain services. Motivators for getting tested were protecting others from infection, wanting to know one's status and getting treatment if diagnosed. Logistic regression analysis demonstrated that knowing people living with HIV [aOR = 6.75, 95% CI (1.11, 41.10)] and length of time since start of injection drug use [aOR = 0.30, 95% CI (0.09, 0.97)] were significantly associated with recently getting tested. These results are important to consider when developing public health interventions to help female sex workers in Russia learn their HIV status and get linked to care and treatment services if needed.

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Editor’s notes: This paper summarises findings from a mixed-method study among a sample of female sex workers in St Petersburg, Russian Federation, the majority of whom also inject drugs. This is an important study, allowing the voices of a highly marginalised group to be heard and highlighting barriers and facilitators to HIV testing. Improving access to testing among this population is particularly important given the increased risk of HIV infection that they face. They are susceptible to HIV infection through both sexual and injecting transmission routes. The paper raises some important points such as the widespread misunderstanding about the severity of HIV in the absence of symptoms. HIV was not perceived to be a major problem among the population; there were more immediate problems associated with drug use and sex work. The necessity to travel for testing was seen as a barrier to HIV testing. For a population with multiple and complex health needs this is an acute problem given the vertical structure of the Russian health system. There is a lack of integration across sexual health, drug dependency and HIV and other infectious disease treatment services necessary for this population.  Many other structural barriers were reported to testing including  fear of being registered as having HIV, fear of stigma from friends and health care workers, fear of the unknown associated with infection and disease progression and uncertainty about availability of HIV treatment.  Concerns about treatment availability are particularly relevant since people who inject drugs are often denied HIV treatment in the Russian Federation while they continue to use drugs. This point is important in understanding the context in which HIV testing is accessed. Further discussion on what real benefits knowing your status brings weighed up against the disadvantages of knowing, warrants further discussion in the paper. We know that there is limited and often interrupted HIV treatment available and few ancillary services (such as opioid substitution therapy) to support maintenance of treatment.  We also know that there is much stigma associated with being HIV positive. People living with HIV experience frequent problems with employment and concerns about having children taken into care. All these problems are compounded if you use drugs or sell sex. In this context, the benefits of knowing your status is questionable and is bound to influence uptake of testing.

Asia, Europe
Russian Federation
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Harm reduction under fire – people who inject drugs in Kabul, Afghanistan

Hepatitis C and HIV incidence and harm reduction program use in a conflict setting: an observational cohort of injecting drug users in Kabul, Afghanistan.

Todd CS, Nasir A, Stanekzai MR, Fiekert K, Sipsma HL, Vlahov D, Strathdee SA. Harm Reduct J. 2015 Oct 16;12:22. doi: 10.1186/s12954-015-0056-z.

Background: Armed conflict may increase the risk of HIV and other pathogens among injecting drug users (IDUs); however, there are few prospective studies. This study aimed to measure incidence and potential predictors, including environmental events and needle and syringe distribution and collection program (NSP) use, of hepatitis C virus (HCV) and HIV among IDUs in Kabul, Afghanistan.

Methods: Consenting adult IDUs completed interviews quarterly in year 1 and semi-annually in year 2 and HCV and HIV antibody testing semi-annually through the cohort period (November 2007-December 2009). Interviews detailed injecting and sexual risk behaviors, NSP service use, and conflict-associated displacement. Quarters with peak conflict or local displacement were identified based on literature review, and key events, including insurgent attacks and deaths, were reported with simple counts. Incidence and predictors of HCV and HIV were measured with Cox proportional hazards models.

Results: Of 483 IDUs enrolled, 385 completed one or more follow-up visits (483.8 person-years (p-y)). All participants were male with a median age of 28 years and a median duration of injecting of 2 years. Reported NSP use among the participants ranged from 59.9 to 70.5 % in the first year and was 48.4 and 55.4 % at 18 and 24 months, respectively. There were 41 confirmed deaths, with a crude death rate of 93.4/1000 p-y (95 % confidence interval (CI) 67.9-125) and overdose as the most common cause. HCV and HIV incidence were 35.6/100 p-y (95 % CI 28.3-44.6) and 1.5/100 p-y (95 % CI 0.6-3.3), respectively. Changing from injecting to smoking was protective for HCV acquisition (adjusted hazard ratio (AHR) = 0.53, 95 % CI 0.31-0.92), while duration of injecting (AHR = 1.09, 95 % CI 1.01-1.18/year) and sharing syringes (AHR = 10.09, 95 % CI 1.01-100.3) independently predicted HIV infection.

Conclusion: There is high HCV incidence and high numbers of reported deaths among male Kabul IDUs despite relatively consistent levels of harm reduction program use; peak violence periods did not independently predict HCV and HIV risk. Programming should increase awareness of HCV transmission and overdose risks, prepare clients for harm reduction needs during conflict or other causes of displacement, and continue efforts to engage community and police force support.

Abstract  Full-text [free] access

Editor’s notes: This is a relatively rare study, documenting HIV and Hepatitis C infection (HCV) among people who inject drugs in Kabul in Afghanistan.  By combining survey data with information on conflict events from literature/media, the authors can look not only at levels of infection but also how these levels are affected by the conflict. In line with findings from other places experiencing conflict, the authors illustrate that violence did not increase the risk of infection. However, the findings do illustrate the value of needle-syringe distribution and collection programmes in reducing HCV incidence, as the men moved from injecting to smoking. Relatively low levels of HIV prevalence in the Kabul area resulted in low HIV-incidence among the study population. If HIV-prevalence were to rise this could change, as reflected in the high levels of Hepatitis C infection. The authors point to the many challenges of providing services for key populations, such as the men they worked with who injected drugs, in many parts of the world. Growing instability and the displacement of a number of the study population because of the closure of the shelter that housed them, made the research challenging.  A shortage of resources for harm reduction in places like Afghanistan, compounds the problems programmes to support people who inject drugs, face.

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Awareness of HIV status and risk among key populations in India

HIV care continuum among men who have sex with men and people who inject drugs in India: barriers to successful engagement.

Mehta SH, Lucas GM, Solomon S, Srikrishnan AS, McFall AM, Dhingra N, Nandagopal P, Kumar MS, Celentano DD, Solomon SS. Clin Infect Dis. 2015 Aug 6. pii: civ669. [Epub ahead of print]

Background: We characterize the HIV care continuum for men who have sex with men (MSM) and people who inject drugs (PWID) across India.

Methods: We recruited 12 022 MSM and 14 481 PWID across 26 Indian cities using respondent-driven sampling (9/2012-12/2013). Participants were ≥18 years and either 1) self-identified as male and reported sex with a man in the prior year (MSM); or 2) reported injection drug use in the prior 2 years (PWID). Correlates of awareness of HIV positive status were characterized using multi-level logistic regression.

Results: 1146 MSM were HIV-infected of whom a median 30% were aware of their HIV positive status, 23% were linked to care, 22% were retained pre-ART, 16% initiated ART, 16% were currently on ART, and 10% had suppressed VL. There was site variability (awareness range: 0-90%; suppressed VL range: 0-58%). 2906 PWID were HIV-infected of whom a median 41% were aware, 36% linked to care, 31% were retained pre-ART, 20% initiated ART, 18% were currently on ART, and 15% had suppressed VL. Similar site variability was observed (awareness range: 2-93%; suppressed VL range: 0-47%). Factors significantly associated with awareness were region, older age, being married (MSM) or female (PWID), other service utilization (PWID), more lifetime sexual partners (MSM) and needle sharing (PWID). Ongoing injection drug use (PWID) and alcohol (MSM) were associated with lower awareness.

Conclusions: In this large sample, the major barrier to HIV care engagement was awareness of HIV positive status. Efforts should focus on linking HIV testing to other essential services.

Abstract access 

Editor’s notes: The UNAIDS target of 90-90-90 (90% of HIV positive individuals knowing their status, 90% of people being on ART and 90% of people on ART being virally suppressed) applies to all people living with HIV, including people in key populations who can be hard to reach in some settings. In India, declines in HIV prevalence have been seen among women attending antenatal clinics, but not in the key populations of gay men and other men who have sex with men and people who inject drugs. In this large, community-based, study of gay men and other men who have sex with men and people who inject drugs across India, the majority of people living with HIV (70% of gay men and other men who have sex with men and 59% of people who inject drugs) were unaware of their HIV status. Of people who were aware of their status, the proportions receiving sustained ART were relatively low (68% of gay men and other men who have sex with men and 52% of people who inject drugs). Notably, among people on ART, levels of viral suppression were high and comparable to that in high-income settings. The study highlights awareness of HIV status as the primary barrier to HIV care in these populations, and the importance of integrating HIV testing across healthcare services for vulnerable populations, using same-day rapid tests to maximise linkage-to-care. However, to have a real impact on outcomes across the HIV care continuum, additional strategies will be necessary. These are needed together with large-scale public policy changes to modify the broader social environment – such as decriminalisation of same-sex behaviour.

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Directly observed PrEP among people who inject drugs – useful for improving adherence?

The impact of adherence to preexposure prophylaxis on the risk of HIV infection among people who inject drugs.

Martin M, Vanichseni S, Suntharasamai P, Sangkum U, Mock PA, Leethochawalit M, Chiamwongpaet S, Curlin ME, Na-Pompet S, Warapronmongkholkul A, Kittimunkong S, Gvetadze RJ, McNicholl JM, Paxton LA, Choopanya K, Bangkok Tenofovir Study Group. AIDS. 2015 Apr 24;29(7):819-24. doi: 10.1097/QAD.0000000000000613.

Objective: To describe participant adherence to daily oral tenofovir in an HIV preexposure prophylaxis (PrEP) trial, examine factors associated with adherence, and assess the impact of adherence on the risk of HIV infection.

Design: The Bangkok Tenofovir Study was a randomized, double-blind, placebo-controlled trial conducted among people who inject drugs, 2005-2012.

Methods: Participants chose daily visits or monthly visits. Study nurses observed participants swallow study drug and both initialed a diary. We assessed adherence using the diary. We examined adherence by age group and sex and used logistic regression to evaluate demographics and risk behaviors as predictors of adherence and Cox regression to assess the impact of adherence on the risk of HIV infection.

Results: A total of 2413 people enrolled and contributed 9665 person-years of follow-up (mean 4.0 years, maximum 6.9 years). The risk of HIV infection decreased as adherence improved, from 48.9% overall to 83.5% for those with at least 97.5% adherence*. In multivariable analysis, men were less adherent than women (P = 0.006) and participants 20-29 years old (P < 0.001) and 30-39 years old (P = 0.01) were less adherent than older participants. Other factors associated with poor adherence included incarceration (P = 0.02) and injecting methamphetamine (P = 0.04).

Conclusion: In this HIV PrEP trial among people who inject drugs, improved adherence to daily tenofovir was associated with a lower risk of HIV infection. This is consistent with trials among MSM and HIV-discordant heterosexual couples and suggests that HIV PrEP can provide a high level of protection from HIV infection.

*The authors mean that effectiveness improved from 48.9% overall to 83.5% in those who were 97.5% adherent.

Abstract access 

Editor’s notes: Randomised controlled trials have illustrated that daily oral tenofovir as pre-exposure prophylaxis (PrEP) can reduce HIV transmission. In this study, using data from the only PrEP trial to be completed among people who inject drugs, the investigators assessed the impact of directly-observed adherence to PrEP on the incidence of HIV infection in the Bangkok Tenofovir Study. Adherence was defined as the proportion of days recorded in the participants’ diaries that the participant took the study drug.  On average, participants took the study drug on 84% of days. Their findings of a strong association of increasing levels of adherence with reduced risk of HIV infection add to existing literature on the importance of adherence for PrEP effectiveness among gay men and other men who have sex with men and HIV-discordant couples. The novelty of this study was to directly observe adherence to PrEP.  Directly observed ART treatment has been used in prisons and drug treatment centres, and the potential of this method to improve adherence estimation is interesting.

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Multiple harms faced by Azerbaijani prisoners

Burden of substance use disorders, mental illness, and correlates of infectious diseases among soon-to-be released prisoners in Azerbaijan.

Azbel L, Wickersham JA, Wegman MP, Polonsky M, Suleymanov M, Ismayilov R, Dvoryak S, Rotberga S, Altice FL. Drug Alcohol Depend. 2015 Mar 19. pii: S0376-8716(15)00136-2. doi: 10.1016/j.drugalcdep.2015.02.034. [Epub ahead of print]

Background: Despite low HIV prevalence in the South Caucasus region, transmission is volatile. Little data are available from this region about addiction and infectious diseases among prisoners who transition back to communities.

Methods: A nation-wide randomly sampled biobehavioral health survey was conducted in 13 non-specialty Azerbaijani prisons among soon-to-be-released prisoners. After informed consent, participants underwent standardized health assessment surveys and testing for HIV, hepatitis B and C, and syphilis.

Results: Of the 510 participants (mean age=38.2 years), 11.4% were female, and 31.9% reported pre-incarceration drug injection, primarily of heroin. Prevalence of HCV (38.2%), HIV (3.7%), syphilis (3.7%), and HBV (2.7%) was high. Among the 19 HIV-infected inmates, 14 (73.7%) were aware of their HIV status, 12 (63.2%) were receiving antiretroviral therapy (ART), and 5 (26.3%) had CD4<350cells/mL (4 of these were on ART). While drug injection was the most significant independent correlate of HCV (AOR=12.9; p=0.001) and a significant correlate of HIV (AOR=8.2; p=0.001), both unprotected sex (AOR=3.31; p=0.049) and working in Russia/Ukraine (AOR=4.58; p=0.008) were also correlated with HIV.

Conclusion: HIV and HCV epidemics are concentrated among people who inject drugs (PWIDs) in Azerbaijan, and magnified among prisoners. A transitioning HIV epidemic is emerging from migration from high endemic countries and heterosexual risk. The high diagnostic rate and ART coverage among Azerbaijani prisoners provides new evidence that HIV treatment as prevention in former Soviet Union (FSU) countries is attainable, and provides new insights for HCV diagnosis and treatment as new medications become available. Within prison evidence-based addiction treatments with linkage to community care are urgently needed.

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Editor’s notes: This is an important study describing prevalence of HIV, hepatitis B and hepatitis C among a prison population in Azerbaijan. The importance of the study stems from the need to monitor infections among a highly vulnerable population of prisoners. While the study does not report on current injecting drug use among the population, a third of the sample reported injecting drugs prior to their detention and will need support with their injecting drug use while in prison. This will include the provision of opioid substitution therapy and needle-syringe programmes.  This study highlights the vulnerability of prisoners to HIV, hepatitis B and hepatitis C and the need for harm reduction in prisons. At the same time, the study also highlights other adverse health outcomes relating to drug use or being in prison in terms of poor mental health outcomes among the sample. It illustrates an association between a measure of anxiety disorder and HIV infection. The strengths of this study lie in the large sample that were recruited from a broad range of prison facilities across the country, increasing the representativeness of the findings to all people living in prisons. Findings suggest an association between HIV infection and condomless sex, as well as a history of working in Russia and Ukraine. This suggests the potential for transmission of HIV across the region and points to the potential for sexual transmission of HIV in a region where transmission has been historically driven by injecting drug use. Findings contribute to the growing evidence for the urgent need for hepatitis C virus (HCV) treatment and increased access to needle-syringe programmes and opioid substitution therapy within prisons and communities in the region.  The high adherence among prisoners to HIV treatment demonstrates the provision of HCV treatment to the population is entirely feasible. Previous evidence from Russia has illustrated the difficulties for people living in prisons in maintaining HIV treatment post-release and this study underscores the need for support to facilitate the integration of individuals into harm reduction programmes including HIV treatment in community settings post-release. 

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