Articles tagged as "Injecting drug use and HIV prevention"

Combination harm reduction may be more effective and cost-effective than partial approaches alone

The cost-effectiveness of harm reduction.

Wilson DP, Donald B, Shattock AJ, Wilson D, Fraser-Hurt N. Int J Drug Policy. 2015 Feb;26 Suppl 1:S5-11. doi: 10.1016/j.drugpo.2014.11.007. Epub 2014 Dec 1.

HIV prevalence worldwide among people who inject drugs (PWID) is around 19%. Harm reduction for PWID includes needle-syringe programs (NSPs) and opioid substitution therapy (OST) but often coupled with antiretroviral therapy (ART) for people living with HIV. Numerous studies have examined the effectiveness of each harm reduction strategy. This commentary discusses the evidence of effectiveness of the packages of harm reduction services and their cost-effectiveness with respect to HIV-related outcomes as well as estimate resources required to meet global and regional coverage targets. NSPs have been shown to be safe and very effective in reducing HIV transmission in diverse settings; there are many historical and very recent examples in diverse settings where the absence of, or reduction in, NSPs have resulted in exploding HIV epidemics compared to controlled epidemics with NSP implementation. NSPs are relatively inexpensive to implement and highly cost-effective according to commonly used willingness-to-pay thresholds. There is strong evidence that substitution therapy is effective, reducing the risk of HIV acquisition by 54% on average among PWID. OST is relatively expensive to implement when only HIV outcomes are considered; other societal benefits substantially improve the cost-effectiveness ratios to be highly favourable. Many studies have shown that ART is cost-effective for keeping people alive but there is only weak supportive, but growing evidence, of the additional effectiveness and cost-effectiveness of ART as prevention among PWID. Packages of combined harm reduction approaches are highly likely to be more effective and cost-effective than partial approaches. The coverage of harm reduction programs remains extremely low across the world. The total annual costs of scaling up each of the harm reduction strategies from current coverage levels, by region, to meet WHO guideline coverage targets are high with ART greatest, followed by OST and then NSPs. But scale-up of all three approaches is essential. These interventions can be cost-effective by most thresholds in the short-term and cost-saving in the long-term.

Abstract   Full-text [free] access

Editor’s notes: The spread of HIV among people who inject drugs has driven epidemics throughout regions of eastern Europe, and central and South-East Asia. In eastern Europe and central Asia, the majority of HIV infections have been attributed to injecting drug use. Some countries in the Middle East and North Africa region have also been experiencing rapidly emerging HIV epidemics among people who inject drugs. Harm reduction refers to methods of reducing health risks when eliminating them may not be possible. This paper provides a comprehensive review of evidence on the effectiveness and cost-effectiveness of different harm reduction approaches. These include needle- syringe programmes, opioid substitution therapy (OST), and antiretroviral therapy (ART), when implemented in different settings. Importantly, alongside considering the potential benefits of each approach separately, it makes the case that combination  prevention strategies are synergistic, and may achieve multiple impacts. Sadly still however, the coverage of harm reduction remains very low across the world. An estimated 90% of people who inject drugs worldwide are not accessing needle-syringe programmes, despite this being a highly effective and cost-effective programme. Along with the need for a greater investment in harm reduction, there are socio-political and legislative reasons for poor coverage of harm reduction. This cannot be improved without first addressing the stigma, discrimination and intolerance that restricts the expansion of harm reduction programmes in many settings. Addressing these barriers remains of paramount importance for facilitating effective harm reduction programmes. Encouragingly however, high OST coverage has been reported in Iran, Czech Republic and western Europe, and several countries in Asia and the Middle East have begun to scale-up their programmes. China has recently had the largest OST scale-up programme in the world. Uptake of ART by people living with HIV who inject drugs illustrates the largest disparities with what is required or deemed to be appropriate access. Only 14% of people living with HIV who inject drugs globally, have access to ART, with the largest gaps in ART provision in eastern Europe and central Asia. The further expansion of harm reduction is urgently needed, both to meet WHO targets, and to achieve the UNAIDS 90-90-90 target.

Asia, Europe, Oceania
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Injecting drug use increases risk of TB disease in Indonesians living with HIV

Active and latent tuberculosis among HIV-positive injecting drug users in Indonesia.

Meijerink H, Wisaksana R, Lestari M, Meilana I, Chaidir L, van der Ven AJ, Alisjahbana B, van Crevel R. J Int AIDS Soc. 2015 Feb 16;18(1):19317. doi: 10.7448/IAS.18.1.19317. eCollection 2015.

Introduction: Injecting drug use (IDU) is associated with tuberculosis but few data are available from low-income settings. We examined IDU in relation to active and latent tuberculosis (LTBI) among HIV-positive individuals in Indonesia, which has a high burden of tuberculosis and a rapidly growing HIV epidemic strongly driven by IDU.

Methods: Active tuberculosis was measured prospectively among 1900 consecutive antiretroviral treatment (ART)-naive adult patients entering care in a clinic in West Java. Prevalence of LTBI was determined cross-sectionally in a subset of 518 ART-experienced patients using an interferon-gamma release assay.

Results: Patients with a history of IDU (53.1%) more often reported a history of tuberculosis treatment (34.8% vs. 21.9%, p < 0.001), more often received tuberculosis treatment during follow-up (adjusted HR = 1.71; 95% CI: 1.25-2.35) and more often had bacteriologically confirmed tuberculosis (OR = 1.67; 95% CI: 0.94-2.96). LTBI was equally prevalent among people with and without a history of IDU (29.1 vs. 30.4%, NS). The risk estimates did not change after adjustment for CD4 cell count or ART.

Conclusions: HIV-positive individuals with a history of IDU in Indonesia have more active tuberculosis, with similar rates of LTBI. Within the HIV clinic, LTBI screening and isoniazid preventive therapy may be prioritized to patients with a history of IDU.

Abstract  Full-text [free] access

Editor’s notes: In Europe and northern America, HIV-positive people who inject drugs are at greater risk of TB infection and disease compared with other HIV-positive individuals. In many Asian countries, there is a growing problem of injecting drug use which has contributed to the HIV epidemic. This study explored the association between injecting drug use and TB among people living with HIV in Indonesia. The main analysis included 1900 HIV-positive, ART-naive individuals without TB disease and followed them from enrolment in HIV care to starting TB treatment. Just over half of the study population gave a history of injecting drug use. There was no differentiation between current and historical drug use.

A history of injecting drug use was associated with a 71% increased risk of TB disease during the first year after enrolment in HIV care. This association was maintained after adjusting for age, CD4 cell count and the use of antiretroviral therapy. The association was similar when the analysis was restricted to microbiologically-proven TB disease. The divergence in risk seemed to be early after enrolment, the first six months after entering HIV care. And the majority of TB diagnoses occurred before initiation of ART. This suggests the need for intensified TB diagnostic strategies on enrolment in HIV care. Despite enrolment over almost six years and follow-up for up to six years, the median follow-up was less than a year in the group without a history of injecting drug use. This compares to just under two years for people who inject drugs. This suggests substantial loss to follow-up and may have contributed to the higher observed risk of TB among people who inject drugs. 

This article also reports the prevalence of a positive QuantiFERON Gold In-Tube assay in a separate group of HIV-positive individuals with a median time on ART of over two years. There was no difference in the proportion with a positive QuantiFERON test among individuals with and without a history of injecting drug use. This was a very different study population, however, with a median CD4 cell count >350 cells/µl. Almost half reported previous TB treatment, which makes the QuantiFERON results more difficult to interpret.

These data underline the importance of screening for active TB among people entering HIV care, and of isoniazid preventive therapy for individuals with latent infection.

Avoid TB deaths
Asia
Indonesia
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People who inject drugs and the effects of stigma on HIV treatment

A tale of two cities: Stigma and health outcomes among people with HIV who inject drugs in St. Petersburg, Russia and Kohtla-Jarve, Estonia.

Burke SE, Calabrese SK, Dovidio JF, Levina OS, Uuskula A, Niccolai LM, Abel-Ollo K, Heimer R. Soc Sci Med. 2015 Feb 16;130C:154-161. doi: 10.1016/j.socscimed.2015.02.018. [Epub ahead of print]

Experiences of stigma are often associated with negative mental and physical health outcomes. The present work tested the associations between stigma and health-related outcomes among people with HIV who inject drugs in Kohtla-Jarve, Estonia and St. Petersburg, Russia. These two cities share some of the highest rates of HIV outside of sub-Saharan Africa, largely driven by injection drug use, but Estonia has implemented harm reduction services more comprehensively. People who inject drugs were recruited using respondent-driven sampling; those who indicated being HIV-positive were included in the present sample (n = 381 in St. Petersburg; n = 288 in Kohtla-Jarve). Participants reported their health information and completed measures of internalized HIV stigma, anticipated HIV stigma, internalized drug stigma, and anticipated drug stigma. Participants in both locations indicated similarly high levels of all four forms of stigma. However, stigma variables were more strongly associated with health outcomes in Russia than in Estonia. The St. Petersburg results were consistent with prior work linking stigma and health. Lower barriers to care in Kohtla-Jarve may help explain why social stigma was not closely tied to negative health outcomes there. Implications for interventions and health policy are discussed.

Abstract access 

Editor’s notes: This study provides extremely important evidence on the impact of anticipated and felt stigma in relation to HIV and drug use on health outcomes among people who inject drugs in the context of high prevalence of HIV. People who inject drugs in both Russia and Estonia are highly marginalised. Previous studies indicate prevalence to be as high as 90% in Kohtla-Järve and incidence of five per 100 person-years in St Petersburg. Despite their close geographical proximity the two cities are framed by very different social and structural policies that enable and disable the provision of HIV prevention programmes to people who inject drugs. In Estonia, the provision of needle–syringe programmes and opioid substitution therapy is widespread and supported by the government. In Russia the limited harm reduction programmes are provided by non-governmental organisations with little or no support from government. Ambiguous drug policies often prohibit the use of needle –syringe programmes on the grounds they promote drug use. Opioid substitution therapy (OST) is not prescribed and people who inject drugs are viewed as potential criminals by police. People who inject drugs are frequently put under surveillance through a mandatory registration system by police and drug treatment (narcology) clinics. High levels of both internalised and anticipated stigma in relation to HIV and drug use were found in both sites. In Estonia this was not associated with poorer HIV outcomes including access to HIV care, CD4 count or self-reported HIV symptoms. Conversely in St Petersburg, internalised stigma associated with drug use was associated with lower CD4 count, reduced access to HIV care and increased HIV symptoms. This underscores the effectiveness of low-threshold HIV prevention and treatment services for people who inject drugs in the treatment of HIV, despite the existence of other social and cultural norms that stigmatise HIV and drug use. This study demonstrates the effect of stigma on HIV outcomes. However, further research is needed to understand the mechanisms through which stigma interplays with other social and structural factors, such as migration, poverty and criminalisation, to impact on health outcomes among people who inject drugs.

The study has clear policy implications. They include the need for structural interventions such as increased government support for harm reduction. These are necessary to prevent the reproduction of HIV and drug-use related stigma and its harmful impacts. Shorter-term programmes are required in Russia, including the urgent scale up of harm reduction activities and HIV treatment and care for people who inject drugs as well as the provision of inter-personal support to assist people who inject drugs in facing stigma within health services. 

Europe
Estonia, Russian Federation
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Sexual health of the partners of people who inject drugs

'Women at risk': the health and social vulnerabilities of the regular female partners of men who inject drugs in Delhi, India.

Sharma V, Sarna A, Luchters S, Sebastian M, Degomme O, Saraswati LR, Madan I, Thior I, Tun W. Cult Health Sex. 2014 Dec 2:1-15. [Epub ahead of print]

Needle and syringe sharing is common among people who inject drugs and so is unprotected sex, which consequently puts their sex partners at risk of sexually transmitted infections (STIs) including HIV and other blood-borne infections, like hepatitis. We undertook a nested study with the regular female partners of men who inject drugs participating in a longitudinal HIV incidence study in Delhi, India. In-depth interviews were conducted with female partners of 32 men. The interviews aimed to gather focused and contextual knowledge of determinants of safe sex and reproductive health needs of these women. Information obtained through interviews was triangulated and linked to the baseline behavioural data of their partner (index men who injected drugs). The study findings illustrate that women in monogamous relationships have a low perception of STI- and HIV-related risk. Additionally, lack of awareness about hepatitis B and C is a cause of concern. Findings also suggest impact of male drug use on the fertility of the female partner. It is critical to empower regular female partners to build their self-risk assessment skills and self-efficacy to negotiate condom use. Future work must explore the role of drug abuse among men who inject drugs in predicting fertility and reproductive morbidity among their female partners.

Abstract access 

Editor’s notes: This is an interesting study describing the HIV and sexual health needs of female partners of people who inject drugs (PWID). The study’s strengths lie in the innovative way in which female partners of PWID were reached and recruited into the study. Female partners of PWID are a highly hidden group and there has been little research conducted among them, with research focussing mostly on PWID and their HIV risk. Therefore the approach to identifying female partners through an existing cohort of male PWID is highly innovative and provides new information on a hidden population. Findings have important implications for HIV programmes for this population. These include the need to increase uptake of HIV testing, teach the importance of condoms as a contraceptive method and for HIV prevention, as well as dispelling myths that assumed monogamy is a sufficient prevention tool. The paper clearly illustrates that addressing sexual and reproductive health needs of this population is paramount, including addressing problems with infertility and the need for contraceptives. The paper usefully highlights the impact of a male partner’s drug use on the daily lives of their female partner, including increased poverty and high levels of violence.

Asia
India
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Reductions in risk taking behaviour among people who inject drugs in Zanzibar – but levels still high

HIV prevalence and risk behaviors among people who inject drugs in two serial cross-sectional respondent-driven sampling surveys, Zanzibar 2007 and 2012

Matiko E, Khatib A, Khalid F, Welty S, Said C, Ali A, Othman A, Haji S, Kibona M, Kim E, Broz D, Dahoma M.AIDS Behav. 2014 Nov 16. [Epub ahead of print]

People who inject drugs (PWID) are at higher risk of acquiring HIV due to risky injection and sexual practices. We measured HIV prevalence and behaviors related to acquisition and transmission risk at two time points (2007 and 2012) in Zanzibar, Tanzania. We conducted two rounds of behavioral and biological surveillance among PWID using respondent-driven sampling, recruiting 499 and 408 PWID, respectively. Through face to- face interviews, we collected information on demographics as well as sexual and injection practices. We obtained blood samples for biological testing. We analysed data using RDSAT and exported weights into STATA for multivariate analysis. HIV prevalence among sampled PWID in Zanzibar was 16.0% in 2007 and 11.3% in 2012; 73.2% had injected drugs for 7 years or more in 2007, while in the 2012 sample this proportion was 36.9%. In 2007, 53.6% reported having shared a needle in the past month, while in the 2012 sample, 29.1% reported having done so. While 13.3% of PWID in 2007 reported having been tested for HIV infection and received results in the past year, this proportion was 38.0% in 2012. Duration of injection drug use for 5 years or more was associated with higher odds of HIV infection in both samples. HIV prevalence and indicators of risk and preventive behaviors among PWID in Zanzibar were generally more favorable in 2012 compared to 2007—a period marked by the scale-up of prevention programs focusing on PWID. While encouraging, causal interpretation needs to be cautious and consider possible sample differences in these two cross sectional surveys. HIV prevalence and related risk behaviors persist at levels warranting sustained and enhanced efforts of primary prevention and harm reduction.

Abstract access 

Editor’s notes: People who inject drugs (PWID) are a marginalized or key population in Africa, and throughout the world. They suffer from disproportionately high rates of HIV infection and other diseases. Like other key populations such as sex workers, the criminalization of PWID makes it difficult to provide specialized services. Members of this community are often fearful of programmes which might identify them. This dynamic causes viruses such as HIV to go undetected and unmanaged. This is evidenced by the difference in HIV prevalence through this study in Zanzibar, United Republic of Tanzania between the general population at 1% and the rates in PWID at 16.0% and 11.3% in 2007 and 2012 respectively. Although the study highlighted where HIV prevalence might be reducing and behaviours such as HIV testing might be improving, multi-person use of contaminated injecting equipment went slightly up. These data are confounded by the fact that it is unclear whether the same segment of the population was surveyed, and by the fact that so few females participated. Issues with recruitment shed light on how difficult it can be to reach these communities. This can usually be attributed to criminalization and distrust, but also to mobility and the lack of engagement generally of governments and local health programmes in acknowledging the need to address and support the specialized needs of PWID communities. To date, there has been little recognition of injection drug use in Africa and the related health needs of these communities, which can vary depending on context and country. Studies such as this one, even with the limitations of recruitment and comparability of samples, should be undertaken more often and with in-depth qualitative components, as mentioned by the authors, to further explore how these communities might be accessed and their needs addressed.

Africa
United Republic of Tanzania
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What happens to people living with HIV who inject drugs in prison?

Within-prison drug injection among HIV-infected Ukrainian prisoners: prevalence and correlates of an extremely high-risk behaviour.

Izenberg JM, Bachireddy C, Wickersham JA, Soule M, Kiriazova T, Dvoriak S, Altice FL. Int J Drug Policy. 2014 Sep;25(5):845-52. doi: 10.1016/j.drugpo.2014.02.010. Epub 2014 Feb 28.

Background: In Ukraine, HIV-infection, injection drug use, and incarceration are syndemic; however, few services are available to incarcerated people who inject drugs (PWIDs). While data are limited internationally, within-prison drug injection (WP-DI) appears widespread and may pose significant challenges in countries like Ukraine, where PWIDs contribute heavily to HIV incidence. To date, WP-DI has not been specifically examined among HIV-infected prisoners, the only persons that can transmit HIV.

Methods: A convenience sample of 97 HIV-infected adults recently released from prison within 1-12 months was recruited in two major Ukrainian cities. Post-release surveys inquired about WP-DI and injection equipment sharing, as well as current and prior drug use and injection, mental health, and access to within-prison treatment for HIV and other comorbidities. Logistic regression identified independent correlates of WP-DI.

Results: Complete data for WP-DI were available for 95 (97.9%) respondents. Overall, 54 (56.8%) reported WP-DI, among whom 40 (74.1%) shared injecting equipment with a mean of 4.4 (range 0-30) other injectors per needle/syringe. Independent correlates of WP-DI were recruitment in Kyiv (AOR 7.46, p=0.003), male gender (AOR 22.07, p=0.006), and active pre-incarceration opioid use (AOR 8.66, p=0.005).

Conclusions: Among these recently released HIV-infected prisoners, WP-DI and injection equipment sharing were frequent and involved many injecting partners per needle/syringe. The overwhelming majority of respondents reporting WP-DI used opioids both before and after incarceration, suggesting that implementation of evidence-based harm reduction practices, such as opioid substitution therapy and/or needle/syringe exchange programmes within prison, is crucial to addressing continuing HIV transmission among PWIDs within prison settings. The positive correlation between Kyiv site and WP-DI suggests that additional structural interventions may be useful.

Abstract access 

Editor’s notes: This is a powerful article contributing to the evidence base on the vulnerability of the health of people living in prisons. It highlights a particularly vulnerable sub-population of people living in prisons who are HIV positive. The study uses an innovative approach in recruiting a sample of people living with HIV recently released from prison, reporting a history of injecting drug use (n=95) on the basis that outside of prison people will be able to talk more freely about their drug use. The rationale for this study is simple: to document the existence of HIV risk associated with injecting drug use among people living in prisons. It is important since Ukraine and other countries of the former Soviet Union, have underplayed the need for HIV programmes including needle syringe programmes by denying that injecting drug use takes place in prison. This provides empirical evidence that it does, and among HIV positive people living in prisons, so the risk of HIV transmission to people who inject is high. It provides further evidence for the urgent need for HIV programmes among people who inject drugs  in prison. This is of particular relevance in the context of Ukraine, which has one of the fastest growing HIV epidemics globally, with infection driven by injecting drug use. The punitive approach to drug use in Ukraine is well highlighted through the study, by the fact that 76% of the sample were in prison on a drug-related charge. This paper confirms that injecting or other injecting risk behaviours occurred in prison, as has been evidenced elsewhere, and the majority of the sample injected prior to incarceration. It also shows that there is a lack of HIV programmes in place, particularly considering half the sample was aware of their diagnosis prior to imprisonment and the remainder found out while in prison. The study also shows a high prevalence of TB or history of TB (69%) but low levels of treatment while in prison. These illustrate a clear disregard for the health of people living in prisons, which is a breach of human rights, as well as being a poor public health strategy. Unlike other countries in the region, Ukraine does provide opiate substitution therapy to people who inject drugs, as part of an HIV prevention and treatment strategy. This paper provides further evidence for the need to extend this package of programmes to prison populations

Europe
Ukraine
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No evidence that antiretroviral therapy increases risk taking behaviour

Effects of HIV antiretroviral therapy on sexual and injecting risk-taking behaviour: a systematic review and meta-analysis.

Doyle JS, Degenhardt L, Pedrana AE, McBryde ES, Guy R, Stoove MA, Weaver E, Grulich AE, Lo YR, Hellard ME. Clin Infect Dis. 2014 Aug 4. pii: ciu602. [Epub ahead of print]

Background:  Increased global access and use of HIV antiretroviral therapy (ART) has been postulated to undermine HIV prevention efforts by changing individual risk-taking behaviour. This review aims to determine whether ART use is associated with changes in sexual or injecting risk-taking behaviour or diagnosis of sexually transmitted infections (STIs).

Methods: A systematic review and meta-analysis was conducted of HIV-seropositive participants receiving ART compared to no ART use in experimental or observational studies. Primary outcomes included: (1) any unprotected sexual intercourse; (2) STI diagnoses; and (3) any unsafe injecting behaviour.

Results: Fifty-eight studies met the selection criteria. Fifty-six studies containing 32 857 participants reported unprotected sex; eleven studies containing 16 138 participants reported STI diagnoses; and four studies containing 1 600 participants reported unsafe injecting behaviour. All included studies were observational. Unprotected sex was lower in those receiving ART than those not receiving ART (odds ratio (OR) 0.73, 95%CI 0.64-0.83, p<0.001; heterogeneity I2=79%) in both high-income (n=38) and low-/middle-income country (n=18) settings, without any evidence of publication bias. STI diagnoses were also lower among individuals on ART (OR 0.58, 95%CI 0.33-1.01, p=0.053; I2=92%), however there was no difference in injecting risk-taking behaviour with antiretroviral use (OR 0.90, 95%CI 0.60-1.35, p=0.6; I2=0%).

Conclusions: Despite concerns that use of ART might increase sexual or injecting risk-taking, available research suggests unprotected sex is reduced among HIV-infected individuals on treatment. The reasons for this are not yet clear, though self-selection and mutually reinforcing effects of HIV treatment and prevention messages among people on ART are likely.

Abstract access 

Editor’s notes: Use of antiretroviral therapy (ART) may modify risk perception, leading to increases in risk-taking behaviour and HIV transmission. This has important implications for HIV prevention. In particular in low and middle-income countries, where the global burden of HIV is greatest and where access to, and use of, ART is rapidly increasing. This systematic review identified observational studies comparing risk-taking behaviour in people living with HIV using ART, compared with people not using ART. The review found that ART does not appear to increase reported unprotected anal or vaginal intercourse, newly diagnosed sexually transmitted infections, or unsafe injecting behaviour among people on treatment. The observation that reductions in unprotected sex are associated with ART use should be interpreted cautiously as limited data are available to accurately assess a causal relationship. The current practice of providing ART with counselling, education and ongoing clinical care probably offers the optimal strategy of ensuring that individuals on ART minimise risks associated with unsafe sex. 

Africa, Asia, Europe, Northern America, Oceania
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Per-act HIV transmission risk during anal sex may be higher than previously thought

Estimating per-act HIV transmission risk: a systematic review.

Patel P, Borkowf CB, Brooks JT, Lasry A, Lansky A, Mermin J. AIDS. 2014 Jun 19;28(10):1509-19. doi: 10.1097/QAD.0000000000000298.

Background: Effective HIV prevention programs rely on accurate estimates of the per-act risk of HIV acquisition from sexual and parenteral exposures. We updated the previous risk estimates of HIV acquisition from parenteral, vertical, and sexual exposures, and assessed the modifying effects of factors including condom use, male circumcision, and antiretroviral therapy.

Methods: We conducted literature searches to identify new studies reporting data regarding per-act HIV transmission risk and modifying factors. Of the 7 339 abstracts potentially related to per-act HIV transmission risk, three meta-analyses provided pooled per-act transmission risk probabilities and two studies provided data on modifying factors. Of the 8 119 abstracts related to modifying factors, 15 relevant articles, including three meta-analyses, were included. We used fixed-effects inverse-variance models on the logarithmic scale to obtain updated estimates of certain transmission risks using data from primary studies, and employed Poisson regression to calculate relative risks with exact 95% confidence intervals for certain modifying factors.

Results: Risk of HIV transmission was greatest for blood transfusion, followed by vertical exposure, sexual exposures, and other parenteral exposures. Sexual exposure risks ranged from low for oral sex to 138 infections per 10 000 exposures for receptive anal intercourse. Estimated risks of HIV acquisition from sexual exposure were attenuated by 99.2% with the dual use of condoms and antiretroviral treatment of the HIV-infected partner.

Conclusion: The risk of HIV acquisition varied widely, and the estimates for receptive anal intercourse increased compared with previous estimates. The risk associated with sexual intercourse was reduced most substantially by the combined use of condoms and antiretroviral treatment of HIV-infected partners.

Abstract access 

Editor’s notes: The study updates the 2005 Centres for Disease Control (CDC) per-act HIV transmission risks with estimates from recent publications. In addition, it summarizes the effects of various co-factors that modify the transmission risks during sexual exposure. These include genital ulcer disease, viral load, disease stage, use of antiretrovirals, condom use and male circumcision. However, estimates from low-income countries on sexual and mother-to-child transmission are very heterogeneous and not included in the analyses. In general, the updated estimates of transmission risks are comparable to figures from the 2005 CDC study. But they also suggest that the transmission probabilities for both receptive and insertive anal intercourse could be higher than previously thought. Further, the study reasserts that the per-act risk for all sexual exposures is substantially attenuated through the use of condoms and antiretrovirals. These new estimates will be important for both modelling studies and prevention programmes. But a better understanding of HIV transmission risks in low-income countries is needed. 

Asia, Northern America, Oceania
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Harm reduction services in Tehran: uptake and barriers

Access to harm reduction programs among persons who inject drugs: findings from a respondent-driven sampling survey in Tehran, Iran.

Rahnama R, Mohraz M, Mirzazadeh A, Rutherford G, McFarland W, Akbari G, Malekinejad M. Int J Drug Policy. 2014 Jun 2. pii: S0955-3959(14)00144-3. doi: 10.1016/j.drugpo.2014.05.013. [Epub ahead of print]

Background: Over the past two decades, drug injection-related risk behaviors have been the major drivers of the HIV epidemic in Iran. This study assesses the access of people who injected drugs (PWID) to harm reduction services (needle-exchange programs [NEP] and methadone maintenance treatment [MMT]) in Tehran, Iran in 2007, almost five years after the large-scale implementation of these programs.

Methods: 572 consenting PWID (>18 years old, ever injected in the past month, lived in Tehran or its suburbs) were recruited (24 seeds) into a sero-behavioral survey using respondent-driven sampling method. Participants completed a face-to-face interview about HIV-related risk behaviors and access to harm reduction services. We calculated adjusted population estimates using RDSAT.

Results: Overall, 99.2% of the participants were male, 41.6% aged between 30 and 39 years old, 55.4% lived alone in the past year, 83.2% were ever incarcerated, and 88.8% lived in the southern areas of Tehran. In terms of "awareness" and "use" of services among PWID, 62.8% and 54.8% reported for NEP (respectively) and 19.7% and 9.1% for drug treatment services (respectively). PWID who lived in Northwest and South-central Tehran were more likely to be aware (85.0% and 82.8%, respectively) of one or more services than PWID who lived elsewhere. Similarly, PWID who lived with friends were more likely to be aware of (88.6%) and use (85.9%) services (vs. other living partners). Overall, 11% of the participants were aware of but had not used any harm reduction services.

Conclusions: Despite a relatively high level of access to NEP among PWID in Tehran, a sizable fraction of the population remains without access to other services five years after their implementation. The use of harm reduction may be affected by certain PWID characteristics (e.g., living partners and geographical location). Ongoing surveillance activities are necessary to track change in access over time.

Abstract access 

Editor’s notes: This paper reports on findings of sero-behavioural survey among people who inject drugs (PWID) conducted in Tehran, The Islamic Republic of Iran. The paper provides a comprehensive description of harm reduction services available in Iran consisting of needle syringe programmes (NSP), methadone maintenance and drug detoxification services and summarises uptake of services among the study sample. The study describes the social-demographic characteristics of PWID, and finds that as elsewhere the majority of PWID recruited into the study are male aged under 40 years. This is similar to the age of PWID in western Europe but older than in eastern Europe (Platt, Jolley, Hope et al June 2013) The study suggests high rates of imprisonment and low rates of HIV testing. The majority of the sample had never been tested for HIV, whereas in western Europe over 90% of PWID participating in studies report experience of HIV testing. The study suggests that a high proportion of PWID are using NSPs at 55% (RDS adjusted estimate). This is high compared to estimates from Europe where proportions of PWID accessing NSPs ranges between 1%  in Georgia, 4% in France to  much higher in Finland at  81% and  68% in Lithuania. Low uptake of HIV testing but high uptake of NSP suggest that providing HIV testing at NSP sites would be a good way of increasing HIV testing. The study found that uptake of harm reduction programmes is associated with living partners. This suggests there might be a role for ‘secondary distribution’ of injecting equipment via partners or social networks to engage people currently not using services and to increase the use of harm reduction services. 

Asia
Iran (Islamic Republic of)
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Correlations between socioeconomic factors and needle sharing among methamphetamine users

Correlates of shared methamphetamine injection among methamphetamine-injecting treatment seekers: the first report from Iran.

Mehrjerdi ZA, Abarashi Z, Noroozi A, Arshad L, Zarghami M. Int J STD AIDS. 2014 May;25(6):420-7. doi: 10.1177/0956462413512806. Epub 2013 Nov 28.

Shared methamphetamine injection is an emerging route of drug use among Iranian methamphetamine injectors. It is a primary vector for blood-borne infections. The aim of the current study is to determine the prevalence and correlates of shared methamphetamine injection in a sample of Iranian methamphetamine injecting treatment seekers in the south of Tehran. We surveyed male and female methamphetamine injectors at three drop-in centres and 18 drug-use community treatment programmes. Participants reported socio-demographic characteristics, drug use, high-risk behaviours, current status of viral infections and service use for drug treatment. Bivariate and multivariate logistic regression models were used to test associations between participants' characteristics and shared methamphetamine injection. Overall, 209 clients were recruited; 90.9% were male; 52.6% reported current methamphetamine injection without any shared injection behaviour and 47.4% reported current shared methamphetamine injection. Shared methamphetamine injection was found to be primarily associated with living with sex partners (AOR 1.25, 95% CI 1.13-1.98), reporting ≥3 years of dependence on methamphetamine injection (AOR 1.61, 95% CI 1.27-2.12), injection with pre-filled syringes in the past 12 months (AOR 1.96, 95% CI 1.47-2.42), homosexual sex without condom use in the past 12 months (AOR 1.85, 95% CI 1.21-2.25), the paucity of NA group participation in the past 12 months (AOR 0.67, 95% CI 0.41-0.99), the paucity of attending psychotherapeutic sessions in the past 12 months (AOR 0.44, 95% CI 0.28-0.96) and positive hepatitis C status (AOR 1.98, 95% CI 1.67-2.83). Deeper exploration of the relationship between shared methamphetamine injection and sexual risk among Iranian methamphetamine injectors would benefit HIV/sexually transmitted infection prevention efforts. In addition, existing psychosocial interventions for methamphetamine-injecting population may need to be adapted to better meet the risks of shared methamphetamine injectors.

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Editor’s notes: This study highlights an important area. The authors demonstrate several links between socioeconomic factors and shared needle use among methamphetamine (MA) users. Multi-person use of contaminated injecting equipment was strongly associated with homelessness and with joblessness. Further, people who engaged in multi-use of contaminated needles were more likely to be divorced or separated than people who did not engage in this practice. People who shared needles were also more likely to be living with sex partners than people who do not. The authors suggest that this is because shared injection might be used as a way of expressing love, support, and care. Duration of dependence on MA injection was also associated with the practice of multi-person use of contaminated injecting equipment. People who used MA for three years or more were more likely to share needles than those who had MA use for a shorter time. The authors also found that participants with low attendance at counselling sessions for people who inject drugs were more likely to be needle sharers. An association between multi-person use of contaminated injecting equipment and hepatitis C infection was also found.

Despite the compelling findings, this study has some limitations. The investigators employ a relatively small sample size which is mainly comprised of men, some 90.9%, making it difficult to generalize findings to a wider population. That said, this study is one of the first of its kind and highlights an area where more research is needed. 

Asia
Iran (Islamic Republic of)
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