Articles tagged as "Injecting drug use and HIV prevention"

Injecting drug use

Are females who inject drugs at higher risk for HIV infection than males who inject drugs: An international systematic review of high seroprevalence areas

Des Jarlais DC, Feelemyer JP, Modi SN, Arasteh K, Hagan H. Drug Alcohol Depend. 2012 Jan 16. [Epub ahead of print]

There are multiple reasons why females who inject drugs may be more likely to become infected with HIV than males who inject drugs. Where this is the case, special HIV prevention programs for females would be needed. Des Jarlais and colleagues undertook an international systematic review and meta-analysis of studies across 14 countries. Countries with high seroprevalence (>20%) HIV epidemics among persons who inject drugs (PWID) were identified from the Reference Group to the United Nations on HIV and Injecting Drug Use. Systematic literature reviews collected data on HIV prevalence by sex for these countries. Non-parametric and parametric tests along with meta-analytic techniques examined heterogeneity and differences in odds ratios across studies. Data were abstracted from 117 studies in 14 countries; total sample size N=128,745. The mean weighted odds ratios for HIV prevalence among females to males was 1.18 [95% CI 1.10-1.26], with high heterogeneity among studies (I(2)=70.7%). There was a Gaussian distribution of the log odds ratios across studies in the sample. There was a significantly higher HIV prevalence among females compared to males who inject drugs in high seroprevalence settings, but the effect size is extremely modest. The high level of heterogeneity and the Gaussian distribution suggest multiple causes of differences in HIV prevalence between females and males, with a specific difference determined by local factors. Greater understanding of factors that may protect females from HIV infection may provide insights into more effective HIV prevention for both females and males who inject drugs.

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Editor’s note: In this first systematic review to assess sex differences in HIV prevalence among people who inject drugs, the 14 countries chosen for analysis had at one time a greater than 20% HIV prevalence among people who inject drugs and had published data from 1985, when HIV antibody tests became available, up until June 2011. They were: Argentina, Brazil, China, Estonia, France, Italy, the Netherlands, Puerto Rico, Russia, Scotland, Spain, Ukraine, Viet Nam, and USA (New York City only). Pooled data from 117 studies with 132 female:male HIV prevalence odds ratio comparisons revealed that there was only a slightly higher HIV prevalence found in women compared to men, with no difference by low- and middle-income countries versus high-income countries. This is encouraging since it suggests that interventions to reduce injecting-related HIV transmission such as large-scale needle/syringe access programmes are effective for both genders. Since many women injectors either rely on men to inject them or use their partner’s injecting equipment, protecting men from acquiring HIV provides indirect benefits to women. The authors of the 10 studies with the greatest sex differences attributed the higher female rates they found to factors related to sexual transmission while the authors of the 10 studies with the lowest female:male ratios proposed no explanations other than that they had only a small number of women in the samples. Knowing more about why and how some women injectors appear to be protected can help improve the effectiveness of HIV prevention programmes among all people who inject drugs.

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Injecting drug use

HIV treatment as prevention among injection drug users

Wood E, Milloy MJ, Montaner JS. Curr Opin HIV AIDS. 2012 Mar;7(2):151-6

The use of highly active antiretroviral therapy as a strategy to prevent the transmission of HIV infection is of substantial international interest. People who inject drugs are an important population with respect to HIV treatment as prevention because they are often less likely to access antiretroviral therapy in comparison with other risk groups. A recent multicentre randomized clinical trial demonstrated a 96% reduction in HIV transmission among heterosexual serodiscordant couples prescribed early antiretroviral therapy. Consistent with these results, independent observational studies from Baltimore and Vancouver have demonstrated that population level rates of antiretroviral therapy use among people who inject drugs are associated with reduced rates of HIV incidence. In addition, impact assessments of antiretroviral therapy delivery to people who inject drugs have generally demonstrated no negative effects of antiretroviral therapy use on rates of unsafe sex or unsafe needle/syringe use. Antiretroviral therapy prevents HIV transmission because it dramatically decreases HIV-1 RNA levels in biological fluids. This is relevant to vertical and sexual HIV transmission and also to blood-borne HIV transmission, as it is often the case among people who inject drugs. Efforts to expand antiretroviral therapy to people who inject drugs should be redoubled in an effort to realize both the individual and public health benefits of antiretroviral therapy.

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Editor’s note: This article reviews the ecological data on reduced ‘community viral load’ associated with antiretroviral treatment scale-up among people who inject drugs. It then makes the case for treatment initiation among people who inject drugs as soon as their HIV infection is detected to reap both individual and population-level benefits. Antiretroviral treatment does not increase the likelihood of unsafe needle/syringe use and it may or may not increase the risk of sexual risk behaviour (studies have produced conflicting results). A meta-analysis has shown that people who inject drugs who are started on antiretroviral treatment are not more likely to develop drug resistance. Finally, harms associated with injecting drugs, such as endocarditis, cellulitis and drug overdose, may bring people who inject drugs into contact with health care providers early in their HIV infection, providing an opportunity for HIV testing and early initiation of antiretroviral treatment. The biggest barrier to scaling up treatment access for people who inject drugs is their stigmatization and criminalisation – these will keep them away from health services and away from the benefits of antiretroviral therapy for themselves, their sexual and injecting partners, and the community.

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Injecting drug use

'It's risky to walk in the city with syringes': understanding access to HIV/AIDS services for injecting drug users in the former Soviet Union countries of Ukraine and Kyrgyzstan

Spicer N, Bogdan D, Brugha R, Harmer A, Murzalieva G, Semigina T.  Global Health. 2011 Jul 13;7(1):22.

Despite massive scale up of funds from global health initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the ambitious target agreed by G8 leaders in 2005 in Gleneagles to achieve universal access to HIV treatment by 2010 has not been reached. Significant barriers to access remain in former Soviet Union countries, a region now recognised as a priority area by policymakers. There have been few empirical studies of access to HIV services in former Soviet Union countries, resulting in limited understanding and implementation of accessible HIV programmes. This study explores the multiple access barriers to HIV services experienced by a key risk group – people who inject drugs. Semi-structured interviews were conducted in two former Soviet Union countries – Ukraine and Kyrgyzstan – with clients receiving Global Fund-supported services (Ukraine n=118, Kyrgyzstan n=84), service providers (Ukraine n=138, Kyrgyzstan n=58) and a purposive sample of national and subnational stakeholders (Ukraine n=135, Kyrgyzstan n=86). Systematic content analyses of these qualitative data were conducted by country teams, and a comparative synthesis of findings undertaken by the authors. Stigmatisation of HIV and drug use was the most important barrier to people who inject drugs accessing HIV services in both countries. Other connected barriers included: criminalisation of drug use; discriminatory practices among government service providers; limited knowledge of HIV, services and entitlements; shortages of commodities and human resources; and organisational, economic and geographical barriers.  Approaches to thinking about universal access frequently assume increased availability of services means increased accessibility of services. This study by Spicer and colleagues demonstrates that while there is greater availability of HIV services in Ukraine and Kyrgyzstan, this does not equate with greater accessibility because of multiple, complex, and interrelated barriers to HIV service utilisation at the service delivery level. Factors external to, as well as within, the health sector are key to understanding the access deficit in the former Soviet Union where low or concentrated HIV epidemics are prevalent. Funders of HIV programmes need to consider how best to tackle key structural and systemic drivers of access including prohibitionist legislation on drugs use, limited transparency and low staff salaries within the health sector.

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Editor’s note: This snapshot in time of the barriers to access to HIV prevention, treatment, care and support services in the Ukraine and Kyrgyzstan provides one of the clearest views of the difference between availability of services and accessibility to services. Easy-to-reach groups and urban populations have been prioritised in response to the need to demonstrate rapid results for continued performance-based funding by funders and, as a result, these were the settings for this study. In the Ukraine, interviews were conducted in the capital Kyiv, the high prevalence city of Odessa, and the low prevalence city of L’viv. In Kyrgyzstan, the study sites were in the capital Bishkek, the high prevalence cities of Osh and Jalalabad, and the low prevalence city of Karakol. The study found that multiple, complex, interrelated barriers both obstruct access and deter service use. First and foremost is criminalisation of people who inject drugs, resulting in widespread police intimidation, discriminatory practices by service providers, and community-level stigmatisation of drug use. Disincentives to returning used injecting equipment include arrests for ‘illegal storage’ of drugs in used syringes, thus the title of this article. Everyone involved with harm reduction programmes in any country will gain insights into why access does not simply mean commodity delivery and service coverage, the more easily measured performance indicators. The Vienna Declaration launched in 2010 at the International AIDS Conference to emphasise that drug policy should be based on evidence not ideology remains highly relevant as we enter 2012. You can find it at: http://www.viennadeclaration.com

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Injecting drug use

Expanded syringe exchange programmes and reduced HIV infection among new injection drug users in Tallinn, Estonia

Uuskula A, Des Jarlais DC, Kals M, Ruutel K, Abel-Ollo K, Talu A, Sobolev I. BMC Public Health. 2011 Jun 30;11(1):517. [Epub ahead of print]

Estonia has experienced an HIV epidemic among people who inject drugs with the highest per capita HIV prevalence in Eastern Europe. Uuskula and colleagues assessed the effects of expanded syringe exchange programmes in the capital city, Tallinn, which has an estimated 10,000 people who inject drugs. Syringe exchange programmes’ implementation was monitored with data from the Estonian National Institute for Health Development. Respondent driven sampling interview surveys with HIV testing were conducted in Tallinn in 2005, 2007 and 2009 (involving 350, 350 and 327 people who inject drugs respectively). HIV incidence among new injectors (those injecting for <= 3 years) was estimated by assuming (1) new injectors were HIV seronegative when they began injecting, and (2) HIV infection occurred at the midpoint between first injection and time of interview. In 2005, 230,000 syringes were exchanged rising to 440,000 in 2007 and 770,000 in 2009. In all three surveys, people who inject drugs were predominantly male (80%), ethnic Russians (>80%), and young adults (mean ages 24 to 27 years). The proportion of new injectors decreased significantly over the years (from 21% in 2005 to 12% in 2009, p=0.005). HIV prevalence among all respondents stabilised at slightly over 50% (54% in 2005, 55% in 2007, 51% in 2009), and decreased among new injectors (34% in 2005, 16% in 2009, p=0.046). Estimated HIV incidence among new injectors decreased significantly from 18/100 person-years in 2005 and 21/100 person-years in 2007 to 9/100 person-years in 2009 (p=0.026). In Estonia, a transitional country, a decrease in the HIV prevalence among new injectors and in the numbers of people initiating injection drug use coincided with implementation of large-scale syringe exchange programmes. Further reductions in HIV transmission among people who inject drugs are still required. Provision of 70 or more syringes per people who inject drugs per year may be needed before significant reductions in HIV incidence occur.

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Editor’s note: Although HIV prevalence among people who inject drugs in many industrialised countries declined and has remained at low levels, many transitional countries with hostile policy environments have increasing HIV prevalence among drug users. In Eastern Europe, on average 9 needles/syringes are distributed per year per person who injects drugs (from 4 in Russia to 151 in the Czech Republic) and 1% of those living with HIV receive antiretroviral therapy (less than 1% in Russia to 81% in Czech Republic). Although only 5 to 12% of people who inject drugs in Estonia report currently receiving antiretroviral therapy, Estonia benefitted from Global Fund support to scale up harm reduction including needle syringe programmes that increased coverage to 70 syringes per person injecting per year and increased methadone treatment slots from 49 to 209 by 2009. The findings of these repeated surveys, conducted using innovative strategies to recruit hard-to-reach individuals, suggest that at the same time that harm reduction programmes were being expanded, both the numbers of new injectors fell and HIV incidence among new injectors declined. This suggests that the population at risk of HIV exposure may be falling and that prevention services are reaching new injectors, often the most difficult population to reach.

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Drug-using Couples

Couple-based HIV prevention for low-income drug users from New York City: a randomized controlled trial to reduce dual risks

El-Bassel N, Gilbert L, Wu E, Witte SS, Chang M, Hill J, Remien RH. J Acquir Immune Defic Syndr 2011.

Dual threats of injection drug use and risky sexual practices continue to increase transmission of HIV and other sexually transmitted infections (STIs) among drug-using couples in low-income communities in the United States. To date, no effective HIV prevention interventions have focused exclusively on this population. Using a randomized controlled trial, 282 HIV-negative drug-using couples (564 individuals) were randomly assigned to receive either: (1) couple-based Risk Reduction; (2) individual-based HIV Risk Reduction, or (3) couple-based Wellness Promotion, which served as an attention control condition. Two hypotheses were tested: (1) “Intervention Effect”--whether the HIV risk reduction intervention provided to the couple or individual partners would be more efficacious in decreasing the number of unprotected sexual acts and having a lower cumulative incidence of biologically confirmed STIs over the 12-month follow-up period compared to the attention control condition; and (2) “Modality Effect”--whether the HIV Risk Reduction intervention would be more likely to decrease the number of unprotected sexual acts and have a lower cumulative STI incidence when delivered to a couple compared to the same intervention delivered to an individual. Over the 12-month follow-up, there was a 30% reduction in the incidence rate of unprotected acts of intercourse with the study partners compared to participants in the attention control arm. Over the12-month follow-up, there was a 29% reduction in the same outcome in the couple arm compared to the individual arm with a 41% reduction at the 12-month follow up. Thus, a couple-based approach that addresses drug and sexual risks and targets low-income, active drug users may help curb the HIV epidemic.

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Editor’s note: It makes sense that the unit of change in reducing HIV risk within heterosexual couples is the couple itself—what is known as a ‘dyadic focus’. Most couple-based research has focused on serodiscordant couples in which one member has HIV infection or on seroconcordant couples in which both members are living with HIV. This is the first randomised controlled trial to test the effectiveness of a couple-based HIV prevention programme for drug-using HIV-negative couples. To be eligible for the trial, HIV-negative couples had to have been together for at least 6 months, have at least one member who had used illicit drugs in the previous 90 days and was either seeking or was in drug treatment, and have had unprotected sexual intercourse with each other in the previous 90 days. Most were recruited through street outreach (homeless shelters, soup kitchens, needles/syringe programmes, and word-of-mouth). The majority were homeless and active crack cocaine users, a population usually excluded from clinical trials. The couple-based risk reduction programme, which was relationship oriented, focused on couple communication, negotiation, problem-solving, disclosure, improving condom skills, and enhancing couple motivation. Not surprisingly, it resulted in less unprotected sex within couples than either the same risk reduction programme delivered to only one partner or a couple wellness programme focused on improving diet, fitness, disease screening, and stress-reduction. Replicating the findings and scaling up this approach for drug-involved couples are the next steps.

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People who inject drugs

Drug Arrests and Injection Drug Deterrence

Friedman SR, Pouget ER, Chatterjee S, Cleland CM, Tempalski B, Brady JE, Cooper HL. Am J Public Health. 2011 Feb, 101:2, 344-349

Friedman and colleagues tested the hypothesis that higher rates of previous hard drug-related arrests predict lower prevalence of injection drug use. They analyzed drug-related arrest data from the Federal Bureau of Investigation's Uniform Crime Reporting Program for 93 large US metropolitan statistical areas in 1992 to 2002 to predict previously published annual estimates of the number of people who inject drugs per 10,000 population. In linear mixed-effects regression, hard drug-related arrest rates were positively associated (parameter=+1.59; SE=0.57) with the population prevalence of people who inject drugs in 1992 and were not associated with change in the prevalence of people who inject drugs over time (parameter =    -0.15; SE=0.39). Deterrence-based approaches to reducing drug use seem not to reduce the prevalence of people who inject drugs. Alternative approaches such as harm reduction, which prevents HIV transmission and increases referrals to treatment, may be a better foundation for policy.

Abstract

Editors’ note: This is an important topic for the USA where drug-related incarceration rates are 8 times higher for African-Americans compared to Whites, with shortages of men in some African-American communities contributing to family breakdown. This ecological study using non-experimental data provides no support for the idea that punishment and stigmatization through arrest will deter people from injecting drugs. Theoretically, if deterrence works then increasing arrest rates should be followed by decreased drug injecting and decreasing arrest rates should be followed by increasing drug use. The study attempted to control for potential confounders such as economic context and social cohesion. The results raise questions about criminal deterrence theory and suggest that greater effort needs to be invested in reinforcing public health approaches to injecting drug use if HIV-related consequences are to be minimized.

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People who inject drugs: harm reduction

Opioid substitution therapy in Manipur and Nagaland, north-east India: operational research in action

Armstrong G, Kermode M, Sharma C, Langkham B, Crofts N. Harm Reduct J. 2010 Dec 1;7(1):29.

There is good evidence for the effectiveness of opioid substitution therapy for people who inject drugs in middle- and high-income countries but little evidence regarding the provision of opioid substitution therapy by non-government organisations in resource-poor settings. This paper reports on outcomes of an non-government organisation-based opioid substitution therapy programme providing sub-lingual buprenorphine to opiate dependent people who inject drugs in two north-east Indian states (Manipur and Nagaland), a region where conflict, under-development and injecting of heroin and Spasmoproxyvon are ongoing problems. The objectives of the study were: 1) to calculate opioid substitution therapy treatment retention, 2) to assess the impact on HIV risk behaviours and quality of life, and 2) to identify client characteristics associated with cessation of treatment due to relapse. This study involves analysis of data that were routinely and prospectively collected from all clients enrolled in an opioid substitution therapy programme in Manipur and Nagaland between May 2006 and December 2007 (n=2569, 1853 in Manipur and 716 in Nagaland) using standardised questionnaires, and is best classified as operational research. The data were recorded at intake into the programme, after three months, and at cessation. Outcome measures included HIV risk behaviours and quality of life indicators. Predictors of relapse were modelled using binary logistic regression. Of all clients enrolled in opioid substitution therapy during the month of May 2006 (n=713), 72.8% remained on treatment after three months, and 63.3% after six months. Statistically significant (p = 0.05) improvements were observed in relation to use of unsterile equipment, unsafe sex, incidents of detention, and a range of quality of life measures. Greater spending on drugs at intake (OR 1.20), frequently missing doses (OR 8.82), and having heroin rather than Spasmoproxyvon as the most problematic drug (OR 1.95) were factors that increased the likelihood of relapse, and longer duration in treatment (OR 0.76) and regular family involvement in treatment (OR 0.20) reduced the likelihood of relapse. The findings from this operational research indicate that the provision of opioid substitution therapy by non-government organisations in the severely constrained context of Manipur and Nagaland achieved outcomes that are internationally comparable, and highlights strategies for strengthening similar programmes in this and other resource-poor settings.

Abstract:

Editors’ note: The comprehensive package of nine core interventions recommended by UNAIDS, UNODC, and WHO for prevention and treatment for people who inject drugs includes opioid substitution therapy – the substitution of orally administered opiates such as buprenorphine and methadone for illicit drugs. This study, conducted in Manipur and Nagaland where approximately 2% of the population inject drugs, is an example of classic operational research to assess effectiveness of a community-based programme operating out of drop-in centres rather than on the confines of a randomised controlled trial. The programme itself was funded at various times by the Bill and Melinda Gates Foundation, the UK Department for International Development, the National AIDS Control Organisation, and Emmanuel Hospital Association. At one year, 50.8% of enrolled clients remained on treatment and 12.8% had completed the programme. There were substantial decreases in drug use and HIV risk behaviours, accompanied by less family conflict, fewer episodes of detention or imprisonment, less work-related absenteeism for those with jobs, increased attendance at social events, and improved self-reported quality of life. Clearly the programme has proven its worth – now the challenge is to see if these results can be replicated in other settings and to assess different strategies to improve retention in the programme – some people will need methadone for life.

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People who inject drugs: harm reduction

Scaling up the national methadone maintenance treatment programme in China: achievements and challenges

Yin W, Hao Y, Sun X, Gong X, Li F, Li J, Rou K, Sullivan SG, Wang C, Cao X, Luo W, Wu Z. Int J Epidemiol. 2010 Dec;39 Suppl 2:ii29-37.

China's methadone maintenance treatment programme was initiated in 2004 as a small pilot project in just eight sites. It has since expanded into a nationwide programme encompassing more than 680 clinics covering 27 provinces and serving some 242,000 heroin users by the end of 2009. The agencies that were tasked with the program's expansion have been confronted with many challenges, including high drop-out rates, poor cooperation between local governing authorities, and poor service quality at the counter. In spite of these difficulties, ongoing evaluation has suggested reductions in heroin use, risky injection practices and, importantly, criminal behaviours among clients, which has thus provided the impetus for further expansion. Clinic services have been extended to offer clients a range of ancillary services, including HIV, syphilis and hepatitis C testing, information, education and communication, psychosocial support services and referrals for treatment of HIV, tuberculosis and sexually transmitted diseases. Cooperation between health and public security officials has improved through regular meetings and dialogue. However, institutional capacity building is still needed to deliver sustainable and standardized services that will ultimately improve retention rates. This article documents the steps China made in overcoming the many barriers to success of its methadone programme. These lessons might be useful for other countries in the region that are scaling-up their methadone programmes.

Abstract

Editors’ note: This historical perspective begins with the identification the first drug-related HIV outbreak in Yunnan province in 1989, the increasing recognition of the need to address the dual epidemic of HIV and drug use, and the initial piloting of harm reduction strategies. In the mid-1990s, study tours by Chinese officials to other countries that had already established policy and practice on methadone maintenance, and the influence of workshops, conferences, and seminars, helped open dialogue on the issues. The foundation for multisectoral collaboration was built through the creation of a supportive policy environment and the leadership of a National Working Group. Eight methadone maintenance treatment clinics with strict eligibility and retention criteria were established in 2004, along with a monitoring and evaluation system to estimate their effectiveness in reducing injecting frequency, reducing HIV incidence among those who stayed in the programme, increasing employment, and reducing imprisonment. Today this is an internet-based database covering the clients and services at all the methadone clinics. Specific targets for scaling up methadone services were set for the end of 2007 and 2010. Outcomes measured are new HIV infections averted, heroin consumption reduced, and heroin trade avoided. Political support at the highest levels has been accompanied by legislative change. Important challenges include suboptimal methadone dosing, dosing strategies that are not flexible (clients have no ‘carry privileges’), poor accessibility in some areas, poor retention, the need for capacity building of staff skills as clinics diversify to offer ancillary services, coverage gaps, and the need for improved cooperation between Ministries of Health and Public Security at lower levels.

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Injecting drug use

Sex, drugs and economic behaviour in Russia: a study of socio-economic characteristics of high risk populations

Wall M, Schmidt E, Sarang A, Atun R, Renton A. Int J Drug Policy. 2010 Nov 3.

Russia faces a worsening HIV epidemic among people who inject drugs. This paper examines the social and economic characteristics of injecting drug users in two cities in Russia and compares this with the general population to explore their social and economic needs and the wider implications of the epidemic for the economy and society. The research team did a cross sectional survey of 711 people who inject drugs in two Russian cities (Volgograd and Barnaul), recruited by a modified chain referral sampling method. Respondents were asked about their education, work, living conditions, expenditure on goods and services and livelihoods. Their characteristics were compared with a random sample of the general population. There are a number of characteristics in which people who inject drugs do not differ systematically from the general population. They have general education; live in the towns where they were born; and their monthly income is comparable with the Russian average. However, people who inject drugs are more likely to have a vocational qualification than a university degree; less likely to have a permanent job; and those employed are skilled manual rather than professional workers. People who inject drugs are less likely to be officially married and more likely to be living with their parents or on their own. The majority rely on financial help from relatives or friends; and much of their income is from illegal or semi-legal activities. People who inject drugs are not atypical or marginal to the Russian economy and society. However, their drug-dependency and related life-style make them particularly vulnerable to the impact of poverty, violence and social insecurity. A failure to effectively control the dual IDU/HIV epidemic can have a significant negative impact on the Russian labour force, health and social costs and overall economy.

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Editors’ note: This study of 700 street-recruited people who had injected drugs in the previous 30 days was restricted to two Russian cities, Volgograd in Southern Russia and Barnaul in Siberia. Its results, comparing their social and economic profiles with those of the general population in Russia, go a long way to countering the common belief that Russians who inject drugs come from disadvantaged and broken families or are migrants from other countries of the former Soviet Union. Overall, 86% were born in the region where they now lived, 75% had not moved house and 14% had moved house only once in the preceding 2 years, and 95% had formal registration with local authorities (propiska) entitling them to state-funded health care and social services. They were more likely to have vocational training and less likely to have completed higher education than the general population; 35% had regular jobs, compared to 51% of the general population, with the construction sector (carpenters, joiners, decorators) predominating. With the Russian economy experiencing a demographic crisis due to high alcohol consumption, low birth rates, and high mortality among men, shortages of workers with vocational qualifications are predicted. Unless harm reduction and antiretroviral treatment access are significantly expanded for people who inject drugs in Russia (estimated at 1.5-3 million), their HIV-related morbidity and mortality are likely to affect the future Russian labour force.

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Injecting drug use

Correlates of HIV risk among injecting drug users in sixteen Ukrainian cities

Taran YS, Johnston LG, Pohorila NB, Saliuk TO. AIDS Behav. 2011 Jan;15(1):65-74.

Taran and colleagues present findings from a HIV survey using respondent driven sampling among 3,711 people who inject drugs in 16 cities in Ukraine in 2008. Eligible participants were males and females who injected drugs in the past 1 month, ≥16 years and lived/worked in their respective interview area. The impact of injecting and sexual risk behaviors on HIV-infection were analyzed using four logistic models. Overall HIV prevalence was 32%. In the sexual risk model, paying for sex in the past 3 months and condom use during last sex increased the odds of HIV infection. Being female, having greater than 3 years of injection drug use, always injecting with equipment used by others and using alcohol with drugs in the past month remained significant in all four models. These findings indicate the urgent need to scale up peer education, needle exchange and methadone substitution programmes for people who inject drugs with specific programmes targeting the needs of female injectors.

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Editors’ note: This large-scale bio-behavioural surveillance study using respondent driven sampling (choosing ‘seeds’ known to organisations working with people who inject drugs to recruit 3 eligible drug users each who then recruited 3 more and so on), is the most extensive study of its kind conducted anywhere. HIV prevalence was higher than 20% in the majority of the 16 cities studied, with unsafe risk behaviours including using pre-filled syringes, using contaminated drug preparation equipment, and having unprotected sex. Few reported using a needle/syringe before or after someone else had used it in the previous month, suggesting that the message about using your own equipment is well understood. However, over half reported extracting their drug solution from a common container, reinforcing the need to emphasise the importance of sterile drug preparation equipment in addition to sterile injecting equipment. The majority reported injecting opiates, mostly in the form of liquid poppy straw purchased in pre-filled syringes that may or may not be sterile. Sexually active drug users were twice as likely to use condoms at last sexual contact if they were HIV-positive. Women were more likely to be HIV-positive and more likely to use contaminated injecting equipment, underscoring the need for outreach programmes that focus on the special needs of women who inject drugs. This study provides a wealth of information to inform, expand, and tailor harm reduction programmes in the Ukraine.

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