Articles tagged as "Injecting drug use and HIV prevention"

Injecting drug use

Yang L, Li J, Zhang Y, Li H, Zhang W, Dai F, Ren Z, Qi G, Cheng W. Societal perception and support for methadone maintenance treatment in a Chinese province with high HIV prevalence. Am J Drug Alcohol Abuse. 2008;34(1):5-16.

Methadone maintenance treatment was first piloted in April 2004 in Yunnan, China, to reduce HIV transmission. This study aimed to examine public support for methadone maintenance treatment and was based on cross-sectional data collected in March-April 2006 on a random sample of 411 police staff, medical/health professionals, community members, and drug users. Multivariate logistic regressions were used to analyze the data. The support was the strongest amongst the police and medical professionals but the lowest in drug users. A considerable proportion of the respondents viewed methadone maintenance treatment as contradictory to China's drug control policies and this factor was negatively associated with support for methadone maintenance treatment. Dissemination of more accurate knowledge and the resolution of these conflicts are urgently needed to increase the public support for methadone maintenance treatment.

Editors’ note: This study in Yunnan province underscores the need to discover the reasons that drug users themselves are the people least supportive of methadone maintenance, particularly as China proceeds to scale-up dramatically such programmes. The reason could be as basic as inadequate knowledge about the effectiveness and safety of methadone substitution.


 Walsh N, Gibbie TM, Higgs P. The development of peer educator-based harm reduction programmes in northern Vietnam. Drug Alcohol Rev. 2008;27(2):200-3.

Injecting drug use remains an important risk factor for transmission in Vietnam, with an estimated 50% of the 290 000 people living with HIV reporting injecting drug use as a risk factor. Despite this, effective harm reduction interventions are generally lacking. Walsh and colleagues describe the implementation of peer-based harm reduction programmes in two rural provinces of Vietnam. Peer educators were trained in basic HIV prevention, including harm reduction. After significant preparation work with the Provincial AIDS Committees of Bac Giang and Thanh Hoa and other relevant national, provincial and local authorities, the interventions were commenced. Harm reduction interventions were delivered through outreach as well as on site. These included needle and syringe distribution and collection. Community advocacy occurred throughout the life of the project. Local authorities and peers believed that while there was a general reduction in stigma and discrimination, legal barriers associated particularly with the carrying of injecting equipment remained. This affected the ability of peer educators to work with their clients. Nonetheless, peer-based delivery of harm reduction interventions, including needle and syringe programmes, is feasible and acceptable in these two rural Vietnamese provinces. Community acceptance and uptake of these interventions are key to successful expansion across the region. Active participation by families of drug users seems crucial. This initiative demonstrates that despite a difficult policy environment, peer-delivered needle and syringe programmes are feasible within a rural Asian environment as long as there is adequate local political and community support.

Editors’ note: This local harm reduction programme delivered through peer educators mobilised communities to change attitudes, engaged families, was acceptable to police and other local government officials, and resulted in a large reduction in discarded needles and syringes. Shifts in drug policy with the release of thousands of detainees from drug rehabilitation suggest the potential for scaling–up community-based harm reduction programmes more widely in Vietnam.


Kerr T, Tyndall MW, Zhang R, Lai C, Montaner JS, Wood E. Circumstances of first injection among illicit drug users accessing a medically supervised safer injection facility. Am J Public Health. 2007;97:1228-30.

There have been concerns that safer injecting facilities may promote initiation into injection drug use. Kerr and colleagues examined length of injecting career and circumstances surrounding initiation into injection drug use among 1065 users of North America’s first safer injecting facility and found that the median years of injection drug use were 15.9 years, and that only 1 individual reported performing a first injection at the safer injecting facility. These findings indicate that the safer injecting facility’s benefits have not been offset by a rise in initiation into injection drug use.

Editors’ note: This supervised injecting facility requires all new visitors to sign a waiver indicating that they have injected previously, a fact that is well known in the community. Deterring people who are insistent on injecting for the first time could be a problem since such individuals tend to use another person’s injecting equipment and are at high risk of overdose. One solution would be for them to be assessed first by an on site addictions counsellor, encouraging consideration of the option of referral for treatment.

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Injecting drug use

Des Jarlais DC, Kling R, Hammett TM, Ngu D, Liu W, Chen Y, Binh KT, Friedmann P. Reducing HIV infection among new injecting drug users in the China-Vietnam Cross Border Project. AIDS. 2007;21 Suppl 8:S109-14.

Des Jarlais and colleagues aimed to assess an HIV prevention programme for injecting drug users (IDU) in the crossborder area between China and Vietnam. The project included peer educator outreach and the large-scale distribution of sterile injection equipment. Serial cross-sectional surveys with HIV testing of community recruited IDU were conducted at baseline (before implementation) and 6, 12, 18, 24 and 36 months post-baseline. HIV prevalence and estimated HIV incidence among new injectors (individuals injecting drugs for < 3 years) in each survey wave were the primary outcome measures. The percentages of new injectors among all subjects declined across each survey waves in both Ning Ming (China) and Lang Son (Vietnam). HIV prevalence and estimated incidence fell by approximately half at the 24-month survey and by approximately three quarters at the 36-month survey in both areas (all P < 0.01). The authors conclude that implementation of large-scale outreach and syringe access programmes was followed by substantial reductions in HIV infection among new injectors, with no evidence of any increase in individuals beginning to inject drugs. This project may serve as a model for large-scale HIV prevention programming for IDU in China, Vietnam, and other developing/transitional countries.

Editors’ note: Large-scale implementation of harm reduction programmes to reduce the risk of HIV exposure and transmission among injecting drug users (which include community outreach, needle and syringe access, and substitution treatment) have brought HIV epidemics under control in a number of high-income countries. This cross-border programme aimed to achieve public health scale implementation, considered as 7 to 10 syringes per injecting drug user per month, through direct syringe provision and no-cost vouchers to exchange for sterile injecting equipment and condoms in participating local pharmacies. Although the observed dramatic reduction in HIV incidence may be due in part to behaviour change motivated by the large number of AIDS deaths, increased access to sterile injecting equipment helped translate increased motivation into effective risk reduction. This study demonstrates that when harm reduction programmes are implemented at a scale commensurate to the size of the problem, they can turn around an HIV epidemic among injecting drug users in a developing or transitional country.


Booth RE, Lehman WE, Kwiatkowski CF, Brewster JT, Sinitsyna L, Dvoryak S. Stimulant Injectors in Ukraine: The Next Wave of the Epidemic? AIDS Behav. 2008 Feb 9 [Epub ahead of print].

This study was designed to assess differences in drug and sex-related risk behaviours between injectors of opiates only, opiate/sedative mix only and stimulants only. Participants were current out-of-treatment injection drug users (IDUs), unaware of their HIV status, recruited through street outreach in Kiev, Odessa and Makeevka/Donetsk, Ukraine. Overall, 22% tested positive for HIV, including 39% among opiate/sedative injectors, 19% among opiate injectors and 17% among stimulant injectors. Despite these differences, stimulant injectors were at higher risk than other IDUs in sharing a used needle/syringe, always injecting with others, injecting a drug solution drawn from a common container, having an IDU sex partner, not using condoms during vaginal or anal sex and on composite measures of injection and sex risks. After controlling for age differences, stimulant injectors remained at higher risk in their needle and sex risk behaviours. Without intervention, it is likely that HIV will increase among stimulant injectors.

Editors’ note: Stimulant injectors in North America generally have higher HIV prevalence, second only to polydrug users, a population excluded from this study. Rather than cocaine, in the Ukraine context the stimulant is pseudo-ephedrine obtained through pharmacies and prepared for injection in a shared mixing container. Although they are younger and have lower HIV prevalence than other drug users, Ukrainian stimulant injectors have the sexual and injecting behaviours to set aflame the next wave of HIV in their country.

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Injecting drug use

Razani N, Mohraz M, Kheirandish P, Malekinejad M, Malekafzali H, Mokri A, McFarland W, Rutherford G. HIV risk behavior among injection drug users in Tehran, Iran. Addiction. 2007 Sep;102(9):1472-82.

Iran faces parallel human immunodeficiency virus (HIV) and injection drug use epidemics; more than 62% of known HIV cases occur among injection drug users (IDU). Razani and colleagues conducted a formative study of IDU in Tehran to explore risk behaviour in the wake of the recent harm reduction efforts. Key informant interviews (n = 40), focus group discussions (nine groups of IDU, n = 66) and a review of existing published and unpublished literature were conducted. Participants included IDU, physicians, policy makers, police, IDU advocates and their families. IDU were diverse in gender, education, income and neighborhood of residence. Interviews were transcribed and analyzed using grounded theory. A typology of IDUs in Tehran, categorized according to self-defined networks as well as HIV risks, is presented. This categorization is based on the groups identified by IDUs, compared to those identified by other key informants, and on a secondary data review. Homeless, female, young IDU and users of a more potent form of heroin were identified as having increased risks for HIV. Participants described shortening transitions from smoked opium to injected opiates. Whereas a majority of participants considered needle sharing less common than previously, sharing continues in locations of group injection, and in states of withdrawal or severe addiction. System-wise barriers to harm reduction were discussed, and include the cost or stigma of purchasing needles from pharmacies, over-burdened clinics, irregular enforcement of laws protecting IDU and lack of efforts to address the sexual risks of IDU. This research is one of the first to describe a diversity of IDU, including women and higher socio-economic class individuals, in Tehran. While efforts in harm reduction in Iran to date have been notable, ongoing risks point to an urgent need for targeted, culturally acceptable interventions.

Editors’ note: Qualitative studies such as these, in a country that has a long-standing history of opiate use, can help paint a contextual picture far beyond the numbers. Such information can provide constructive ideas for programmes that can help reduce the likelihood of transition to injecting and minimise the harm associated with opium use.

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Injecting Drug Use

McKnight I, Maas B, Wood E, Tyndall MW, Small W, Lai C, Montaner JS, Kerr T. Factors associated with public injecting among users of Vancouver’s supervised injection facility. Am J Drug Alcohol Abuse 2007;33:319-25.

McKnight and colleagues evaluated factors associated with public drug injection among a cohort of injection drug users (SEOSI Scientific Evaluation of Supervised Injecting cohort study) originally recruited from within Vancouver’s supervised injecting facility. The authors used univariate statistics and logistic regression to examine factors associated with public drug injection among SEOSI participants. Between June 2004 and July 2005, 714 IDU were followed up as part of SEOSI. In multivariate analyses, factors associated with public drug injection included homelessness (adjusted odds ratio (aOR) = 3.10; p < .001), syringe lending (aOR = 5.39; p < .001), requiring help injecting (aOR = 1.60; p = .05), and reporting that wait times affected frequency of supervised injecting facility use (aOR = 3.26; p < .001). Persistent public injection was independently associated with elevated HIV risk behaviours, as well as programmatic factors that limit supervised injecting facility use. Supervised injecting facility programme expansion may further help to reduce persistent risk behaviours and the community concerns related to public injection drug use.

Editors’ note: Public injecting carries a much higher risk of HIV exposure because it is generally furtive, rushed, and undertaken under conditions of poor lighting with whatever equipment is available. As well, discarded injecting equipment may pose risks of accidental needle stick injuries to the community. This study determined several variables independently linked to public injecting, including one that is under the control of programme planners – waiting times at the supervised injecting facility.

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Men who have sex with men and Methamphetamine use

Shoptaw S, Reback CJ. Methamphetamine use and infectious disease-related behaviors in men who have sex with men: implications for interventions. Addiction 2007;102 Suppl 1:130-5.

Shoptaw and Reback aimed to review the current evidence regarding the prevalence of methamphetamine use among men who have sex with men (MSM) and to evaluate the factors that contribute to methamphetamine use and potential for sexual transmission of HIV and other infectious diseases. The authors used data based reports to address (1) epidemiology of methamphetamine use in MSM; (2) methamphetamine use and risk behaviours for sexually transmitted infections; and (3) interventions. Their findings showed that methamphetamine use is highly prevalent in MSM. Strong associations between methamphetamine use and HIV-related sexual transmission behaviours are noted across studies of MSM and correspond to increased incidence for HIV and syphilis compared to MSM who do not use the drug. Behavioural treatments produce sustained reductions in methamphetamine use and concomitant sexual risk behaviours among methamphetamine-dependent MSM. In conclusion, brief screening of methamphetamine use for MSM who seek physical, mental health and substance abuse services is recommended. Behavioural interventions that address methamphetamine use may range from brief interventions to intensive out-patient treatments.

Editors’ note: If you don’t ask, you’ll never know. Methamphetamine use can increase the likelihood of sexual risk-taking and therefore of sexually transmitted infections and of HIV acquisition and transmission. Behavioural treatments can work to reduce risk but can’t even be offered if providers don’t become comfortable asking about drug use and sexual behaviour patterns.

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Injecting Drug Use and HIV prevention

Abdool, R, Sulliman FT, Dhannoo, MI. The injecting drug use and HIV/AIDS nexus in the Republic of Mauritius. African Journal of Drug & Alcohol Studies, Special Issue: Substance Abuse and HIV/AIDS in Sub-Saharan Africa 2006;5. http://www.sahealthinfo.org/admodule/afrjourinjecting2006.pdf

Mauritius has the highest per capita injection drug use in Africa and, in the last 6 years, injecting drug use has become the main mode of HIV transmission. To report on the drug use, high risk injection practices, and high risk sexual behaviour among imprisoned injecting drug users (IDUs), sex-worker IDUs, and non-prisoner, non-sex worker IDUs, Abdool and colleagues drew data and findings from a 2004 rapid assessment of drug use in Mauritius, and from the Mauritius Epidemiological Network on Drug Use, the AIDS Unit at Ministry of Health; and the Mauritius Prison Service. The findings showed that there are an estimated 17,000-18,000 IDUs in Mauritius of whom 4,800 are sex workers and 2,871 are prisoners. Prevalence of use of unsterile needles among IDUs is estimated at 25-50%, and 75-90% of IDUs report using condoms “seldom” or “never.” Mauritius is facing a serious concentrated HIV epidemic among IDUs. The Mauritius government, through bilateral and multi-lateral collaboration, is making considerable progress in providing comprehensive services for people living with HIV/AIDS. Strengthening prevention interventions targeting IDUs will be critical to addressing this emerging epidemic.

Editors’ note: Although heterosexual transmission is generally the most common mode of HIV transmission in sub-Saharan Africa, injecting drug use is on the rise in Mauritius and other countries. The peer reviewed papers in this supplement review research findings from seven countries—Kenya, Mauritius, Nigeria, Rwanda, South Africa, Tanzania, and Zambia on injecting and non-injecting drug use and on alcohol misuse, and their links to HIV transmission. The issue, which should help inform policy and programmes addressing drug- and alcohol-related HIV risks, is freely available at http://www.sahealthinfo.org/admodule/journal52006.htm

 

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Injecting drug use

Millson P, Challacombe L, Villeneuve PJ, Strike CJ, Fischer B, Myers T, Shore R, Hopkins S. Reduction in injection-related HIV risk after 6 months in a low-threshold methadone treatment program. AIDS Educ Prev 2007;19:124-136.

This study assessed injection-related HIV risk behavioural changes among opioid users 6 months after enrollment in low-threshold (harm reduction based) methadone maintenance treatment (MMT) programs within needle exchange services in Kingston and Toronto, Ontario, Canada. Changes were assessed for all participants (whole cohort), participants who continued to use illicit drugs by any route (drug-using subcohort); and those who continued to inject drugs (injecting subcohort). In this prospective observational cohort study, an interviewer-administered questionnaire examining injection-related HIV risk behaviours was administered to 183 study participants at entry to treatment and 6 months later. Changes in risk behaviours were analyzed using conditional logistic regression which took into account the paired nature of the data. The authors found that the proportion of participants injecting drugs, sharing needles, sharing drug equipment, indirectly sharing and using shooting galleries declined with follow-up for the whole cohort. Within the drug-using subcohort, there was a decrease in the proportion of individuals who injected drugs, while within the injecting subcohort the sharing of injection equipment and the use of shooting galleries declined. Our findings suggest that low-threshold MMT programs can reduce the risk of HIV without the enforcement of abstinence-based policies.

Editors’ note: Effective harm reduction programmes based on a “different strokes for different folks” principle such as this low threshold methadone programme, demonstrate that one size does not fit all. People who are not prepared to abstain from drug use currently can benefit from lower threshold programmes that assist them to make healthier choices.

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Harm reduction

Ball AL. HIV, injecting drug use and harm reduction: a public health response. Addiction 2007 Mar 9; [Epub ahead of print]

Injecting drug use is driving HIV epidemics in many countries around the world. There is evidence that such epidemics can be averted, halted and reversed if comprehensive HIV programmes targeting drug users are put into place. The term ‘harm reduction’ is used widely to describe the goals, policies and interventions of such programmes. However, despite its rapidly expanding use, the term has no universally accepted definition. This paper aims to describe the evolution and branding of the term ‘harm reduction’ and the adoption of the concept across a wide range of countries. It highlights a range of issues that remain controversial in the harm reduction discourse related to HIV and injecting drug use, including: the definition of ‘harm reduction’ and related terms; the scope of harm reduction; the promotion of a public health versus drug control dichotomy; the feasibility and appropriateness of harm reduction in low-and middle-income countries; and the strength of evidence on harm reduction interventions. The paper argues that harm reduction should be a core element of a public health response to HIV where injecting drug use exists. The effectiveness of policies and programmes targeting drug users should be measured against public health outcomes. This requires the alignment of drug control measures with public health goals. A ‘model package’ for harm reduction is proposed, which provides guidance to countries on the selection of evidence-based policies and interventions, including: interventions for reducing HIV transmission; treatment of HIV and associated co- morbidities; appropriate models of service delivery; creation of supportive policy, legal and social environments; and strengthening of strategic information systems to better guide responses.

Editors’ note: Ensuring that people who inject drugs have timely access to sterile injecting equipment in adequate quantities is a pillar of harm reduction but it must be contextualized within a comprehensive programme for prevention, treatment, care and support to achieve reductions in HIV incidence and prevalence in this population. Although the UN has defined harm reduction as being needle exchange, substitution therapy and peer outreach, the broader framework presented here by WHO reflects what is really needed to make these components effective.

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Substance use

Altaf A, Shah SA, Zaidi NA, Memon A, Rehman NU, Wray N. High risk behaviors of injection drug users registered with harm reduction programme in Karachi, Pakistan. Harm Reduct J 2007;4:7 [Epub ahead of print]

Surveillance data of Sindh AIDS Control Programme, Pakistan suggest that HIV infection is rapidly increasing among injecting drug users (IDUs) in Karachi and had reached 9% in 2004-5 indicating that the country had progressed from nascent to concentrated level of HIV epidemic. Findings of 2nd generation surveillance in 2004-5 also indicated 104/395 (26.3%) IDUs HIV positive in the city. Altaf and colleagues conducted a cross sectional study among registered IDUs of a needle exchange and harm reduction programme in Karachi, Pakistan. A total of 161 IDUs were included in the study between October-November 2003. A detailed questionnaire was implemented and blood samples were collected for HIV, hepatitis B & C and syphilis. HIV, hepatitis B and C antibody tests were performed using Enzyme Linked Immunosorbent Assay (ELISA) method. Syphilis tests (RPR & TPHA) were performed on Randox kit. Besides calculating frequencies, univariate analysis was performed using t tests for continuous variables as age, age at first intercourse and average age of initiation of addiction and chi square for categorical variables like paid for sex or not to identify risk factors for hepatitis B and C and syphilis. The average age of IDU was 35.9 years and average age of initiation of drugs was 15.9 years. Number of drug injections per day was 2.3. Shooting drugs in group sharing syringes was reported by 128 (79.5%) IDUs. Over half 94 (58.3%) reported paying for sex and 64% reported never using a condom. Commercial selling of blood was reported by 44 (28%). 1 of 161 was HIV positive (0.6%). The prevalence of hepatitis B was 12 (7.5%), hepatitis C 151 (94.3%) and syphilis 21 (13.1%). IDUs who were hepatitis C positive were more likely to start sexual activity at an earlier age and had never used condoms. Similarly IDUs who were hepatitis B positive were more likely to belong to a younger age group. Syphilis positive IDUs were more likely to have paid for sex and had never used a condom. The authors conclude that prudent measures such as access to sterile syringes, rehabilitation and opiate substitution therapies are required to reduce high risk behaviours of IDUs in Pakistan.

Editors’ note: Although HIV prevalence is still low in this population of Karachi injecting drug users, the use of non sterile injecting equipment has already led to an extremely high hepatitis C prevalence. Furthermore, low condom use among clients of sex workers and a syphilis prevalence of 13% suggest that the conditions are ripe for HIV transmission in this population and among their spouses, other sexual partners and injecting partners. The focus must broaden from drug related harm reduction (sterile injecting equipment, substitution treatment, rehabilitation) to include programmes focused on prevention of sexual transmission and rapid establishment of a volunteer blood collection system.

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Harm reduction

Li MQ, Lee SS, Gan ZG, Tan Y, Meng JH, He ML. Achieving a high coverage - the challenge of controlling HIV spread in heroin users. Harm Reduct J 2007;4:8 [Epub ahead of print]

In China, the national plan to open 1000 methadone clinics over a five-year period provides a unique opportunity to assess the impacts of harm reduction in a country with concentrated HIV epidemic amongst heroin users. To track the progress of this public health response, data were collected from the first methadone clinic in Liuzhou, Guangxi, a province with a high HIV prevalence. In the first 15 months of its operation, a cumulative total of 488 heroin users, 86% of which male, had joined the programme. The first dose of methadone was given efficiently at a median of 2 days after registration. Of the 240 heroin users attending the clinic in August 2006, 61% took methadone for four days each week. The number of active methadone users, however, leveled off at around 170 after the first two months, despite the availability of capacity to deliver more services. The reasons for this observation are: firstly, the provision of one single service that may not be convenient to all heroin users; and secondly, concerns of heroin users who may feel insecure to come forward. As broad coverage is essential in ultimately reducing HIV risk, a low threshold approach is crucial, which should be supported by the removal of social obstacles and a refinement of the administrative procedures.

Editors’ note: China has an excellent plan for 1000 medically assisted drug treatment clinics but, as this article highlights, it is always critical to interview the intended users of services for ideas about how to improve programmes for maximum effectiveness. This is the only way to learn the answer to the question ‘If we build it, will they come?’ Some clients may need a low threshold programme to get them started on reducing the frequency of drug injecting, others may prefer to commit to a more structured approach – and the hours of operation and staffing of each service will likely need to be different to meet users’ needs.

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