Articles tagged as "Injecting drug use and HIV prevention"

Substance use and HIV

Kalichman SC, Simbayi LC, Kaufman M, Cain D, Jooste S. Alcohol use and sexual risks for HIV/AIDS in Sub-Saharan Africa: systematic review of empirical findings. Prev Sci 2007 Jan 31; [Epub ahead of print]

Alcohol consumption is associated with risks for sexually transmitted infections, including HIV. In this paper, Kalichman and colleagues systematically review the literature on alcohol use and sexual risk behaviour in southern Africa, the region of the world with the greatest HIV burden. Studies show a consistent association between alcohol use and sexual risks for HIV infection. Among people who drink, greater quantities of alcohol consumption predict greater sexual risks than does frequency of drinking. In addition, there are clear gender differences in alcohol use and sexual risks; men are more likely to drink and engage in higher risk behaviour whereas women's risks are often associated with their male sex partners' drinking. Factors that are most closely related to alcohol and sexual risks include drinking venues and alcohol serving establishments, sexual coercion, and poverty. Research conducted in southern Africa therefore confirms an association between alcohol use and sexual risks for HIV. The authors conclude that sexual risk reduction interventions are needed for men and women who drink and interventions should be targeted to alcohol serving establishments.

Editors’ note: This article highlights the relevance of venue-based HIV prevention programmes to reach drinking men and women at risk for HIV.


Wood E, Lloyd-Smith E, Li K, Strathdee SA, Small W, Tyndall MW, Montaner JS, Kerr T. Frequent needle exchange use and HIV incidence in Vancouver, Canada. Am J Med 2007;120:172-9.

Opposition to needle exchange programs has been fuelled by a Vancouver study showing an association between frequent program use and elevated rates of human immunodeficiency virus (HIV) infection among injection drug users. Wood and colleagues evaluated possible explanations for the observed association between elevated HIV rates and frequent needle exchange attendance using a prospective observational cohort study of injection drug users in Vancouver, BC, Canada. HIV incidence rates were examined using stratified Kaplan-Meier methods and Cox proportional hazards regression. Between May 1996 and December 2004, 1035 individuals were recruited. At 48 months after recruitment, the cumulative HIV incidence rate was 18.1% among those reporting daily needle exchange use at baseline, compared with 10.7% among those who did not report this behaviour (P <.001). However, comparing HIV incidence among daily versus nondaily exchange users, while stratifying the cohort into those who did (23.2% vs 16.8%; P=.157) and did not (11.4% vs 9.0%; P=.232) report daily cocaine injection at baseline, the association between daily exchange use and HIV incidence was no longer significant. In an adjusted Cox model, daily exchange use was not associated with the time to HIV seroconversion (relative hazard=1.41 [95% confidence interval, 0.95-2.09]). The authors concluded that the differential HIV incidence rates between frequent and nonfrequent needle exchange attendees can be explained by the higher risk profile of daily attendees. Causal factors, including the high rates of cocaine injection and other local injection drug user characteristics, explain the Vancouver HIV outbreak.

Editors’ note: This study emphasises the importance of looking at confounding factors, in this case cocaine use, in explaining differences in HIV incidence, rather than jumping to conclusions.

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People who inject drugs

Tyndall MW, Wood E, Zhang R, Lai C, Montaner JS, Kerr T. HIV seroprevalence among participants at a medically supervised injection facility in Vancouver, Canada: implications for prevention, care and treatment. Harm Reduct J 2006;3:36.http://www.harmreductionjournal.com/content/3/1/36

North America’s first government sanctioned medically supervised injection facility was opened during September 2003 in Vancouver, Canada. This was in response to a large open public drug scene, high rates of HIV and hepatitis C transmission, fatal drug overdoses, and poor health outcomes among the city’s injection drug users. Between December 2003 and April 2005, a representative sample of 1,035 supervised injection facility participants were enrolled in a prospective cohort that required completing an interviewer-administered questionnaire and providing a blood sample for HIV testing. HIV infection was detected in 170/1007 (17%) participants and was associated with Aboriginal ethnicity (OR 2.70, 95% CI 1.84-3.97), a history of borrowing used needles/syringes (OR 2.0, 95% CI 1.37-2.93), previous incarceration (OR 1.87, 95% CI 1.11-3.14), and daily injection cocaine use (OR 1.42, 95% CI 1.00-2.03). The supervised injection facility has attracted a large number of marginalized injection drug users and presents an excellent opportunity to enhance HIV prevention through education, the provision of sterile injecting equipment, and a supervised environment to self-inject. In addition, the supervised injection facility is an important point of contact for HIV positive individuals who may not be participating in HIV care and treatment.

Editors’ note: This supervised injecting facility is attracting a clientele which often has poor contact with health and social services. Increased safer injecting, lowered morbidity and mortality and lower HIV incidence are the end results to be achieved and documented, as they have in been in Switzerland.

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People who inject Drugs

Azim T, Chowdhury EI, Reza M, Ahmed M, Uddin MT, Khan R, Ahmed G, Rahman M, Khandakar I, Khan SI, Sack DA, Strathdee SA. Vulnerability to HIV infection among sex worker and non-sex worker female injecting drug users in Dhaka, Bangladesh: evidence from the baseline survey of a cohort study. Harm Reduct J 2006;3:33.

http://www.harmreductionjournal.com/content/pdf/1477-7517-3-33.pdf

 

Very little is known about women who inject drugs in Bangladesh but anecdotal evidence suggests that they are hidden and very vulnerable to HIV through both their injection sharing and sexual risk behaviours. Azim and colleagues determined HIV prevalence and risk behaviours among women who inject drugs (those who had injected in the last six months and were 15 years or older) identified from three cities in the Dhaka region. Of the 130 women who inject drugs enrolled, 82 were sex workers and 48 were non-sex workers. None had HIV but more sex workers (60%) had lifetime syphilis than non-sex workers (37%). Fewer sex workers than non-sex workers lived with families (54.9% and 81.3% respectively), but more reported lending used needles/syringes to others (29.3% and 14.6% respectively) and using non-sterile injection paraphernalia (74.4% and 56.3% respectively) in the past six months. Although more sex workers used condoms during last sex than non-sex workers (74.4% and 43.3% respectively), more reported anal sex (15.9% and 2.1% respectively) and serial sex with multiple partners (70.7% and 0% respectively). Lifetime sexual violence and being jailed in the last year was more common in sex workers. The authors conclude female injecting drug users are vulnerable to HIV through their injection and sexual risk behaviours and sex workers who use drugs appear especially vulnerable. Services such as needle exchange programmes should become more comprehensive to address the needs of women who inject drugs.

Editors’ note: Little appears to have changed in Bangladesh since the country wide behavioural mapping of both sex workers and drug users by a team led by Carol Jenkins several years ago.

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People who inject Drugs

Booth RE, Kwiatkowski CF, Brewster JT, Sinitsyna L, Dvoryak S. Predictors of HIV sero-status among drug injectors at three Ukraine sites. AIDS 2006 14;20:2217-23.

Booth and colleagues assessed the HIV sero-status of people who inject drugs in Ukraine, as well as associations between sero-status and selected demographic and risk factors. People who inject drugs were recruited from the streets in Kiev, Odessa and Makeevka/Donesk, and interviewed using an HIV risk behaviour assessment and tested for HIV with a finger-stick rapid test. Of the 891 people who inject drugs surveyed, one-third came from each site and 22% were women. Their mean age was 29 years and on average they had been injecting for slightly more than 10 years. Seven hundred and seventy-eight of the total sample did not know their HIV status when first interviewed. Of these, 33% tested positive for HIV, including 34% in Kiev, 51% in Odessa and 17% in Makeevka/Donesk. Independent predictors of HIV included injecting a sedative/opiate mixture, female sex, having sex with a person who was HIV positive or whose HIV status was unknown and injecting daily. HIV-negative people who inject drugs were significantly younger than those infected, they were more likely to be from Makeevka/Donesk and they were more likely to have been sexually active. The authors conclude that rates of HIV infection among people who inject drugs vary considerably across Ukraine, although even in the site with the lowest rate nearly one in five was infected. The extent of drug and sex-related risk behaviours calls for programmes to reduce the spread of HIV and other infectious diseases.

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Substance abuse

Copenhaver MM, Johnson BT, Lee IC, Harman JJ, Carey MP; SHARP Research Team. Behavioral HIV risk reduction among people who inject drugs: Meta-analytic evidence of efficacy. J Subst Abuse Treat 2006;31:163-71.

Copenhaver conducted a meta-analysis of randomised controlled trials to evaluate behavioural HIV risk reduction interventions targeting people who inject drugs. The authors included 37 trials evaluating 49 independent HIV risk reduction interventions with 10,190 participants. Compared to people in the control arm, participants in the intervention arm reduced injecting drug use and other drug use, increased drug treatment entry, increased condom use, and decreased trading sex for drugs. Interventions were more successful at reducing injecting when participants were non-Caucasians, when content focused equivalently on drug-related and sex-related risks, and when content included interpersonal skills training specific for safer needle use. Condom use outcomes improved when two intervention facilitators were used instead of one. Injecting drug use outcomes did not decay, but condom use outcomes did. The authors conclude that behavioural interventions reduce risk behaviours among people who inject drugs, especially when interventions target both drug risk and sexual risk behaviours, and when they include certain behavioural skills components.

Editors’ note: Although UNAIDS recommends avoidance of the term ‘intervention’ [1]because it conveys “doing something to someone or something” and as such undermines the concept of participatory approaches, in the context of clinical trials the term ‘intervention’ is appropriate because of the very nature of clinical trials. The results of this meta-analysis highlight the effectiveness of interpersonal skills training and suggest the need for booster sessions to address emergent challenges and maintain behaviour change.


Strathdee SA, Stachowiak JA, Todd CS, Al-Delaimy WK, Wiebel W, Hankins C, Patterson TL. Complex Complex Emergencies, HIV, and Substance Use: No "Big Easy" Solution. Subst Use Misuse. 2006;41(10):1637-51.Although it is widely recognized that complex emergencies create any number of intense hardships such as enormous death tolls, injuries, communicable diseases, famine, homelessness, displacement, unemployment, psychological traumas, and rape, only in recent years has increased drug use been recognized as a potential consequence of some complex emergencies. Substance use can quickly reach epidemic proportions in various settings in response to posttraumatic stress, severe disruption of socioeconomic situations, or prolonged instability or hardships within societies and governments. Increased substance use can also be exacerbated by changing market factors such as the sudden availability of illicit drugs in societies with previously limited exposure and the decreased purity or increased price of opiates, which can inadvertently lead to transitions from smoking, snorting, or inhalation to injecting, which is a more efficient route of drug administration. Furthermore, armed conflicts and other complex emergencies may have direct and indirect effects on HIV transmission both locally and in surrounding countries, both directly through effects on the dynamics of HIV transmission and indirectly through reallocation of public funds away from HIV prevention and treatment toward security and defence. In this commentary, Strathdee and colleagues provide illustrations of complex emergencies—most witnessed firsthand in five distinct settings and situations: the period following the fall of the Iron Curtain in Russia, ongoing armed conflicts in Afghanistan, Iraq, and parts of Africa, and the tsunami in Aceh, Indonesia. The juxtaposition of these circumstances provides important lessons for the prevention of both substance use, misuse, and HIV infection in developing and developed countries and helps conceptualize how destabilizing forces can contribute to drug use and HIV transmission.

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Injecting Drug Use

Irwin K, Karchevsky E, et al. Secondary syringe exchange as a model for HIV prevention programmes in the Russian Federation. Subst Use Misuse 2006;41:979-99.

Effective prevention of syringe-borne transmission of HIV and hepatitis viruses can be undermined if contact between injection drug users and the staff of prevention programmes is impeded by police harassment, limited programme resources, and the absence of an open "drug scene." Irwin and colleagues say that all these are commonplace in the Russian Federation. In response, "Project Renewal," the harm reduction programme of the AIDS Prevention and Control Center of the Tatarstan Ministry of Health in Kazan, has created a hybrid syringe exchange programme that, as its primary focus, has recruited and trained volunteers to provide secondary syringe exchange. To compensate for operational barriers, the programme staff identified private venues and trained responsible individuals to work through their own and related networks of injectors to provide clean syringes, other harm reduction supplies, and educational materials, while facilitating the collection and removal of used and potentially contaminated syringes. Programme staff developed a detailed set of tracking instruments to monitor, on a daily and weekly basis, the locations and types of contacts and the dissemination of trainings and materials to ensure that the secondary distribution network reaches its target audience. Data collected and analysed by Irwin and colleagues show that these secondary exchange sites have proven more productive than the primary mobile and fixed-site syringe exchanges in Kazan. Beginning in 2001, Project Renewal has trained other harm reduction programmes in the Russian Federation to use this model of reaching injectors, identifying and training volunteers, and monitoring results of secondary syringe exchange.

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Injection Drug Use

Vickerman P, Hickman M, et al. Model projections on the required coverage of syringe distribution to prevent HIV epidemics among injecting drug users. J Acquir Immune Defic Syndr 2006;42:355-61.http://gateway.ut.ovid.com/gw2/ovidweb.cgi

Although syringe distribution is effective in preventing HIV transmission among injecting drug users (IDUs), there is little evidence on the required coverage to substantially reduce HIV transmission. Vickerman and colleagues developed a mathematical model to explore the relationship between endemic HIV prevalence among IDUs and the coverage of syringe distribution. They used data from IDU populations in the UK and Belarus to explore the implications of increasing coverage and the effect of changes in other behaviours. Their projections suggest that there is a coverage threshold, which, if reached, could lead to substantial decreases in HIV prevalence. The threshold largely depends on the frequency that IDUs inject and (safely) reuse their syringes, and corresponds to less than 4 syringe-sharing events per IDU per month. Other factors, such as the injecting cessation rate and efficacy of syringe cleaning, only have substantial impact near threshold coverage levels. Vickerman and colleagues conclude that their results support a policy of increasing the coverage of syringe distribution but highlight the difficulty in producing a universal coverage target. They continue by saying that great public health benefit could be conferred by encouraging the safe reuse of an IDU's own syringes and small stable injecting groups, and that policies which discourage this will negate the impact of syringe distribution interventions.

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Injecting Drug Use

de la Fuente L, et al. Injecting and HIV prevalence among young heroin users in three Spanish cities and their association with the delayed implementation of harm reduction programmes. J Epidemiol Community Health 2006;60:537-42. http://jech.bmjjournals.com/cgi/content/full/60/6/537

The authors conducted two cross sectional surveys to evaluate changes in the prevalence of HIV infection among young heroin users in three Spanish cities, and their association with harm reduction programmes (HRPs). The 1995 study included 596 users; half were street recruited and half were recruited at drug treatment centres. The 2001-2003 study included 981 street recruited users. Face to face interviews were conducted using a structured questionnaire. Samples for HIV testing (saliva in 1995 and dried blood spot in 2001-2003) were collected. The proportion who had ever injected (IDUs) decreased in all three cities. HIV prevalence in IDUs decreased by half in Barcelona (44.1% to 20.8%) and Seville (44.2% to 22.2%), but remained constant in Madrid (36.8% and 34.9%). This difference was attributable to a decrease in HIV prevalence among long-term IDUs in Barcelona and Seville, but not in Madrid. The crude odds ratio for HIV prevalence in Madrid compared with Barcelona in long-term IDUs was 2.3 (95%CI 1.4-3.7), increasing to 3.1 (95%CI 1.5-6.2) after adjusting for socio-demographic and risk factors. HIV prevalence in short-term IDUs was similar in all cities. In 1992 Barcelona already had 20 heroin users in methadone maintenance programmes (MMPs) per 10,000 population aged 15-49 years; Seville reached this rate in 1994, and Madrid not until 1998. The authors conclude that the delayed implementation of HRPs, especially MMPs, may explain why HIV prevalence did not decrease in long term injectors in Madrid. This finding should shed light on decision making in countries in a similar epidemiological and sociological situation.


Rockwell R, Joseph H, Friedman SR. New York City Injection Drug Users' Memories of Syringe-Sharing Patterns and Changes During the Peak of the HIV/AIDS Epidemic. AIDS Behav 2006 May 18; [Epub ahead of print]. http://www.springerlink.com/(3sii0b55cifjhefoechbvyfv)/app/home/issue.asp?referrer=parent&backto=journal,1,40;linkingpublicationresults,1:104828,1

Rockwell and colleagues interviewed 23 injecting drug users (IDUs) in New York about the mid-1970s to mid-1980s when they could not legally purchase or possess syringes, and the threat of AIDS began to loom large. Several themes emerged, including: abrupt changes in syringe-sharing patterns; the effects of illnesses or deaths of others on their understanding of AIDS; and, racial/ethnic differences in responses to the threat of AIDS. Settings, such as "shooting galleries," helped HIV spread rapidly in the earliest stages of the city's AIDS epidemic. HIV entered the drug scene in the mid-1970s, just when IDUs were shifting from sharing homemade "works" (consisting of steel needles and syringes devised from rubber baby pacifiers and similar sources) among many IDUs to mass produced and distributed plastic, disposable needle and syringe sets. IDUs remember when they first became aware of AIDS and began to adjust their behaviours and social assumptions.

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