Articles tagged as "Prevent HIV among drug users"

Why get tested for HIV in Russia?

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

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

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

Abstract access 

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

Asia, Europe
Russian Federation
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Large multi-centre study finds few differences between mortality in migrant and native populations in western Europe

Mortality in migrants living with HIV in western Europe (1997-2013): a collaborative cohort study.

Migrants Working Group on behalf of COHERE in EuroCoord. Lancet HIV. 2015 Dec;2(12):e540-9. doi: 10.1016/S2352-3018(15)00203-9. Epub 2015 Nov 18.

Background: Many migrants face adverse socioeconomic conditions and barriers to health services that can impair timely HIV diagnosis and access to life-saving treatments. We aimed to assess the differences in overall mortality by geographical origin in HIV-positive men and women using data from COHERE, a large European collaboration of HIV cohorts from 1997 to 2013.

Methods: In this observational cohort study, we included HIV-positive, antiretroviral-naive people accessing care in western Europe from COHERE. Individuals were eligible if enrolled in a cohort that collected information on geographical origin or ethnic origin from Jan 1, 1997, to March 19, 2013, aged 18-75 years, they had available information about sex, they were not infected perinatally or after the receipt of clotting factor concentrates, and were naive to combination antiretroviral therapy at cohort entry. Migrants' origins were grouped into seven regions: western Europe and similar countries (Australia, Canada, New Zealand, and the USA); eastern Europe; North Africa and the Middle East; sub-Saharan Africa; Latin America; the Caribbean; and Asia and the rest of Oceania (excluding Australia and New Zealand). Crude and adjusted mortality rate ratios were calculated by use of Poisson regression stratified by sex, comparing each group with the native population. Multiple imputation with chained equations was used to account for missing values.

Findings: Between Oct 25, 1979, and March 19, 2013, we recruited 279 659 individuals to the COHERE collaboration in EuroCoord. Of these 123 344 men and 45 877 women met the inclusion criteria. Our data suggested effect modification by transmission route (pinteraction=0.12 for men; pinteraction=0.002 for women). No significant difference in mortality was identified by geographical origin in men who have sex with men. In heterosexual populations, most migrant men had mortality lower than or equal to that of native men, whereas no group of migrant women had mortality lower than that in native women. High mortality was identified in heterosexual men from Latin America (rate ratio [RR] 1.46, 95% CI 1.00-2.12, p=0.049) and heterosexual women from the Caribbean (1.48, 1.29-1.70, p<0.0001). Compared with that in the native population, mortality in injecting drug users was similar or low for all migrant groups.

Interpretation: Characteristics of and risks faced by migrant populations with HIV differ for men and women and for populations infected heterosexually, by sex between men, or by injecting drug use. Further research is needed to understand how inequalities are generated and maintained for the groups with higher mortality identified in this study.

Abstract access 

Editor’s notes: This topical analysis on migrant health from the large COHERE collaboration examined mortality in people living with HIV who are treatment-naïve and enrolling for care in 11 western European countries. Routinely collected data were analysed to explore differences in mortality by region of origin. Overall, few differences in mortality were seen between migrant and native populations, with a general trend of similar or lower mortality among migrants than native populations.  However, diversity within migrant groups even from the same region makes it challenging to interpret summary data. The authors provide interesting insights into these difficulties. For example, the reasons for migration are likely to result in different socio-economic conditions in the host country, but heterogeneity in mortality between sub-groups may be masked when looking at overall mortality in migrants compared with the native population. The authors discuss both the “healthy migrant effect” (the fact that it is often healthier, younger populations who are able to migrate), and the “salmon bias” (the fact people who are ill often return to their place of origin). Both of these effects can lead to an observed lower disease burden in migrants than native populations. At a time when immigration is a hotly debated issue in western Europe this study highlights the challenges in assessing migrant health and the need for further empirical and methodological research in this area.

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

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

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

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

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

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

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

Abstract  Full-text [free] access

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

Asia
Afghanistan
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Awareness of HIV status and risk among key populations in India

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

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

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

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

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

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

Abstract access 

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

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

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

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

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

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

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

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

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

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

Abstract access 

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

Asia
Thailand
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Multiple harms faced by Azerbaijani prisoners

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

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

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

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

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

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

Abstract access 

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

Europe
Azerbaijan
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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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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.

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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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