Articles tagged as "Prevent HIV among drug users"

Harm reduction services in Tehran: uptake and barriers

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

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

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

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

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

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

Abstract access 

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

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

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

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

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

 Abstract access 

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

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

Asia
Iran (Islamic Republic of)
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Predicting the impact of treatment as prevention for people who inject drugs

Treatment as prevention among injecting drug users; extrapolating from the Amsterdam cohort study.

de Vos AS, Prins M, Coutinho RA, van der Helm JJ, Kretzschmar ME. AIDS 2014 Jan 7. [Epub ahead of print]

Objective: To determine the potential of treatment as prevention for reducing HIV incidence among injecting drug users (IDU).

Methods: Transmission dynamics of HIV as influenced by cART uptake and demographic changes were studied using an individual-based model. Parameters were based on data of the Amsterdam Cohort Study, and counterfactual treatment scenarios were examined for this city. Demography of the modeled population was also varied to allow for more general conclusions.

Results: We estimated that over the complete HIV epidemic among IDU in Amsterdam the historic use of cART has led to only 2% less incidence. As individuals were treated from low CD4-counts, their decreased infectiousness was offset by increased infectious lifetime. Large reduction in incidence could result from a test and immediate treat strategy, with elimination of HIV occurring when the average time from infection to starting treatment was less than 2 months. However, substantial proportions of new infections were prevented only if the test and treat intervention was implemented within the first few years after HIV-epidemic onset, especially for a declining IDU population. Ignoring heterogeneity in risk-behavior led to overly optimistic expectations of the prevention effects of treatment. In general, treatment led to much greater reduction in incidence compared with stopping HIV+ IDU from lending out syringes.

Conclusion: A test and immediate treat strategy for HIV among IDU could lead to great reductions in incidence. To fully eliminate the spread of HIV, treatment as prevention should be combined with other interventions, with behavioral intervention directed at those not yet HIV infected.

Abstract access 

Editor’s notes: Treatment as prevention has been shown to substantially reduce the risk of sexual HIV transmission, and modelling has been used to estimate the impact of treatment as prevention in epidemics driven by sexual spread. Much less attention has been paid to the potential for treatment as prevention to reduce transmission amongst people who inject drugs, who account for 10% of people living with HIV globally. In this modelling study, the authors use a mathematical model of HIV transmission amongst people who inject drugs in Amsterdam to estimate the impact that treatment has had in this setting. The authors then estimate the impact that different testing and treatment strategies could have had in this setting and in other settings with increasing or stable populations of people who inject drugs. Their findings suggest that treatment has had little impact on incidence among people who inject drugs in Amsterdam.  This was partly due to late treatment, declining HIV prevalence and a declining population of people who inject drugs. They find that more frequent testing, coupled with earlier treatment could have a large impact if it is introduced soon after the introduction of HIV into populations of people who inject drugs, particularly if the population is stable or increasing in size. This could be relevant in places where injecting drug use is becoming more common, or in settings where HIV has only recently begun to be spread through injecting drug use. The authors do highlight however, that treatment as prevention alone is unlikely to lead to elimination of HIV, and that harm reduction strategies remain important.     

Europe
Netherlands
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Female sex work in Central Asia: a neglected population for research and intervention

HIV among female sex workers in the Central Asian Republics, Afghanistan, and Mongolia: contexts and convergence with drug use.

Baral S, Todd CS, Aumakhan B, Lloyd J, Delegchoimbol A, Sabin K. Drug Alcohol Depend. 2013 Nov;132 Suppl 1:S13-6. doi: 10.1016/j.drugalcdep.2013.07.004. Epub 2013 Aug 14.

Background: Central Asia is culturally and demographically diverse, both between and within its respective countries. That diversity is represented in the range of individual, network, community, and structural risks for female sex workers (FSWs) regionally. FSWs have several risk factors for HIV acquisition and transmission including behavioral, biological, and structural risk factors. Across Central Asia, sexual risks have become conflated with risks associated with injection and non-injection illicit drug use.

Methods: Peer-reviewed literature databases and gray literature were searched for articles on sex work in Central Asia. The medical subject heading (MeSH) of "sex work" was cross-referenced with terms associated with Uzbekistan, Tajikistan, Turkmenistan, Kazakhstan, Kyrgyzstan, Mongolia, and Afghanistan.

Results: HIV prevalence data for FSWs suggest sustained or increasing prevalence in the region. There are increasing data directly linking HIV among FSWs to injection drug use; odds of HIV are up to 20 times higher among FSWs reporting injecting drug use. Though injecting drug use among FSWs is rare in some settings, recreational drugs and alcohol use limits other risk reduction behaviors, such as condom use.

Conclusions: The Central Asian HIV epidemic has traditionally been assumed to be driven nearly exclusively by drug use, resulting in surveillance systems focused on parenteral transmission. The reviewed data highlight limited attention to characterizing the burden of HIV and risk factors for HIV acquisition and transmission among FSWs who use drugs. Moving forward will require enhanced HIV surveillance and research to inform HIV prevention approaches to address all levels of HIV risks affecting FSWs in Central Asia.

Abstract access 

Editor’s notes: This paper summarises available data on HIV prevalence among female sex workers in Central Asia. The many gaps in information are striking – with data on HIV prevalence being available for only three of the seven countries reviewed, data on HIV among injecting female sex workers (FSW) available from three countries, and data on HIV among non-injecting female sex workers being available from one country only. The most detailed data came from Kyrgyzstan, where, as would be expected, injecting female sex workers were at greatest risk of HIV, and also had very high levels of hepatitis C infection. The findings highlight the need to expand surveillance systems in the region. Doing so will lead to better geographical coverage, and also to obtain more routinely compiled information on the extent of sex work and the prevalence of HIV infection among injecting and non-injecting sex workers. The high risk of HIV and hepatitis C infection among injecting FSW highlight also the importance of programmes for sex workers who inject drugs.   

Asia
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Needle syringe programmes are effective structural interventions

Effectiveness of Structural-Level Needle/Syringe Programs to Reduce HCV and HIV Infection Among People Who Inject Drugs: A Systematic Review.

Abdul-Quader AS, Feelemyer J, Modi S, Stein ES, Briceno A, Semaan S, Horvath T, Kennedy GE, Des Jarlais DC. AIDS Behav. 2013 Aug 22. [Epub ahead of print]

Needle-syringe programs (NSP) have been effective in reducing HIV and hepatitis C (HCV) infection among people who inject drugs (PWID). Achieving sustainable reductions in these blood-borne infections requires addressing structural factors so PWID can legally access NSP services. Systematic literature searches collected information on NSP coverage and changes in HIV or HCV infection prevalence or incidence at the population level. Included studies had to document biomarkers (HIV or HCV) coupled with structural-level NSP, defined by a minimum 50% coverage of PWID and distribution of 10 or more needles/syringe per PWID per year. Fifteen studies reported structural-level NSP and changes in HIV or HCV infection prevalence/incidence. Nine reported decreases in HIV prevalence, six in HCV infection prevalence, and three reported decreases in HIV incidence. The results support NSP as a structural-level intervention to reduce population-level infection and implementation of NSP for prevention and treatment of HIV and HCV infection.

Abstract access

Editor’s notes: Injection drug use is one of the most efficient modes of transmission of human immunodeficiency virus (HIV), hepatitis C (HCV), and other blood-borne diseases. There are an estimated 16 million people who inject drugs (PWID) worldwide, of whom approximately 3 million are estimated to be HIV-positive. Structural interventions focus on contextual or environmental factors that influence risk behaviour, rather than characteristics of individuals who engage in risk behaviours. This paper reviewed evidence from studies that included interventions that evaluated changes in policies, laws and regulations in relation to access and availability of sterile injecting equipment, use of public funds for establishing structural level large-scale syringe access programmes (NSP), and distribution of sterile equipment at the population level. The findings highlight the importance of establishing structural-level large-scale syringe access programmes for HIV prevention, especially early in an epidemic among PWID.  Further, it emphasizes that significant public health benefits can be obtained even when at least 50% of the injecting population in a community receive at least 10 or more sterile syringes per year.

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Extensive liver fibrosis in HIV-Hepatitis C co-infected patients compared to HCV mono-infected patients

HIV, Age, and the Severity of Hepatitis C Virus–Related Liver Disease: A Cohort Study.

Kirk GD, Mehta SH, Astemborski J, Galai N, Washington J, Higgins Y, Balagopal A, Thomas DL. Ann Intern Med. 2013;158(9):658-666

Background: Persons with HIV infection have been reported to develop age-related diseases at younger ages than those without HIV. Whether this finding is related to HIV infection or failure to control for other risk factors is unknown.

Objective: To investigate whether persons with HIV infection develop hepatitis C virus (HCV)–related liver disease at younger ages than similar persons without HIV.

Design: Comparison of the severity of liver fibrosis by age among persons who have HCV with and without HIV followed concurrently in the same protocol.

Setting: Observational cohort from Baltimore, Maryland, participating in the ALIVE (AIDS Linked to the IntraVenous Experience) study.

Participants: 1176 current and former injection drug users with antibodies to HCV.

Measurements: Liver fibrosis assessed semiannually from 2006 to 2011 by elastography (FibroScan, Echosens, Paris, France) and using previously validated thresholds for clinically significant fibrosis and cirrhosis; concurrent assessment of medical history, alcohol and illicit drug use, HCV RNA levels, hepatitis B virus surface antigen level, body mass index, and (for those with HIV) CD4+ lymphocyte count and HIV RNA levels.

Results: Among 1176 participants with antibodies to HCV, the median age was 49 years and 34% were coinfected with HIV and HCV. Participants contributed 5634 valid liver fibrosis measurements. The prevalence of clinically significant fibrosis without cirrhosis (12.9% vs. 9.5%) and of cirrhosis (19.5% vs. 11.0%) was greater in persons coinfected with HIV and HCV than in those with only HCV (P < 0.001). Increasing age and HIV infection were independently associated with liver fibrosis, as were daily alcohol use, chronic hepatitis B virus infection, body mass index greater than 25 kg/m2, and greater plasma HCV RNA levels. When these factors were kept constant, persons with HIV had liver fibrosis measurements equal to those of persons without HIV, who were, on average, 9.2 years older.

Limitation: The process of liver fibrosis began before the study in most persons.

Conclusion: In this cohort, persons who have HCV with HIV have liver fibrosis stages similar to those without HIV who are nearly a decade older.

Abstract access 

Editor’s notes: Patients with HIV/HCV co-infection have markedly increased rates of liver disease, liver failure and death compared to patients with HCV mono-infection. Due to the shared routes of infection, HIV-infection is highly prevalent in individuals with HCV infection, and the co-infection rate of 34% seen in this study is typical of the reported US figures. Although ART has led to some improvement in outcomes, morbidity and mortality are still excessive in HIV/HCV co-infected patients. This is in part due to difficulties in initiating, adhering to, and managing the side effects of treatment, and also reflects increased exposures to other risk factors such as excessive alcohol use. This cohort study confirms the previously described findings of increased rates of liver fibrosis, with or without cirrhosis, in HIV/HCV co-infected patients compared to HCV mono-infected patients. This association remained highly significant even after careful adjustment for age and other factors associated with disease severity such as alcohol use, chronic hepatitis B infection, body-mass index and hepatitis C viral load. Within the subgroup of HIV/HCV co-infected individuals, the presence of clinically significant fibrosis was associated with lower CD4 cell counts and higher HIV viral loads, but interestingly not ART. These findings emphasize the importance of defining effective new treatment regimens for HCV in HIV co-infected individuals.

Northern America
United States of America
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Declines in HIV incidence and risk behaviours among drug users in Amsterdam

Drug Users in Amsterdam: Are They Still at Risk for HIV?

Nienke van der Knaap, Bart P. X. Grady, Maarten F. Schim van der Loeff, Titia Heijman, Arjen Speksnijder, Ronald Geskus, Maria Prins. PLoS One. 2013;8(3):e59125. doi: 10.1371/journal.pone.0059125. Epub 2013 Mar 18.

Background and Aims: To examine whether drug users (DU) in the Amsterdam Cohort Study (ACS) are still at risk for HIV, we studied trends in HIV incidence and injecting and sexual risk behaviour from 1986 to 2011.

Methods: The ACS is an open, prospective cohort study on HIV. Calendar time trends in HIV incidence were modelled using Poisson regression. Trends in risk behaviour were modelled via generalized estimating equations. In 2010, a screening for STI (chlamydia, gonorrhoea and syphilis) was performed. Determinants of unprotected sex were studied using logistic regression analysis.

Results: The HIV incidence among 1298 participants of the ACS with a total follow-up of 12,921 person-years (PY) declined from 6.0/100 PY (95% confidence interval [CI] 3.2–11.1) in 1986 to less than 1/100 PY from 1997 onwards. Both injection and sexual risk behaviour declined significantly over time. Out of 197 participants screened for STI in 2010–2011, median age 49 years (IQR 43–59), only 5 (2.5%) were diagnosed with an STI. In multivariable analysis, having a steady partner (aOR 4.1, 95% CI 1.6–10.5) was associated with unprotected sex. HIV-infected participants were less likely to report unprotected sex (aOR 0.07, 95% CI 0.02–0.37).

Conclusions: HIV incidence and injection risk behaviour declined from 1986 onwards. STI prevalence is low; unprotected sex is associated with steady partners and is less common among HIV-infected participants. These findings indicate a low transmission risk of HIV and STI, which suggests that DU do not play a significant role in the current spread of HIV in Amsterdam.

Abstract access   

Editor’s notes: Drug users are at high risk of HIV, both from the risk of HIV arising from sharing injecting paraphernalia, along with HIV risks from sexual behaviour – including the increased risk of unprotected sex associated with the use of cocaine and other stimulants, or if drug users work as commercial sex workers. Earlier research showed a decline in injecting risk behaviour up to 2005, but a remaining risk of HIV transmission from sexual risk behaviour. This analysis shows that risk from injecting has continued to decline. The prevalence of unprotected sex was substantial, but mainly associated with having a steady partner, and was less common in HIV-infected participants. Taken together, the findings indicate a low transmission risk of HIV and STI in this population cohort, and suggest that drug use no longer plays a significant role in the spread of HIV in Amsterdam. This is in contrast to the increasing levels of HIV infection among drug users in other Eastern European settings, and underscores the importance of effective harm reduction programmes for drug users.  

Europe
Netherlands
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Harm reduction among drug users dramatically reduces new HIV and Hepatitis C virus infections

Decline in incidence of HIV and Hepatitis C virus infection among injecting drug users in Amsterdam; evidence for harm reduction?

de Vos AS, van der Helm JJ, Matser A, Prins M, Kretzschmar ME. Addiction. 2013 Jan 24. doi: 10.1111/add.12125. [Epub ahead of print]

In Amsterdam HIV prevalence has nearly halved among injecting drug users since 1990. Hepatitis C Virus (HCV) prevalence also declined, HIV and HCV incidence dropped to nearly zero. The authors examined possible explanations for these time trends, among which the implementation of harm reduction measures aimed at reducing risk behavior of IDU. Individual-based modeling of the spread of HIV and HCV was used. Information about demographic parameters was obtained from the Amsterdam Cohort Study (ACS) among drug users. The model included changes in inflow of new IDU and death-rates over time, the latter dependent on age and time since HIV-seroconversion. Different scenarios of risk behavior were considered. Simulated HIV and HCV incidence and prevalence were compared with ACS data. Assuming harm reduction measures had led to strong decrease in risk-behavior over time improved the model fit (squared residuals decreased by 30%). Substantial incidence and HIV prevalence decline were reproduced by incorporating demographic changes in the model. In particular, lowered disease spread might be a result of depletion of high-risk IDU among those at risk for disease, and a decrease in the number of high-risk individuals in the population due to HIV-related mortality. Marked decreases in HIV and HCV in Amsterdam since 1990 could be partly due to harm reduction measures; however, they may also be largely attributable to changes in the IDU population. Future research aimed at quantifying the benefits of interventions should not neglect the impact of natural epidemic progression and demographic changes.

Abstract access 

Editor’s notes: This article from Amsterdam highlights the impressive information that HIV and HCV incidence has dropped nearly to zero among drug users. Modeling exercises indicate that it is a challenge to attribute the cause of these results, however clearly harm reduction measures have been widely implemented, beyond the level seen in many other countries where drug users are a key population at risk for HIV acquisition.

Europe
Netherlands
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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.

For abstract access click here. 

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.

For abstract access click here. 

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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