Attitudes toward HIV treatments influence unsafe sexual and injection practices among injecting drug users

OBJECTIVE: To determine if HIV treatment-related attitudes are associated with unprotected sex and needle sharing among HIV-seropositive and -seronegative injecting drug users (IDU) in Baltimore, Maryland. DESIGN AND METHODS: IDU participating in a cohort study seen between December 2000 and July 2001 completed an interviewer-administered questionnaire on attitudes toward HIV treatment and risk behaviors (593 HIV-seronegative, 338 HIV-seropositive), including: perceived HIV transmissibility through unprotected sex and needle sharing, and safer sex and injection fatigue. Logistic regression was used to examine the role of attitudinal factors on needle sharing and unsafe sex. RESULTS: Almost two-thirds of sexually active participants engaged in unprotected sex and approximately half of those injecting drugs shared needles. Among HIV-seropositive IDU, perception of reduced HIV transmissibility through unprotected sex was significantly associated with unprotected sex [adjusted odds ratio (AOR), 3.33; 95% confidence interval (CI), 1.05-10.55). Safer injection fatigue was independently associated with needle sharing among HIV-seropositive IDU (AOR, 6.55; 95% CI, 1.69-25.39). Among HIV-seronegative IDU, safer sex fatigue and safer injection fatigue were independently associated with unprotected sex (AOR, 3.12; 95% CI, 1.17-8.35) and needle sharing (AOR, 5.15; 95% CI, 2.33-11.37), respectively. CONCLUSION: Among HIV-seropositive IDU, perceiving that HIV treatments reduce HIV transmission was significantly associated with unprotected sex. Risk reduction fatigue was strongly associated with unsafe sexual and injection behaviors among HIV-seronegative individuals. HIV prevention interventions must consider the unintended impact of HIV treatments on attitudes and risk behaviors among IDU.     

Hepatitis C virus risk behaviors within the partnerships of young injecting drug users

Aims Young injection drug users (IDU) are at high risk for hepatitis C virus (HCV). We sought to determine whether perceiving one's injecting partner to be HCV positive was associated with decreased odds of engaging in receptive needle/syringe sharing (RNS) or ancillary equipment sharing (AES) with that partner. Design Cross sectional study. Setting 2003 to 2007 in San Francisco. Participants 212 young (under age 30) IDU who were HCV antibody negative reported on 492 injecting partnerships. Measurements Self‐reported RNS and AES within injecting partnerships. Findings RNS and AES (in the absence of RNS) occurred in 23% and 64% of injecting partnerships in the prior month. The odds of engaging in RNS were significantly lower for relationships in which the participant reported that his/her partner was HCV positive (odds ratio [OR] 0.49; 95% confidence interval [CI] 0.25–0.95). This association was attenuated when adjusted for reusing one's own needle/syringe (adjusted OR 0.57; 95% CI 0.28–1.15). The odds of engaging in AES were lower for participants who did not know the HCV status of their partner, only among non‐sexual partnerships (OR 0.47; 95% CI 0.29–0.76). Conclusions Because perceiving one's partner to be HCV positive was associated with decreased RNS, increased HCV testing and partner disclosure may be warranted. AES was common and was decreased only among non‐sexual partnerships in which the HCV status of the partner was not known. This suggests that interventions to reduce AES in young IDU must be widespread.     

Background demographics and risk behaviors of injecting drug users in Karachi, Pakistan.

OBJECTIVE: To find the prevalence of HIV infection and risk behaviors among injecting drug users (IDUs) in Karachi, Pakistan. DESIGN: A cross-sectional study of IDUs conducted in Karachi, Pakistan from February through June 1996. RESULTS: Of the 242 IDUs, 11 (4%) refused HIV testing. One (0.4%; 95% confidence interval (CI) = 0.37-0.48%) was HIV positive. All subjects were male. Over the past 6 months 47% had engaged in receptive needle sharing, 38% had perceived a change in their social network, 22% had had sexual intercourse, of whom only 7% always used condoms, and none had washed their needles with bleach. Younger age (28 vs. 31 years; p = 0.01), younger age at first injection (25 vs. 28 years; p = 0.001), fewer years of schooling (3 vs. 5 years; p = 0.001), lower monthly income (70 dollars vs. 80 dollars; p = 0.03), inhaling fumes of heroin from a foil in the year before injecting (OR = 4.8; CI = 2.2-10.3), injecting first time with heroin (OR = 3.6; CI = 1.2-12.6), having a temporary job (OR = 2.5; CI = 1.2-5.2), and a perceived change in one's social network (OR = 4.4; CI = 2.4-7.9) were all associated with receptive needle sharing. IDUs who knew about HIV spread through contaminated needles were less likely to share (OR = 0.4; CI 0.2-0.8). In the final logistic regression model receptive needle sharing was associated with inhaling of fumes of heroin on a foil in the year prior to injecting (adjusted OR = 5.6; CI = 2.6-12.0), a perceived change in one's social network (adjusted OR = 4.0; CI = 2.2-7.4), and inversely associated with age at first time of injection (beta = -0.07; p = 0.002). CONCLUSION: Background HIV prevalence was low among IDUs in Karachi despite high-risk behavior in 1996. In order to control HIV transmission among IDUs in Pakistan, continual HIV surveillance with well-coordinated and effective HIV risk reduction, and drug demand reduction programs need to be implemented among drug users.     

云南省美沙酮维持治疗门诊受治者共用针具的相关影响因素分析

目的了解云南省参与美沙酮维持治疗的吸毒人员共用针具的相关影响因素,为美沙酮受治人员进一步综合干预工作提供科学依据。方法采用项目设计并经预实验修正后的问卷进行现场调查,内容包括人口学特征、参与美沙酮维持治疗前后高危注射行为、共用针具高危影响因素,并进行个人深入访谈。结果共调查12个县美沙酮门诊1 935名维持治疗人员,HIV抗体阳性731人,阳性检出率为39.3%（731/1 860）。72.50%的受治人员治疗期间曾偷吸海洛因及其他毒品,在偷吸毒品人员中有69.14%的人是注射毒品,在注射毒品人员中有29.69%的人共用针具。共用针具的影响因素中,第一次注射吸毒的年龄越大,与他人共用针具的概率越低（OR值=0.831）;注射吸毒的频率低者不易与他人共用针具（OR值=0.254）。结论美沙酮治疗人群中仍然普遍存在偷吸现象和共用针具等高危行为,需在美沙酮门诊加强对注射吸毒年龄较小及频率较多的受治人员进行心理咨询,强化干预活动,以减少共用针具现象。     

Survey of risk behaviour and HIV prevalence in an English prison.

An anonymous, voluntary, linked cohort study was undertaken to determine the prevalence of HIV infection and identify risk factors for the spread of infection in an English prison. Three hundred and seventy-eight (68%) of the inmates participated. The HIV point prevalence was 0.26%. Injecting drug use (IDU) was the most significant HIV risk factor within 20% admitting IDU at any time, of whom 58% injected whilst in prison. Of those injecting in prison 73% shared needles. Two inmates admitted having sex with a male partner in prison. This study demonstrates that the potential exists in this setting for an outbreak of blood-borne virus infection; hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV infection. Injecting drug use and needle sharing represent the greatest risk.     

Correlates of HIV infection among young adult short-term injection drug users

OBJECTIVES: To identify risks associated with HIV infection among young adult short-term injection drug users. METHODS: Current injection drug users, between 18 and 29 years of age, were recruited through street outreach to participate in a cross-sectional survey of HIV prevalence by circumstances of drug injection initiation, HIV-related risk behaviors, and a follow-up to estimate HIV incidence. RESULTS: At enrollment, 33 (14.4%) of 229 participants were HIV-seropositive. Significant bivariate associations with HIV at the time injection drug use was initiated included age less than or equal to 18 years, having receptive anal sex with the person who assisted with initiation, and having two or more 'trainers' before being able to self-inject. Injecting risks positively associated with HIV included cocaine or speedball (heroin and cocaine together) injection versus heroin or amphetamine injection, injecting five or more times per day, daily crack smoking, backloading, sharing needles at peak drug use, and not using a new needle for every injection. Sexual practices associated with HIV included reporting > 100 lifetime sex partners, a history of sexual assault, being gay or bisexual, and trading sex for money or drugs after starting to inject. In a multivariate model, trading anal sex for money or drugs after initiating injection drug use [odds ratio (OR), 14.2; 95% confidence interval (CI) 3.2-62.3], cocaine/speedball injection (OR, 10.3; 95% CI, 2.2-47.9), daily crack smoking (OR, 4.2; 95% CI, 1.7-10.5), and having two or more trainers (OR, 2.6; 95% CI, 1.1 - 5.9) were independently associated with HIV. During 12 months of follow-up, four persons seroconverted for HIV (annual incidence: 2.6%; 95% CI, 1.1 -5.9%) CONCLUSIONS: Among short-term injectors, both sexual and injecting practices were important predictors of HIV infection, indicating that a proportion of HIV infections among young injection drug users can be attributed to sexual transmission. The incidence rate for HIV infection suggests that immediate steps should be taken to prevent new infections among young injection drug users.     

The STEP into Action study: a peer-based, personal risk network-focused HIV prevention intervention with injection drug users in Baltimore, Maryland

Aims To assess the effectiveness of a peer‐based, personal risk network‐focused HIV prevention intervention to (i) train injection drug users (IDUs) to reduce injection and sex risk behaviors, (ii) conduct outreach to behaviorally risky individuals in their personal social networks [called risk network members (RNM)], and (iii) reduce RNM HIV risk behaviors. Design Randomized controlled trial with prospective data collection at 6, 12 and 18 months. Intervention condition consisted of five group sessions, one individual session and one session with Index and the RNM. Setting This study was conducted in Baltimore, Maryland from March 2004 to March 2006. Participants (i) Index participants were aged ≥18 years and self‐reported injection drug use in the prior 6 months and (ii) their RNM who were aged ≥18 years and drug users or sex partners of Index. Measurements Outcomes included: (i) injection risk based on sharing needles, cookers and cotton for injection and drug splitting, (ii) sex risk based on number of sex partners, condom use and exchanging sex and (iii) Index HIV outreach behaviors. Findings A total of 227 Index participants recruited 336 RNM. Retention of Index at 18‐month follow‐up exceeded 85%. Findings suggest that the experimental condition was efficacious at 18 months in reducing Index participant injection risk [odds ratio (OR) = 0.38; 95% confidence interval (CI) = 0.18–0.77), drug‐splitting risk (OR = 0.46; 95% CI = 0.25–0.88) and sex risk among Index (OR = 0.53; 95% CI = 0.34–0.86). Significant intervention effect on increased condom use among female RNM was observed (OR = 0.34; 95% CI = 0.18–0.62). Conclusions Training active IDU to promote HIV prevention with behaviorally risky individuals in their networks is feasible, efficacious and sustainable.     

Hepatitis C virus among non‐injecting cocaine users (NICUs) in South America: can injectors be a bridge?

Aim To investigate the factors associated with hepatitis C virus (HCV) infection among non‐injecting cocaine users (NICUs) and to compare practices associated with HCV and HIV infection. Design An intercountry cross‐sectional study. Setting Buenos Aires and Montevideo metropolitan areas. Participants A total of 871 NICUs. Measurements NICUs were interviewed and their blood was drawn and used for HCV, HIV, HBV surface antigen (HbsAg), HB‐anticore and Venereal Disease Research Laboratory (VRDL) antibody assays. Bivariate and multivariate logistic regression analyses included comparisons of HCV and HIV mono‐infected participants with HCV–HIV seronegatives. Findings Prevalence rates were 8.8 [95% confidence interval (CI): 6.9–10.8) for HCV and 7.9 (95% CI: 6.1–9.7) for HIV. HCV‐infected NICUs were twice as likely as HCV–HIV seronegatives to have shared straws for cocaine snorting or sniffing, even when adjusted for other variables. HCV prevalence rates ranged from 3.6% among NICUs who denied sharing straws and having had an injection drug user (IDU) or an HIV‐positive sexual partner to 12.6% among participants who reported ever having shared straws or having had either an IDU‐ or HIV‐positive sexual partner (χ²_trend = 6.56, P = 0.01). Conclusions Non‐injecting cocaine users from South America are vulnerable to multiple infections and HCV infection appears to occur through the sharing of straws. HCV infection is associated with intimate relationships with IDUs or HIV‐seropositive partners, supporting the hypothesis that HCV risk may be due primarily to risk‐taking behaviour associated with drugs in this population.     

HIV prevalence among injection drug users in rural Guangxi China

AIMS: To determine the HIV-1 seroprevalence, risk behaviors and demographic characteristics associated with HIV-1 infection among injection drug users (IDU) in rural Guangxi, China. DESIGN AND SETTING: Between July and November 2002, 702 IDU were screened for HIV-1 antibody through community outreach in rural Guangxi, China for enrollment in an HIV sero-incidence study. PARTICIPANTS: A total of 702 active high-risk IDU were screened. High-risk injection was defined as anyone who reported injecting drugs at least three times per week in the last month or injected drugs with shared equipment on at least three occasions in the last 3 months. MEASUREMENTS: HIV-1 antibody testing with confirmation by Western blot was performed on all subjects. Demographic and risk assessment survey data were collected at screening from everyone whose baseline HIV antibody status was known. FINDINGS: HIV-1 antibody prevalence among 702 IDU at baseline was 25% with a median age of 26.7 years (18.2-43.2). Based on a multivariate logistic regression model using risk factors identified in univariate analyses, the following risk factors were associated significantly with an increase in risk for HIV seropositivity: age > 26 years (OR 1.50; 95% CI 1.04, 2.17), sharing of rinse water (OR = 1.24; 95% CI 1.09, 1.40), not having sex in the last 6 months (OR = 1.62; 95% CI 1.08, 2.43). CONCLUSIONS: HIV infection among IDU in Guangxi, one of China's major HIV epidemic regions, is high and the infection occurs predominantly among older IDU males who share rinse water.     

Does opioid substitution treatment in prisons reduce injecting‐related HIV risk behaviours? A systematic review

Objectives To review systematically the evidence on opioid substitution treatment (OST) in prisons in reducing injecting‐related human immunodeficiency virus (HIV) risk behaviours. Methods Systematic review in accordance with guidelines of the Cochrane Collaboration. Electronic databases were searched to identify studies of prison‐based opioid substitution treatment programmes that included assessment of effects of prison OST on injecting drug use, sharing of needles and syringes and HIV incidence. Published data were used to calculate risk ratios for outcomes of interest. Risk ratios were not pooled due to the low number of studies and differences in study designs. Results Five studies were included in the review. Poor follow‐up rates were reported in two studies, and representativeness of the sample was uncertain in the remaining three studies. Compared to inmates in control conditions, for treated inmates the risk of injecting drug use was reduced by 55–75% and risk of needle and syringe sharing was reduced by 47–73%. No study reported a direct effect of prison OST on HIV incidence. Conclusions There may be a role for OST in preventing HIV transmission in prisons, but methodologically rigorous research addressing this question specifically is required. OST should be implemented in prisons as part of comprehensive HIV prevention programmes that also provide condoms and sterile injecting and tattooing equipment.     

The impact of needle and syringe provision and opiate substitution therapy on the incidence of hepatitis C virus in injecting drug users: pooling of UK evidence

Aims To investigate whether opiate substitution therapy (OST) and needle and syringe programmes (NSP) can reduce hepatitis C virus (HCV) transmission among injecting drug users (IDUs). Design Meta‐analysis and pooled analysis, with logistic regression allowing adjustment for gender, injecting duration, crack injecting and homelessness. Setting Six UK sites (Birmingham, Bristol, Glasgow, Leeds, London and Wales), community recruitment. Participants A total of 2986 IDUs surveyed during 2001–09. Measurement Questionnaire responses were used to define intervention categories for OST (on OST or not) and high NSP coverage (≥100% versus <100% needles per injection). The primary outcome was new HCV infection, measured as antibody seroconversion at follow‐up or HCV antibody‐negative/RNA‐positive result in cross‐sectional surveys. Findings Preliminary meta‐analysis showed little evidence of heterogeneity between the studies on the effects of OST (I² = 48%, P = 0.09) and NSP (I² = 0%, P = 0.75), allowing data pooling. The analysis of both interventions included 919 subjects with 40 new HCV infections. Both receiving OST and high NSP coverage were associated with a reduction in new HCV infection [adjusted odds ratios (AORs) = 0.41, 95% confidence interval (CI): 0.21–0.82 and 0.48, 95% CI: 0.25–0.93, respectively]. Full harm reduction (on OST plus high NSP coverage) reduced the odds of new HCV infection by nearly 80% (AOR = 0.21, 95% CI: 0.08–0.52). Full harm reduction was associated with a reduction in self‐reported needle sharing by 48% (AOR 0.52, 95% CI: 0.32–0.83) and mean injecting frequency by 20.8 injections per month (95% CI: ?27.3 to ?14.4). Conclusions There is good evidence that uptake of opiate substitution therapy and high coverage of needle and syringe programmes can substantially reduce the risk of hepatitis C virus transmission among injecting drug users. Research is now required on whether the scaling‐up of intervention exposure can reduce and limit hepatitis C virus prevalence in this population.     

Drug Use, Increasing Incarceration Rates, and Prison-Associated HIV Risks in Thailand

Background: Incarceration is a known risk for HIV infection in Thai drug users. Through the 1990s, incarceration rates for drug-related offenses rose sharply, whereas HIV prevention and drug treatment in prisons remained limited. Methods: We assessed HIV and incarceration risks for injection drug users (IDU) and non-IDU in a large treatment center cohort in northern Thailand to investigate HIV and prison risks in this period. We used Thai Bureau of Corrections data to assess incarceration and prevention funds in prisons, 1992–2000. Results: Among 1,865 drug user in the treatment cohort, 503 (27.0%) had ever been jailed. Men (OR 3.3, 95% CI 2.1, 5.2), IDU (OR 6.3, 95% CI 5.1, 7.9), and men who have sex with men (MSM) (OR 3.4, 95% CI 1.8, 6.3) were more likely to have been jailed. Among male IDU who had ever been jailed (N = 272), 15.8% had used drugs in prison. In a multivariate model, incarceration and ever IDU remained independently associated with HIV infection; IDU, MSM behaviors, and harmful traditional practices remained independently associated with having been jailed. From 1992 to 2000, overall alleged narcotics offenses increased from 117,000 to 276,000/year. The number of persons incarcerated for narcotics offenses increased fivefold from 1992 to 1999, from 12,860 to 67,440. For FY 2000, narcotics treatment accounted for 0.06% of the Thai corrections budget, whereas HIV programs in prisons were 0.017%. Conclusions: Incarceration rates for narcotics offenses have increased sharply in Thailand, whereas prevention has lagged. Having been jailed is an important independent risk for HIV infection among Thai male drug users, especially IDU and MSM. HIV prevention and drug treatment are urgently needed in Thai prisons.     

针具交换结合同伴宣传对注射吸毒人群吸毒行为的影响

目的通过同伴宣传和针具交换项目减少吸毒者的共用注射器行为，降低吸毒人群中艾滋病病毒的传播流行。方法通过卫生工作人员和同伴宣传员向吸毒者提供清洁针具并回收污染针具，发放宣传折页，张贴宣传画以及对吸毒者进行面对面的宣传等措施，在广西壮族自治区某县注射吸毒者中开展了为期一年的针具交换和同伴宣传项目。在干预前后分别进行基线和终期横断面调查，通过对比两次调查中吸毒者自我报告的高危注射行为等变化情况对于预效果进行评估。结果基线调查205人，终期调查234人。终期调查时吸毒者的针具共用率、水和容器的共用率分别为30．34％、33．33％和11．54％，均显著地低于基线调查(分别为60．59％、62．69％和61．00％)；同基线调查相比，终期调查中吸毒者的每日注射毒品次数也显著减少。结论针具交换结合同伴宣传干预措施不仅能显著减少吸毒者对针具、清洗水和容器等的共用行为，还能有效降低吸毒者的针具共用频率，同时并不会增加吸毒者的毒品注射次数。     

Injection Drug Use in Rural Iran: Integrating HIV Prevention into Iran’s Rural Primary Health Care System

Major opium trafficking routes traverse rural Iran, but patterns of drug use and HIV infection in these areas are unknown. In 2004, Iran’s Ministry of Health integrated substance use treatment and HIV prevention into the rural primary health care system. Active opium or heroin users (N = 478) were enrolled in a rural clinic. Participants received counseling for abstinence from substances, or daily needle exchange and condoms. On enrollment, 108 (23%) reported injecting; of these, 79 (73%) reported sharing needles. Of 65 participants tested for HIV, 46 (72%) tested positive. Participants who received daily needle exchange/condoms stayed in the program longer than those who did not (AOR 2.08, 95% CI 1.1–3.88). This project demonstrates that HIV risks exist in rural Iran and suggests the innovative use of Iran’s rural health care system to extend prevention and treatment services to these populations.     

The Health of the Nation target on syringe sharing: a role for routine surveillance in assessing progress and targeting interventions

The Health of the Nation initiative in the United Kingdom includes a target aimed at reducing the proportion of current injecting drug users who share syringes. The PHLS Collaborative Survey of Salivary Antibodies to HIV and Hepatitis B core in injecting drug users is a comprehensive and national surveillance mechanism which routinely collects data that can be used to monitor progress toward this target. Nineteen per cent of injecting drug users (353/1876) in 1992 and 18% (375/2138) in 1993 shared previously used injecting equipment (difference of - 1.3%, 95% Cl – 3.7%, 1.1%). Only with further years of data collection will it be possible to tell if this decline represents a real change in behaviour. There was a substantial reduction in the proportion of sharers mho received previously used needles and syringes from more than one person, from 45% (138/305) in 1992 to 27% (81/298) in 1993 (fall of 18%, 95% Cl 11%, 26%). This decline could indicate a real reduction in risk behaviour thai is not reflected in the target. Monitoring this aspect of sharing could be an important supplementary measure. Women were more likely to have shared (adjusted OR = 1.87, 95% Cl 1.53, 2.28) and the likelihood of sharing declined with age (adjusted OR of each 5-year age band = 0.75, 95% Cl 0.72, 0.79). Particular attention should be given to interventions which aim to reduce sharing among women and young people. Clients of agencies at which the main service provided was syringe exchange were less likely to have shared than offenders of other types of agencies (adjusted OR = Q.69y 95% Cl 0.51, 0.93). This suggests that syringe exchange schemes play a role in reducing the transmission of HIV infection.     

女性静脉注射吸毒感染HIV危险因素的病例对照研究

目的探讨女性静脉注射吸毒（IDus）感染艾滋病病毒（HIv）的危险因素,为制定针对这一人群的干预措施提供理论依据。方法通过1：1配对50对女性IDUs病例对照研究,探索其感染HIV的危险因素。结果对各个变量进行单因素条件Logistic回归分析后发现,与HIV感染有显著相关的因素有：无固定居所、共用针具史、过去1年有多性伴或以性换钱／毒品、有HIV阳性固定性伴、有IDU性伴、有暴力虐待史、曾感染梅毒、认为自己有很大／一定感染HIV危险。HIV感染的危险因素为：有HIV阳性的固定性伴（OR=28．05;95％CI=2．34,335．67）,过去一年曾以性换钱鹰品（OR=5．89;95％CI=1．12,31．09）,以及无固定居所（OR=10．77;95％CI=1．21,96．06）。结论广东省的女性IDUs中,性行为较注射行为对于HIV传播更为危险,干预重点应该放在如何减少在吸毒情况下经性途径传播HIV的危险因素上。     

Female Gender and HIV Transmission Risk Behaviors Among People Living with HIV Who Have Ever Used Injection Drugs in St. Petersburg,Russia

Among persons who inject drugs, women have a higher HIV prevalence (than men) in many settings. Understanding how gender affects risk for infection among HIV-negative, and transmission among HIV-positive people who currently or previously injected drugs is key to designing effective prevention and treatment programs. We analyzed data from 291 persons living with HIV who had ever injected drugs. Participants were drawn from the Russia Alcohol Research Collaboration on HIV/AIDS cohort (2012–2015) to examine associations between female gender and HIV transmission risk. Primary outcomes were sharing drug injecting equipment (e.g., needle/syringes) and condomless sex. Secondary outcomes were alcohol use before sharing drug injecting equipment; before condomless sex; and both sharing drug injecting equipment and condomless sex. Logistic regression models assessed associations between gender and outcomes, controlling for demographics, partner HIV status and use of antiretroviral treatment. Female gender was not significantly associated with sharing drug injecting equipment [aOR?=?1.45, 95% confidence interval (CI) 0.85–2.46, p value?=?0.18] but was associated with condomless sex (aOR?=?1.91, 95% CI 1.12–3.23, p?=?0.02) in adjusted models. Female gender was not significantly associated with any secondary outcomes. Better understanding of risky sex and drug use behaviors among people who currently or previously injected drugs can support the design of effective gender-tailored HIV prevention interventions.     

Drug use contexts and HIV-consequences: the effect of drug policy on patterns of everyday drug use in Rotterdam and the Bronx

Epidemiological data on HIV seroprevalence has been essential in assessing the (future) extent of the AIDS epidemic. By coupling these data with quantifiable variables related to injection drug use (frequency of injecting, number of needle sharing partners) specific ‘risk behaviors’ could be determined, accounting for the rapid spread of the virus in the injecting drug user (IDU) population. Yet, such data give little information on the social mechanisms and setting generating such risk behaviors. In order to understand the transmission of HIV among the IDU population one needs to study the micro settings and social context of drug use. This paper describes and explores certain patterns of drug use, sharing, and natural support systems found amongst IDUs in two very different cities, Rotterdam (The Netherlands) and the Bronx, New York City (USA). By specifying details of the micro-settings of everyday drug use in both locales, it is possible to identify certain common elements and consequences of personal and social behavior driven by drug use per se (e.g. drug preference), and to differentiate these from behaviors and consequences determined by drug policy and the social context in which drug use actually occurs. These policies and the social context they create can in turn be shown to relate to risks for HIV transmission, e.g. the increased likelihood of sharing injection equipment. A more careful ethnographic approach, taking advantage of natural experimental opportunities, comparisons and controls, may be utilized to examine drug-related behaviors in their social context and to better assess their relevance to public health–especially to AIDS     

Do needle exchange programmes increase the spread of HIV among injection drug users?: an investigation of the Vancouver outbreak.

OBJECTIVE: An association between needle exchange attendance and higher HIV prevalence rates among injecting drug users (IDU) in Vancouver has been interpreted by some to suggest that needle exchange programmes (NEP) may exacerbate HIV spread. We investigated this observed association to determine whether needle exchange was causally associated with the spread of HIV. DESIGN AND METHOD: Prospective cohort study of 694 IDU recruited in the downtown eastside of Vancouver. Subjects were HIV-negative at the time of recruitment and had injected illicit drugs within the previous month. RESULTS: Of 694 subjects, the 15-month cumulative HIV incidence was significantly elevated in frequent NEP attendees (11.8+/-1.7 versus 6.2+/-1.5%; log-rank P = 0.012). Frequent attendees (one or more visits per week) were younger and were more likely to report: unstable housing and hotel living, the downtown eastside as their primary injecting site, frequent cocaine injection, sex trade involvement, injecting in 'shooting galleries', and incarceration within the previous 6 months. The Cox regression model predicted 48 seroconversions among frequent attendees; 47 were observed. Although significant proportions of subjects reported obtaining needles, swabs, water and bleach from the NEP, only five (0.7%) reported meeting new friends or people there. When asked where subjects had met their new sharing partners, only one out of 498 respondents cited the needle exchange. Paired analysis of risk variables at baseline and the first follow-up visit did not reveal any increase in risk behaviours among frequent attendees, regardless of whether they had initiated drug injection after establishment of the NEP. CONCLUSIONS: We found no evidence that this NEP is causally associated with HIV transmission. The observed association should not be cited as evidence that NEP may promote the spread of HIV. By attracting higher risk users, NEP may furnish a valuable opportunity to provide additional preventive/support services to these difficult-to-reach individuals.