Factors associated with injection cessation, relapse and initiation in a community-based cohort of injection drug users in Chennai, India

Aims To characterize factors associated with injection cessation, relapse and initiation. Design The Madras Injection Drug User and AIDS Cohort Study (MIDACS) is a prospective cohort of injection drug users (IDUs) recruited in 2005–06 with semi‐annual follow‐up to 2009. Discrete‐time survival models were used to characterize predictors of time to first injection cessation and relapse. Setting Chennai, India. Participants A total of 855 IDUs who reported injecting in the 6 months prior to baseline and had >1 follow‐up visit. Measurements Cessation was defined as the first visit where no injection drug use was reported (prior 6 months) and relapse as the first visit where drug injection (prior 6 months) was reported after first cessation. Findings All participants were male; median age was 35 years. Over 3 years, 92.7% reported cessation [incidence rate (IR): 117 per 100 person‐years]. Factors associated positively with cessation included daily injection and incarceration and factors associated negatively with cessation included marriage, alcohol and homelessness. Of those who reported cessation, 23.6% relapsed (IR: 19.7 per 100 person‐years). Factors associated positively with relapse included any education, injection in the month prior to baseline, sex with a casual partner, non‐injection drug use, incarceration and homelessness. Alcohol was associated negatively with relapse. The primary reasons for cessation were medical conditions (37%) and family pressure (22%). The majority initiated with non‐injection drugs, transitioning to injection after a median 4 years. Conclusions Injection drug users in southern India demonstrate a high rate of injection cessation over 3 years, but relapse is not uncommon. Compensatory increases in alcohol use indicate that cessation of injection does not mean cessation of all substance use. Family pressure, concerns about general health, fear of human immunodeficiency virus infection and a history of non‐injection drug use are important correlates of cessation.     

Illicit drug initiation among institutionalized drug users in China

Aims To examine the circumstances and correlates associated with initiation of illicit drug use among institutionalized drug users in China. Design Cross‐sectional, retrospective study. Settings Six compulsory drug cessation programs in Yunnan Province and Gunagxi Zhuang Autonomous Region of China. Participants A gender‐stratified random sample of 833 drug users (88% males and 12% females) enrolled in compulsory drug cessation programs in November 1996. Measurements Circumstances of illicit drug initiation (age, type of drugs, routes of drug administration, social setting, source of drugs, reasons for drug use), the risk behaviors and risk perceptions prior to drug initiation. Findings The majority of participants initiated drug use with heroin (90%). Initial drugs were frequently administered through sniffing/snorting (55%) and smoking cigarettes mixed with a drug (38%). First drug use occurred most commonly at a friend’s home (65%) and in the company of other drug users (83%). Drugs were generally provided free for first‐time use by other drug users (72%). Reasons for first drug use included experimentation (90%), being lured into drugs by other people (44%) and relaxation (42%). Most drug users had a history of regular cigarette smoking (89%), alcohol consumption (49%) and deviant behaviors (51%) prior to their drug initiation. The majority perceived that their friends (90%) and neighbors (88%) used illicit drugs. Conclusions The findings are similar to studies in western countries with respect to the pattern and correlates of illicit drug initiation, and underscore the need for drug prevention efforts in China.     

Some characteristics of early-onset injection drug users prior to and at the time of their first injection

AIMS: This paper examines differences between early- and late-onset injection drug users (12-16 years versus 17-24 years) in terms of the antecedents and circumstances of first injection. DESIGN: Cross-sectional retrospective design, using logistic regression. Setting Australia: Sydney, Brisbane, rural New South Wales. PARTICIPANTS: A total of 336 injection drug users aged 16-25 years at the time of interview. MEASUREMENTS: Independent variables included family injection drug use, homelessness and other demographic variables, drugs used prior to the first injection, length of pre-injection drug career, behaviours at time of first injection (e.g. drug injected, reasons/motives for the first injection, risk behaviours). FINDINGS: Early-onset injection was associated independently with: having a family who injected drugs, having left school early, an unreliable source of income, a short pre-injection drug career, planning of the first injection, reliance on others for administration of the first injection and denial that experimentation was the motive for the first injection. In bivariate analysis, early-onset injection was associated further with: homelessness, being an Indigenous Australian, omission of use of certain pre-injection drugs, group presence at first injection, reliance on others for acquisition of the first needle and syringe and having injected the first time because an injection was offered. CONCLUSIONS: The research shows that early-onset, compared with late-onset injectors, are more likely to have an immediate family who inject drugs and other problematic beginnings in early life. They have an accelerated transition to injection, and differences in autonomy and motivation at first injection. These characteristics may make them more vulnerable to risk taking.     

Initiation of Warfarin Therapy: Recommendations and Clinical Pearls

Warfarin is a commonly used medication with a narrow therapeutic index. The initiation of warfarin requires consideration of a variety of factors, which include reviewing the indications and contraindications for this agent, performing a thorough clinical assessment along with a risk-benefit analysis for anticoagulation, consideration of warfarin pharmacology, developing strategies to monitor the intensity of anticoagulation and for the detection of adverse events, and education of the patient. The process of warfarin initiation has been studied by many researchers, but much of this literature has not been employed in clinical practice. This article presents a strategy for the clinician to use when initiating patients on warfarin.     

Factors Associated with Public Injecting Among Users of Vancouver's Supervised Injection Facility

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

Employment Among Users of a Medically Supervised Safer Injection Facility

A supervised injection facility (SIF), where individuals can inject drugs under medical supervision, opened in Vancouver in 2003. The scientific evaluation of the SIF has demonstrated positive public health-related outcomes. However, the influence of supervised injection facilities on individual efforts to reintegrate into mainstream society has not been studied. We examined for a possible relationship between use of the SIF and employment among a cohort of 1090 SIF users using generalized estimating equations (GEE). In a multivariate analysis of factors associated with employment, using the SIF for ≥ 25% of injections (versus > 25% of injections) was not statistically significant (AOR = 1.05, 95% CI: 0.88–1.27). These findings suggest that the SIF is not having an adverse impact on efforts to seek employment.     

Delayed progression to AIDS in volunteers treated with long-term HIV-1 Immunogen (REMUNE) therapy in Thailand

OBJECTIVES: To observe the long-term effects of an immune-based therapy HIV-1 Immunogen (REMUNE; Immune Response Corp., Carlsbad, CA, USA) as a first course of treatment designed to sustain the immune system and thus delay the initiation of therapy with antiretroviral drugs and/or delay disease progression. METHODS: In this open-label, multi-institute extended phase II P2101B study, disease progression, CD4 and CD8 T-cell counts, HIV-1 RNA levels, and genotypic antiretroviral drug resistance were examined in 223 asymptomatic HIV-1-infected Thai volunteers receiving REMUNE every 12 weeks over 132 weeks. A subset of subjects was randomly selected by the physicians to receive antiretroviral drugs for 10 months. RESULTS: Patients treated with REMUNE demonstrated a low rate of clinical disease progression (0.72 per 100 person-years), higher CD4 and CD8 T-cell counts, higher body weight before and after treatment in the same patient, and stable viral load with no serious adverse events. We found no genotypic evidence of drug resistance in subgroups of patients on REMUNE monotherapy or REMUNE plus antiretrovirals (ARTs). CONCLUSIONS: This Thai study, like previous US and European studies, confirms that therapeutic immunization of HIV-infected volunteers modifies disease progression, as evidenced by stabilization of CD4 and CD8 T-cell counts, body weight, and viral load. As the majority of asymptomatic patients demonstrated an objective response to immunization, this study suggests that REMUNE may be utilized prior to initiation of antiviral drug therapy when CD4 cell counts are still above the current ART guidelines. Further work should be carried out to examine its potential use in combination with ART in order to reduce the increasingly common occurrence of drug resistance.     

Incarceration and drug use patterns among a cohort of injection drug users

Aims   Drug law enforcement remains the dominant response to drug-related harm. However, the impact of incarceration on deterring drug use remains under-evaluated. We sought to explore the relationship between incarceration and patterns of drug use among people who inject drugs (IDU).
Design   Using generalized estimating equations (GEE), we examined the prevalence and correlates of injection cessation among participants in the Vancouver Injection Drug User Study followed over 9 years. In subanalyses, we used McNemar's tests and linear growth curve analyses to assess changes in drug use patterns before and after a period of incarceration among participants reporting incarceration and those not incarcerated.
Findings   Among 1603 IDU, 842 (53%) reported injection cessation for at least 6 months at some point during follow-up. In multivariate GEE analyses, recent incarceration was associated negatively with injection cessation [adjusted odds ratio (AOR) = 0.43, 95% confidence interval (CI) 0.37–0.50], whereas the use of methadone was associated positively with cessation (AOR = 1.38, 95% CI 1.22–1.56). In subanalyses assessing longitudinal patterns of drug use among incarcerated individuals and those not incarcerated over the study period, linear growth curve analyses indicated that there were no statistically significant differences in patterns of drug use between the two groups (all P  > 0.05).
Conclusions   These observational data suggest that incarceration does not reduce drug use among IDU. Incarceration may inhibit access to mechanisms that promote injection cessation among IDU. In contrast, results indicate that methadone use is associated positively with injection cessation, independent of previous frequency of drug use.     

Drug Sharing Among Heroin Networks: Implications for HIV and Hepatitis B and C Prevention

Qualitative and quantitative findings from the baseline survey of a longitudinal, socially-focused blood-borne disease intervention study among 611 heroin IDU in Denver indicate that high risk injection practices—the sharing of contaminated drug solution in particular—often occur as a consequence of how heroin is obtained, the quantity obtained and the setting where it is injected. Contamination occurs if a contaminated syringe is used to liquefy and apportion the shared drug. In our cohort of 304 heroin injecting networks there was at least one member who, when asked to describe their last injection, reported dividing the drug as a liquid (82%), using a reservoir of water that syringes had been rinsed in to mix drugs (67%), using a common cooker (86%)—a proxy for drug sharing—and beating a shared cotton filter (58%). In contrast, only 22% reported syringe sharing. Variables associated with various injection practices included location of the last injection episode, quantity of drug injected, dope sickness, and years injecting. When compared to those who injected in a safe setting, those in an unsafe location had almost three times the odds (OR = 2.9; 95% CI: 1.9, 4.6) of being part of an injection episode where there was cooker sharing; and the smaller the quantity of heroin (1/4 gram v. > 1/4 gram) present at the episode, the greater the odds that cooker sharing occurred (OR = 1.8; 95% CI: 1.2, 2.6). Use of a used, unbleached syringe to prepare shared drugs had twice the odds of occurring in unsafe v. safe settings (OR = 2.2; 95% CI: 1.3, 4.0) and in episodes in which a participant was dopesick (OR = 2.1; 95% CI: 1.2, 3.6). In summary, risky injection practices occur within an injection process that is, in part, a response to a structurally imposed risk environment. Lessening the blood-borne disease risks embedded within this process requires interventions designed to mitigate the environmental factors that influence it, including syringe accessibility, law enforcement strategies and the settings where IDU inject drugs.     

Gender influences on initiation of injecting drug use

Background and objectives: Gender differences in illicit drug use patterns and related harms (e.g. HIV infection) are becoming increasingly recognized. However, little research has examined gender differences in risk factors for initiation into injecting drug use. We undertook this study to examine the relationship between gender and risk of injection initiation among street-involved youth and to determine whether risk factors for initiation differed between genders. Methods: From September 2005 to November 2011, youth were enrolled into the At-Risk Youth Study, a cohort of street-involved youth aged 14–26 in Vancouver, Canada. Cox regression analyses were used to assess variables associated with injection initiation and stratified analyses considered risk factors for injection initiation among male and female participants separately. Results: Among 422 street-involved youth, 133 (32.5%) were female, and 77 individuals initiated injection over study follow-up. Although rates of injection initiation were similar between male and female youth (p?=?0.531), stratified analyses demonstrated that, among male youth, risk factors for injection initiation included sex work (Adjusted Hazard Ratio [AHR]?=?4.74, 95% Confidence Intervals [CI]: 1.45–15.5) and residence within the city’s drug use epicenter (AHR?=?1.95, 95% CI: 1.12–3.41), whereas among female youth, non-injection crystal methamphetamine use (AHR?=?4.63, 95% CI: 1.89–11.35) was positively associated with subsequent injection initiation. Conclusion: Although rates of initiation into injecting drug use were similar for male and female street youth, the risk factors for initiation were distinct. These findings suggest a possible benefit of uniquely tailoring prevention efforts to high-risk males and females.     

Use of supervised injection facilities and injection risk behaviours among young drug injectors

Aims   To study the use of supervised injection facilities (SIFs) as a predictor of safer injecting practices.
Design   Cross-sectional study conducted with face-to-face interview using a structured questionnaire with computer-assisted personal interviewing. Dried blood spot samples were collected for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) antibody testing.
Setting   All participants were street-recruited by chain referral methods in Madrid and Barcelona.
Participants   A total of 249 young heroin drug injectors recruited by the ITINERE cohort study in two Spanish cities with SIFs.
Measurements   The main outcome measures were self-reported injecting behaviours and SIFs attendance.
Results   SIF users were more marginalized socially than non-users. They were also more often regular injectors (weekly or more versus sporadic) [odds ratio (OR) = 4.9, 95% confidence interval (CI): 2.7–8.8], speedball users (OR = 2.5, 95% CI: 1.5–4.3) and anti-HCV-positive (OR = 3.1, 95% CI: 1.4–7.1). In the logistic regression analysis, using SIFs was associated independently with not borrowing used syringes (OR = 3.3, 95% CI: 1.4–7.7). However, no significant association was found between SIF use and not sharing injection equipment indirectly (OR = 1.1, 95% CI: 0.5–2.2).
Conclusions   SIFs attract highly disadvantaged drug injectors who engage none the less in less borrowing of used syringes than non-users of these facilities. The risks of indirect sharing should be emphasized when counselling SIF attendees.