A Rapid Assessment of Heroin Use in Mombasa,Kenya

This article reports on a rapid assessment (RA) carried out in the city port of Mombasa, Kenya in March 2004 by the Omari Project to inform the scaling up of their services to heroin users. Heroin has been a street drug in Mombasa for over 25 years. From 1998, white crest, probably from Thailand, started to replace brown sugar, and there was a major shift from inhalation of the vapor (“chasing the dragon”) to injecting. The Omari Project has been monitoring the heroin situation in Mombasa and treating heroin users from Mombasa since 1997. In the course of the RA, 496 heroin users were interviewed of whom 95% were men and 5% were women. A range of methods were used, including mapping of the Mombasa region, work with a key informant/guide who was a heroin user, administration of a brief questionnaire and informal interviews, and feedback of findings to other local agencies working with drug users. Respondents were from a wide range of cultural/ethnic groups, the two largest being Mijikenda and Swahili, who are indigenous to the Kenya coast. Overall, 15% of respondents had “ever injected” heroin, and 7% were current injectors (n = 37). These data indicate a shift away from injecting but also reflect the death of many established injectors, either through overdose or AIDS or hepatitis. The figure of 7% of the sample reporting being current injectors is likely to be an underestimate. Syringes were available from a number of pharmacies and most injectors reported using a syringe for 1–3 days. The majority reported injecting in a group of three or more and described risk behaviors for HIV transmission. The results of the assessment highlight the need for a range of services, including needle exchange, counseling, and referral to residential treatment programs. However, progress toward responding to the findings of the RA by establishing effective services are hampered because of legal impediments to operating needle exchange programs in Kenya.     

The characteristics and recent growth of heroin injecting in a Kenyan coastal town

This article discusses the challenges of estimating levels and patterns of heroin use in a setting where there were no official records. Ethnographic fieldwork, carried out in a Kenyan Coastal town, utilised a range of qualitative research methods in an attempt to estimate numbers of male and female users and the proportion of them who were injectors of heroin. In the town of at least 85?000 people, it was estimated that there were perhaps about 600 heroin users, of whom about 30 were women. The ratio of male to female users was estimated to be 20?:?1. Fifty per cent of users in the town were estimated to be injectors of heroin. They were found to have poor injecting techniques, to share equipment from time to time and to have low awareness of the link between injecting drug use and HIV infection. An urgent need for harm reduction strategies was identified.     

Changes in route of drug administration among continuing heroin users: outcomes 1 year after intake to treatment

This study investigates the type and extent of changes in route of drug administration among heroin users after treatment: whether injectors move to other routes of use; whether changes in route for one drug influence routes used for other drugs; and associations between changes in route of administration and other substance use outcomes. The sample comprised 641 heroin users recruited to 54 UK treatment programmes. At intake, the main routes of heroin use were injecting (61%) and "chasing the dragon" (37%). After 1 year, 81% of those using heroin took it by the same route as at intake, while 19% reported a change, with 14% switching from injecting to chasing. Changes from injecting to chasing were associated with improvements in other substance use behaviours. Changes in route represent an important aspect of drug-taking behaviours. Interventions to prevent the change to injecting should be developed and offered to noninjectors. "Reverse transitions" (from injecting to chasing) may represent a useful intermediate treatment goal for drug injectors who cannot achieve abstinence.     

Increasing popularity of injection as the route of administration of amphetamine in Edinburgh

Six hundred and thirty four interviews of injecting drug users were performed between 1992 and 1994 as part of a study of injecting drug use and HIV prevalence in Edinburgh, Scotland. Amphetamine was injected by more subjects (44%) than any other drug. Preference for injection as the route of administration of amphetamine increased over the period despite no change in the popularity of the drug generally. Simultaneously, heroin use and injection declined. Analyses indicated that amphetamine injectors comprised two distinct sub-groups. The majority were polydrug injectors who injected frequently, had a longer injecting history and were more likely to share injection equipment. About one-fifth were stimulant-only injectors who injected infrequently, were relatively recent initiates to injecting and whose numbers increased over the 3 years. Drug treatment and prevention services may need to explore alternative methods to respond effectively to these emerging trends.     

Differences in Characteristics of Heroin Inhalers and Heroin Injectors at Admission to Treatment: A Preliminary Study Using a Large Database of Client Records

Aims.?To compare the characteristics of heroin injectors vs. inhalers at their first admission to publicly funded treatment in Texas. Methods.?The sample consisted of 9732 unique clients who entered publicly funded treatment programs in Texas between 1997 and 2001 and who had a primary problem with either injected or inhaled heroin, which they had used in the past 30 days. The records were analyzed using a generalized linear model of logistic regression with the outcomes modeled as binomial and multinomial distribution and a hierarchical linear model for continuous outcomes to compare heroin inhalers and injectors. Findings.?There were large statistically significant differences between injectors and inhalers. Inhalers were more likely to be older at first use of heroin, to have entered treatment sooner, to have minor children at home, to have higher annual incomes, to be first admissions to treatment, and to have a secondary drug problem with crack cocaine. They were also more likely to be Hispanic [odds ratio (OR) = 1.74] or African-American (OR = 12.32). Conclusions.?Even though the race/ethnic differences in the Texas population and the type of heroin available for use in Texas differs from that studied elsewhere, many of the characteristics of heroin users are similar. Inhalers have more strengths in many areas, and these findings raise the possibility that there are factors, particularly among African-American participants in Texas, that lessen the risk of injecting heroin. Efforts should be directed to providing therapeutic interventions to discourage the transition to injecting and to encourage inhalers to enter treatment earlier rather than progressing on to injecting. This analysis is the first part of a larger study of heroin users in public and private treatment.     

Differences in characteristics of heroin inhalers and heroin injectors at admission to treatment: a preliminary study using a large database of client records

AIMS: To compare the characteristics of heroin injectors vs. inhalers at their first admission to publicly funded treatment in Texas. METHODS: The sample consisted of 9732 unique clients who entered publicly funded treatment programs in Texas between 1997 and 2001 and who had a primary problem with either injected or inhaled heroin, which they had used in the past 30 days. The records were analyzed using a generalized linear model of logistic regression with the outcomes modeled as binomial and multinomial distribution and a hierarchical linear model for continuous outcomes to compare heroin inhalers and injectors. FINDINGS: There were large statistically significant differences between injectors and inhalers. Inhalers were more likely to be older at first use of heroin, to have entered treatment sooner, to have minor children at home, to have higher annual incomes, to be first admissions to treatment, and to have a secondary drug problem with crack cocaine. They were also more likely to be Hispanic [odds ratio (OR) = 1.74] or African-American (OR = 12.32). CONCLUSIONS: Even though the race/ethnic differences in the Texas population and the type of heroin available for use in Texas differs from that studied elsewhere, many of the characteristics of heroin users are similar. Inhalers have more strengths in many areas, and these findings raise the possibility that there are factors, particularly among African-American participants in Texas, that lessen the risk of injecting heroin. Efforts should be directed to providing therapeutic interventions to discourage the transition to injecting and to encourage inhalers to enter treatment earlier rather than progressing on to injecting. This analysis is the first part of a larger study of heroin users in public and private treatment.     

Injecting risk behaviour and related harm among men who use performance- and image-enhancing drugs

Introduction and Aims . Performance‐ and image‐enhancing drugs have the potential to be a significant public health issue. Detailed data on PIEDs injection are difficult to obtain because of the illicit and unsupervised way in which many PIEDs are used, and the hidden nature of the group. Our study examines the patterns of use, risk behaviours and related harm associated with PIEDs injection. We also report the ways in which PIEDs users currently seek injecting equipment and harm‐reduction advice. Design and Method . Data were obtained via a structured questionnaire administered in face‐to‐face interviews with 60 men who used PIEDs (primarily anabolic androgenic steroids) for non‐medical purposes. Results . Although the rates of needle sharing were low (5%), the men more frequently reported re‐use of needles/equipment, injecting from a shared container (bladders, vials, etc.), injecting other illicit drugs, injecting insulin and targeting small muscle groups. Self‐reports of being hepatitis C antibody positive were associated with lifetime use of heroin and injection of other illicit drugs. All HIV positive participants were gay/bisexual men. Participants reported a range of other injection‐related injuries and diseases such as fevers, scarring and abscesses. ‘Risky’ injectors (38% of participants) were more likely to initiate PIEDs use at a younger age, use PIEDs in a larger number of cycles per year and report involvement in a violent/aggressive incident than ‘low risk’ injectors and report involvement in a violent/aggressive incident than ‘low risk’ injectors. Participants mainly reported seeking information about PIEDs from internet sites (62%) and friends (55%). Conclusions . An over‐reliance on personal networks and internet forums limits this groups' access to objective harm reduction advice and primary care services. Targeted, PIEDs‐specific interventions are needed.     

Multiple risks for HIV and hepatitis B infection among heroin users

This study investigates the extent to which heroin users are exposed to multiple forms of infection risk. Structured interviews were administered to a prospective network sample of 408 heroin users. Subjects were contracted in south London in a wide range of social settings by specially recruited privileged access interviewers. Most heroin users (74.5%) had been exposed to more than one infection risk factor and more than half of the sample had been exposed to three or more risk factors. HIV serostatus was primarily related to men having sex with men. Hepatitis B seropositive status was primarily related to the number of years injecting drugs. At this stage of the HIV epidemic in London, HIV infection among heroin users may be related more to homosexual risk behaviour than drug risk factors. Heroin injectors were at greater risk of infection than heroin chasers both through their sexual behaviour as well as through their injecting practices. Heroin users who refused to give a saliva sample for analysis were found to be more likely to engage in several health risk behaviours than those who provided samples. This finding has important methodological implications for seroprevalence surveys. Other implications of the results for prevention programmes aimed at health risk behaviours of heroin users are also discussed.     

Overdosing among young injection drug users in San Francisco.

Heroin overdoses increased sharply in the US in the 1990s, but few studies have addressed overdose risk. We examined overdosing and injection-related risk behavior in young injection drug users (IDUs). We interviewed all consenting injectors under age 30 at needle exchanges and youth outreach sites in San Francisco. Their median age was 22, and their median number of years of injecting was 4. About 48% reported at least one overdose, with a median of two overdoses reported. Overdosing was associated with injecting "speedballs" (i.e. mixtures of heroin and cocaine), with borrowing syringes, and (with P-values of borderline statistical significance) with heroin injection and with gay or bisexual behavior. It was not associated with age, sex, years of injecting, or frequency of injecting. In multivariate analysis, only borrowing syringes and gay or bisexual behavior were independent statistically significant predictors, probably because gay and bisexual subjects were more likely to be heroin or "speedball" injectors. Most subjects (65%) reported that they had not received medical attention at time of last overdose. Risk of overdose in young injectors is acute and closely associated with HIV risk. HIV interventions should include overdose prevention. Emergency response protocols should minimize risk of arrest. Injectors and providers should be trained in overdose prevention, and developing overdose interventions should be a priority among drug educators.     

A comparison of the harms associated with the injection of heroin and amphetamines

An investigation into whether or not the level of harm associated with injecting drug use varies depending on the drug that is injected was conducted among 151 primary heroin injectors and 145 primary amphetamine injectors. Compared to primary amphetamine injectors, primary heroin injectors were more dependent on their primary drug, had poorer social functioning, and had recently exhibited a higher degree of criminal behaviour. There were no differences between the two groups in terms of the prevalence of needle sharing, their health, or their psychological functioning, despite the amphetamine users being significantly younger and having used less frequently. It is concluded that while there are some harms that are attributable to injecting per se, the type of drug that is injected does play a mediating role in the relationship between injecting drug use and its associated harm.     

Injection frequency mediates health service use among persons with a history of drug injection

Drug injectors are known to have high rates of hospital and emergency room (ER) use. We hypothesized that out-of-treatment injection drug users (IDUs) have higher rates of health service use than methadone-maintained persons, and that heroin injection frequency mediates health service use among drug injectors (IDUs). HIV-negative individuals with a history of drug injection were recruited from a needle exchange program (NEP) and a methadone maintenance treatment program (MMT) in Providence, RI. ER visits, outpatient visits, and hospitalizations in the last 6 months were the dependent variables with number of heroin injections the hypothesized mediator variable. The 472 participants were predominately male (60.6%) and white (82%) with a mean age of 37. NEP clients were more likely than MMT clients to visit an ER (39.2% vs. 29.8%; P=0.03). NEP participants were somewhat more likely to report a hospital admission (16.0% vs. 10.6%; P=0.08). Relative to non-injecting MMT participants, the odds of visiting an ER were 1.80 and 1.67 times higher for subjects recruited through NEP and actively injecting MMT participants, respectively. Additionally, subjects recruited through NEP (OR=2.2) and actively injecting MMT participants (OR=2.3) were over twice as likely to report a hospital admission than non-injecting MMT participants. Each increase of one heroin injection per day increased the expected odds of injection-related infection by a factor of 1.92. NEP clients are more likely to have ER visits and hospitalizations than methadone clients. We describe a pathway by which injection frequency influences health service use.     

Social context of needle selling in Baltimore, Maryland

Although much of the debate surrounding the distribution of sterile syringes to injection drug users (IDUs) has focused on needle exchange programs (NEPs), IDUs acquire their syringes from three major sources: NEPs, pharmacies, and secondary exchangers or needle sellers. The purpose of the present study is to examine types and frequencies of social interactions among drug injectors who sell needles, most of which come from NEPs, compared with individuals who do not sell needles. Specifically, we compared engagement in drug-related behaviors, roles in the drug economy, and social network membership. Data were collected as part of the SHIELD study, an HIV prevention intervention targeted at drug users and their social networks (n=910) from February 2001 through September 2003 in Baltimore, Maryland (USA). In this sample, 56 participants reported selling needles. Needle sellers had higher levels of engagement in drug-related social interactions, including using drugs with others, giving or receiving drugs from others, and buying drugs with other users. Participants who sold needles had a significantly higher number of roles in the drug economy. Also, they had more social network members who were injectors, with whom they talked about risky drug behaviors, gave needles to, and shared cookers and bleach with. Compared with nonselling injectors, needle sellers engage in HIV risk-related behaviors, such as injecting daily and sharing injection equipment, more frequently. The study's findings may be useful to determine whether secondary exchangers should be targeted for HIV prevention activities both to reduce their own risk and to diffuse risk reduction information throughout the drug using community.     

Changes in the initiation of heroin use after a reduction in heroin supply

Increasing heroin use in Australia over the past 30 years has been associated with a decline in the age of initiation to heroin use. The 2001 Australian heroin shortage was used to assess the effects of a reduction in heroin supply on age of initiation into heroin injecting. Data collected from regular injecting drug users (IDU) over the period 1996 - 2004 as part of the Australian Illicit Drug Reporting System were examined for changes in self-reported age of first heroin use after the onset of the heroin shortage. Estimates were also made of the number of young people who may not have commenced injecting heroin during the heroin shortage. The proportion of IDU interviewed in the IDRS who were aged ≤24 years decreased from 46% in 1996 to 12% in 2004, with the most marked drop in 2001, the year in which there was an abrupt and marked reduction in heroin availability. Of those who reported first injecting between 1993 and 2000, similar proportions reported heroin and amphetamine as the first drug injected. After 2000, methamphetamine was the drug most often reported as being the first injected. Estimates suggested that between 2745 and 10 560 young people may not have begun to inject heroin in 2001 as a result of reduced heroin supply. If around one in four of these young users had progressed to regular or dependent heroin use, then there may have been a reduction of between 700 and 2500 dependent heroin users. There was an increase in amphetamine injecting but it is unclear to what extent any reduction in heroin injecting has been offset by increased amphetamine injecting. Reduced heroin availability probably resulted in a reduction in the number of new heroin injectors in Australia. Efforts need to be made to reduce the chances that young people who have initiated methamphetamine injecting do not move to heroin injecting when the heroin supply returns. [Day C, Degenhardt L, Hall W. Changes in the initiation of heroin use after a reduction in heroin supply. Drug Alcohol Rev 2006;25:307 - 313]     

海洛因滥用者中22例HIV感染分析

目的··:了解海洛因滥用者HIV感染行为 ,评估海洛因滥用者人群HIV感染的趋势。方法·· :对我院1997年至1999年收治的3015例海洛因依赖者感染HIV的情况进行调查分析。结果··:发现22例 (占0.73 % )海洛因依赖者HIV抗体阳性 ,其中男性19例 (19/2613 ,占0.73 % ) ,女性3例 (3/402 ,占0.75 % );86.36 %(19/22)为静脉注射毒品者 ,静脉注射者中大部分 (89.47 % )有共用注射器具史。72.73 % (16/22)的HIV感染者同时具有性混乱史。结论··:海洛因滥用者是HIV感染的高危人群 ,海洛因滥用者的感染行为主要包括共用注射器具和性混乱行为     

Reawakening the dragon: changing patterns of opiate use in Asia, with particular emphasis on China's Yunnan province

Asian countries adjacent to the Golden Triangle and their neighbors have witnessed an evolution in "drug abuse" from traditional opium smoking to heroin eating, smoking, and finally heroin injection. A recent study of 630 heroin users was conducted in China's Yunnan Province, located close to the Golden Triangle. Data collected between August 1997 and February 1998 indicate injecting heroin users, in comparison to noninjectors, were more likely to have used drugs for a longer period of time, and to use drugs more frequently everyday. Other major differences existed between urban and rural subjects, especially highlighting differences between men and women. Women comprised a much higher proportion of urban subjects than rural subjects. Rural injectors were much more likely to be male, but urban injectors were almost evenly split between men and women. The emerging epidemic of heroin use in China and the continuing substance abuse problem in the United States provide an opportunity for collaborative research of mutual benefit.     

Citizens who inject drugs: the 'Fitpack' study

Most injecting drug users have never been in drug treatment yet much research is done on samples with high treatment rates drawn from agency and peer recruited populations. This study accessed drug injectors with little or no prior drug treatment, described their characteristics, BBVI risk behaviours and feedback on services. Its results challenge some stereotypes about citizens who inject drugs. A sample of 511 'hidden' drug injectors, of whom only 28.7% had any specialist drug treatment agency contact, completed a questionnaire which was distributed with 'Fitpack' needle packs sold through community pharmacies in WA. The mean age of respondents was 26.2 years, 43.4% were women, 44.3% were living with their sexual partner, 41.7% were parents, and 46.4% were employed, mostly in full time work. In the previous month 61.2% had injected less frequently than daily. The study accessed a diverse group of drug injectors not typically seen in agency and peer recruited research. They provided useful feedback about how harm reduction strategies among injectors can be improved. However, they also reported higher rates of injecting and sharing than found previously in traditionally recruited samples of injectors which suggests there is no room for complacency regarding the potential for blood-borne viral infection (BBVI) transmission in this group.     

Transition to injection and sharing of needles/syringes: potential for HIV transmission among heroin users in Chengdu, China

This cross-sectional survey interviewed heroin injectors admitted in three detoxification centres from August 2003 to June 2004 in Chengdu City, China. Logistic regression and survival analysis were performed to identify factors associated with sharing of needles/syringes and time from initiation of heroin to adoption of injection, respectively. Out of 266 subjects studied, 206 (77.44%) were males, 103 (38.72%) never shared injecting materials, 113 (42.48%) were non-Chengdu residents and 9 (3.38%) belonged to ethnic minorities. Those with short history of heroin injection (P<0.05) and those belonged to ethnic minorities (P<0.05) were more likely to share injecting materials. Only age, ethnicity and duration of heroin use were associated with time to first injection. Median time to injection was 6 months for those who used heroin for the duration up to 1 year and 21 months for those who used heroin for 2-5 years. The study suggests that there is early initiation of injection and sharing of injecting materials is high among heroin users, a major risk for HIV transmission. Ethnic minorities have been identified to be the most risky group, which needs further attention.     

The role of "long-term" and "new" injectors in a declining HIV/AIDS epidemic in Rio de Janeiro, Brazil

BACKGROUND: A substantial decline of HIV prevalence has been observed in injection drug users (IDUs) from Rio de Janeiro, in recent years. Differential characteristics and behaviors of new (injecting for <6 years) and long-term (>=6y) injectors may help to understand recent changes and to implement appropriate prevention strategies. METHODS: Between October 1999 and December 2001, 609 active/ex-IDUs were recruited from different communities, interviewed, and tested for HIV. Contingency table analysis and t-tests were used to assess differences between new and long-term injectors. Multiple logistic regression was used to identify independent predictors of HIV serostatus for long-term and new injectors. RESULTS: HIV prevalence was 11.7% for 309 long-term injectors (95% CI 8.1-15.3) and 4.3% for 300 new injectors (95% CI 2.0-6.6). New injectors reported having engaged in treatment and having received syringes from needle exchange programs (NEPs) more frequently than long-term injectors in the last 6 months, but sharing behaviors remained frequent and even increased vis-à-vis long-term injectors. For male new injectors, "sexual intercourse with another man" was found to be the sole significant risk factor for HIV infection (Adj OR = 8.03; 95% CI 1.52-42.48). Among male long-term injectors, "to have ever injected with anyone infected with HIV" (Adj OR = 3.91; 95% CI 1.09-14.06) and to have "ever been in prison" (Adj OR = 2.56; 95% CI 1.05-6.24) were found to be significantly associated with HIV infection. DISCUSSION: New injectors are seeking help in drug treatment centers or needle exchange programs. They differ from long-term injectors in terms of their risk factors for HIV infection and have lower prevalence levels for HIV. Such differences may help to understand the recent dynamics of HIV/AIDS in this population and highlight the need to reinforce new injectors' help-seeking behavior and to reduce current unacceptably high levels of unprotected sex and syringe sharing in new injectors despite attendance of prevention/treatment programs.     

Prevalence rates and risk factors for hepatitis C among drug users not in treatment in Malaysia

Introduction and Aims. The prevalence of hepatitis C virus (HCV) among heroin dependants in treatment was estimated at 89.9%; however, virtually no information exists on the prevalence or risk behaviour among the larger population of drug users not in treatment. This study assessed the prevalence of HCV and associated risk factors among this group with a view to designing more effective intervention programs. Design and Methods. A cross‐sectional survey of 552 not‐in‐treatment drug users recruited from five key urban centres across peninsular Malaysia with on‐site serological testing for HCV and HIV seropositivity was conducted. Results. HCV prevalence was 65.4% for the overall sample, but higher among injecting drug users (67.1%) relative to non‐injecting drug users (30.8%). Bivariate analysis suggested seven risk factors though only sharing injecting paraphernalia and lifetime homosexual/bisexual behaviour remained significant in multivariate analysis. Discussion and Conclusions. With the majority (65.9%) sharing injecting equipment and about the same proportion (65.4%) being HCV positive, the risk of further transmission to new drug users is high. It is imperative that the nascent needle and syringe exchange and condom distribution program and its ancillary services—launched in 2005 to fight HIV—be fine tuned, as a first step, to control HCV. With its greater infectivity and non‐symptomatic character, HCV is more insidious. Given the shared risk factors of HCV and HIV, routine screening of drug users for HCV—currently non‐existent—should be instituted. This, with other intervention measures, will help detect and control HCV at an earlier stage while also checking the spread of HIV.[Vicknasingam B, Narayanan S, Navaratnam V. Prevalence rates and risk factors for hepatitis C among drug users not in treatment in Malaysia. Drug Alcohol Rev 2009;28:447–454]