Patterns of drug use and associated harms among rural injecting drug users: comparisons with metropolitan injecting drug users

OBJECTIVE: Given the harms associated with injecting drug use to both individuals and community and the paucity of such data from rural areas, the study aimed to compare: patterns of drug use, harms, and service access and utilisation among rural and metropolitan injecting drug users (IDU). DESIGN: Cross-sectional survey, using interviewer-administered structured questionnaire. PARTICIPANTS: One hundred and sixty-four rural and 96 metropolitan IDU from seven different New South Wales Area Health Services, recruited through needle and syringe programs (NSPs), snowballing techniques and advertisement. RESULTS: Age, gender, education and employment were similar for rural and metropolitan participants. Both samples reported use of a range of drugs, but rural participants were less likely than metropolitan participants to report daily heroin use (2% vs 10%), but more likely to report having injected morphine (50% vs 21%) in the last six months. Similar proportions reported using a needle/syringe after another person. Rural participants were less likely to report use of NSPs (36% vs 80%) and reported a number of barriers to NSP access and also to drug treatment services. Rural participants reported a significantly longer period of time between blood-borne virus testing. CONCLUSION: Samples of rural IDU are similar to metropolitan, although report some differences in patterns of drug use. Service provision, including access to new injecting equipment, blood-borne virus testing and drug treatment was found to cause considerable problems for rural IDU. These issues warrant further consideration.     

Hepatitis C infection in a cohort of injecting drug users

Objectives: To establish prevalence rates for hepatitis C antibodies in a cohort of injecting drug users and to study factors influencing positivity. To record current injecting practices. To identify the entry of hepatitis C into the cohort. To investigate the association between HCV positivity and PCR status.

Design: (i) Questionnaire covering demographic data, injecting behaviour, number of sexual partners, awareness of risk behaviour, awareness of serological status and subsequent behaviour change. (ii) Second questionnaire on recent drug use and injecting practices with a strong focus on frequency of sharing paraphernalia. (iii) PCR testing on HCV positive. (iv) Retrospective testing of subgroup to determine entry of hepatitis C into the cohort.

Setting: Recruitment in a large general practice in North West Edinburgh.

Participants: The main study group consisted of a large cohort (619) of past or present illegal drug injectors. The first, n=95, received the questionnaire (i). If they had injected in the past month they also completed the second questionnaire (n=26). PCR testing was carried out on a subset of the group of 95, selected because they had had a recent blood test (n=33). A random group of 20 of the main cohort of 619 who had hepatitis C antibody positive tests were selected for retrospective testing.

Main outcome measures: Prevalence of HCV antibodies, perceived and actual risk-taking behaviour. Antibody status of randomly selected early stored specimens. HCV PCR status.

Results: Positivity was associated with age, year of first use, sharing of injecting paraphernalia, year of most sharing, as well as length of use of injected drugs.

Awareness of HCV as a risk was found to be later than either HBV or HIV. No significant difference was found in numbers of sexual partners between those who were HCV positive and negative. Women and younger drug users were found to engage in more sharing of injecting paraphernalia, with women having more sharing partners. The entry of HCV into the cohort predated the early stored blood samples. No correlation was identified between length of drug use and PCR status.

Conclusions: HCV is acquired early in drug injecting careers. Whether or not this is changing is unclear but attempts to educate and support need to be directed towards younger drug users and women, who are at risk. Knowledge of risks from sharing injecting paraphernalia is poor. The impact of the hepatitis C epidemic is likely to continue to escalate with cases progressing to advanced clinical stages. PCR tests could be employed to select cases for referral or treatment. The harm reduction message needs to be clarified and re-emphasised.     

Mobility of Scottish injecting drug users and risk of HIV infection

Nine hundred and nineteen injecting drug users (IDUs) were interviewed in Glasgow, Scotland during 1990 and 1991, as part of a wider study of HIV risk behaviour, about their injecting and sexual behaviour outside the city in the previous two years. Forty-five percent of respondents injected outside Glasgow, 6% shared needles and syringes (n/s) and 20% had sexual intercourse. Much activity occurred outside Scotland but mainly within the UK, particularly London. Predictors of n/s sharing outside Glasgow during the previous two years included current injecting with and passing on of used n/s and sexual intercourse with casual partners. Predictors of sexual behaviour outside Glasgow included passing on used n/s, having sexual intercourse with casual partners and, for females, engaging in prostitution. Glasgow IDUs are a highly mobile group and although HIV prevalence remains low within this population, considerable potential for importation/ exportation of HIV and other bloodborne and sexually transmitted infections exists. Further work is required to establish why IDUs travel to, and engage in high-risk activities in locations outside their home environment, and detailed data about activities such as frequency of condom usage and n/s cleaning practices need to obtained. While there is a widespread network of services for IDUs in the UK, information provided usually relates to local services and may not fully address the needs of this mobile population. Therefore, we recommend that IDUs be provided with details of facilities such as n/s exchange schemes and drug-treatment establishments in centres to where they most commonly travel.     

Exploring the contingent reality of biomedicine: Injecting drug users,hepatitis C virus and risk1

Hepatitis C is an emerging theme of contemporary public health discourses related to illicit drug injection practices. Such discourses differentiate injecting from non-injecting users in an actuarial risk logic, targeting drug-injecting users as a population in need of support in the management of risks attributed to their practices. Public health strategies suppose, among other things, that injecting drug users adopt a homogeneous vision of hepatitis C, and of its risk, that is compatible with the reality produced by biomedicine. The majority of studies conducted on hepatitis-related risks in the context of harm reduction strategies are interested in socio-demographic factors to understand the behavioural variations within this targeted population. The meaning given to the virus and to its risk has remained marginal and the diversity of areas of construction of meaning tends to be ignored in the academic literature. Attention to this diversity indicates a complex tissue of social and communicational relations and the contingency of the symbolic instruments that people manipulate in their relation with their body and towards others; a complex tissue in which the reality of biomedicine is one among many alternative realities.     

注射毒品者丙型肝炎病毒感染率及其危险因素研究

目的了解北京市注射毒品者HCV感染状况及其危险因素,评估注射毒品人群中HIV感染高危行为流行水平,为制定预防和控制艾滋病的策略和措施提供科学依据。方法选择北京市强制戒毒所新收治的注射毒品者和自社区招募的注射毒品者作为研究对象,采用问卷调查的方法进行资料的收集,采集静脉血5ml,实验室检测HCV抗体。资料的分析采用单因素分析、多因素分析。结果北京市注射毒品者的HIV感染率和HCV感染率分别为7.33%和52.59%。多因素分析结果表明HCV感染的危险因素有在强制戒毒所(OR=2.37,95%CI为1.55~5.72)、非北京市户籍(OR=1.94,95%CI为1.05~3.45)和注射次数≥100次(OR=2.60,95%CI为1.54~7.03)。结论北京市注射毒品人群HCV的感染率高达52.59%,标志着HIV感染高危行为在这一人群中广泛存在,应立即采取相应措施控制HIV和HCV感染的进一步扩散。     

A study of young people who inject drugs: an opportunity to decrease high risk injecting by improving knowledge about hepatitis C prevention

The population of young people who inject drugs (PWID) displays a unique constellation of features that are not found in other groups who are at risk of acquiring hepatitis C: they exhibit a smaller pool of existing infection and a higher incidence of unsafe injecting. This means there is vast opportunity to prevent the spread of hepatitis C for young PWID. This article uses survey data collected from clients of a community pharmacy needle exchange scheme in New South Wales, Australia, to describe the extent of unsafe injecting among young PWID, their knowledge about hepatitis C prevention and use of services. It examines whether poor knowledge and service use are related to unsafe injecting. A sample of 215 respondents aged 18–25 years was compared to 1464 respondents aged 26 years or older. Young respondents engaged in riskier injecting practices than their older counterparts, with higher proportions saying they had shared needles and other injecting equipment. Moreover, those who had shared equipment did so in a more risky manner than older respondents by sharing with a larger number of people and with people who were possibly less well-known to them, such as casual sex partners. While knowledge about hepatitis C transmission was good among young respondents, it was significantly worse than that of older respondents. More importantly, however, this poorer knowledge was related to both increased needle sharing and increased ancillary equipment sharing. Many studies do not observe a relationship between knowledge and risk behaviour but the findings of this study suggest a pressing opportunity to improve knowledge of young PWID. While it is unlikely that better knowledge will alone prevent infection among young people, it is a necessary starting point and, in the current case, has the potential to decrease young people’s risk of acquiring hepatitis C.     

A computer model of the spread of hepatitis C virus among injecting drug users

A number of behavioural and clinical parameters influence the transmission of an infectious agent through direct contact between two individuals. The behavioural parameters encountered in such situations are also likely to exhibit an enormous amount of variability. With the spread of hepatitis C among injecting drug users, the parameters associated with injecting behaviour play an important role in the modelling of the transmission process. Computer simulation modelling is an ideal approach to deal with a large number of parameters as well as high levels of variability without excessive simplification. The simulation model presented in this paper is tested on data from a cohort of injecting drug users and the results obtained are very encouraging from a public health perspective. The model clearly indicates that the rate at which HCV spreads through a population of injecting drug users is extremely sensitive to the interaction rate and to the probability of infection through a single contact with an infective. At the same time it shows that rate of spread is not very sensitive to initial prevalence, which is very encouraging from a public health perspective.     

新疆静脉吸毒者HIV-1原发耐药分析

目的研究新疆伊犁州经静脉吸毒(IDU)感染人类免疫缺陷病毒1型(HIV-1)未经抗病毒治疗者原发耐药株的流行情况。方法于2009年12月—2010年3月收集新疆伊犁州77例IDU HIV-1感染者血样及流行病学信息,提取血浆病毒RNA,逆转录聚合酶链反应(RT-PCR)和巢式PCR方法扩增pol基因区1.3 kb片段并测序;构建系统进化树分析病毒亚型,提交斯坦福大学HIV耐药数据库进行耐药性分析。结果 77例感染者中,76例(98.7%)为CRF07_BC亚型,1例(1.3%)为B亚型;蛋白酶区未检出主要耐药突变,耐药相关次要突变主要出现在第10、58和71位;其中71位氨基酸突变发生频率最高(11/77),其次为第10位(6/77)和第58位(3/77);第71位氨基酸由野生型的A突变为V者7例,突变为T者3例,突变为I者1例;第10位氨基酸由野生型的L突变为I者5例,突变为V者1例;第58位氨基酸由野生型的Q突变为E者3例;1例病例逆转录酶区同时存在Y181C及M184V耐药突变。结论新疆伊犁州未接受抗病毒治疗的IDU感染者中检出原发耐药株,原发耐药率处于较低水平,但应加强该地区IDU感染者的耐药监测,防止耐药株产生和流行。     

Young people at risk of transitioning to injecting drug use in Sydney,Australia: social disadvantage and other correlates of higher levels of exposure to injecting

While numerous studies have examined characteristics of young people who have recently initiated injecting, little attention has focused on young people who may be at high risk of transitioning to injecting. This study sought to examine the extent that socially disadvantaged young people were exposed to injecting, determine their level of hepatitis C (HCV) knowledge and identify correlates of higher injecting exposure. A cross‐sectional survey was administered to 210 young people in 2010–2011 who were exposed to injecting drug use, but had not transitioned to injecting. Respondents were primarily recruited from youth services in metropolitan Sydney. Exposure to injecting in the previous 12 months was assessed with four items that examined whether close friends, romantic/sexual partners or family members/acquaintances injected drugs, and whether they were offered an injection. Most respondents had at least a few close friends who injected drugs (65%) and almost half had been offered drugs to inject in the previous 12 months (48%). It was less common for respondents to report having a partner who injects (11%). Correlates of higher injecting exposure were examined with multivariate ordinal regression. In the multivariate model, higher exposure to injecting was independently associated with the experience of abuse or violent crime [adjusted odds ratio (AOR) = 1.80] and reporting more favourable attitudes towards injecting (AOR = 0.86). Higher exposure to injecting was not independently associated with patterns or history of drug use. HCV knowledge was low to moderate and was not associated with higher exposure to injecting. That drug use was not independently associated with higher injecting exposure may suggest that exposure is shaped more by social disadvantage than by drug use patterns. Additional research is required to investigate this, using an improved measure of exposure to injecting.     

Determinants of current HIV risk behaviour among injecting drug users in Warsaw, Poland

Of the injecting drug users (IDUs), 24% had borrowed, and 37% had passed on syringes in the previous 6 months. In logistic regression analysis, current borrowing of syringes was significantly associated with a shorter duration of injecting drug use, a higher number of drug-injecting sex partners in the previous 6 months, and with current lending of syringes. A majority of the IDUs have modified previous HIV risk behaviour but these modifications are insufficient and not sustained over time. Intensified AIDS prevention measures for IDUs in Poland are needed.     

Screening for Hepatitis C in injecting drug users: a cost utility analysis

BACKGROUND: Hepatitis C is a major public health problem of increasing importance among injecting drug users, among whom screening has been proposed. We therefore estimated the cost utility of screening for hepatitis C infection among people with a history of injecting drug use in contact with drug misuse services. METHODS: A spreadsheet-based model of screening using ELISA followed by polymerase chain reaction tests and treatment using combination therapy with interferon alpha and ribavirin was developed. Parameters were informed by literature review, expert opinion and a survey of current screening practice in England. A range of one-way sensitivity analyses were carried out to explore uncertainty in the results for cost effectiveness. RESULTS: Screening for HCV is likely to yield benefits in the population concerned at around 28,000 pounds per quality adjusted life year. This estimate is reasonably stable when explored in extensive one-way sensitivity analysis but appeared sensitive to the proportion of HCV positive people who accept biopsy or treatment and the utility gains associated with successful drug treatment. Important other areas of uncertainty include the effects of mortality from other causes on the cost effectiveness of screening in this population and the time at which symptoms would have led to presentation in the absence of a screening programme. CONCLUSION: Screening for HCV in this population is moderately cost effective, although some caution must remain in accepting this estimate given the current uncertainties in this field, and further research is required.     

Coinfections by HIV, hepatitis B and hepatitis C in imprisoned injecting drug users

In order to know the prevalence and risk factors for coinfections by human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) among injecting drug users (IDUs), a cross-sectional study was carried out in two prisons of the province of Cantabria, northern Spain. Three hundred and sixty-two IDU inmates were recruited. All inmates were interviewed and their blood tested for HIV, HBV and HCV. Crude and multiple risk factor adjusted for (by polychotomous logistic regression) odds ratios were calculated. Prevalence of HBV-HCV coinfection (42.5%) was higher than HIV-HBV-HCV coinfection (37.3%), whereas monoinfections were very uncommon (overall: 13%). Long-term injectors and reincarceration were the foremost risk factors for both coinfections, showing a trend between the degree of association and the number of viruses infecting a patient. No significant relationship between coinfection status and sexual practices was observed. The results related to coinfections are consistent with previous studies of prevalence and risk factors for HIV, HBV and HCV, in indicating that the high rates of coinfections among IDU inmates emphasise the need to harm-reduction policy across prisons in Spain.     

High HIV testing and low HIV prevalence among injecting drug users attending the Sydney Medically Supervised Injecting Centre

Objective: Measure the self-reported prevalence of HIV, history of HIV testing and associated risk factors among injecting drug users (IDUs) attending the Sydney Medically Supervised Injecting Centre (MSIC).
Methods: Cross-sectional survey of IDUs attending the Sydney MSIC (n=9,778).
Results: The majority of IDUs had been tested for HIV (94%), most within the preceding 12 months. Self-reported prevalence of HIV was only 2% (n=162) and homosexuality (AOR 20.68), bisexuality (AOR 5.30), male gender (AOR 3.33), mainly injecting psychostimulants (AOR 2.02), use of local health service (AOR 1.56) and increasing age (AOR 1.62) were independently associated. Among the 195 homosexual male sample 23% were self-reported being HIV positive. HIV positive homosexual males were more likely to report mainly psychostimulant injecting than other drugs, a finding not replicated among the heterosexual males.
Conclusions: The associations in this sample are consistent with other data indicating Australia has successfully averted an epidemic of HIV among heterosexual IDUs. The absence of any significant associations between HIV positive sero-status and the injecting-related behaviours that increase vulnerability to BBV transmission suggests that HIV infection in this group may be related to sexual behaviours. In particular, the strong associations between homosexual males and psychostimulant injectors with HIV positive sero-status suggests that patterns of infection within this group reflect the epidemiology of HIV in Australia more generally, where men who have sex with men remain most vulnerable to infection.     

Sexually transmitted infections,sexual risk behaviours and perceived barriers to safe sex among drug users

Objective : Drug users are at elevated risk of HIV and other sexually transmitted infections (STIs). This study examines prevalence of STIs and perceived barriers to safe sex among drug users accessing low‐threshold primary healthcare in inner‐city Sydney. Methods : Data were extracted manually from clients’ medical records and analysed using STATA. Results : Prevalence of HIV, syphilis, chlamydia and gonorrhoea were low (<2%), whereas hepatitis C (62%), hepatitis A (30%), and previous exposure to hepatitis B (25%) were more common. Recent unprotected vaginal and anal intercourse were reported by 85% and 26% of clients, respectively. Younger clients and those with a history of sex work or recent anal intercourse were more likely to report multiple recent unprotected sex partners. Having a regular sex partner was the most prevalent barrier to condom use (37%), and was more likely to be identified by clients who were older, of Indigenous descent, and/or heterosexual. Drug intoxication was a second important barrier (20%), and was more commonly identified by excessive alcohol users. Conclusions : Targeted programs might increase awareness regarding the benefits of condom use and potential sexual risk associated with regular partners. Periodic assessments of alcohol use, and brief interventions for drug users who report problematic use, should also be considered.