Rapid assessment and response to injecting drug use in Madras, south India

HIV infection among injecting drug users (IDUs) is preventable, and in order to develop appropriate interventions, an assessment was carried out at Madras, South India using the Rapid Assessment and Response Guide on Injecting Drug Use developed by WHO. Data were collected with multiple methods from multiple sources using the principles of triangulation and induction. A total of 100 IDUs were interviewed. These interviews were complemented by focus groups and observations. A community advisory board ensured community ownership and participation. Findings showed that heroin, buprenorphine, diazepam and avil were the drugs most commonly injected. The use of pharmaceutical preparations as a 'cocktail' was also prevalent. Drug injectors interviewed were males, and most (81%) were from low-income groups living in slums. Direct (69%) as well as indirect sharing (94%) was common. Such unhygienic injecting practices, and the lack of access to sterile water, contribute to the high incidence of adverse health consequences. Compared with the buprenorphine injectors, heroin injectors were more likely to share injecting equipment (P=0.0022), inject more frequently (P=0.0013), have more drug using network members (P=0.0104), frequent 'shooting' locations (P=0.002), use the dealer's place to inject (P=0.0317), and face threats of arrest (P=0.0023). Many buprenorphine injectors managed their life without serious crises, and seemed to adopt a 'natural' harm reduction response. Sexual risk behaviour was prevalent among opioid users, and a history of commercial sex was associated with daily alcohol use (P=0.0221). The assessment led to an action plan which was presented and endorsed in an advocacy meeting by key stake-holders and decision-makers. The critical importance of implementing quality, accessible, community-oriented, and effective HIV interventions with the capacity to reach the majority of IDUs is discussed. Public health responses to injecting drug use must target changes among individuals at-risk, as well as in the community and risk environment.     

Demographic, HIV risk behavior, and health status characteristics of "crack" cocaine injectors compared to other injection drug users in three New England cities

OBJECTIVES: To compare demographic, HIV risk behaviors, and health status characteristics of injection drug users (IDUs) who have injected "crack" cocaine with IDUs who have not. METHODS: Nine hundred and eighty-nine IDUs were recruited in New Haven, CT, Hartford, CT and Springfield, MA from January 2000 to May 2002. Participants were administered a modified version of the National Institute on Drug Abuse Risk Behavior Assessment Questionnaire. RESULTS: Nine percent (n = 89) of participants reported "ever" injecting crack cocaine and 4.2% (n = 42) reported injecting crack in the past 30 days. Lifetime and current crack injectors did not differ significantly on any demographic characteristics. Lifetime and current crack injectors did not differ on gender, age or marital status from IDUs who have never injected crack. Significant differences were found on race, education, employment and residence, with crack injectors more likely to be white, employed, better educated and living in New Haven than IDUs who have never injected crack. After adjusting for current (past 30 day) speedball and powder cocaine injection, crack injectors reported higher rates of risky drug use behaviors and female crack injectors reported higher rates of risky sexual behaviors. Crack injectors reported higher rates of abscesses, mental illness and Hepatitis C infection, but not Hepatitis B or HIV infection. CONCLUSIONS: The emergence of crack cocaine injection requires urgent attention, as this new drug use behavior is associated with elevated rates of high risk behaviors.     

Injecting drug users, HIV risk behaviour and shooting galleries in Rajshahi, Bangladesh

The purpose of this study was to investigate HIV risk behaviours of IDUs and the drug scene in Bangladesh. The setting for the study was the city of Rajshahi, in the northwestern area of Bangladesh, which shares a border with India. Sixty-four clients of a drug treatment agency were surveyed about their drug use, drug injecting, sexual behaviour and knowledge about HIV and AIDS. All participants were males with a mean age of 32 years. Most participants had no or little formal education. All participants had injected drugs, primarily buprenorphine. The majority of participants were long-term drug users who had begun injecting drugs recently - 70% had commenced injecting in the last 3 years. Sexual contact with sex workers (50%) and with casual partners (85%) was common among participants. Although most participants had heard of AIDS, few knew how HIV is transmitted. Most participants (81%)injected in groups at shooting galleries where they paid another to inject them. The shooting galleries operated without concern for hygiene or user safety. The potential for HIV to spread among IDUs and onto their non-injecting sexual partners in Bangladesh is cause for concern. A rapid assessment of HIV prevalence among IDUs in Bangladesh is urgently required. [Hossain M. Injecting drug users, HIV risk behaviour and shooting galleries in Rajshahi, Bangladesh. Drug Alcohol Rev 2000;19:413-417]     

Patterns and trends in alcohol-related hospitalizations in Victoria, Australia, 1987/88 - 1995/96

The objective of this study was to examine patterns and yearly trends in alcohol-related hospitalization rates during the period 1987/88 - 1995/96 for men and women living in metropolitan and rural/remote Victoria. Alcohol-related hospitalizations were extracted from the Victorian Inpatient Minimum Dataset (VIMD) for the years 1987/88-1995/96 (public hospitals) and 1993/94 - 1995/96 (private hospitals), and adjusted by the appropriate aetiological fractions. Sex-specific age-adjusted rates were expressed per 10 000 residents/year. During 1993/94 - 1995/96, alcohol-related hospitalizations comprised 1.0% of all Victorian hospitalizations (about 12 000/year), with men accounting for over two-thirds of alcohol-related hospitalizations. Approximately half of the alcohol-related hospitalizations were for disease conditions and the other half for external cause (injury) conditions. About 80%of all alcohol-related hospitalizations were to public hospitals, with the exception of alcohol dependence (63% to private hospitals). Alcohol-related hospitalization rates were generally higher for people living in rural/remote areas compared to urban areas. During 1987/88 - 1995/96, the age-adjusted alcohol-related hospitalization rates in public hospitals did not change significantly for disease conditions (14.8 - 14.7 for men and 6.3 - 6.4 for women) or female external cause conditions (6.7 - 6.1), but decreased for external cause conditions (18.4 - 15.5). In private hospitals during 1993/94 - 1995/96, the age-adjusted alcohol-related hospitalization rates for disease conditions decreased (5.4 - 4.1 for men and 3.7 - 3.0 for women) but increased for external cause conditions (1.8 - 2.4 for men and 1.0 - 1.2 for women). These patterns and time-trends in Victorian alcohol-related hospitalizations reflect a combination of alcohol-related morbidity levels, hospital admission practices and patterns and levels of service provision. They suggest a potential need to focus on services and programmes in rural/remote Victoria. [Hanlin K, Jonas H, Laslett A-M, Dietze P, Rumbold G. Patterns and trends in alcohol-related hospitalizations in Victoria, Australia, 1987/88 - 1995/96. Drug Alcohol Rev 2000;19:381-390]     

Characteristics of treatment provided for amphetamine use in New South Wales, Australia

The purpose of this study was to examine the types of treatment services provided for amphetamine use, the characteristics of amphetamine treatment clients and the geographic areas most affected by amphetamine treatment provision within New South Wales (NSW), Australia. Data on completed amphetamine treatment episodes were extracted from the NSW Minimum Data Set for Alcohol and Other Drug Treatment Services for the year 2002/03 (n = 4337). The geographic area of treatment presentations was based on the location of the treatment service, and was categorized as metropolitan, regional or rural. Treatment disproportionately affected regional and rural NSW, and treatment clients often presented with concurrent cannabis and/or alcohol problems. Clients were overwhelmingly injecting drug users with poor socio-demographic characteristics. Counselling was the most common treatment service provided, followed by detoxification and residential rehabilitation. Detoxification was usually provided in an in-patient setting, particularly within metropolitan NSW. Compliance with residential rehabilitation was notably poor. In conclusion, the development of appropriate interventions for amphetamine use needs to consider that the majority of treatment recipients will be based in a regional or rural setting, and treating amphetamine users will often involve treatment of concurrent cannabis and alcohol problems. The nature and appropriateness of treatment services provided for amphetamine use needs to be reviewed in detail, and further research is needed into the nature of problematic amphetamine use and factors affecting treatment demand in regional and rural NSW. [McKetin R, Kelly E, Indig D. Characteristics of treatment provided for use of amphetamines in New South Wales, Australia. Drug Alcohol Rev 2005;24:433-436]     

HIV infection and risk behaviour of primary fentanyl and amphetamine injectors in Tallinn,Estonia: Implications for intervention

BackgroundFollowing a heroin shortage, fentanyl and 3-methylfentanyl, known as “China White” and “White Persian”, have become the most widely used drugs, along with amphetamine, among injecting drug users (IDUs) in Tallinn, Estonia.MethodsIn order to assess the relationships between the injection of fentanyl and amphetamine, and levels of HIV prevalence and risk behaviour, 350 current IDUs were recruited using respondent-driven sampling for an interviewer-administered unlinked cross-sectional survey and HIV testing. IDUs were categorised into groups based on self-report of the main drug used within the last 28 days.Results77% (256/331) of participants reported fentanyl and 23% (75/331) amphetamine as their main drug of injection. HIV prevalence was 27% (95% confidence interval [CI]: 18.45–35.51) and 62% (95% CI: 56.97–67.03) among amphetamine and fentanyl injectors, respectively. After adjustment, fentanyl injectors had three times the odds of being HIV positive (adjusted odds ratio [AOR] = 2.89; 95% CI: 1.55–5.39). They also had higher odds for injecting in the street with a previously used needle/syringe (AOR = 2.39; 95% CI: 1.14–5.04) and sharing a needle/syringe with somebody known to have HIV (AOR = 3.00, 95% CI: 1.33–6.79). Fentanyl injectors also had higher odds for lifetime overdose (AOR = 3.02, 95% CI: 1.65–5.54).ConclusionThe injection of fentanyl is associated with elevated injecting risk behaviour derived from injection practice and situational risk factors, and needs urgently targeted interventions.     

Comparing injection and non-injection routes of administration for heroin, methamphetamine, and cocaine users in the United States

Research examining the demographic and substance use characteristics of illicit drug use in the United States has typically failed to consider differences in routes of administration or has exclusively focused on a single route of administration?injection drug use. Data from National Survey on Drug Use and Health were used to compare past-year injection drug users and non-injection drug users' routes of administration of those who use the three drugs most commonly injected in the United States: heroin, methamphetamine, and cocaine. Injection drug users were more likely than those using drugs via other routes to be older (aged 35 and older), unemployed, possess less than a high school education, and reside in rural areas. IDUs also exhibited higher rates of abuse/dependence, perceived need for substance abuse treatment, and co-occurring physical and psychological problems. Fewer differences between IDUs and non-IDUs were observed for heroin users compared with methamphetamine or cocaine users.     

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.     

Processes and outcomes of training on rapid assessment and response methods on injecting drug use and related HIV infection in the Russian Federation

In September 1997, Médecins Sans Frontières-Holland (MSF-H) began a project to provide training and support for HIV/AIDS prevention among injecting drug users (IDUs) in the Russian Federation, focusing on the use of the World Health Organization Rapid Assessment and Response Guide on Injecting Drug Use, and the European Peer Support Manual. As part of the training, participants are asked to carry out a rapid situation assessment (RSA) in their city or region as a major step towards designing and implementing an effective program to prevent HIV transmission among IDUs. This paper focuses on the first four training cycles of the programme (from January 1998 to January 1999), in which 89 health professionals and others from 32 Russian cities took part. A total of 28 rapid situation assessments were completed or almost completed by participants during these four cycles. The paper provides an overview of the methods used and major problems faced by participants undertaking these assessments, as well as summarising the 14 harm reduction programmes which resulted.     

Negotiated safety: what you don't know won't hurt you,or will it?

People inject drugs for a variety of reasons, and most do not want to harm themselves in the process. Drug injectors develop rituals for 'low risk' drug-taking based on experience, information received, hearsay and ignorance. The rituals developed are not always able to be used due to the illegal nature of the activity. Understanding of the beliefs of injecting drug-users (IDUs) and the events that influence behaviour is a potential pathway for ameliorating this often hazardous act. Needle-sharing is now not a common behaviour although, if there are no new needles at the time of injecting, IDUs will still share needles, usually with sexual partners and 'close friends'. Other injecting equipment, such as spoons, filters, water, etc., are usually shared. IDUs, like all other drug users, make many assumptions and it appears that IDUs rarely negotiate their drug use to make it 'safer'.     

Injecting Equipment Provision in Australia: The State of Play

Injecting equipment provision measures in Australia can be judged reasonably successful as HIV prevention measures. In the capital cities of all Australian States and Territories, access to needles and syringes is easy, at least during the day in at least some areas. In conjunction with peer education and other activities, needle and syringe supply appears to have led to a change in norms away from the sharing of needles and other injecting equipment among at least older heroin injectors in large population centers. However, in many other areas, and in many subpopulations-particularly further marginalized groups such as Aboriginal and Vietnamese-Australian injectors-messages about HIV/AIDS risk are either not penetrating or are being ignored, and needle and other equipment sharing still appears to be common. The strategy of providing access to needles and syringes as a separate activity from peer education among injecting drug users (IDUs) needs to be reconsidered in the light of the widespread epidemic of hepatitis C among Australian IDUs. The level of supply of all injecting equipment also needs to be increased to assist all IDUs in learning and carrying out an aseptic injecting technique given the lack of an effective disinfection technique to prevent the spread of hepatitis C, and me problems surrounding both the promotion of disinfection and the promotion of noninjecting routes of administration.     

HCV synthesis project: preliminary analyses of HCV prevalence in relation to age and duration of injection

Early acquisition of hepatitis C virus (HCV) infection appears to affect a substantial proportion of injection drug users (IDUs)--between 20 percent and 90 percent. Analysing the range of HCV prevalence estimates in new injectors may help identify factors that can be modified to reduce HCV transmission. The HCV Synthesis Project is a meta-analysis of studies of HCV epidemiology and prevention in drug users worldwide. In this preliminary analysis, we examined data from 127 studies of IDUs that reported HCV prevalence in relation to age or year since onset of drug injection, analysing heterogeneity and calculating summary statistics where appropriate. Six studies reported gender-specific HCV prevalence rates among young or new injectors; the group mean prevalence was 47 percent for men and 44 percent for women (NS). Group mean age for HCV-negatives was 24.7 years (range 24-28) and 26.1 years (range 21-31) for HCV-positives (n=8 studies). Data were examined from 13 studies that compared HCV prevalence among young injectors to older injectors using 5-year age categories; substantial variation was present within these categories such that measures of central tendency were not calculated. Similarly, among studies reporting HCV prevalence among IDUs in relation to 1-year intervals of duration of injection (<1 year, <2 years, and <3 years), considerable variability was observed. Notably, there were studies in each category that reported prevalence of 70 percent or higher among recent-onset drug injectors. Our findings confirm previous studies reporting high risk of acquiring HCV shortly after onset of injection; thus, HCV prevention programmes must emphasize methods to reach new injectors. Future research should (1) report data on time to infection in depth, (2) provide detailed information on study methodology, and (3) characterize the research setting with respect to underlying factors that affect injection practices and networks. This will permit synthesis of a greater number of studies and may lead to the identification of factors that impede HCV transmission.     

The drug career of the older injector

Drug theorists have used the concept of a “career” to understand why some individuals enter and become deeply entrenched in a life organized around illicit drug-use. Previously career analyses have focussed on the lives and activities of chronic users at youth and middle age. We extend this work by examining the drug careers of life-long drug injectors (injection drug users, IDUs) of age 50 and more. Based on in-depth interviews with 40 active injectors between ages 50 and 68, we explore the interactional effects of aging and drug-use as they affect the lives of older injectors on the streets. We show that age forms a career contingency with the power to realign former roles and relationships. Retiring from the life career of chronic users seems doubtful for older users except through illness and death. Our findings point to the developmental aspects of a drug-dependent life style and why patterns and practices of drug-use change over time.     

Can drug injectors be encouraged to adopt non‐injecting routes of administration (NIROA) for drugs?

Drug use by injection can cause problems specific to this form of administration. Problems include an increased risk of drug overdose, drug dependence, the transmission of HIV, hepatitis B and hepatitis C and vein damage. Shifting drug injectors from injecting to another route of administration may minimize these problems. The aims of the study were to develop and trial an intervention to assist willing injecting drug users (IDUs) to shift to non-injecting routes of administration (NIROA) and to explore the acceptability and practicality of facilitating NIROA. IDUs were assessed and suitable subjects entered a cognitive behavioural trial consisting of five 1-hour sessions of individual therapy with a registered psychologist. Forty-two subjects were assessed (22 males and 20 females). Thirty subjects entered treatment. The mean age was 36 years. Twenty-one subjects were followed-up at 3 months and 10 subjects at 6 months. At 3 and 6 months, the proportion of subjects who had commenced using NIROA was 30% and 50%, respectively. This pilot study showed that it was possible to assist a minority of drug injectors to move from injecting to the non-injecting administration of drugs. However, many of these appeared to be already motivated to cease using drugs and adopting NIROA was one way of assisting this. Poor follow-up rate, lack of control group, questions about cost-effectiveness and the impact of market factors which possibly constrain shifting to NIROA suggest that further research is needed before it could be said that NIROA should be recommended as a viable harm reduction strategy in the Australian context.     

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 drug use in Calcutta: a potential focus for an explosive HIV epidemic

Our objective was to assess HIV risk perceptions, risk behaviours and factors that may facilitate an increase in injection drug use in Calcutta. Focus group discussions and in-depth interviews were conducted with a selected group of drug users to delineate drug use patterns, languages used to express addictive and related experiences and acceptance of harm minimization messages. Results from these were used to develop a semi-structured interview instrument which was used to interview 111 drug users (76 IDUs and 35 non-IDUs) recruited from jails and detoxification centres. Secondary data of narcotic seizures for the last 5 years were collected from the Calcutta police department. Data on percentage of IDUs admitted to large detox facility in the city was also collected. Findings show that HIV/AIDS knowledge and risk perceptions were low; sharing of injection equipment was reported by 66% of the injectors; and condom use was insignificant. Non-availability, rising cost and increasing tolerance to heroin were cited as factors contributing to switch to injection. Ecological association was found between intensified police activity and an increase in: the amount of smokable heroin seized; increased injection of buprenorphine; and admission to detoxification centres. In addition to HIV, IDUs were also found to be prone to hepatitis B and C. The findings suggest an urgent need for developing and implementing community-based HIV prevention interventions targeting drug users in Calcutta.     

Buprenorphine injection in Melbourne, Australia--an update

Objective. To investigate the prevalence and associations of buprenorphine injection among a field-recruited cohort of injecting drug users. Design. Cross-sectional data from a prospective longitudinal cohort. Setting. Metropolitan Melbourne, Australia. Subjects. Current injecting drug users (IDUs). Main Outcome Measures. Prevalence of buprenorphine injection, associations with location, buprenorphine as prescribed pharmacotherapy, markers of hepatitis C virus (HCV) exposure and risk behaviours for HCV. Results. More than 10% of our 316 participants reported buprenorphine as the drug they had most often injected, and 32% had injected buprenorphine at least once in the 3 months prior to interview. Primary buprenorphine injection was significantly more likely to be reported by IDUs recruited at one of our three research sites, and by those being prescribed buprenorphine for opioid dependence. Frequency of sharing a used needle was also associated with buprenorphine injection, but HCV exposure was not. Conclusions. Buprenorphine injection has become entrenched among some groups of Victorian IDUs. The practice carries serious risks to health, including some related to microbiological contamination of buprenorphine during diversion. While measures can be taken to reduce the occurrence of buprenorphine diversion and injection and the associated harm, an alternative harm reduction measure would be to provide IDUs with an injectable pharmacotherapy. [Aitken CK, Higgs PG, Hellard ME. Buprenorphine injection in Melbourne, Australia—an update. Drug Alcohol Rev 2008;27:197-199]     

A mixed methods approach to delineating and understanding injection practices among clientele of a Victoria, British Columbia needle exchange program

Introduction and Aims. Systematic reviews and meta‐analyses show that needle exchange programs reduce HIV and HCV transmission for injection drug users (IDUs) but far less is known about the injection practices of IDUs enrolled in these programs. This study adopts a mixed methods approach to quantify high‐risk injection practice patterns among IDUs enrolled in a needle exchange program in Victoria, British Columbia, Canada and gather qualitative data to understand underlying injection behaviour rationales and patterns. Design and Methods. Survey data collected in 2008 from 105 IDUs registered as clientele of the AIDS Vancouver Island‐Street Outreach Services (AVI‐SOS) Needle Exchange were analysed via univariate and multivariate statistical methods. Presentation of this analysis to an AVI‐SOS needle exchange clientele group generated qualitative data offering an explanation for quantitative results. Results. Univariate analysis showed all respondents reporting at least one high‐risk practice within the past month. Multivariate logistic regression analysis using input from AVI‐SOS clientele confirmed the importance of housing status as a determinant of injection practices. Discussion and Conclusions. The importance of housing status points to the need to combine harm reduction services, for example needle exchange and appropriate housing and highlights the benefits of including IDUs in data interpretation.[Gibson EK, Exner H, Stone R, Lindquist J, Cowen L, Roth EA. A mixed methods approach to delineating and understanding injection practices among clientele of a Victoria, British Columbia needle exchange program. Drug Alcohol Rev 2011;30:360–365]     

Association between neighbourhood socioeconomic characteristics and high-risk injection behaviour amongst injection drug users living in inner and other city areas in Montréal,Canada

BackgroundArea-level socioeconomic conditions are associated with epidemic rates of viral hepatitis and HIV amongst urban injection drug users (IDUs), but whether specific socioeconomic markers are uniformly related to IDU outcomes across different urban environments is unclear. We evaluated whether injection behaviour is differentially related to neighbourhood socioeconomic characteristics for IDUs in inner city vs. surrounding urban areas.MethodsThe study population was 468 active IDUs on the Island of Montréal. Neighbourhoods were represented as 500 m radius buffers around individual IDU dwelling places. High-risk injection behaviour (HRIB) was defined dichotomously. Relations between neighbourhood socioeconomic disadvantage (percentage households below low-income cutoff), neighbourhood educational attainment (percentage adults with university degree), and HRIB were assessed using multivariate logistic regression. Stratified analyses were conducted for inner city IDUs (n = 219), and those in surrounding areas (n = 249).ResultsSimilar proportions of IDUs in inner city and surrounding areas reported HRIB. Neighbourhood socioeconomic characteristics were not associated with HRIB for IDUs in surrounding areas. For inner city IDUs, those in socioeconomically disadvantaged neighbourhoods were more likely to practice HRIB (OR 4.34; 95% CI 1.15–16.35). Conversely, inner city IDUs residing in lower educational attainment neighbourhoods had a lower odds of HRIB (OR 0.41; 95% CI 0.21–0.80).ConclusionHRIB did not vary according to urban environment but for inner-city IDUs was differentially related to socioeconomic markers. Associations between HRIB and neighbourhood socioeconomic disadvantage and lower educational attainment, positive and negative, respectively, indicate that adverse socioeconomic circumstances are not related to a uniformly greater likelihood of HRIB.