Factors associated with recent-onset injection drug use among drug users in Pakistan

Seventy-two recent-onset injection drug users and 241 non-injection drug users were recruited in Quetta and Lahore, Pakistan, in 2003. Trained interviewers administered questionnaires regarding drug use behaviors and perceived changes in drug cost/supply. Logistic regression identified independent correlates of recent-onset injection. In Lahore, a perceived increase in drug cost was associated with higher odds of recent-onset injection, with no association in Quetta. Recent-onset injection was also associated with family history of drug use, group drug use, and sharing snorting/chasing tools. Changes in perception of the drug supply may be associated with recent-onset injection drug use. Familial/social influences were also associated with recent-onset injection, suggesting peer-led interventions could discourage transition to injection drug use.     

Social support and zero sharing risk among hazardously drinking injection drug users

We compared the sociodemographic, drug use, and social support characteristics of injection drug users (IDUs) who reported at least 6 months having not "shared needles or works" (zero sharing risk) with those who reported recent equipment sharing. 187 AUDIT-positive (>8), active IDUs were recruited between February 1998 and October 1999 from a needle exchange program in Providence, RI. The sample was 64% male and 87% white, with a mean age of 36 years, and 32% of subjects reported zero sharing risk in the prior 6 months. Variables having significant (P<.05) associations with zero sharing risk included: older age, lower heroin use frequency, lower cocaine use, and increased frequency of needle exchange visits. As social support from friends increased, the likelihood of sharing decreased. Subjects with substance-using friends or partners were significantly more likely to share than those without such associations (OR = 9.4; P<.05). Social support and social network composition influenced sharing behaviors in active, out-of-treatment drug injectors. Interventions that mobilize social support may increase the possibility of zero sharing, an important public health goal.     

乌鲁木齐市吸毒人群首次注射吸毒和共用器具注射吸毒的调查研究

目的：了解新疆乌鲁木齐市吸毒人群从首次注射吸毒到首次共用器具注射吸毒的发生情况及影响因素。方法：于2005年4-6月以社区为基础招募吸毒者，调查其社会人口学特征、首次吸毒、首次注射吸毒和首次共用器具注射吸毒情况。结果：在调查的静脉吸毒者401人中，68．6％（275／401）的吸毒者曾经共用器具注射吸毒。从首次吸毒到首次注射吸毒的发生率为23．58／100人年（95％CI=21。27-25．89），多因素Cox比例风险回归模型分析结果显示：女性（HR=1.65，95％CI=1．21-2，24）和首次吸毒年份为1994年及以后（HR=3．56，95％CI=2．84～4．47）与首次注射吸毒发生的关系有统计学意义；从首次注射吸毒到首次共用器具注射毒品的发生率为24．99／100人年（95％CI=22．04-27，94），多因素Cox比例风险回归模型分析结果显示：维族（HR=I，41，95％CI=1.08～1．85）、初中及以下文化程度（HR=1，41，95％CI=1.09-1．82）和首次注射吸毒年份为1998年及以后（HR=1．56，95％CI=1．20-2．04）与首次共用器具注射吸毒发生的关系有统计学意义。结论：近期开始滥用毒品的吸毒者易于从口吸转变为注射吸毒进而共用器具注射吸毒。注射吸毒是HIV感染和传播的主要途径。     

Serosorting for hepatitis C status in the sharing of injection equipment among Seattle area injection drug users

Background

Hepatitis C virus (HCV) is a major health problem among injection drug users (IDU). One potential means of reducing risk of HCV transmission among IDU is serosorting, whereby IDU preferentially share injection equipment with persons of like HCV status.

Methods

We surveyed Seattle area IDU recruited by respondent-driven sampling as part of the National HIV/AIDS Behavioral Surveillance system in 2005.

Results

Of 337 participants, 91% reported ever having been tested for HCV. Fifty-three percent of participants who shared any injection equipment in the last 12 months reported knowing the HCV status of the last person with whom they shared injection equipment. Thirty-seven percent of self-reported HCV-positive participants reported that their last injection equipment sharing partner was also HCV-positive and 7% reported a HCV-negative partner. Among self-reported HCV-negative participants, 11% reported a HCV-positive partner and 23% a negative partner. The disproportionate tendency to share injection equipment with a partner of like HCV status persisted after control for characteristics associated with HCV positivity in stratified and logistic regression analyses. Among participants sharing injection equipment, 39% reported that they had intentionally shared injection equipment with a partner based on knowledge of their concordant HCV status.

Conclusions

We conclude that a measurable degree of serosorting by HCV status is occurring among Seattle area IDU. Promotion of serosorting among HCV-positive IDU may be a useful harm reduction strategy for IDU who continue to practice sharing injection equipment. If judged efficacious, serosorting would provide a further rationale to encourage and support HCV testing among IDU.     

Beyond needle sharing: meta-analyses of social context risk behaviors of injection drug users attending needle exchange programs

This study gathered data from U.S. and international needle exchange programs (NEPs). Of particular interest were outcome measures of dependent variables related to behaviors within social contexts of injection drug users (IDUs), an area not well understood. Thirty-one studies, with a total of 86 separate measures of 36 dependent variables were included. Because combining all results into a single meta-analysis would be inappropriate, dependent variables were placed into five categories for five separate meta-analyses: risky contexts, injection frequency, sharing drug paraphernalia, drug preparation, and syringe use. NEP attendance was inversely related to declines in all categorical behaviors except for "risky context." NEP attenders are slightly more likely to be in a risky circumstance when injecting drugs than non-attenders. While injection frequency declined only slightly among NEP attenders, that result may be interpreted as a positive outcome, given the often-stated criticism that providing clean needles encourages increased drug use. NEP use was weakly associated with a decrease in the sharing of drug paraphernalia. Clean needles alone do not appear to be sufficient motivation to motivate major changes in contextual risk behaviors analyzed herein. Research is needed to assess the impact of interpersonal IDU relationships with other stakeholders (clinic employees, van drivers, medical personnel, nutritionists, sexual partners, etc.) on IDU drug-using behaviors at many levels.     

HIV prevalence and correlates of receptive needle sharing among injection drug users in the Mexican-U.s. border city of Tijuana

Injection drug use is a growing but understudied problem in Tijuana, a city situated on the northwestern Mexico-U.S border. The authors studied factors associated with receptive needle sharing in an effort to inform prevention activities. In 2003, street-recruited injection drug users (IDUs) in Tijuana underwent interviews on injection risk behaviors and rapid HIV antibody tests. Logistic regression was used to identify correlates of receptive needle sharing at the last injection episode. Of 402 IDUs, 87.6% were male; the median age was 34. HIV prevalence was 4.01% (95% CI: 2.29-6.51). One third reported receptive needle sharing at last injection. Factors independently associated with receptive needle sharing were years living in Tijuana (Adjusted Odds Ratio [AdjOR]= 0.97 per year, 95% CI: 0.96-0.99), being bisexual/homosexual (AdjOR=2.12; 95% CI: 1.30 - 3.44), unemployed (AdjOR=2.5; 95% CI: 1.52-4.10), never having an HIV test (AOR: 4.02; 95% CI: 2.44-6.60), having friends who placed importance on avoiding HIV (AdjOR: 0.36; 95% CI: 0.19-0.68) and last injecting in a shooting gallery (AdjOR=1.98; 95% CI: 1.21-3.24). These results underscore the need to increase access to voluntary HIV testing and counseling to IDUs and migrants in Tijuana, as well as expand access to sterile syringes in an effort to avert widespread HIV transmission.     

Collateral damage in the war on drugs: HIV risk behaviors among injection drug users

Objective: To determine whether two key War on Drugs policies, the criminalization of syringes and the disqualification of drug users from the Supplemental Security Income (SSI) program, are associated with injection-related human immunodeficiency virus (HIV) risk behaviors among injection drug users (IDUs). Methods: IDUs were interviewed regarding HIV risk behaviors, drug use, and criminal activities in six San Francisco Bay Area communities in 1996 and followed through 1997 (n=1257). Multivariate analysis was conducted to examine the association between concern about arrest while carrying drug paraphernalia and injection-related risk behaviors. Regarding SSI, respondents were interviewed before (1996) and after (1997) drug and alcohol addicts were disqualified from SSI (n=88). Bivariate analysis was conducted comparing IDUs who lost SSI benefits with those who retained benefits. Results: Among our study sample, 32% of IDUs reported being concerned about possible arrest while carrying drug paraphernalia. In multivariate analysis, concerned IDUs were over one-and-a-half times more likely to share syringes than IDUs not concerned (adjusted odds ratio=1.74; 95% confidence interval =1.24, 2.44). Regarding SSI, 60% (53/88) of baseline SSI recipients had lost benefits by their follow-up interview. IDUs who lost benefits were more likely to participate in illegal activities (48 vs. 27%; P<0.05), more likely to share syringes (17 vs. 0%; P<0.05) and injected drugs on average more (43.8 vs. 36.4 per month; P<0.03) than those who retained benefits. Conclusions: These data suggest that War on Drugs policies which deny injection equipment and federal income support to IDUs also increase their risk for HIV infection, and should be reconsidered.     

Correlates of sharing injection equipment among male injecting drug users in Kathmandu, Nepal

BackgroundHIV prevalence is high and risky injection practices occur frequently among injecting drug users (IDUs) in Nepal. We explored the correlates of sharing injection equipment (having injected with a needle or syringe previously used by another) among male IDUs in Kathmandu, Nepal.MethodsFrom August to September 2007, we anonymously interviewed 296 male IDUs in Kathmandu, Nepal, using a structured questionnaire. We performed bivariate and multivariable logistic regression analysis and identified variables associated with sharing injection equipment.ResultsOver half (n = 152) of the participants reported injecting drugs with a needle or syringe previously used by another in the past year. Of these, 70% reported engaging in sharing injection equipment with multiple persons. The unavailability of new needles and drinking alcohol were independently associated with sharing injection equipment among the study participants.ConclusionsIDUs who drank alcohol or who could not obtain new needles when needed were more likely to share injection equipment. Our results suggest that reducing alcohol use and increasing the availability of new needles and syringes might improve safer injection practices among male IDUs in Kathmandu, Nepal.     

Changes in the sharing of drug injection equipment among street-recruited injection drug users in Chicago, Illinois, 1994--1996

This study examines changes in the multi-person use of drug injection paraphernalia during the mid-1990s, a time of increasing awareness of HIV transmission modes and availability of prevention programs. Beginning in 1994, 794 street-recruited injection drug users in Chicago were interviewed and followed at 6 and 12 months postbaseline. Random-effects, pattern-mixture logistic regression models were used to determine correlates of five injection-equipment sharing practices, while accounting for repeated measurement and study attrition. At baseline, 45.7% of participants reported receptive syringe sharing in the previous 6 months. Syringe-mediated sharing was reported by 28.7% of participants and the sharing of cookers (65.1%), cotton filters (55.7%), and rinse water (46.9%) was common. During follow-up, the proportion of all sharing behaviors decreased significantly, especially receptive syringe sharing. Participation in a syringe exchange program was associated with reductions in receptive syringe sharing and syringe-mediated sharing, but not the sharing of cookers.     

A cross-sectional assessment of utilization of addiction treatment among injection drug users in Kabul, Afghanistan

The purpose of this study was to describe prior use of detoxification and addiction-treatment programs among injection drug users (IDUs) in Kabul, Afghanistan. From 2005-2006, IDUs (n = 464) recruited into this cross-sectional study completed an interviewer-administered questionnaire and whole blood rapid testing with fingerstick samples for HIV, syphilis, and hepatitis C antibody and B surface antigen testing. Participants were predominantly male (99.8%), Afghan (98.9%), and had little formal education. Correlates of detoxification and addiction treatment were identified with logistic regression. The majority (94.0%, n = 435) felt great/urgent need for treatment, of whom 56.3% (n = 245) reported inability to access treatment. Prior detoxification was associated with new needle use with each injection (AOR = 1.91, 95% CI: 1.12-3.26) and prior incarceration (AOR = 1.81, 95% CI: 1.04-3.13). The study's limitations are noted. Rapid scale-up and subsidy of needle and syringe programs and opioid agonist treatment is urgently needed in Kabul.     

Cross-border drug injection relationships among injection drug users in Tijuana, Mexico

BackgroundInternational borders are unique social and environmental contexts characterized by high levels of mobility. Among drug users, mobility increases risk for human immunodeficiency virus (HIV) in part through its effects on the social environment. However, the social dynamics of drug users living in border regions are understudied.Methods1056 injection drug users (IDUs) residing in Tijuana, Mexico were recruited using respondent-driven sampling (RDS) from 2006 to 2007, and underwent surveys and testing for HIV, syphilis, and tuberculosis (TB). Using logistic regression on baseline data, we identified correlates of having ever injected drugs with someone from the US.ResultsAlmost half (48%) reported ever injecting drugs with someone from the US. In RDS-adjusted logistic regression, factors independently associated with having ever injected with someone from the US included: having greater than middle school education (Adjusted Odds Ratio [AOR] 2.91; 95% confidence interval [C.I.] 1.52, 5.91), speaking English (AOR 3.24, 95% C.I. 1.96, 5.36), age (AOR 1.10 per year; 95% C.I. 1.07, 1.14), age at initiation of injection drug use (AOR 0.90 per year; 95% C.I. 0.86, 0.94), homelessness (AOR 2.61; 95% C.I. 1.27, 5.39), and having ever been incarcerated (AOR 11.82; 95% C.I., 5.22, 26.77). No associations with HIV, syphilis, TB, drug use, or injection risk behavior were detected.ConclusionFindings suggest that IDU networks in Mexico and the US may transcend international borders, with implications for cross-border transmission of infectious disease. Binational programs and policies need to consider the structure and geographic distribution of drug using networks.     

Predictors of sharing drugs among injection drug users in the South Bronx: implications for HIV transmission

HIV may be transmitted in the process of sharing injected drugs, even if all participants have their own syringes. In an effort to gain understanding of the extent and predictors of drug sharing, data were obtained via personal interviews with 1,024 injection drug users from four neighborhoods in the South Bronx. The relationship between drug-sharing and demographic, sexual, and drug-related variables was first examined in a bivariate analysis, and then via multiple logistic regression. Individuals who split drugs were more likely to be female, have had sex with a casual partner, exchanged sex for drugs or other needs, recently smoked crack cocaine, and shared needles. They were less likely to live or inject at their own home or have used a new needle the last time they injected. In a final logistic model, correlates of drug sharing included trading sex, injecting outside one's home, and using borrowed, rented or shared needles. Despite the lack of significance for gender in the final logistic model, females were at high risk of drug sharing because they constituted the great majority of those who exchanged sex. Continuing research is needed to understand how drug-sharing contributes to the spread of HIV and other infections, as are studies of approaches to reducing drug sharing. Prevention strategists and outreach organizations should be aware of the HIV risks inherent in the widespread practice of drug sharing.     

Distributive syringe sharing among young adult injection drug users in five U.S. cities

Blood-borne pathogens such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV) are transmitted most commonly among injection drug users (IDUs) through the sharing of needles and syringes. Distributive syringe sharing (DSS) (i.e., passing on a used needle/syringe to another IDU) poses the potential risk of transmitting HIV and viral hepatitis to others. We studied the prevalence and correlates of DSS among IDUs enrolled in a randomized behavioral intervention trial designed to reduce behaviors associated with HIV and HCV transmission in five U.S. cities. Among 3129 IDUs ages 15-30 years who completed the baseline visit, 1432 (45.8%) engaged in DSS during the 3 months prior to baseline. Significant correlates of DSS were perception that peer norms condone needle sharing, frequent injection, not obtaining most syringes from needle exchange programs or pharmacies, injecting most frequently in shooting galleries and with sex partners, low perceived risk of HIV from sharing syringes, increased anxiety, low self-esteem, and having unprotected sex. Restricting to only those IDUs who reported not injecting with previously used syringes, similar independent correlates of DSS were found. These findings suggest that interventions to reduce ongoing transmission of blood-borne infections should focus on altering peer norms among networks of young IDUs.     

Trends in the injection of midazolam and other drugs and needle sharing among injection drug users enrolled in the AIDSVAX B/E HIV-1 vaccine trial in Bangkok,Thailand

Midazolam injection may increase the hazards of drug use. Its ability to cause amnesia may be associated with increased HIV risk behaviour and its interaction with other licit and illicit drugs may cause overdose and death. We analysed midazolam injection among injecting drug users (IDUs) participating in the AIDSVAX B/E HIV-1 vaccine trial in Bangkok, Thailand. From March 1999 to August 2000, 2545 IDUs were enrolled and randomised to receive AIDSVAX B/E or placebo. An interviewer-administered questionnaire assessed demographics (at baseline) and drug use behaviour (every 6 months). Reports of midazolam injection were statistically evaluated. During 36 months of follow-up, injection of any drug decreased from 94 to 51% and needle sharing decreased from 33 to 16%. Among those who continued to inject, midazolam injection increased from 10 to 31% (all p < 0.0001). Earlier study visit, lower education and less frequent injection were independently associated with less frequent midazolam injection; younger age, reports of needle sharing and receiving methadone treatment were independently associated with more frequent midazolam injection. Preventive interventions to educate IDUs and midazolam prescribers are urgently needed.     

Non-fatal overdose and subsequent drug treatment among injection drug users

Overdose is a leading cause of death among illicit drug users. Nine hundred twenty-four injection drug users (IDUs) in Baltimore, Maryland, were interviewed to characterize overdose events and determine the circumstances under which they lead to drug treatment. Overall, 366 (39.7%) reported at least one non-fatal drug overdose. Most (96.2%) used heroin on the day of their last overdose and almost half (42.6%) used heroin and alcohol but few (4.1%) used tranquilizers or benzodiazepines. Five percent were in drug treatment when the overdose occurred and 7.1% had been incarcerated 2 weeks prior. One in four IDUs (26.2%) sought drug treatment within 30 days after their last overdose of whom 75% enrolled. Speaking with someone about drug treatment after the overdose was associated with treatment seeking (AOR 5.22; 95% CI: 3.12, 8.71). Family members were the most commonly cited source of treatment information (53.7%) but only those who spoke with spouses, crisis counselors and hospital staff were more likely to seek treatment. Not being ready for treatment (69.6%) and not viewing drug use as a problem (30.7%) were the most common reasons for not seeking treatment and being placed on a waiting list was the most common reason for not subsequently enrolling in treatment (66.7%). Of the IDUs treated by emergency medical technicians, ER staff or hospital staff, only 17.3%, 26.2% and 43.2% reported getting drug treatment information from those sources, respectively. Interventions that provide drug treatment information and enhance motivation for treatment in the medical setting and policies that reduce barriers to treatment entry among motivated drug users are recommended.     

Hepatitis C knowledge among new injection drug users

Aims: New injection drug users (IDUs) are vulnerable to hepatitis C infection from risky injection practices. This article considers the range of hepatits C virus (HCV) knowledge among participants in a 2-year study examining the behaviours of new IDUs.

Methods: Respondents (n = 36) were members of a cohort of new IDUs recruited in the New York City metropolitan area whose first injection occurred within the previous 18 months. Respondents were offered human immuno virus (HIV), hepatits B virus (HBV) and HCV testing. Two tested HIV positive and 12 tested HCV positive. During pre-test counselling they completed a qualitative interview focusing on aspects of HCV including: transmission, symptoms, long-term effects, prevention, treatment, concern regarding contracting HCV and how this concern impacted drug use and injection practices.

Findings: Substantial gaps were seen in HCV knowledge. While respondents were aware that HCV is a blood-borne virus, the majority had only approximate knowledge regarding transmission, symptoms and effects. Respondents reported little discussion of HCV with peers and minimal concern about contracting HCV, especially compared with HIV.

Conclusion: Accurate HCV information is failing to reach new IDUs, and new IDUs may not value the little information they do receive. More effective and innovative efforts are required to disseminate effective HCV prevention information to new IDUs.     

Activity spaces among injection drug users in San Francisco

BackgroundRepresentations of activity spaces, defined as the local areas within which people move or travel in the course of their daily activities, are unexplored among injection drug users (IDUs). The purpose of this paper is to use an activity space framework to study place and drug user health.MethodsData for this analysis is from an epidemiological study of street-recruited IDUs in San Francisco (N = 1084). Study participants reported geographic intersections of where they most often slept at night, hung out during the day, and used drugs during a 6 month time period. We used GIS software to construct and map activity space routes of street-based network paths between these intersections. We further identified if syringe exchange program (SEP) locations intersected with, participant activity space routes. We used logistic regression to estimate associations between activity space variables and HIV serostatus, syringe sharing, and non-fatal overdose, after adjusting for individual and Census tract covariates.ResultsMean activity space distance for all participants was 1.5 miles. 9.6% of participants had a SEP located along their activity space. An increase in activity space distance was associated with a decrease in odds of being HIV positive. An increase in residential transience, or the number of different locations slept in by participants in a 6 month time period, was associated with higher odds of syringe sharing. Activity space distance was not independently associated with overdose or syringe sharing.DiscussionResearch that locates individuals in places of perceived importance is needed to inform placement and accessibility of HIV and overdose prevention programs. More attention needs to be given to the logistics of collecting sensitive geospatial data from vulnerable populations as well as how to maximize the use of GIS software for visualizing and understanding how IDUs interact with their environment.     

Drug injection cessation among HIV-infected injecting drug users

This article reports findings from a cohort study that investigated drug injection cessation over an 18-month period among HIV-infected injecting drug users followed up in a clinical setting. At 18th month visit, individuals reporting persistent injection practices were compared with individuals who reported drug injection cessation for at least 12 months. Crude and adjusted odds ratios were used to assess the impact of change in addictive and sexual behaviors, contacts with the drug network, depression, negative life events, clinical status, HIV therapy, and drug maintenance treatment (DMT) on drug injection cessation. After multiple adjustment, a general decrease of addiction practices (alcohol and cannabis) and of unsafe sexual behaviors significantly accompanied injection cessation. Individuals with higher education level, still in contact with the drug network, and not yet treated for their HIV disease were significantly more likely to persist injecting behaviors. These results underscore the importance and the need of monitoring addiction practices and unsafe sexual behaviors among HIV-positive individuals to properly address primary and secondary prevention in the era of highly active antiretroviral treatments (HAART).