Blood‐borne viruses and their survival in the environment: is public concern about community needlestick exposures justified?

BACKGROUND: More than 30 million needle syringes are distributed per year in Australia as a component of harm-reduction strategies for injecting drug users (IDU). Discarded needle syringes create considerable anxiety within the community, but the extent of needlestick injuries and level of blood-borne virus transmission risk is unclear. We have undertaken a review of studies of blood-borne virus survival as the basis for advice and management of community needlestick injuries. METHODS: A Medline review of published articles on blood-borne virus survival and outcome from community injuries. RESULTS: Hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) can all survive outside the human body for several weeks, with virus survival influenced by virus titer, volume of blood, ambient temperature, exposure to sunlight and humidity. HBV has the highest virus titers in untreated individuals and is viable for the most prolonged periods in needle syringes stored at room temperature. However, prevalence of HBV and HIV are only 1-2% within the Australian IDU population. In contrast, prevalence of HCV is 50-60% among Australian IDUs and virus survival in needle syringes has been documented for prolonged periods. There have been no published cases of blood-borne virus transmission following community needlestick injury in Australia. CONCLUSION: The risk of blood-borne virus transmission from syringes discarded in community settings appears to be very low. Despite this, procedures to systematically follow up individuals following significant needlestick exposures sustained in the community setting should be developed.     

The prevalence and risk behaviours associated with the transmission of blood-borne viruses among ethnic-Vietnamese injecting drug users

OBJECTIVE: To measure the prevalence and determinants of blood-borne virus (BBV) transmission in ethnic Vietnamese injecting drug users (IDUs). METHODS:The study was conducted in Melbourne, Australia, in 2003. It was a cross-sectional design with participants recruited from street-based illicit drug markets predominately using a snowball technique. One hundred and twenty-seven participants completed a questionnaire that asked about illicit drug use and participants' blood samples were tested for HIV, HCV and HBV. RESULTS: One hundred and three (81.1%) ethnic Vietnamese IDU study participants were HCV positive and three (2.4%) were HIV positive. More than 60% had evidence of being infected with HBV (either in the past, acute infection or chronic infection). Almost 60% had injected daily over the past 12 months. Fifty-nine participants had recently travelled to Vietnam; 24 (41%) had injected drugs in Vietnam; and three (12.5%) reported sharing injecting equipment in Vietnam. CONCLUSION: The prevalence of BBVs was higher in this study's IDU population compared with IDUs in Australia generally, despite the fact that the injecting risk behaviours were similar to IDUs more generally. IMPLICATIONS: Culturally sensitive drug treatment and education programs need to be developed in Australia for both ethnic Vietnamese IDUs and their families to reduce this group's risk of contracting a BBV.     

HIV and HCV prevalence among trawler crew

A survey of 51 people who work on trawlers was carried out to describe injecting and sexual behaviour and the prevalence of HIV and HCV antibody. All crew members who were departing from an Australian port during the last week of February 1996 to work on trawlers were asked to complete a brief, self-administered questionnaire and provide a finger prick blood sample. Questionnaires were received from 51 (77%) and blood samples from 45 (68%) of the 66 crew from 15 vessels. Almost half the respondents reported ever injecting illicit drugs. No respondents had HIV antibody while 27% had HCV antibody detected. Among 20 injecting drug user (IDU) respondents, the prevalence of HCV was 55% (95% Cl 32%-77%). Twelve respondents reported new sex partners in the past month of whom half reported no condom use with these sex partners. The survey emphasises the diversity of the IDU population in Australia. Yet it would appear that regardless of the sub-population surveyed that HCV is endemic among IDUs in Australia. Effective HCV prevention programs targeted specifically for these (and other) sub-populations of IDUs should be devised.     

The impact of behavioural changes on the prevalence of human immunodeficiency virus and hepatitis C among injecting drug users

BACKGROUND: Prevalence of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) in the injecting drug user (IDU) community can differ considerably. In Australia in 1997, HIV prevalence among attendees at Needle Exchange Programs was 1% while HCV prevalence was 50%. The impact that different needle-sharing behaviour and drug injecting use may have on the future levels of these viruses is uncertain. METHOD: We develop a mathematical model of the number of people who inject drugs with each of these infections to determine their changes under different scenarios. The impact of transmission probabilities and needle sharing on the incidence and prevalence of HIV and HCV infections are assessed. RESULTS: Critical levels of needle sharing, below which total infections would fall to minimal levels, were estimated to be 17 IDU partners per year for HIV compared with 3 IDU partners per year for HCV. Current average levels of needle sharing in Australia are estimated to be six IDU partners per year. CONCLUSIONS: This analysis suggests that under current drug injecting behaviour, HIV prevalence in IDU in Australia should remain below 1% but that HCV prevalence will stay elevated.     

Needle and syringe sharing practices of injecting drug users participating in an outreach HIV prevention program in Tehran,Iran: A cross-sectional study

HIV infection rates have reached epidemic proportions amongst injecting drug users (IDUs) in Iran. Although a number of community-based interventions have being implemented in the country, there is little information on the risk behaviors of IDU participants in these programs. This cross-sectional report aimed to compare the risk behaviors of injecting drug users with differential exposure rates to an HIV outreach program in Tehran, Iran. Results indicated that shared use of needle/syringe in the past month was significantly lower among IDUs who received estimated ≥ 7 syringes per week than those who did not [adjusted odds ratio (OR) = 14.36, 95% confidence interval (CI) 2.30–89.56]. While the effectiveness of this outreach program needs further evaluation through a longitudinal investigation, our preliminary findings suggest that the outreach program in Tehran may have been beneficial in reducing direct sharing among those who received more than several needles/syringes from the program.     

Factors associated with drug-related harms related to policing in Tijuana, Mexico

Background

A nascent HIV epidemic and high prevalence of risky drug practices were detected among injecting drug users (IDUs) in Kabul, Afghanistan from 2005-2006. We assessed prevalence of HIV, hepatitis C virus (HCV), hepatitis B surface antigen (HBsAg), syphilis, and needle and syringe program (NSP) use among this population.

Methods

IDUs were recruited between June, 2007 and March, 2009 and completed questionnaires and rapid testing for HIV, HCV, HBsAg, and syphilis; positive samples received confirmatory testing. Logistic regression was used to identify correlates of HIV, HCV, and current NSP use.

Results

Of 483 participants, all were male and median age, age at first injection, and duration of injection were 28, 24, and 2.0 years, respectively. One-fifth (23.0%) had initiated injecting within the last year. Reported risky injecting practices included ever sharing needles/syringes (16.9%) or other injecting equipment (38.4%). Prevalence of HIV, HCV Ab, HBSAg, and syphilis was 2.1% (95% CI: 1.0-3.8), 36.1% (95% CI: 31.8-40.4), 4.6% (95% CI: 2.9-6.9), and 1.2% (95% CI: 0.5-2.7), respectively. HIV and HCV infection were both independently associated with sharing needles/syringes (AOR = 5.96, 95% CI: 1.58 - 22.38 and AOR = 2.33, 95% CI: 1.38 - 3.95, respectively). Approximately half (53.8%) of the participants were using NSP services at time of enrollment and 51.3% reported receiving syringes from NSPs in the last three months. Current NSP use was associated with initiating drug use with injecting (AOR = 2.58, 95% CI: 1.22 - 5.44), sharing injecting equipment in the last three months (AOR = 1.79, 95% CI: 1.16 - 2.77), prior incarceration (AOR = 1.57, 95% CI: 1.06 - 2.32), and greater daily frequency of injecting (AOR = 1.40 injections daily, 95% CI: 1.08 - 1.82).

Conclusions

HIV and HCV prevalence appear stable among Kabul IDUs, though the substantial number having recently initiated injecting raises concern that transmission risk may increase over time. Harm reduction programming appears to be reaching high-risk drug user populations; however, monitoring is warranted to determine efficacy of prevention programming in this dynamic environment.     

Risk behaviours of young Indo-Chinese injecting drug users in Sydney and Melbourne

OBJECTIVE: To investigate patterns of drug use and injection-related risk behaviours among young Indo-Chinese injecting drug users (IDUs). METHOD: Cross-sectional survey. A structured questionnaire was administered to 184 Indo-Chinese IDUs aged 15 to 24 in Sydney and Melbourne. Participants were recruited using snowball sampling techniques; measures included patterns of heroin and other drug use, injection-related risk behaviours, perceived susceptibility to HIV and HCV infection and access to services. RESULTS: Despite perceived high availability of sterile injecting equipment, 36% had ever shared a needle and syringe and 22% had done so in the preceding month. Lifetime sharing was significantly associated with duration of injecting, history of incarceration and residence in Sydney. Sharing of injecting paraphernalia other than needles and syringes was also common, with young women and Sydney residents significantly more likely to report sharing equipment in the preceding month. CONCLUSIONS: Young Indo-Chinese IDUs are at high risk of infection with hepatitis C and other blood-borne viruses. Results indicate an urgent need for culturally appropriate and sustainable risk reduction programs which specifically target this population. Implications: Health services must respond swiftly to implement effective blood-borne virus prevention programs for young Indo-Chinese IDUs. Failure to do so may sustain the current epidemic of hepatitis C among IDUs.     

广东省社区吸毒者针具交换项目试点效果评价

目的　探讨社区中开展针具交换预防艾滋病在吸毒人群中传播的可行性。方法　本研究为设立对照组的社区干预试验。干预区采用针具交换措施 (同伴教育员和医务人员在吸毒人群中宣传安全注射观念、提供免费针具、回收用过的注射器 ) ,对照区不采取任何干预措施 ,为期 10个月(2 0 0 2年 9月至 2 0 0 3年 6月 )。干预前后分别采用滚雪球的方式抽取注射吸毒者进行横断面调查以评估干预效果。结果　干预前后分别对干预区 (42 8名 )和对照社区 (42 9名 )静脉吸毒者进行调查。结果显示 ,干预区的艾滋病知识知晓率由 2 9 4 %上升到 5 8 7% ;多因素logistic分析结果表明 ,看过艾滋病宣传折页或宣传画者知晓率高 ;同基线调查相比 ,干预区中最近 30d内共用针具率由基线的4 8 9%下降到 2 0 4 % ,而在对照区中共用针具率同基线相比无明显改善 ;干预后干预区最近 30d共用针具的原因中“夜间买不到针、到朋友家打针人多针少、害怕被抓不敢买针和没钱买针”的现象相对基线情况有明显改善。结论　针具交换项目可以有效降低社区吸毒者共用针具现象。为控制艾滋病在吸毒人群中的传播 ,针具交换措施应尽快在全国范围内推广。     

Vietnamese-speaking injecting drug users in Melbourne: the need for harm reduction programs

While research on aspects of injecting drug use (IDU), including injecting and sexual risks for HIV transmission, has been progressing in 'mainstream' Australian populations, there has been little among non-English speaking background (NESB) communities in Australia, particularly the South-East Asian communities, of which the Vietnamese is the largest. This exploratory study employed and trained peer workers to recruit and interview IDUs of Vietnamese origin in Melbourne on a wide range of subjects related to risks associated with their drug using, as an initial assessment of risk-taking behaviours for blood-borne viruses among Vietnamese-speaking IDUs. A finger-prick blood sample was taken where possible to measure antibody status to HIV, HBV and HCV.
The profile which emerged was not dissimilar to that of their English-speaking counterparts prior to the benefit of currently available harm-reduction programs. A relatively isolated group whose social world often related only to other Vietnamese-speaking drug users, they were engaging in unsafe sex and unsafe injecting and were unfamiliar with procedures for cleaning injecting equipment and where they could seek out information and services, including needle exchanges. This study has identified an urgent need not only to promote currently available information and services to this group, but also to provide culturally relevant education and other harm-reduction measures needed to prevent transmission of HIV, other BBVs and STDs. The study has highlighted the lack of responsiveness of mainstream health services to the needs of Vietnamese-speaking IDUs.     

The provision of non-needle/syringe drug injecting paraphernalia in the primary prevention of HCV among IDU: a systematic review

Background  

Sharing drug injecting paraphernalia other than needles and syringes (N/S) has been implicated in the transmission of Hepatitis C virus (HCV) among injecting drug users (IDU). We aimed to determine whether the provision of sterile non-N/S injecting paraphernalia reduces injecting risk behaviours or HCV transmission among IDU.     

Legal access to needles and syringes/needle exchange programmes versus HIV counselling and testing to prevent transmission of HIV among intravenous drug users: a comparative study of Denmark, Norway and Sweden

BACKGROUND: Countries have adopted different strategies to prevent the transmission of HIV among intravenous drug users. Legal access to needles and syringes/needle exchange programmes as part of such a strategy has been heavily debated. HIV counselling and testing has also been part of prevention strategies. The objective of this study was to discuss the effectiveness of legal access to needles and syringes/ needle exchange programmes versus HIV counselling and testing among intravenous drug users (IDUs) as part of HIV prevention strategies. METHODS: Differences in HIV prevention strategies in Denmark, Norway and Sweden among IDUs are described. Outcome variables of effectiveness were HIV incidence rates over time. These were estimated by back calculation methods from 1980 through 1996, using data from the national HIV and AIDS registers. RESULTS: A comparison of HIV prevention strategies in Denmark, Norway and Sweden suggests that a high level of HIV counselling and testing might be more effective than legal access to needles and syringes/needle exchange programmes. Sweden and Norway, with higher levels of HIV counselling and testing, have had significantly lower incidence rates of HIV among IDUs than Denmark where there was legal access to needles and syringes and a lower level of HIV counselling and testing. In Sweden there was no legal access to drug injection equipment. CONCLUSION: Promotion and accessibility of HIV counselling and testing among intravenous drug users should be considered in countries where such a strategy is not adopted or has low priority.     

Methadone maintenance treatment and HIV risk-taking behaviour among injecting drug users in Berlin.

STUDY OBJECTIVE: To determine whether methadone maintenance treatment (MMT) is effective in reducing the levels of HIV risk-taking behaviour (borrowing and lending of injection equipment, irregular condom use) among injecting drug users (IDUs), and to identify independent predictors of the borrowing of used syringes. DESIGN: Cross sectional study of IDUs in MMT and not in MMT, using standardised interviews for collection of sociodemographic and behavioural data, and laboratory tests for detecting HIV antibodies. SETTING AND PARTICIPANTS: The 612 IDUs were recruited at different services for drug users such as treatment centres, walk in agencies, a hospital, and on the streets. MAIN RESULTS: Of all IDUs, 41% had borrowed and 34% had passed on used injection equipment in the previous six months. In univariate analysis, IDUs receiving MMT had injected less frequently and were significantly less likely to borrow and lend syringes. In logistic regression analysis, MMT was protective against the borrowing of syringes (adjusted odds ratio 0.36, 95% confidence interval 0.2, 0.8), but not against syringe lending nor against sexual risk behaviour (i.e., numbers of sex partners, lack of condom use). Important independent predictors of the borrowing of syringes were injecting drug use in prison, use of sedatives, and sex with another IDU in the previous six months. CONCLUSIONS: MMT may play a significant role in reducing the levels of borrowing of syringes among IDUs. However, additional prevention measures are needed which should specifically address sexual risk behaviour and target subgroups of IDUs with high levels of needle sharing, such as IDUs who have been in prison and and those who are sedative users.     

Gender differences in sexual and injection risk behavior among active young injection drug users in San Francisco (the UFO study)

Female injection drug users (IDUs) represent a large proportion of persons infected with HIV in the United States, and women who inject drugs have a high incidence of hepatitis B virus (HBV) and hepatitis C virus (HCV) injection. Therefore, it is important to understand the role of gender in injection risk behavior and the transmission of blood-borne virus. In 2000–2002, 844 young (<30 years old) IDUs were surveyed in San Francisco. We compared self-reported risk behavior between 584 males and 260 female participants from cross-sectional baseline data. We used logistic regression to determine whether demographic, structural, and relationship variables explained increased needle borrowing, drug preparation equipment sharing, and being injected by another IDU among females compared to males. Females were significantly younger than males and were more likely to engage in needle borrowing, ancillary equipment sharing, and being injected by someone else. Females were more likely than males to report recent sexual intercourse and to have IDU sex partners. Females and males were not different with respect to education, race/ethnicity, or housing status. In logistic regression models for borrowing a used needle and sharing drug preparation equipment, increased risk in females was explained by having an injection partner who was also a sexual partner. Injecting risk was greater in the young female compared to male IDUs despite equivalent frequency of injecting. Overlapping sexual and injection partnerships were a key factor in explaining increased injection risk in females. Females were more likely to be injected by another IDU even after adjusting for years injecting, being in a relationship with another IDU, and other potential confounders. Interventions to reduce sexual and injection practices that put women at risk of contracting hepatitis and HIV are needed.     

High hepatitis C incidence in new injecting drug users: a policy failure?

OBJECTIVE: Evidence of ongoing hepatitis C (HCV) transmission among injecting drug users (IDUs) suggests a need for a better understanding of seroconversion characteristics among new IDUs and other vulnerable subgroups. This study aimed to determine incidence of HCV and associated risk factors among new IDUs in Sydney. METHODS: IDUs who had injected drugs in the past six months and who were unaware of their antibody HCV status or knew their serostatus to be negative were recruited through street-based outreach, methadone clinics and needle and syringe programs in south-western Sydney. Anti-HCV negative IDUs (n = 215) were enrolled and followed-up at 3-6 monthly intervals. New IDUs (n = 204) were defined as aged below 30 years or injecting for < or = 6 years at baseline. RESULTS: A total of 61 seroconversions were observed and incidence was 45.8 per 100 person years. Independent predictors of seroconversion were duration of injecting < 1 year (IRR = 3.10; 95% CI 1.47-6.54), female gender (IRR = 2.0; 95% CI 1.16-3.45), culturally and linguistically diverse background (CALDB) (IRR = 2.03; 95% CI 1.06-3.89) and intravenous cocaine use (IRR = 2.37; 95% CI 1.26-4.44). While new IDUs shared common risk factors, strong associations were observed between HCV seroconversion and sharing syringes, sharing other injecting equipment and backloading in CALDB new IDUs. CONCLUSION: Incidence of HCV infection among new IDUs in Sydney is unacceptably high. IMPLICATIONS: Extremely high rates of incident infection among newly initiated CALDB IDUs indicate an urgent need for enhanced policy and resource commitments to reduce the vulnerability of this group to HCV and other blood-borne infections.     

Analysis of a Targeted Intervention Programme on the Risk Behaviours of Injecting Drug Users in India: Evidence From the National Integrated Biological and Behavioural Surveillance Survey

ObjectivesThis study provides insights on the impact of a targeted intervention (TI) programme on behaviour change among injecting drug users (IDUs) in India.MethodsThis paper examined the data from the Integrated Biological and Behavioural Surveillance 2014–2015 for IDUs in India. Logistic regression was performed to understand the factors (TI programme services) that affected injecting risk behaviours by adjusting for covariates. Propensity score matching was conducted to understand the impact of the TI programme on using new needles/syringes and sharing needles/syringes in the most recent injecting episode by accounting for the covariates that predicted receiving the intervention.ResultsParticipants who received new needles and syringes from peer educators or outreach workers were 1.3 times (adjusted odds ratio, 1.29; 95% confidence interval [CI], 1.09 to 1.53) more likely to use new needles/syringes during most recent injecting episode than participants who did not receive needles/syringes. The matched-samples estimate (i.e., average treatment effect on treated) of using new needles in the most recent injecting episode showed a 2.8% (95% CI, 0.0 to 5.6) increase in the use of new needles and a 6.5% (95% CI, −9.7 to −3.3) decrease in needle sharing in the most recent injecting episode in participants who received new needles/syringes. There was a 2.2% (95% CI, −3.8 to −0.6) decrease in needle sharing in the most recent injecting episode among participants who were referred to other services (integrated counselling and testing centre, detox centres, etc.).ConclusionsThe TI programme proved to be effective for behaviour change among IDUs, as substantiated by the use of new needles/syringes and sharing of needles/syringes.     

"The first shot": the context of first injection of illicit drugs, ongoing injecting practices, and hepatitis C infection in Rio de Janeiro, Brazil

The context of first drug injection and its association with ongoing injecting practices and HCV (hepatitis C virus) infection were investigated. Injection drug users (IDUs) (N = 606) were recruited in "drug scenes" (public places, bars) in Rio de Janeiro, Brazil, interviewed, and tested for HCV. Sharing of needles/syringes was more prevalent at the first injection (51.3%) than at the baseline interview (36.8%). Those who shared syringes/needles at first injection were more likely to be currently engaged in direct/indirect sharing practices. Among young injectors (< 30 years), those reporting sharing of needles/ syringes at the first injection were about four times more likely to have been infected by HCV. Hepatitis C virus prevalence among active IDUs (n = 272) was 11%. Prison history and longer duration of drug injection were identified as independent predictors of HCV infection. To effectively curb HCV transmission among IDUs and minimize harms associated with risk behaviors, preventive strategies should target individuals initiating drug injection beginning with their very first injection and discourage the transition from non-injecting use to the self-injection of illicit drugs.     

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.     

Hepatitis C Virus Acquisition among Injecting Drug Users: A Cohort Analysis of a National Repeated Cross-sectional Survey of Needle and Syringe Program Attendees in Australia, 1995–2004

High hepatitis C virus (HCV) prevalence has been documented among many injecting drug user (IDU) populations worldwide; however, there is limited published data on trends in incidence of infection in these epidemics over time. To address this, we used a novel method of analyzing data collected via repeat, cross-sectional sero-surveys by injection initiation cohorts to investigate trends in HCV seropositivity among a population of needle and syringe program (NSP) attendees in Australia between 1995 and 2004, and thereby infer annual incidence trends. Injection initiation cohorts were defined by their time of entry into the IDU population. We also investigated the associations between HCV antibody seroprevalence and risk factor data, and trends in risk factor data over the decade. Approximately 20,000 NSP attendees participated in the study over the 10-year period. Within each injection initiation cohort, we found an increase in HCV prevalence over time, with prevalence appearing to reach saturation around 90%. There was little indication that the slopes of increase had changed with more recent initiation cohorts. While duration of injecting was most strongly associated with HCV seropositivity in this study, we also found that self-reported history of needle and syringe sharing and imprisonment were independently associated with higher HCV prevalence regardless of duration of injecting, with the exception of IDUs who have 15 or more years injecting experience. In this group, recent risk behavior had no relationship to prevalence. In summary, our findings suggest a persistent HCV epidemic despite significant harm reduction efforts in Australia since the mid-1980s, with HIV incidence effectively constant in successive initiation cohorts. FUNDING SOURCE: Australian Government Department of Health and Ageing