静脉吸毒人群前瞻性研究队列随访方法的应用

目的:探讨我国静脉吸毒人群前瞻性研究的方法.方法:于2002年11月,在四川省凉山地区从社区招募了HIV抗体阴性的静脉吸毒人群前瞻性研究队列333人.分析队列本底的静脉吸毒人群社会人口学和HIV高危行为特征,以及在6个月队列保持中各种随访跟踪方法的使用情况.结果:队列6个月随访阶段的保持率为74.8%(249/333)和HIV阳转率为4.04/100人年(95%CI: 0.50-7.59).通过种子通知、种子预约、种子或他人寻找和工作人员寻找为本研究队列6个月随访的主要方法.结论:在静脉吸毒人群研究队列随访中可考虑采用多种联系方式,其中通过外勤工作人员以及种子帮助来联系参加者为主要的队列随访方法.     

Predictors of risky needle use following interventions with injection drug users in Ukraine

This study was designed to assess factors associated with change in needle-related risk behaviors as well as predictors of continued high-risk behavior following intervention efforts among injection drug users (IDUs) in Ukraine. In each of three locations--Kiev, Odessa, and Makeevka/Donesk--100 IDUs were recruited using modified targeted sampling methods. Following a baseline interview, participants were offered free HIV testing and, over the course of the next 5 months, individualized interventions focusing on reducing HIV-related risk behaviors. Former IDUs conducted interventions through street outreach. The intervention model was based on the Indigenous Leader Outreach Model (ILOM) and stressed assessing an individual's unique risks and developing strategies by which to minimize those risks. Follow-up assessments showed significant reductions in every risk behavior measured. Following the intervention, however, approximately one of four participants reported front- or backloading, using drugs obtained from a common container or injecting with a used needle/syringe. Although the sample as a whole averaged only 28 years of age, those who were younger were significantly more likely to engage in each of these behaviors than those who were older. In light of the overall young age of the Ukrainian IDUs observed in this study, the consistent finding that younger IDUs were at highest risk foreshadows a worsening HIV epidemic in Ukraine.     

Drug use, AIDS knowledge, and HIV risk behaviors of Cuban-, Mexican-, and Puerto-Rican-born drug injectors who are recent entrants into the United States.

To date, relatively little research attention has been devoted to the HIV-risky behaviors of persons who are newly arrived in the United States and who use drugs. Data gathered from street-recruited injection drug users (IDUs) recruited in 10 United States cities who were born in Mexico, Cuba, and Puerto Rico and who are recent entrants into the United States suggest that, in comparison to US-born IDUs, Mexican-born subjects are at elevated risk for acquiring and transmitting HIV as a result of sharing needles with friends and running partners; sharing drug injection implements such as cookers, cotton, and rinse water; frequent injection in HIV-risky settings; use of unsterilized needles; and relatively frequent trading of sex for drugs or money. Puerto-Rican-born IDUs were found to inject drugs relatively frequently, and to do so relatively often in high-risk settings in which sterile injecting equipment and cleaning materials often are scarce. These data also show generally lower levels of AIDS knowledge among the in-migrant IDUs than among US-born IDUs. Respondents from each nationality group most often cited television as the source of their most useful and reliable AIDS information, but also tended to regard community outreach workers as a significant source of reliable AIDS and needle cleaning information. The high levels of involvement in HIV-risky behaviors, deficits in knowledge concerning the means of HIV transmission, and relative ease of mobility of the at-risk (for HIV) individuals examined here indicate a need for a comprehensive public health prevention initiative to limit the future spread of HIV. At a minimum, such an undertaking would do well to incorporate group-specific, culturally appropriate behavioral interventions as well as an information campaign.     

Socio-demographic factors,health risks and harms associated with early initiation of injection among people who inject drugs in Tallinn,Estonia: Evidence from cross-sectional surveys

AimTo explore socio-demographic factors, health risks and harms associated with early initiation of injecting (before age 16) among injecting drug users (IDUs) in Tallinn, Estonia.MethodsIDUs were recruited using respondent driven sampling methods for two cross-sectional interviewer-administered surveys (in 2007 and 2009). Bivariate and multivariate logistic regression analysis was used to identify factors associated with early initiation versus later initiation.ResultsA total of 672 current IDUs reported the age when they started to inject drugs; the mean was 18 years, and about a quarter of the sample (n = 156) reported early initiation into injecting drugs. Factors significantly associated in multivariate analysis with early initiation were being female, having a lower educational level, being unemployed, shorter time between first drug use and injecting, high-risk injecting (sharing syringes and paraphernalia, injecting more than once a day), involvement in syringe exchange attendance and getting syringes from outreach workers, and two-fold higher risk of HIV seropositivity.ConclusionsOur results document significant adverse health consequences (including higher risk behaviour and HIV seropositivity) associated with early initiation into drug injecting and emphasize the need for comprehensive prevention programs and early intervention efforts targeting youth at risk. Our findings suggest that interventions designed to delay the age of starting drug use, including injecting drug use, can contribute to reducing risk behaviour and HIV prevalence among IDUs.     

Reaching and enrolling drug users for HIV prevention: a multi-site analysis

Since 1994, several sites have participated in a NIDA Cooperative Agreement for AIDS Community-based Outreach/Intervention Research Program to examine rates of HIV risk behaviors and evaluate HIV risk reduction interventions among out-of-treatment drug injection and crack cocaine and heroin smokers. We studied the process and outcome of community outreach for recruitment of drug users in AIDS research and education projects in three metropolitan areas: St. Louis, MO; San Antonio, TX, and Durham and Wake Counties, NC. There were two primary areas of focus: (1) the level of accuracy among community health outreach workers (CHOWs) in identifying potentially eligible persons for HIV prevention, and (2) overall effectiveness in recruiting and enrolling persons in formal assessment and intervention studies. We found cross-site and within-site differences in levels of accuracy and in recruitment and enrollment yields. Drug users who had never been in treatment and drug users who had never been tested for HIV infection were underrepresented at all sites. We discuss the factors which may have contributed to cross-site and within-site differences. The findings suggest a need for continued study, refinement, and evaluation of community outreach strategies in order to enroll a broad spectrum of vulnerable groups in HIV prevention activities.     

Drug use,AIDS Knowledge,and HIV Risk Behaviors of Cuban-, Mexican-, and Puerto-Rican-Born Drug Injectors who are Recent Entrants into the United States

To date, relatively little research attention has been devoted to the HIV-risky behaviors of persons who are newly arrived in the United States and who use drugs. Data gathered from street-recruited injection drug users (IDUs) recruited in 10 United States cities who were born in Mexico, Cuba, and Puerto Rico and who are recent entrants into the United States suggest that, in comparison to US-born IDUs, Mexican-born subjects are at elevated risk for acquiring and transmitting HIV as a result of sharing needles with friends and running partners; sharing drug injection implements such as cookers, cotton, and rinse water; frequent injection in HIV-risky settings; use of unsterilized needles; and relatively frequent trading of sex for drugs or money. Puerto-Rican-born IDUs were found to inject drugs relatively frequently, and to do so relatively often in high-risk settings in which sterile injecting equipment and cleaning materials often are scarce. These data also show generally lower levels of AIDS knowledge among the in-migrant IDUs than among US-born IDUs. Respondents from each nationality group most often cited television as the source of their most useful and reliable AIDS information, but also tended to regard community outreach workers as a significant source of reliable AIDS and needle cleaning information. The high levels of involvement in HIV-risky behaviors, deficits in knowledge concerning the means of HIV transmission, and relative ease of mobility of the at-risk (for HIV) individuals examined here indicate a need for a comprehensive public health prevention initiative to limit the future spread of HIV. At a minimum, such an undertaking would do well to incorporate group-specific, culturally appropriate behavioral interventions as well as an information campaign.     

Psychiatric and Physiological Reactions Produced by Over-the-Counter Medications

Abstract

Injecting practices of illicit drug users in San Antonio, Texas, were studied by means of informal field interviews and participant observation. The methods injection drug users (IDUs) employed to obtain drugs seemed to affect their HIV risk behaviors. Many of the methods involve reciprocal exchanges between a person who has drugs and a person who wants drugs. The exchanges frequently occur in the context of asymmetrical social interactions. The person with the drugs usually occupies the dominant role in the interaction and determines the needle hygiene for both parties. Analysis of the decision-making process of IDUs indicates that the party in the dominant role may choose not to disinfect a syringe for a variety of reasons. An understanding of the subcultural rules that govern these interactions may provide valuable clues to researchers or educators who are designing interventions aimed at reducing HIV risk behaviors among IDUs. This research suggests that for IDUs in subordinate roles, education alone may be insufficient to produce behavior changes necessary to eliminate risk of HIV infection.     

HIV transmission from drug injectors to partners who do not inject,and beyond: Modelling the potential for a generalized heterosexual epidemic in St. Petersburg,Russia

Background

HIV infection is prevalent among drug injectors in St. Petersburg and their non-injecting heterosexual partners (PIDUs). There are fears that sexual transmission of HIV from IDUs to PIDUs may portend a self-sustaining, heterosexual epidemic in Russia.

Methods

Our model combines a network model of sexual partnerships of IDUs and non-IDUs to represent sexual transmission of HIV and a deterministic model for parenteral transmission among IDUs. Behavioural parameters were obtained from a survey of St. Petersburg IDUs and their sexual partners. We based our model fits on two scenarios for PIDU prevalence in 2006 (5.6% and 15.1%, calculated excluding and including HCV co-infected PIDUs respectively) and compared predictions for the general population HIV prevalence.

Results

Results indicate that sexual transmission could sustain a non-IDU HIV epidemic. The model indicates that general population prevalence may be greater than current estimates imply. Parenteral transmission drives the epidemic and the PIDU bridge population plays a crucial role transferring infection to non-IDUs. The model indicates that the high PIDU prevalence is improbable because of the high risk behaviour this implies; the lower prevalence is possible.

Conclusion

The model implies that transmission through PIDUs will sustain a heterosexual epidemic, if prevalence among IDUs and PIDUs is as high as survey data suggest. We postulate that current estimates of population prevalence underestimate the extent of the HIV epidemic because they are based on the number of registered cases only. Curtailing transmission among injectors and PIDUs will be vital in controlling heterosexual transmission.     

Racial differences in acquisition of syringes from pharmacies under conditions of legal but restricted sales

BackgroundInjecting drug users (IDUs) are at increased risk of acquiring and transmitting HIV and other bloodborne pathogens through the multi-person use of syringes. Although research has shown that increased access to syringes through syringe exchange programs (SEPs) is an effective strategy to reduce risky injection practices many areas of the United States still do not have SEPs. In the absence of SEPs, legislation allowing pharmacies over-the-counter sales of syringes has also been shown to reduce syringe sharing. The success of pharmacy sales however is limited by other legal stipulations, such as drug paraphernalia laws, which in turn may contribute to fear among IDUs about being caught purchasing and carrying syringes.MethodsBetween 2003 and 2006, 851 out-of-treatment IDUs were recruited using street outreach in the Raleigh-Durham (North Carolina) area. Data were collected using audio-computer assisted interview (ACASI) technology. Multiple logistic regression analyses were performed to assess factors associated with purchasing syringes from pharmacies.ResultsIn our study sample, African-American IDUs were one-fifth as likely as white IDUs to report pharmacies as their primary source of syringes.ConclusionsGiven the absence of syringe exchange programs and the relatively high prevalence of HCV and HIV among IDUs in the Raleigh-Durham area, the limited use of pharmacies as a source of syringes among African-American IDUs in this study sample is problematic. The study findings support the need for effective multilevel interventions to increase access to clean needles in this population, as well as for policy interventions, such as legalization of SEPs and elimination of penalties for carrying syringes, to reduce harm and eliminate the health threats posed by receptive syringe sharing.     

Report on injecting drug use in Bali (Denpasar and Kuta): results of an interview survey

The number of reported HIV cases in Indonesia is growing every year, although few are officially attributed to IDU transmission. Bali has the fourth highest number of reported HIV infections among Indonesia’s 27 provinces. Specific data among drug users from a public health perspective is needed to develop intervention and prevention programs. Currently management of the issue is limited to police action, high school based lectures and hospital based rehabilitation. This questionnaire study set out to gather baseline information on the knowledge, attitudes, behaviours and social background of substance abusers (mainly heroin) in the Kuta and Denpasar areas of Bali, particularly relating to public health problems, specifically AIDS and other STDs. Subjects were recruited based on prior contacts and information gained during preliminary informal observation and mapping and word-of-mouth information from key informants. Our final sample was 34 respondents (30 male and only four female), 30 of whom were currently using by injecting. It is estimated that there are up to 1000 IDUs in Bali. The young age of initiation into use of narcotics and injecting drug use is a key concern. Half of the respondents began their drug use before age 18, almost 80% before age 20. Low use of sterilised needles and high needle sharing behaviour clearly places IDUs in this sample at high risk of disease infection. This problem has recently been worsened due to the increasing price of needles and heroin with the event of the economic crisis. Sexual behaviour patterns among these IDUs further increase the risks of HIV/STD infection, including sex with sex workers (26.5%), sex with foreigners (17.6%), multi-partner (26.5%), and under the influence of drugs (70.7%) and with low condom use. Of the 34 respondents, 10 perceived that they probably or possibly were infected with HIV. There is a need for public health oriented initiatives here to balance the police action currently used to manage this issue. Development of appropriate written educational materials targeted at IDU and urban youth is necessary. A local foundation with a staff team including IDUs could undertake core programs applying the philosophy of harm reduction, involving a drop-in center for peer counselling and information distribution plus outreach. In the longer term, needle exchange and rehabilitation programs should be considered.     

Effectiveness of community-based outreach in preventing HIV/AIDS among injecting drug users

This paper focuses on the evidence for the effectiveness of community-based outreach intervention as one component of a comprehensive HIV prevention model for preventing HIV infection in injecting drug user (IDU) populations. Three empirical questions guided the review of the evidence. This article includes primarily published literature on community-based outreach derived mostly from developing countries but also unpublished literature. Wherever possible, evidence from multi-country, multi-site studies or meta-analytical studies is included. More than 40 published studies reveal that injecting drug users (IDUs), who are reached by community-based outreach and provided with access to risk reduction services, report reducing HIV risk behaviours. The strength of the evidence was assessed using Hill's criteria, which permit a review of multiple studies with different designs. Using the criteria, it is possible to infer causation about the evidence of effectiveness of the intervention. The evidence for the effectiveness of a community-based outreach strategy is strong. Despite evidence from 20 years of evaluation studies of the effectiveness of community-based outreach, a huge gap exists in most countries between the number of IDUs who want or could benefit from outreach services and the number of IDUs who actually receive them. Findings from evaluation studies on the effectiveness of community-based outreach must be made accessible, disseminated globally and provided to policy- and decision-makers to persuade them to take action and implement scaled-up prevention programmes. This requires ongoing advocacy and constant strengthening of the evidence base. Plans are needed to link evidence-based findings with technical assistance as well as training to enhance the capacity of regions and countries to introduce, scale up and sustain HIV prevention outreach to IDUs as part of a comprehensive HIV prevention strategy.     

Case study: accessible primary health care--a foundation to improve health outcomes for people who inject drugs

ISSUE: Injecting drug users (IDUs) represent a large part of the population with HIV globally, however, IDUs continue to have less access to HIV treatment than non-IDUs. While IDUs with HIV potentially fare as well on anti-retroviral therapy (ART) as non-IDUs in terms of HIV disease progression, ART adherence is critical. Opioid dependent IDUs may experience lifestyle instability affecting ART adherence. IDUs often have a range of complex health and social welfare needs beyond HIV. THE APPROACH: Opioid agonist pharmacotherapies such as methadone maintenance treatment, improve overall health and psychosocial stability among opioid-dependent IDUs. The integration of pharmacotherapies into primary health care settings also allows the direct observation of the concomitant administration of HIV treatments. This dual treatment approach maximises HIV treatment adherence and enables the timely management of other clinical issues. Where relevant, sexual and reproductive, infant and maternal health services should also be incorporated alongside HIV and hepatitis B and C prevention services. Services should be anonymous and confidential, and be provided by a multidisciplinary team in a non-judgemental way. Involvement of IDUs in service planning should also be promoted to ensure the acceptability of the model to the target population. A CASE STUDY: The Kirketon Road Centre (KRC) in Kings Cross, Australia, is an example of a community-based primary health care service delivery model that comprehensively addresses a range of complex health and social welfare needs IDUs may have. Established in 1987 to prevent HIV/AIDS and other transmissible infections among "at risk" young people, IDUs and commercial sex workers, the KRC model has also proven versatile in upscaling to meet hepatitis C and other emerging health needs of IDUs in a timely way. CONCLUSION: Integrated primary health care models should be promoted more widely as a foundation to improve the health outcomes of IDUs.     

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]     

Values and identity: the meaning of work for injection drug users involved in volunteer HIV prevention outreach

Most HIV behavioral interventions provide participants with preventive information emphasizing how not to behave, and have neglected to provide attractive and feasible alternatives to risky behavior. Interventions that emphasize cultural strengths may have more powerful effects and may help remove the stigma of HIV, which has hampered prevention efforts among African American communities. Starting in 1997, the SHIELD (Self-Help in Eliminating Life-Threatening Diseases) intervention trained injection drug users (N=250) to conduct risk reduction outreach education among their peers. Many participants saw their outreach as "work," which gave them a sense of meaning and purpose and motivated them to make other positive changes in their lives.     

Intra-couple communication dynamics of HIV risk behavior among injecting drug users and their sexual partners in Northern Vietnam

This paper elucidates the social context of HIV risk behavior and intra-couple risk communication among injecting drug users (IDUs) and their main sex partner. Data on shared injection equipment, unprotected sex with multiple partners, unprotected sex with a main partner and couples' dynamics and risk communication were gathered through separate in-depth interviews with 11 active male IDUs and 11 of their primary female sex partners in Northern Vietnam. The majority of IDUs' sex partners does not inject drugs and is monogamous. In contrast, most IDUs reported a wide range of risky practices including needle sharing and unprotected sex with multiple, often concurrent, sex partners. Men rarely used condoms with primary partners. Many IDUs worried about their HIV-status, but none disclosed their injecting or sexual practices to their sex partners, leaving their partners unaware of their HIV risk. Among women who worried about HIV/AIDS, the vast majority was unable to influence their partner's needle sharing or extramarital affairs and most would not initiate condom use because they feared their partner's reaction. Couple-based interventions to facilitate risk communication combined with programs to promote condom use among male IDUs, may help to reduce HIV transmission from IDUs to their primary partners.     

Impact of HIV risk and infection and the role of prevention services

Blood-borne infection associated with injection drug use is a significant cause of morbidity and mortality. Over the last decade, HIV infection and its clinical sequelae have had a significant impact on research and interventions involving injecting drug users (IDUs) in the United States and elsewhere. Discussed are some of the major intervention options for reducing blood-borne infections in general and HIV in particular. The use of multiple interventions is considered within the community context in which both IDUs and service providers operate. Intervention options discussed include treatment for drug dependence; voluntary and confidential HIV testing and counseling; community health outreach; bleach distribution; and easy, legal access to needles and syringes through pharmacy sales and needle exchange programs. Many surveillance and evaluative studies have examined multiple intervention efforts that include all or some of these program components and suggest positive outcomes. However, these studies tend to be limited by experimental designs that restrict attribution of causal inference. Examples of such programs in the United States and abroad are examined in terms of their potential for reducing HIV risk behaviors and averting new infections. The article concludes that diversity among AIDS prevention programs, rapid deployment (at earlier stages of epidemics), and effective coordination (minimization of interagency conflicts) are important factors in successful AIDS prevention programming and attaining disease prevention objectives.     

Using Goal-Oriented Counseling; and Peer Support to Reduce HIV/AIDS Risk Among Drug Users Not in Treatment

SUMMARY

A six-month HIV/AIDS risk intervention program for injection drug and crack users not in treatment is described, incorporating behavioral contracting, social support, and social modeling as core elements. The program utilizes goal-oriented behavioral counseling and HIV testing in conjunction with social support by peers and project outreach workers to facilitate personal change by drug-using participants. The intervention incorporates both group workshops and individual counseling sessions plus monthly social events for participants, supportive peers, and project staff. Local drug users who have successfully reduced their own risk of HIV/AIDS are utilized as positive role models for risk reduction. In addition, outreach workers maintain structured supportive contacts with program participants on a scheduled basis. The efficacy of this enhanced intervention program in comparison with standard HIV testing and AIDS education is currently being evaluated in a follow-up study.     

Harm Reduction and Street-Based Program: Looking into Nepal

In August 1991 the Lifesaving and Lifegiving Society (LALS) became the first nongovernmental organization in Nepal to work with injecting drug users (IDUs) to reduce the harm caused by drugs in order to prevent HIV/AIDS. Its mission is to provide education, counseling, and primary health care, as well as bleach, sterile water, condoms, and new needles and syringes to IDUs to lower their risk of acquiring blood-borne diseases. An evaluation of the program found diat the prevalence of HIV infection among IDUs who were in regular contact with the program from 1991 to 1994 was 1.6%. No new cases of HIV infection were detected among participants in either 1993 or 1994. Though a harm reduction program is expensive to implement and sustain in Nepal, through its nonjudgmental, noncoercive, and confidential philosophy, LALS has engaged drug users into recovery and given them a platform by which they are able to address their concerns in a public forum.