Chronic hepatitis C virus infection and increases in viral load in a prospective cohort of young, HIV-uninfected injection drug users

Background

Chronic hepatitis C (HCV) infection, defined as persistent RNA (viral load) for at least 6 months, accounts for up to 50% of all cirrhosis, end-stage liver disease and liver cancer cases. Moreover, elevated HCV viral load is consistently associated with high infectivity and poor therapy response. This study aims to identify modifiable behavioral correlates both chronic HCV infection and increases in viral load over time among injection drug users (IDUs).

Methods

Cross-sectional and longitudinal analyses were performed using self-interview and serological data from a prospective cohort study (2002-2006) among young (age 18-35), HIV-negative, HCV therapy-naïve IDUs (n = 113) from metropolitan Chicago, Illinois, USA.

Results

After adjustment for age, gender and race/ethnicity, using drugs measured or mixed in someone else's syringe (odds ratio = 2.7, 95% confidence interval: 1.1, 6.7) was associated with chronic (n = 75, 66%) versus resolved (n = 38, 34%) HCV infection status. Among chronically-infected IDUs, injecting with a new, sterile syringe infrequently (<1/2 half the time when injecting) compared to frequently (1/2 the time or more when injecting) was associated with increases in viral load over time after adjusting for age, gender, race/ethnicity and time effects.

Conclusions

Reductions in risky injection-related practices among young IDUs may ameliorate both the burden of chronic HCV infection-related liver disease and elevated viral load-related poor treatment response.     

Cigarette, marijuana, and alcohol use and prior drug treatment among newly homeless young adults in New York City: Relationship to a history of foster care

Background

This study examined whether a history of foster care was associated with the risk for substance use among newly homeless young adults, controlling for demographics and other risk factors.

Methods

Multiple logistic regression analyses, adjusted for controls, among consecutive admissions of 424 newly homeless young adults (18-21 years), determined the association between foster care and substance use.

Results

A history of foster care was reported by 35% of the sample. Alcohol, marijuana, and cigarettes were the most frequently used substances. After adjusting for demographics, childhood emotional, physical, and sexual abuse, prior arrest, unemployment, lack of high school diploma, and family drug use, homeless young adults with histories of foster care were: three times as likely to smoke cigarettes (AOR = 3.09); more than three times as likely to use marijuana (AOR = 3.30); and almost nine times as likely to have been in drug treatment (AOR = 8.81) than those without such histories.

Conclusions

It is important to screen homeless young adults who exited foster care for substance use, particularly cigarettes and marijuana. Risk reduction interventions should be targeted and tailored to their substance prevention needs.     

The prospect of implementing a Safer Injection Facility in San Francisco: perspectives of community stakeholders

Background

Government-sanctioned Safer Injection Facilities (SIFs) have been implemented around the world to address public health and public order concerns associated with injection drug use. The goal of this study was to investigate how community stakeholders in San Francisco's Tenderloin district respond to the idea of implementing a SIF.

Methods

Qualitative in-depth interviews were conducted with 20 purposively sampled stakeholders including representatives from neighbourhood and business associations, politicians, law enforcement, religious leaders, school officials, community activists and service providers. Data were analysed using an inductive approach.

Results

Stakeholders were concerned that implementation of a SIF would further degrade a community struggling with safety and cleanliness and questioned the efficacy of harm reduction strategies to address drug use. Stakeholders were open to dialogue about how a SIF might support neighbourhood goals, stressed the importance of respect and collaboration between stakeholders and those potentially implementing a SIF, and were interested in evidence of the impact SIFs have on communities. Government protection and political leadership would be necessary to implement a SIF.

Conclusions

Employment of a community collaborative model combined with political leadership could move the policy debate about implementation of a SIF in San Francisco forward.     

A systematic review of the impact of alcohol use disorders on HIV treatment outcomes, adherence to antiretroviral therapy and health care utilization

Background

Alcohol use disorders (AUDs) are highly prevalent and associated with non-adherence to antiretroviral therapy, decreased health care utilization and poor HIV treatment outcomes among HIV-infected individuals.

Objectives

To systematically review studies assessing the impact of AUDs on: (1) medication adherence, (2) health care utilization and (3) biological treatment outcomes among people living with HIV/AIDS (PLWHA).

Data sources

Six electronic databases and Google Scholar were queried for articles published in English, French and Spanish from 1988 to 2010. Selected references from primary articles were also examined.

Review methods

Selection criteria included: (1) AUD and adherence (N = 20); (2) AUD and health services utilization (N = 11); or (3) AUD with CD4 count or HIV-1 RNA treatment outcomes (N = 10). Reviews, animal studies, non-peer reviewed documents and ongoing studies with unpublished data were excluded. Studies that did not differentiate HIV+ from HIV− status and those that did not distinguish between drug and alcohol use were also excluded. Data were extracted, appraised and summarized.

Data synthesis and conclusions

Our findings consistently support an association between AUDs and decreased adherence to antiretroviral therapy and poor HIV treatment outcomes among HIV-infected individuals. Their effect on health care utilization, however, was variable.     

Modelling the prevalence of HCV amongst people who inject drugs: An investigation into the risks associated with injecting paraphernalia sharing

Background

In order to prevent the spread of the hepatitis C virus (HCV) amongst people who inject drugs (PWID), it is imperative that any injecting risk behaviour which may contribute to the transmission of disease has its role quantified. To inform public health organisations, mathematical modelling techniques were used to explore the risk of HCV infection through the sharing of injecting paraphernalia (including filters, cookers and water).

Methods

A mathematical model was developed for the spread of HCV based on the injecting behaviour of PWID in Scotland, with transmission occurring through the sharing of needles/syringes and other injecting paraphernalia. Numerical simulations were used to estimate the transmission probability for HCV through the sharing of injecting paraphernalia such that the modelled endemic HCV prevalence fitted with that observed amongst PWID in Scotland.

Results

The transmission probability of HCV through injecting paraphernalia was modelled to be over 8 times lower than that through needles/syringes (approximately 0.19–0.30% and 2.5%, respectively), assuming transmission occurs through a combination of at least filters and cookers. In the context of reported needle/syringe and paraphernalia sharing rates in Scotland, it is estimated that 38% and 62% of HCV infections are contributed by these practices, respectively. If needle/syringe sharing rates were to be twice those reported, the contributions would be 70% and 30%, respectively.

Conclusion

Given that the sharing of injecting paraphernalia among PWID is common, HCV transmission through this route could be contributing to the growing healthcare burden associated with this chronic disease. Every effort should therefore be made to establish (a) the contribution that paraphernalia sharing is making to the spread of HCV, and (b) the effectiveness of services providing sterile paraphernalia in preventing infection.     

Neural activation during inhibition predicts initiation of substance use in adolescence

Background

Problems inhibiting non-adaptive behaviors have been linked to an increased risk for substance use and other risk taking behaviors in adolescence. This study examines the hypothesis that abnormalities in neural activation during inhibition in early adolescence may predict subsequent substance involvement.

Methods

Thirty eight adolescents from local area middle schools, ages 12-14, with very limited histories of substance use, underwent functional magnetic resonance imaging (fMRI) as they performed a go/no-go task of response inhibition and response selection. Adolescents and their parents were then followed annually with interviews covering substance use and other behaviors. Based on follow-up data, youth were classified as transitioning to heavy use of alcohol (TU; n = 21), or as healthy controls (CON; n = 17).

Results

At baseline, prior to the onset of use, youth who later transitioned into heavy use of alcohol showed significantly less activation than those who went on to remain non to minimal users throughout adolescence. Activation reductions in TU at baseline were seen on no-go trials in 12 brain regions, including right inferior frontal gyrus, left dorsal and medial frontal areas, bilateral motor cortex, cingulate gyrus, left putamen, bilateral middle temporal gyri, and bilateral inferior parietal lobules (corrected p < .01, each cluster ≥32 contiguous voxels).

Conclusions

These results support the hypothesis that less neural activity during response inhibition demands predicts future involvement with problem behaviors such as alcohol and other substance use.     

Use of gelatine capsules for application of methamphetamine: a new harm reduction approach

Background

In order to reduce injecting drug use, low-threshold facilities in the Czech Republic have started to distribute empty gelatine capsules as an oral alternative of drug application for those injecting methamphetamine. This report reviews implementation of this intervention and its possible benefits and limitations.

Methods

Between December 2008 and January 2009, 109 low-threshold facilities were asked to complete a questionnaire about the capsule programmes. Two focus groups were conducted, one with professionals involved in distribution and one with peer outreach workers who were interviewed on their experience of using the capsules.

Results

A total of 50 facilities (46%) responded to the questionnaire; 16 (32%) distributed the capsules regularly and 19 (38%) were planning to introduce this practice. The main target groups were injecting users of methamphetamine whose veins had been damaged, and methamphetamine users wishing to reduce injecting. The advantages of capsules, as perceived by service staff and peer outreach workers, were their easy use and the satisfactory effect of the oral application; health risks related to the oral use of methamphetamine were considered drawbacks.

Conclusion

Capsule distribution is a promising harm reduction approach for injectors of methamphetamine or other stimulants; nonetheless its benefits and limitations should be further analysed in an in-depth longitudinal study.     

The social context of controlled drug use amongst young people in a slum area in Makassar, Indonesia

Background

There are few studies exploring the social context of controlled drug use amongst young people in Indonesia. This qualitative study examines the experience of young people in a slum area (lorong) in Makassar, eastern Indonesia, who use drugs but are not drug dependent and who employ various forms of self regulation to control their use.

Methods

Semi-structured interviews were conducted with eight controlled drug users.

Results

The study found that whilst controlled drug users lived in a drug risk environment, they were not deeply embedded in the street culture, risk-taking practises and drug scene within their locality. Their employment, albeit in the informal economy and in low-paid jobs, facilitated their perspective that the status of rewa (a local construct of masculinity) and gaul (being sociable and up-to-date) could and should be accomplished through conventional means such as jobs and halal (legitimate) income. Their employment generated both direct benefit (legitimate income) and indirect benefit, including meaningful activities, structured time, positive identity and wider social networks (bridging social capital). This enabled them to have a stake in mainstream society and provided an incentive to control drug use. All factors which are protective against escalation into problematic drug use.

Conclusion

The study showed the importance of sociological concepts of direct and indirect benefits of employment and of social capital in understanding the social context of controlled drug use amongst young people in the lorong. Additionally, drug policy should be more cognizant of the social vulnerability in the lorong and of the need to increase access to employment amongst young people in order to potentially decrease the likelihood of problematic drug use.     

Use patterns and self-reported effects of Salvia divinorum: An internet-based survey

Background

There is growing use of Salvia divinorum (SD), a psychoactive plant that produces hallucinogen-like effects through a kappa opioid receptor (KOR) mechanism. Little is known about KOR agonist effects in humans and about users of SD.

Objectives

To characterize the reasons, methods, and reported consequences of SD use.

Methods

Individuals reading SD-related pages of a drug-information website were invited to anonymously complete an online questionnaire if they had used SD.

Results

Participants (N = 500) were 92.6% male and 23.4 ± 8.7 (mean ± s.d.) years old. They had used a median of six times (range 1-250). 80.6% probably or definitely would use SD again. Most participants (92.6%) typically smoked or vaporized SD product. When smoked, the drug's main effects were estimated to last 14.1 ± 12.8 (range 0.5-120) minutes. When asked to compare SD effects to other methods of altering consciousness, the most common answer was that SD was unique (38.4%). 25.8% reported persisting (≥24 h) positive effects (often described as increased sense of well-being) on at least one occasion. 4.4% reported persisting negative effects (most often anxiety).

Conclusions

SD is typically smoked, acute effects are brief, and persistent adverse effects are uncommon. In addition to acute hallucinogenic effects, SD may produce subacute increases in subjective well-being. Such a subacute effect would be unusual for a drug that is used non-medically, as withdrawal from other drugs typically either does not affect mood or causes dysphoria. Findings from this convenience sample should be confirmed and extended using surveys of random samples and controlled clinical studies.     

A venue analysis of predictors of alcohol use prior to sexual intercourse among female sex workers in Senggigi, Indonesia

Background

Female sex workers’ (FSWs’) use of alcohol, a known disinhibitor to risk behaviour, has been largely understudied. Knowledge of how various sex work venues influence FSW's alcohol consumption before engaging in commercial sex is even rarer. Our analysis identifies those factors across three types of sex-work venues that predict alcohol use among FSWs prior to paid sexual intercourse with clients. Our data were collected through structured interviews with FSWs engaging in commercial sex in Senggigi Beach, Lombok Island in the eastern Indonesian province of West Nusa Tenggara.

Methods

Employing a cross-sectional and multilevel design, three categories of venues where FSWs meet clients in Senggigi were sampled: (1) discotheques and bars (freelance), (2) brothels, and (3) recreational enterprises such as karaoke establishments and massage parlors. The sample consisted of 115 women “nested” within 16 sex work venues. The FSWs reported on 326 clients interactions.

Results

Results show that FSWs consumed alcohol before commercial sex with 157 (48%) of the 326 clients interactions. Alcohol use varied by differences in HIV policies and services offered at the sex work venue, the FSW's educational level and age, and client characteristics.

Conclusion

Alcohol use is common prior to sexual intercourse among FSWs and their clients in Senggigi, and the venue where FSWs meet their clients influences the women's alcohol use. Freelancers were likelier to use alcohol than those who work at brothels and recreational enterprises. Given the recognized links between alcohol use prior to sex and high risk behaviour, HIV prevention programmes that discourage alcohol use should be introduced to both women who engage in commercial sex and also sex-work venue managers, owners, and clients.     

Treatment costs of hepatitis C infection among injection drug users in Canada, 2006-2026

Background

Canadian injection drug users (IDUs) are at high risk of hepatitis C virus infection (HCV). However, little is known about the costs associated with their HCV-related medical treatment. We estimated the medical costs of treating HCV-infected IDUs from 2006 to 2026.

Methods

We employed a Markov model of entry through birth or immigration to exposure-related behaviours or experiences, HCV infection, progression to HCV sequelae and mortality for active and ex-IDUs in Canada. We estimated direct and indirect treatment costs using data from the Ontario Case Costing Initiative (OCCI).

Result

Approximately 137,000 IDUs will suffer from HCV-related disease each year until 2026. Applying the OCCI cost data to the prevalence of HCV-related disease from 2006 to 2026 yielded an estimated cost of $3.96 billion CND to treat HCV-infected IDUs.

Conclusions

Substantial costs are associated with the treatment of HCV-related disease among Canadian IDUs. Given the lack of effective HCV prevention strategies in Canada, we must develop targeted evidence-based responses to prevent HCV transmission and ensure appropriate allocation of medical resources to meet the present and future treatment needs of HCV-infected IDUs.     

Concurrent heroin use among methadone maintenance clients in China

Background

The study examined concurrent illicit heroin use among methadone maintenance clients in China and its association with clients' demographic characteristics, treatment experience, and personal social network.

Methods

Face-to-face surveys were conducted with 178 clients randomly recruited from six methadone maintenance treatment (MMT) clinics in Sichuan, China. Concurrent heroin use was measured based on self-report of heroin use during the past 30 days and a confirmatory urine morphine test. The participants' demographic characteristics and treatment factors were measured and examined. The drug use status of their family members and friends was also assessed.

Results

A total of 80 participants (44.9%) who either reported illicit heroin use in the past 30 days or had a positive urine test were defined as using heroin concurrently. Having drug-using friends was significantly associated with increased concurrent heroin use. Longer length of treatment (2 years or longer) was associated with increased concurrent heroin use. Among those who had both drug-using family members and friends, more women (71.4%) than men (50.0%) used heroin. For those who had no drug-using family members or friends, more men (34.8%) than women (20.8%) used heroin.

Discussion

Study findings indicate an urgent need to address concurrent illicit heroin use among MMT clients. Further examination of the influence of social networks on concurrent drug abuse behavior is encouraged. Results also highlight the importance of understanding gender differences in treatment seeking and behavioral changes, which is crucial to the development of gender-specific treatment strategies.     

"It's not rocket science, what I do": Self-directed harm reduction strategies among drug using ethno-racially diverse gay and bisexual men

Background

Research on harm reduction has typically focused on broad-based or organisational strategies such as needle exchange and opiate substitute programmes. Less attention has been paid to the self-directed harm reduction practices of substance users themselves. Few studies have focused on sexual minority populations such as gay and bisexual men and fewer still on the marginalised groups that constitute these populations. This paper identifies self-directed harm reduction strategies among substance using ethno-racially diverse gay and bisexual men.

Methods

This article presents findings from the Party Drugs Study in Toronto's gay dance club scene, a community-based qualitative study in Toronto, Canada. We present a thematic analysis of interviews with 43 gay and bisexual men from diverse ethno-racial backgrounds about their substance use in the gay dance club scene.

Findings

We identify five self-directed harm reduction strategies: rationing, controlling or avoiding mixing, controlling quality, maintaining a healthy lifestyle, and following guidelines during substance use.

Conclusions

We discuss our findings in relation to prior research and to critical theory. We suggest that drug users’ awareness of possible harm, and their personal investment in harm reduction, constitute a viable platform from which community-based and public health organisations may promote and strengthen harm reduction among gay and bisexual men from ethno-racially diverse backgrounds.     

Contingency management is efficacious and improves outcomes in cocaine patients with pretreatment marijuana use

Background

Marijuana use is common in patients seeking treatment for cocaine use. Nevertheless, few studies have examined effects of marijuana use on treatment outcomes in general, and even fewer with respect to contingency management (CM) treatment, which has been criticized for potentially increasing non-reinforced drug use.

Methods

Data from three randomized clinical trials of CM versus standard treatment (ST) in cocaine-abusing patients were examined ( [Petry et al., 2004], [Petry et al., 2005a] and [Petry et al., 2006a]; N = 393) to assess effects of pretreatment marijuana use on outcomes. Patients were divided into two groups: (1) no self-reported marijuana use (No Pre-M; n = 315) and (2) any self-reported marijuana use (Pre-M; n = 78) in the 30 days pretreatment.

Results

CM was especially efficacious in enhancing retention in Pre-M patients such that retention nearly doubled among Pre-M patients assigned to CM versus those assigned to ST. In contrast, CM exerted only modest benefits on retention in No Pre-M patients. Pretreatment marijuana use was not related to during-treatment abstinence from cocaine, opioids, and alcohol, or abstinence at a Month 9 follow-up. However, CM treatment and longest duration of abstinence achieved during treatment were significant predictors of Month 9 abstinence. Pre-M patients also evidenced more improvements in drug problems over time when randomized to CM.

Conclusions

CM was especially efficacious in facilitating retention and improving severity of drug-related problems in those who used marijuana in the month before initiating treatment.     

Uptake of paraphernalia from injecting equipment provision services and its association with sharing of paraphernalia among injecting drug users in Scotland

Background

There has been a significant increase in the provision of injecting paraphernalia from Scottish injecting equipment provision (IEP) services. However, there is currently a lack of evidence on whether uptake of paraphernalia has any impact on paraphernalia sharing among injecting drug users (IDU). The aim of this study was to examine the factors associated with paraphernalia sharing; in particular, whether uptake of filters, spoons and sterile water from IEPs is associated with a reduction in the sharing of these items.

Methods

A cross-sectional voluntary anonymous survey of 2037 IDUs was administered during 2008–2009. Participants were asked whether they had shared filters, spoons or water (paraphernalia) in the previous 6 months, and their uptake of these items from an IEP during an average week in the previous 6 months.

Results

Self-reported uptake of paraphernalia in an average week during the previous 6 months was associated with reduced odds of sharing paraphernalia: (i) uptake of >30 filters was associated with a reduced odds of sharing filters (adjusted odds ratio (AOR) 0.50, 95% confidence interval 0.32–0.79); (ii) uptake of >30 spoons was associated with a reduced odds of sharing spoons (AOR 0.46, 95% confidence interval 0.28–0.74); and (iii) uptake of sterile water was associated with a reduced odds of sharing water (AOR 0.36, 95% confidence interval 0.22–0.61) compared to no uptake of each of these items.

Conclusions

Uptake of paraphernalia appears to be associated with safer injecting practice. Further research is needed to establish the impact of paraphernalia provision on HCV transmission.     

Associations between substance use disorder sub-groups, life expectancy and all-cause mortality in a large British specialist mental healthcare service

Background

People with substance use disorders (SUDs) have increased risk of mortality but risk in sub-groups is poorly understood.

Methods

SUD cases, aged 15 years or older, were identified in the South London and Maudsley Case Register which contains over 150,000 specialist mental healthcare and addictions service users linked to regular national mortality tracing. Standardized mortality ratios (SMRs) for the period 2007-2009 were calculated based on expected numbers of deaths for England and Wales in 2008 then stratified by gender, age, ethnicity, and type of substance use disorder. Life expectancies at birth were estimated.

Results

We detected 10,927 cases with a primary substance use disorder diagnosis prior to 2010, who were active to South London and Maudsley NHS Foundation Trust services between 2007 and 2009. Alcohol and opioid use disorders were the most common disorders (45.4% and 44.2% of the SUD cohort respectively) and were associated with increased mortality (SMRs 4.04 and 4.85 respectively). Subgroups at particularly high risk were women with opioid use disorder (SMR 7.32) and those under the age of 45 years with alcohol use disorder (SMR 9.25). SMRs associated with alcohol and opioid use disorders diminished with age. Life expectancies of individuals with alcohol and opioid use disorders were reduced by 9-17 years compared to national norms.

Conclusions

Those under 45 years with alcohol use disorder and women with opioid use disorder are at particularly high risk of mortality. More targeted health care is required to address the specific needs of these vulnerable subgroups.     

A cross-national study on Mexico-US migration, substance use and substance use disorders

Background

Epidemiologic research has consistently found lower prevalence of alcohol and drug use disorders among Hispanic immigrants to the US than among US-born Hispanics. Recent research has begun to examine how this change occurs in the process of assimilation in the US. We aimed to study immigration, US nativity, and return migration as risk factors for alcohol and drug use among people of Mexican origin in both the US and Mexico.

Methods

Data come from nationally representative surveys in the United States (2001-2003; n = 1208) and Mexico (2001-2002; n = 5782). We used discrete time event history models to account for time-varying and time-invariant characteristics.

Results

We found no evidence that current Mexican immigrants in the US have higher risk for alcohol or alcohol use disorders than Mexicans living in Mexico, but current immigrants were at higher risk for drug use and drug use disorders. Current Mexican immigrants were at lower risk for drug use and drug disorders than US-born Mexican-Americans. US nativity, regardless of parent nativity, is the main factor associated with increasing use of alcohol and drugs. Among families of migrants and among return migrants we found increased risk for alcohol use, drug use and alcohol and drug use disorders. Evidence of selective migration and return of immigrants with disorders was found regarding alcohol use disorders only.

Conclusions

Research efforts that combine populations from sending and receiving countries are needed. This effort will require much more complex research designs that will call for true international collaboration.     

The relationship between social network factors, HIV, and Hepatitis C among injection drug users in Chennai, India

Objective

The purpose of this study was to examine whether social network factors predict HIV and Hepatitis C (HCV) serostatus after controlling for individual-level factors at baseline among a cohort of male injection drug users in Chennai, India.

Methods

The sample, which was recruited through street outreach, consists of 1078 males who reported having injected drugs in the last 6 months.

Results

The participants reported 3936 social support and risk network members. HIV and HCV positive serostatus were negatively associated with network member providing emotional support, and positively associated with network member providing material support. In addition, HCV positivity was associated with network member being an active drug user known for more than 10 years and network member being male kin networks, even after adjusting for individual demographic factors and risk behaviors.

Conclusions

These findings suggest that social network factors are significantly linked to HIV and HCV status among IDUs in Southern India and highlight the mixed effects of social capital on health. Future HIV/HCV prevention efforts should incorporate IDU peers to alter drug network injection risk norms. For drug users who have minimal network support, support groups and other informal and formal support mechanisms may be need to help them with health care and psychological support needs for dealing with HIV/HCV.