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.     

Risk factors for hepatitis B in an outbreak of hepatitis B and D among injection drug users

During January-April, 2000, 12 cases of acute hepatitis B were reported in Pierce County, Washington, compared with seven in all of 1999. Seven (58.3%) case patients were injection drug users (IDUs), three of whom were coinfected with hepatitis D virus (HDV) and died of fulminant hepatitis. Vaccination clinics were implemented at the local health department and needle exchange program to control the outbreak. We investigated this outbreak to determine risk factors for hepatitis B virus (HBV) transmission among IDUs. Hepatitis B cases were ascertained through routine surveillance and prevaccination testing at vaccination clinics. We conducted a case-control study comparing IDU case patients with HBV-susceptible IDUs identified at the vaccination clinics. Fifty-eight case patients were identified during January-December, 2000, 20 (34.5%) of whom were coinfected with HDV. Thirty-eight case patients (65.5%) reported current IDU. In the case-control study, the 17 case patients were more likely than the 141 controls to report having more than one sex partner [odds ratio (OR) =4.8, 95% confidence interval (CI) =1.5-15.0], injecting more than four times a day (OR = 4.5, 95% CI =1.2-15.6) and sharing drug cookers with more than two people (58.8% vs. 14.0%, OR =14.0, 95% CI =2.4-81.5). Results were similar after controlling for syringe sharing in multivariable analysis. IDUs should be vaccinated against hepatitis B and should be advised against sharing drug injection equipment.     

HIV outbreak among injecting drug users in the Helsinki region: social and geographical pockets

BACKGROUND: Incidence of newly diagnosed HIV infections among injecting drug users (IDUs) in Helsinki rose from 0 per 100,000 inhabitants in 1997 to 2.9 in 1998 and to 11.1 in 1999. Thereafter incidence declined to 2.1 in 2003. METHODS: Data were collected from interviews with HIV-positive IDUs who attended the University Hospital in Helsinki from 1998 until 2003. We studied the sociodemographic profile and spatial distribution of IDUs who were diagnosed in the beginning of the outbreak and those diagnosed later. The indicator for the spatial differentiation within the metropolitan area is % employed males aged 25-64. RESULTS: The outbreak occurred among a marginalized population of IDUs characterized by a long history of injecting drug use (10.7 years), mean age 32 years, homelessness (66.3%), history of imprisonment (74.7%) and psychiatric hospital care (40.6%). Compared with 98 early cases diagnosed during the first 2 years until 2000, 47 recent cases diagnosed after 2001 were 4 years older, and as marginalized. Except for the city centre, both early and recent cases had been living or using drugs in the same deprived neighbourhoods with the highest unemployment rates. Up to 40% of cases in the two big geographical clusters did not have contact with the city centre, where the needle exchange services were available. CONCLUSIONS: The Finnish HIV outbreak is restricted socially to a very marginalized IDU population, and spatially to local pockets of poverty. In low prevalence countries, prevention programs should be targeted early at high-risk areas and populations.     

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.     

Sudden rise in uptake of hepatitis B vaccination among injecting drug users associated with a universal vaccine programme in prisons

Hitherto, services have failed to deliver the UK Government's 1988 recommendation to vaccinate injecting drug users (IDUs) against hepatitis B virus (HBV). In April 1999, the Scottish Prison Service implemented an initiative to offer HBV vaccination to all inmates; we sought to determine the impact of this initiative on the IDU population. Among community-recruited IDUs (who had injected for < or =5 years) in Glasgow, vaccine uptake was significantly higher among those surveyed in 2001-2002 (52% of 387) than in 1993 (16% of 166), 1994 (19% of 138) or January-March 1999 (15% of 128); of the 2001-2002 vaccinees, 56% had been vaccinated in prison. Our results indicate that the universal offer of vaccination to all prisoners, within two years of the initiative's implementation, has had a dramatic impact on uptake among IDUs.     

Acute hepatitis B infection in England and Wales: 1985-96

Confirmed acute hepatitis B infections are reported to the Public Health Laboratory Service Communicable Disease Surveillance Centre by laboratories in England and Wales. These reports have been used to monitor trends in the incidence of hepatitis B virus (HBV) infection over time, and between exposure categories and age groups. Between 1985 and 1996 a total of 9252 cases of acute HBV infection were reported; the number of reports fell from 1761 in 1985 to 581 in 1996. Most infections were reported in adults aged 15-44 years [n = 7365 (80%)], and infections were more commonly reported in males [n = 6490 (70%)] than females [n = 2658 (29%)]. The probable means of acquisition was known for just over half of all adult cases [4827/8956 (54%)]. Injecting drug use was the most common exposure [n = 1901 (21%)], followed by sex between men and women [n = 1140 (13%)] and sex between men [n = 1025 (11%)]. The number of infections in injecting drug users fell in the late 1980s, but increased again from 1991 onwards. In children aged under 15 years, infections acquired by mother to baby transmission accounted for 35/170 (21%) of the total. Surveillance indicates that the incidence of acute hepatitis B infection fell in the late 1980s, probably reflecting changed behaviour in injecting drug users. An increase in the number of infections in injecting drug users since 1993 may indicate ongoing transmission that has not been contained by the introduction of needle exchange schemes or by selective vaccination.     

Epidemiology of hepatitis C virus infection among injecting drug users in Australia.

STUDY OBJECTIVE: To review the epidemiology of hepatitis C virus (HCV) infection among injecting drug users (IDUs) in Australia, and consider needs for further research and prevention policies and programmes. DESIGN: (1) Review of the results of surveillance for HCV; (2) review of published literature on prevalence, incidence, and risk factors for HCV among IDUs; and (3) reconstruction of incidence rates from prevalence studies of HCV in IDUs. SETTING AND PARTICIPANTS: Field and clinic based studies of IDUs in Australia. MAIN RESULTS: HCV has been present at high prevalences (of the order of 60-70%) in populations of Australian IDUs since at least 1971. Duration of injecting and main drug injected were the main predictors of seropositivity, the latter possibly a surrogate for frequency of injecting and both together as surrogate for cumulative numbers of times injected. Risk of infection begins with first injection and continues as long as injecting does. Current incidence is approximately 15 per 100 person years, and up to 40 per 100 person years in some subpopulations. Incidence may have decreased through the 1980s as a result of behaviour change in relation to HIV, as it has for hepatitis B, but not significantly so. CONCLUSIONS: Control of HCV infection in Australia will depend on effectiveness of measures to control HCV spread among IDUs. This will be a greater challenge than the control of HIV in this population has been. Needs identified include improved surveillance, especially for recently acquired infection, better understanding of exact transmission modes, and urgent improvement in prevention strategies.     

Hitting up in the top end: characteristics of needle exchange clients in Darwin

OBJECTIVE: Little is known about injecting drug use (IDU) and blood-borne viral (BBV) infection in rural Australia. METHOD: These repeat cross-sectional studies were conducted during a two-week period in July and October-November 1998 at the Darwin needle exchange, with 129 and 121 respondents respectively. RESULTS: The commonest drug of choice was heroin, but the commonest drug injected was morphine. Self-reported sharing of needles and syringes was uncommon. Self-reported serostatus for HIV was high (8% and 11.4% respectively), but seemingly mostly associated with sexual rather than IDU risk; for hepatitis C (HCV) status, these were 54% and 37%. Among IDUs of Aboriginal or Torres Strait Islander (ATSI) background, who made up 14% of the first round respondents, patterns of IDU and of BBV infection were the same as among non-ATSI respondents. CONCLUSIONS: These surveys reveal patterns of IDU in Darwin that have both similarities and differences with those in the major urban centres in Australia. In the absence of a comprehensive methadone maintenance program, many participate in a more or less informal morphine substitution program. HIV is present among these IDUs, and the risks of further sexual transmission may be high. IMPLICATIONS: These surveys confirm the presence among injecting drug users in Darwin of HIV, HBV and HCV, and of the risk for further spread of these viruses. Control of blood-borne virus transmission among IDUs requires an even greater commitment to abolishing sharing of needles and syringes, and therefore continued support and enhancement of needle and syringe availability.     

Prevalence and incidence of bloodborne viral infections among Danish prisoners

In order to determine the prevalence and incidence of bloodborne viral infections among prisoners, we conducted a prospective study in a Danish medium security prison for males. The prisoners were offered an interview and blood test for hepatitis and human immunodeficiency virus HIV at inclusion as well as at release from prison or end of study. Of 403 prisoners available 325 (79%) participated in the initial survey and for 142 (44%) a follow-up test was available. 43% (140/325) of the participants were injecting drug users (IDUs) of whom 64% were positive for hepatitis B (HBV) and 87% for hepatitis C (HCV) markers. No cases of HIV or human T lymphotropic virus (HTLV) were found. 32% of all prisoners could transmit HBV and/or HCV by blood contact. 70% of IDUs had shared injecting equipment, and 60% had injected inside prison. Only 2% of IDUs were vaccinated against HBV. Duration of injecting drug use, numbers of imprisonments, and injecting in prison were independently and positively associated with the presence of HBV antibodies among IDUs by logistic regression analysis. The HBV incidence was 16/100 PY (95% CI: 2–56/100 PY) and the HCV incidence 25/100 PY (1–140) among injecting drug users (IDUs). We conclude that IDUs in prison have an incidence of hepatitis B and C 100 times higher than reported in the general Danish population. They should be vaccinated against hepatitis B and new initiatives to stop sharing of injecting equipment in and outside prison is urgently needed.     

HIV prevalence and risk behaviours among injecting drug users in six indonesian cities implications for future HIV prevention programs

ABSTRACT: BACKGROUND: The HIV prevalence among injecting drug users (IDUs) in Indonesia reached 50% in 2005. While drug use remains illegal in Indonesia, a needle and syringe program (NSP) was implemented in 2006. METHODS: In 2007, an integrated behavioural and biological surveillance survey was conducted among IDUs in six cities. IDUs were selected via time-location sampling and respondent-driven sampling. A questionnaire was administered face-to-face. IDUs from four cities were tested for HIV, syphilis, gonorrhoea and chlamydia. Factors associated with HIV were assessed using generalized estimating equations. Risk for sexual transmission of HIV was assessed among HIV-positive IDUs. RESULTS: Among 1,404 IDUs, 70% were daily injectors and 31% reported sharing needles in the past week. Most (76%) IDUs received injecting equipment from NSP in the prior week; 26% always carried a needle and those who didn't, feared police arrest. STI prevalence was low (8%). HIV prevalence was 52%; 27% among IDUs injecting less than 1 year, 35% among those injecting for 1-3 years compared to 61% in long term injectors (p < 0.001). IDUs injecting for less than 3 years were more likely to have used clean needles in the past week compared to long term injectors (p < 0.001). HIV-positive status was associated with duration of injecting, ever been imprisoned and injecting in public parks. Among HIV-infected IDUs, consistent condom use last week with steady, casual and commercial sex partners was reported by 13%, 24% and 32%, respectively. CONCLUSIONS: Although NSP uptake has possibly reduced HIV transmission among injectors with shorter injection history, the prevalence of HIV among IDUs in Indonesia remains unacceptably high. Condom use is insufficient, which advocates for strengthening prevention of sexual transmission alongside harm reduction programs.     

新旧注射吸毒人群HIV传播因素研究

目的探讨和分析新旧注射吸毒者的人口学特征及HIV传播因素,为预防控制艾滋病流行提供科学依据。方法选取针具交换点和戒毒所新旧人群为研究对象,采用面对面问卷调查,问卷内容包括新旧人群的人口学特征、艾滋病相关知识、干预服务参号隋况、高危行为学特征及HIV传播影响因素。应用SPSS16．0软件进行统计分析。结果共调查474例注射吸毒者,其中新人群（注射吸毒≤5年）及旧人群（注射吸毒〉5年）分别为157例（33．1％）和317例（66．9％）。调查对象的HIV感染率为20．5％,HIV感染率与吸毒年限呈正相关趋势（_=0．83,P=0．004）,且在5年内的变化速率最快。多因素Logistic回归模型结果显示,在〈30岁的新人群中,男性、重复使用及共用针具是HIV传播的影响因素;在30～40岁的旧人群中,男性、知晓共用注射辅助材料的危害及共用针具是HIV传播的影响因素;在〉40岁的旧人群中,男性、文化程度初中及以上、参加过针具交换及共用针具是HIV传播的影响因素。结论加强对新旧人群的宣传教育力度,倡导针具交换、有套性交、扩大干预服务覆盖面,知而信、信而行,是预防控制HIV传播与流行的有效措施。     

Sudden rise in uptake of hepatitis B vaccination among injecting drug users associated with a universal vaccine programme in prisons

Hitherto, services have failed to deliver the UK Government’s 1988 recommendation to vaccinate injecting drug users (IDUs) against hepatitis B virus (HBV). In April 1999, the Scottish Prison Service implemented an initiative to offer HBV vaccination to all inmates; we sought to determine the impact of this initiative on the IDU population. Among community-recruited IDUs (who had injected for ≤5 years) in Glasgow, vaccine uptake was significantly higher among those surveyed in 2001–2002 (52% of 387) than in 1993 (16% of 166), 1994 (19% of 138) or January–March 1999 (15% of 128); of the 2001–2002 vaccinees, 56% had been vaccinated in prison. Our results indicate that the universal offer of vaccination to all prisoners, within two years of the initiative’s implementation, has had a dramatic impact on uptake 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。     

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.     

A study of young people who inject drugs: an opportunity to decrease high risk injecting by improving knowledge about hepatitis C prevention

The population of young people who inject drugs (PWID) displays a unique constellation of features that are not found in other groups who are at risk of acquiring hepatitis C: they exhibit a smaller pool of existing infection and a higher incidence of unsafe injecting. This means there is vast opportunity to prevent the spread of hepatitis C for young PWID. This article uses survey data collected from clients of a community pharmacy needle exchange scheme in New South Wales, Australia, to describe the extent of unsafe injecting among young PWID, their knowledge about hepatitis C prevention and use of services. It examines whether poor knowledge and service use are related to unsafe injecting. A sample of 215 respondents aged 18–25 years was compared to 1464 respondents aged 26 years or older. Young respondents engaged in riskier injecting practices than their older counterparts, with higher proportions saying they had shared needles and other injecting equipment. Moreover, those who had shared equipment did so in a more risky manner than older respondents by sharing with a larger number of people and with people who were possibly less well-known to them, such as casual sex partners. While knowledge about hepatitis C transmission was good among young respondents, it was significantly worse than that of older respondents. More importantly, however, this poorer knowledge was related to both increased needle sharing and increased ancillary equipment sharing. Many studies do not observe a relationship between knowledge and risk behaviour but the findings of this study suggest a pressing opportunity to improve knowledge of young PWID. While it is unlikely that better knowledge will alone prevent infection among young people, it is a necessary starting point and, in the current case, has the potential to decrease young people’s risk of acquiring hepatitis C.     

静脉注射吸毒人群HIV和HCV感染现状及影响因素的Meta分析

目的 了解中国内地静脉注射吸毒人群（injecting drug users,IDUs）中人类免疫缺陷病毒（human immunodeficiency virus,HIV）和丙型肝炎病毒（hepatitis C virus,HCV）感染状况及相关影响因素。方法 通过相应检索策略收集2000-2015年期间针对该人群的HIV和HCV感染状况的文献,提取数据建立数据库后进行Meta分析。结果 中国内地IDUs中HIV感染率为7.00%（95%CI:6.10%~8.00%）,HCV感染率为67.10%（95%CI:61.00%~73.20%）。亚组分析显示,不同地区、不同人群和不同时间段HIV和HCV感染率不同;单因素Meta回归分析显示HCV感染率是HIV感染率的主要影响因素,高HCV感染率组HIV感染率高于低HCV感染率组。结论 2000-2015年中国内地IDUs HIV和HCV感染率较高,HIV感染率与HCV感染率关系密切,在IDUs中可用HCV感染率的高低来评估该人群中HIV的感染和流行风险。     

Low perceived benefits and self-efficacy are associated with hepatitis C virus (HCV) infection-related risk among injection drug users

Hepatitis C prevention counselling and education are intended to increase knowledge of disease, clarify perceptions about vulnerability to infection, and increase personal capacity for undertaking safer behaviours. This study examined the association of drug equipment sharing with psychosocial constructs of the AIDS Risk Reduction Model, specifically, knowledge and perceptions related to hepatitis C virus (HCV) among injection drug users (IDUs). Active IDUs were recruited between April 2004 and January 2005 from syringe exchange and methadone maintenance treatment programs in Montreal, Canada. A structured, interviewer-administered questionnaire elicited information on drug preparation and injection practices, self-reported hepatitis C testing and infection status, and AIDS Risk Reduction Model constructs. Separate logistic regression models were developed to examine variables in relation to: (1) the sharing of syringes, and (2) the sharing of drug preparation equipment (drug containers, filters, and water). Among the 321 participants, the mean age was 33 years, 70% were male, 80% were single, and 91% self-identified as Caucasian. In the multivariable analyses, psychosocial factors linked to syringe sharing were lower perceived benefits of safer injecting and greater difficulty to inject safely. As with syringe sharing, the sharing of drug preparation equipment was associated with lower perceived benefits of safer injecting but also with low self-efficacy to convince others to inject more safely. Interventions should aim to heighten awareness of the benefits of risk reduction and provide IDUs with the skills necessary to negotiate safer injecting with their peers.     

Acute hepatitis B in Edinburgh 1975-92: a retrospective study in a population where human immunodeficiency virus is highly prevalent.

A retrospective study of notified hepatitis B virus (HBV) infection in Edinburgh during 1975-92 identified 525 acute cases. For 343 where a probable transmission route could be determined, 215 were due to shared equipment by injection drug users (IDUs), 29 to homosexual intercourse, 25 to heterosexual or household contact with IDUs, 21 to heterosexual contact with infected non-IDU partners and 53 to various other or multiple routes. Cases were unevenly distributed geographically, particularly those among IDUs. The highest incidence within a post code district was approximately 2.5 times that for all Edinburgh. Annual cases peaked in 1984 then declined to low levels in the early 1990s. This reduction was most marked among IDUs, and may be ascribed both to changed injecting behaviour and decreased susceptibility within this group. The latter factor implies that HBV infections may be an unreliable guide to human immunodeficiency virus (HIV) infection in populations where HBV is highly prevalent.