Active Intravenous Drug Users Research Articles

Substance use and risk behaviour patterns among people who inject drugs

Abstract Background Substance use and injecting drug use in particular are related to health damages, reduced quality of life and life expectancy. Injecting drug use is a risk factor for acquiring infectious diseases among people who inject drugs (PWID). The aim of the study was to assess the risk behavior related to the use of intravenous psychoactive substances among PWID in Lithuania. Methods In 2023 a cross sectional study using respondent driven sampling (RDS) of active intravenous drug users (n = 370) was conducted in 5 different sites across Lithuania. RDS is a sampling methodology based on peer-referral in underserved populations that cannot be sampled randomly. Descriptive statistical and regression analyses were conducted using SPSS 23.0. Results 78% of the sample were males, 22% - females. Age mean is 40.6 years, SD-7.7. The first injecting drug was used at the age of 18 (mode). 69% of PWID received drug dependance treatment at least once in life. 70% of the PWID in harm reduction services are also in the substitution therapy programmes. Fentanyl is the main substance for every second respondent which is injected 3 times a day and commonly used with alcohol (64%). 79% of PWID during the last injection used sterile needles and syringes. 45% of respondents reported overdosing during the last 12 months and half of all PWID had naloxone for death prevention. Nearly 70% were tested for TB and syphilis during the last 12 months. Conclusions PWID are mainly males who began injecting drugs at 18 years. Unsafe injecting behaviour (frequency and mode), using alcohol were related to lower participation in health care services for PWID. Main messages • Lower participation in health care services is related to behavioural risk factors. • Ongoing research is needed to assess the factors determining engagement into healthcare of PWID.

Stabilization of Tibial Fractures at Risk of Complications With the Bactiguard Intramedullary Nail: Early to Medium Results With a Novel Metal-Coated Device.

The purpose of this study was to investigate the safety and early clinical results from the use of a novel, noble metal-coated titanium tibial nail for the definite stabilization of tibial shaft fractures at risk of developing complications. This is a retrospective case series with prospectively collected data. Level I Trauma Centre in the United Kingdom. Thirty-one patients who were managed with the Bactiguard-coated Natural Nail and achieved a minimum of a 12-month follow-up. The main outcomes of this study were the incidence of adverse events (related to implant safety), complications (particularly infection), and reinterventions. Thirty-one patients with a mean age of 41.6 years were included in this study. Active heavy smokers or intravenous drug users were 25.8% and 9.7% of them were diabetic. Five fractures were open while 13 had concomitant soft-tissue involvement (Tscherne grade 1 or 2). Twenty-seven patients healed with no further intervention in a mean time of 3.3 months. Three patients developed nonunion and required further intervention. The overall union rate was 96.7%. One patient developed deep infection after union (infection incidence 3.2%). Six patients (6/31; [19.3%]) required reinterventions [2 for the treatment of nonunion, 3 for removal of screws soft-tissue irritation, and 1 for the management of infection). The management of tibial shaft fractures with a noble metal-coated titanium tibial nail demonstrates encouraging outcomes. Further studies are desirable to gather more evidence in the performance of this innovative implant. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Risk behavior among people who inject drugs

Abstract Background Addiction to illicit drugs is considered as medical condition requiring effective measures to prevent the disease and minimize harms of this addiction. Injecting drug use increases the risk for acquiring blood-borne infections among people who inject drugs (PWID). The aim of the study was to assess the risk behavior related to the use of intravenous narcotic and psychotropic substances among PWID in Lithuania. Methods A cross sectional survey using respondent driven sampling (RDS) of active intravenous drug users (n = 369) in Lithuania has been conducted in 2018-2019. RDS is a peer-referral sampling methodology applied to estimate characteristics of underserved populations that cannot be sampled randomly. 8 seeds were selected in 5 different sites across the country to recruit the study subjects. Descriptive statistics and logistic regression were conducted. Results Data collection was completed using 4 waves. Each seed yielded 3 to 24 eligible recruits. 80% of the sample were males, 20% - females. Age mean is 36.8 years, SD-7.69. The age of debut injecting drugs was 13 years, average age 20 years, SD 4.8. Average injecting duration was 12 years. 76% were incarcerated during their lifetime. 59% of PWID reported injecting heroin, 39% phentanyl, 13% amphetamines. 79% reported using sterile needles and syringes while injecting the last time and 21% were not. 17% were sharing non sterile injecting equipment during the last 30 days. Conclusions Younger age when started injecting drugs, duration of injecting drugs and imprisonment increased the risk of using unsterile needles and syringes and sharing injecting equipment. Main messages Behavioural risk factors are related to higher risks of drug use related infectious diseases. Targeted psychosocial interventions are needed to prevent the behavioural risks of injecting drug use.

Surgery in drug use-associated infective endocarditis: long-term survival is negatively affected by recurrence.

The prevalence of infectious endocarditis (IE) in intravenous drug users (IDUs) is increasing, and the number of patients who need surgery is also rising. Relatively little is known about the short-term and long-term outcomes of these operations. This study is a retrospective analysis of our institutional results, focussing on risk factors for perioperative death, major adverse events and long-term survival. A total of 50 of the 66 (75.75%) patients had postoperative follow-up, and the mean follow-up time was 53.9 ± 9.66 months. Patients were divided into 2 groups depending on whether they were having their first operation or were being reoperated for recurrent IE. From March 2006 to December 2015, a total of 158 patients underwent surgery for IE; 72 (45.6%) of them were identified as active IDUs. The operative mortality in IDUs was 8.33% (6 patients), with no significant difference between the 2 groups (P = 0.6569). Survival rates at 1 year, at 3 years and at the end of follow-up were 92%, 72% and 64%, respectively. There was significantly worse survival of patients with recurrent IE (log-rank test, P = 0.03). Although the short-term results of operation for IE in IDUs are good, long-term outcomes are not satisfactory. The survival of patients with recurrence of IE caused by return to intravenous drug use is significantly worse.

SAT-266-High rates of early HCV reinfections after DAA therapy in active intravenous drug users attended at mobile harm reduction units

SAT-266-High rates of early HCV reinfections after DAA therapy in active intravenous drug users attended at mobile harm reduction units

Hepatitis C treatment for difficult to access populations: can telementoring (as distinct from telemedicine) help?

Although hepatitis C virus (HCV) infection is curable, treatment of difficult to access populations (DTAP) presents unique challenges. Project ECHO (PE) (Extension for Community Healthcare Outcomes) is a telementoring programme adopted to support clinicians treating DTAP. To determine if the PE model supports primary care clinicians treating HCV and to compare cohort of PE patients with those in a tertiary liver clinic (TLC). Weekly PE group video conferences were conducted. Clinical information, laboratory indices, psychosocial elements and treatment outcomes, including sustained virological response (SVR) data were recorded in the first 100 consecutive cases and retrospectively compared to 100 consecutive patients seen at a TLC from July 2016 to April 2017. Some patient characteristics were similar between PE and TLC: gender (72% vs 75% male; P = 0.23), median age (45 vs 50; P = 0.344) and the proportion of treatment naïve patients (95.0% vs 90.9%). Treatment for HCV was commenced in 78% of the PE patients and 81% of the TLC patients; 67/68 of the TLC patients and 60/61 PE patients with virological follow up who completed treatment and attended follow up have confirmed SVR. PE patients are more likely to have ongoing substance use (44% vs 17% P < 0.001), be active intravenous drug users (32% vs 17%; P < 0.001) and polysubstance abusers (26% vs 7%; P < 0.001) and were more likely to be taking opioid substitution therapy (74% vs 20%; P < 0.001). Indigenous patients were three times more greatly represented in PE (15% vs 5%; P = 0.018). PE is an effective model to support primary healthcare providers treating HCV in DTAP with similar rates of treatment uptake and SVR compared to patients in TLC.

Characteristics and Clinical Outcomes of Hospitalized Patients with Community-Acquired Pneumonia who are Active Intravenous Drug Users

Background: Intravenous drug users (IVDU) have a 10-fold increased risk of community-acquired pneumonia (CAP) compared to the general population. There is scarce data available evaluating the clinical outcomes of IVDU hospitalized patients with CAP and that data mostly focuses on mortality. The objective of this study was to evaluate the clinical characteristics, incidence and outcomes of hospitalized patients with CAP in active intravenous drug users in Louisville, Kentucky.

Sloughing skin in intravenous drug user

A 32 year old female, an active intravenous drug user, was admitted for fever, myalgias and an erythematous macular rash on her distal extremities. She quickly decompensated and developed septic shock. Her examination was significant for a progressive rash which within two days developed bullae and necrosis with progression to a confluent rash involving her palms and soles (Figs. 1 and 2). Her rash involved nearly one third of her body with what was equivalent to a third degree burn. Her labs were significant for leukocytosis with bandemia, elevated liver function tests with worsening thrombocytopenia and fibrinogen levels consistent with disseminated intravascular coagulation (DIC) Her transthoracic echocardiogram (Fig. 3) showed a 5 cm vegetation on the tricuspid valve. Her blood cultures were positive for methicillin-sensitive Staphylococcus aureus. She was meeting the clinical criteria for toxic shock syndrome (TSS) and subsequent testing for toxic shock syndrome toxin antibody was positive. She was treated with antibiotics and intravenous gamma globulin (IVIG). Due to her worsening rash she was transferred to a burns unit. She was diagnosed with Purpura fulminans (PF) which is a skin manifestation of DIC and has a rare association with Staphylococcus aureus infection.The main focus of this case report is to emphasise this rare association, prompt an early diagnosis and referral to prevent life threatening complications.

Characteristics and Clinical Outcomes of Hospitalized Patients with Community-Acquired Pneumonia who are Active Intravenous Drug Users

Characteristics and Clinical Outcomes of Hospitalized Patients with Community-Acquired Pneumonia who are Active Intravenous Drug Users

Hepatitis‐Viral

Hepatitis‐Viral

Case Report: Clinical and Ethical Dilemmas in Active Intravenous Drug Users (IDUs) with Recurrent Bacteraemia

Case Report: Clinical and Ethical Dilemmas in Active Intravenous Drug Users (IDUs) with Recurrent Bacteraemia

Discordance between Tuberculin Skin Test and Interferon Gamma Release Assay is Associated with Previous Latent Tuberculosis Infection Treatment

Background: The performance of Interferon gamma release assays (IGRA) in drug users and the impact of previous latent tuberculosis infection (LTBI) treatment on discordance of IGRA and tuberculin skin test (TST) are unclear. Objective: To determine the prevalence and incidence of LTBI using TST and Quantiferon Gold In-Tube test (QFT-G-IT) in a cohort of persons with hepatitis C virus (HCV) and drug use history. Design: Eligible participants had baseline TST and QFT-G-IT assay and were retested with QFT-G-IT after 12 months to assess prevalence and incidence of LTBI. Results: Of 193 HCV-infected persons enrolled, 162 (84%) were HIV infected; 132 (81%) were on anti-retroviral therapy and 131 (81%) had a CD4 count >200. 190 (98%) had a history of drug use; only 19 (10%) were active intravenous drug users. 55 (28.5%) had LTBI based on TST results and 13 (7%) were diagnosed with LTBI based on QFT-G-IT. 46/193 persons (23.8%) had positive TST with negative QFT-G-IT test. History of LTBI treatment was a strong predictor of this discordance (OR=41.5; 95%CI 16.2-106.7; p<0.0001). No QFT-G-IT conversions were detected among the 101 initially QFT-G-IT negative patients retested at one year (95% CI: 0-3.6%). Conclusions: Intravenous drug users who are not actively using drugs have a low prevalence and incidence of LTBI by IGRA. Previous LTBI treatment is associated with a positive TST and a concurrent negative QFT-G-IT.

Prevalence of hepatitis C virus in mothers and their children in Malawi.

ObjectivesHepatitis C virus (HCV) prevalence is poorly mapped in the East African region; with the advent of novel HCV therapies, better epidemiological data are required to target the infection. We sought to estimate HCV prevalence in healthy Malawian mothers and assess mother-to-child transmission (MTCT); context is provided by reviewing previously published HCV prevalence data from the region.MethodsUsing ELISA screening and confirmatory blot, serological testing of 418 healthy Malawian mothers for HCV was performed. To examine MTCT, the children of any positive women were also tested for HCV; all children had malignant disease unrelated to hepatocellular carcinoma. We compared our results to published literature on HCV prevalence in Malawi and its neighbouring countries.ResultsThree of 418 women were HCV reactive by ELISA; two were confirmed positive by immunoblot (0.5%). One child of an HCV-infected mother was HCV seropositive. The literature review revealed HCV prevalence ranging from 0 to 7.2% in the region, being highest in Tanzania and specifically for cohorts of inpatients and HIV-co-infected people. The overall estimated prevalence of HCV in Malawi was 1.0% (95%CI 0.7–1.4) when all studies were included (including this one), but lower in healthy cohorts alone at 0.3% (95%CI 0.1–1.2).ConclusionsThis is the first study using confirmatory tests to examine HCV prevalence in healthy Malawian mothers; the prevalence was low. Future studies need to address the source of infection in healthy women.

Early HIV diagnosis through use of rapid diagnosis test (RDT) in the community and direct link to HIV care: a pilot project for vulnerable populations in Athens, Greece.

IntroductionAn increase in the incidence of HIV new infections among intravenous drug users (IDUs) by 1500%, was noted in the center of Athens in 2011. Increasing problematic drug use, homelessness, health cuts amidst the economic crisis, have contributed to the epidemic. New cases doubled within a year, challenging the HIV care delivery system [1].Materials and MethodsA pilot project funded by the National Strategic Reference Framework (NSRF) 2007–2013 of the European Union (EU), was launched from August 2012 to March 2014. It was a partnership between the HIV Clinic of Evangelismos Hospital and the NGO PRAKSIS. The project is aimed at offering early diagnosis and comprehensive care to hard to reach populations. RDT diagnosis through mobile units, direct linkage to care, elimination of waiting times, flexibility, psychosocial support and link to harm reduction services for active IDUs were offered to the beneficiaries.ResultsA total of 117 people enrolled in the program following HIV RDT offered by mobile units of the NGO PRAKSIS in community sites. Sixty-eight percent were IDUs, 12% were men who have sex with men (MSM) and 19.5% were heterosexuals. Men were 74.3% and women were 25.6%. Country born patients were 43.5% and non-country born patients were 56.4%. Nine people were HIV negative but needed post-exposure prophylaxis (PEP), treatment for Hepatitis C and one test was false positive. Two deaths occurred and six people were deported. Of the remaining 100 patients, 84 enrolled in the care program. Of those 77% (65/84) remain in care for three months after the end of the project. Care retention was 73.5% (39/53) for IDUs, 91% (10/11) for MSM, 80% (16/20) for heterosexuals, 73% (25/35) for country born and 82% (40/49) for non-country born individuals. Among those that remain in care, 77.7% (42/54) with <350 CD4 are on antiretroviral therapy (ART). Among those on ART >90% have undetectable viral load. Mean value of CD4 cells at enrollment was 298 cells/mm3. At follow up, three months after the end of the program, the mean value of CD4 cells was 464 cells/mm3.ConclusionsThe project has proven the feasibility of a novel approach of active case finding in the community with direct link to care. Retention to care was satisfactory as most of those patients would not have been able to access care through the normal ART delivery mode of the Public Health System. However, more obstacles to care remain. Being homeless, poor nutrition, complicated access to harm reduction services, lack of One Stop Shop services and police operations in the city center impede further progress [2,3].

Surgical treatment of infective endocarditis in active intravenous drug users: a justified procedure?

BackgroundInfective endocarditis is a life threatening complication of intravenous drug abuse, which continues to be a major burden with inadequately characterised long-term outcomes. We reviewed our institutional experience of surgical treatment of infective endocarditis in active intravenous drug abusers with the aim of identifying the determinants long-term outcome of this distinct subgroup of infective endocarditis patients.MethodsA total of 451 patients underwent surgery for infective endocarditis between January 1993 and July 2013 at the University Hospital of Heidelberg. Of these patients, 20 (7 female, mean age 35 ± 7.7 years) underwent surgery for infective endocarditis with a history of active intravenous drug abuse. Mean follow-up was 2504 ± 1842 days.ResultsStaphylococcus aureus was the most common pathogen detected in preoperative blood cultures. Two patients (10%) died before postoperative day 30. Survival at 1, 5 and 10 years was 90%, 85% and 85%, respectively. Freedom from reoperation was 100%. Higher NYHA functional class, higher EuroSCORE II, HIV infection, longer operating time, postoperative fever and higher requirement for red blood cell transfusion were associated with 90-day mortality.ConclusionsIn active intravenous drug abusers, surgical treatment for infective endocarditis should be performed as extensively as possible and be followed by an aggressive postoperative antibiotic therapy to avoid high mortality. Early surgical intervention is advisable in patients with precipitous cardiac deterioration and under conditions of staphylococcal endocarditis. However, larger studies are necessary to confirm our preliminary results.

Profile of infective endocarditis observed from 2003 - 2010 in a single center in Italy

BackgroundThis study aimed to provide a contemporary picture of the epidemiologic, clinical, microbiologic characteristics and in-hospital outcome of infective endocarditis (IE) observed in a single center in Italy.MethodsWe performed a retrospective study of patients with definite or probable IE observed at the “L. Sacco” Hospital in Milan, Italy, from January 1, 2003 through December 31, 2010.Results189 episodes of IE in 166 patients were included. The mean number of incident IE in the study period was of 1.27 (range 0.59-1.76) cases per 1000 patients admitted. The median age of the cohort was 57 (interquartile range, 43-72) years, 63% were male and 62.5% had native valve IE. Twenty-six percent were active intravenous drug users (IVDU), 29% had a health care-associated IE and 5% chronic rheumatic disease. Twenty-nine percent of the cases occurred in patients affected by chronic liver disease and 19% in HIV positive subjects. Staphylococcus aureus was the most common pathogen (30%), followed by streptococci. The mitral (34%) and aortic (31%) valves were involved most frequently. The following complications were common: stroke (19%), non-stroke embolizations (25%), heart failure (26%) and intracardiac abscess (9%). Surgical treatment was frequently employed (52%) but in hospital mortality remained high (17%). Health care-associated IE and complications were independently associated with an increased risk of in-hospital death, while surgery was associated with decreased mortality.ConclusionS. aureus emerged as the leading causative organism of IE in a University hospital in northern Italy. Our study confirmed the high in-hospital mortality of IE, particularly if health care associated, and the protective role of surgery.

Evolution of CD8+ T cell responses after acute PARV4 infection.

PARV4 is a small DNA human virus that is strongly associated with hepatitis C virus (HCV) and HIV infections. The immunologic control of acute PARV4 infection has not been previously described. We define the acute onset of PARV4 infection and the characteristics of the acute-phase and memory immune responses to PARV4 in a group of HCV- and HIV-negative, active intravenous drug users. Ninety-eight individuals at risk of blood-borne infections were tested for PARV4 IgG. Gamma interferon enzyme-linked immunosorbent spot assays, intracellular cytokine staining, and a tetrameric HLA-A2-peptide complex were used to define the T cell populations responding to PARV4 peptides in those individuals who acquired infection during the study. Thirty-five individuals were found to be PARV4 seropositive at the end of the study, eight of whose baseline samples were found to be seronegative. Persistent and functional T cell responses were detected in the acute infection phase. These responses had an active, mature, and cytotoxic phenotype and were maintained several years after infection. Thus, PARV4 infection is common in individuals exposed to blood-borne infections, independent of their HCV or HIV status. Since PARV4 elicits strong, broad, and persistent T cell responses, understanding of the processes responsible may prove useful for future vaccine design.

A new era for hepatitis C-new diagnostics tools and new weapons.

A new era for hepatitis C-new diagnostics tools and new weapons.

Invited Commentary

This retrospective review from the Cleveland Clinic details the outcomes of 428 patients surgically treated for native (58%) and prosthetic valve (42%) endocarditis over a 5-year period [1]. Two thirds of the patients lived in Ohio and one third came from other states or countries. Only 24 patients (5.6%) were active intravenous drug users. The majority of patients admitted with endocarditis to this facility underwent surgical treatment, which would suggest a degree of chronicity of the infection and infers prolonged antibiotic therapy there or elsewhere.

Epidemiology of acute and chronic hepatitis B virus infection in Norway, 1992-2009.

BackgroundNorway is classified as a low prevalence country for hepatitis B virus infection. Vaccination is only recommended for risk groups (intravenous drug users (IDUs), Men who have Sex with Men (MSM), immigrants and contacts of known carriers). We describe the epidemiology of reported cases of hepatitis B in Norway, during the years 1992-2009 in order to assess the validity of current risk groups and recommend preventive measures.MethodsWe used case based data from the national surveillance system on acute and chronic hepatitis B. The Norwegian Statistics Bureau provided population and migration data and the Norwegian Institute for Alcohol and Drug Research the estimated number of active IDUs between 2002-2007. Incidence rates (IR) and incidence rate ratios (IRR) for acute hepatitis B and notification rates (NR) and notification rate ratios (NRR) for chronic hepatitis B with 95% confidence intervals were calculated.ResultsThe annual IR of acute hepatitis B ranged from 0.7/100,000 (1992) to 10.6/100,000 (1999). Transmission occurred mainly among IDUs (64%) or through sexual contact (24%). The risk of acquiring acute hepatitis B was highest in people aged 20-29 (IRR = 6.6 [3.3-13.3]), and in males (IRR = 2.4 [1.7-3.3]). We observed two peaks of newly reported chronic hepatitis B cases in 2003 and 2009 (NR = 17.6/100,000 and 17.4/100,000, respectively). Chronic hepatitis B was more likely to be diagnosed among immigrants than among Norwegians (NRR = 93 [71.9-120.6]), and among those 20-29 compared to those 50-59 (NRR = 5.2 [3.5-7.9]).ConclusionsIDUs remain the largest risk group for acute hepatitis B. The observed peaks of chronic hepatitis B are related to increased immigration from high endemic countries and screening and vaccination of these groups is important to prevent further spread of infection. Universal screening of pregnant women should be introduced. A universal vaccination strategy should be considered, given the high cost of reaching the target populations. We recommend evaluating the surveillance system for hepatitis B as well as the effectiveness of screening and vaccinating immigrant populations.