HIV-positive People Who Inject Drugs Research Articles

Engagement in HIV care and its correlates among people who inject drugs in St Petersburg, Russian Federation and Kohtla-Järve, Estonia.

HIV infection and mortality in Eastern Europe are driven by unsafe injection drug use. We sought to compare engagement in care from HIV testing through receipt of antiretroviral treatment among HIV-positive people who inject drugs (PWID) in St Petersburg, Russian Federation (RF) and Kohtla-Järve, Estonia and identify factors associated significantly with failure to progress at each stage of the HIV treatment cascade. Cross-sectional biobehavioral surveys of PWID with an analysis stratified by location-two Russian-speaking regions with similar HIV epidemic histories and current prevalence. Field-based surveys conducted in St Petersburg, RF and Kohtla-Järve, Estonia. We recruited 452 HIV-positive PWID in St Petersburg (November 2012 to June 2013) and 370 HIV-positive PWID in Kohtla-Järve (June-August 2012) using respondent-driven sampling. Participants were tested for antibodies to HIV, and administered a questionnaire focusing on participants' medical care histories. Engagement in care was categorized as a cascade of five transitional steps through six stages, ranging from HIV testing to current receipt of antiretroviral medications. Progress along the cascade was greater in Kohtla Järve (32.7% were receiving antiretroviral medications) than in St Petersburg (9.7%). In both locations, we found the steps with high failure rates were the transitions from being aware of one's HIV diagnosis to being in regular care and initiation of highly active antiretroviral therapy (HAART). Factors associated significantly with transition failure in both locations and across steps included high alcohol consumption, variables associated with drug choice and injection frequency and lack of basic medical insurance. The two steps in treatment cascade for HIV-positive PWID in St Petersburg, RF and Kohtla-Järve, Estonia requiring greatest improvement are retention in regular care and initiation of HAART. Both individual behavioral and structural factors are associated with failure to transition along the cascade.

“It is easier for me to shoot up”: stigma, abandonment, and why HIV-positive drug users in Russia fail to link to HIV care

ABSTRACTMany HIV-positive people who inject drugs (PWID) globally are not receiving HIV care. This represents a major challenge among key populations to end the global HIV epidemic. This qualitative study explored the process and associated barriers of linking HIV-positive PWID who are in addiction treatment to HIV care in St. Petersburg, Russia. We conducted three focus groups and seven semi-structured interviews with participants in the LINC (“Linking Infectious and Narcology Care”) project at addiction and HIV hospitals in St. Petersburg. The sample consisted of 25 HIV-infected patients with opioid dependence and seven health-care providers, including addiction and infectious disease physicians and case managers. A variety of intertwining factors influence effective engagement of PWID with HIV treatment. Stigma, problematic patient–provider relationships, and fragmented health care were the main challenges for HIV care initiation by PWID, which were further exacerbated by injection drug use. Effective linkage of PWID to HIV care requires acknowledging and addressing stigma’s role and different perspectives of patients and providers.

Reducing rates of preventable HIV/AIDS-associated mortality among people living with HIV who inject drugs.

The modern antiretroviral therapy (ART) era has seen substantial reductions in mortality among people living with HIV. However, HIV-positive people who inject drugs (PWIDs) continue to experience high rates of suboptimal HIV-related outcomes. We review recent findings regarding factors contributing to premature and preventable mortality among HIV-positive PWID, and describe the promise of interventions to improve survival in this group. The current leading causes of death among HIV-positive PWID are HIV/AIDS-related causes, overdose, and liver-related causes, including infection with hepatitis C virus. Elevated mortality levels in this population are driven by social-structural barriers to ART access and adherence, particularly criminalization and stigmatization of drug use. In contexts where opioid substitution therapy and ART adherence support programs are widely accessible, evidence highlights comparable levels of survival among HIV-positive PWID and people living with HIV who do not inject drugs. The life-saving benefits of ART can be realized among HIV-positive PWID when it is paired with strategies that address barriers to evidence-based medical care. Joint administration of ART and opioid substitution therapy, as well as repeal of punitive laws that criminalize drug users, are urgently needed to reduce HIV and injection-related mortality among PWID.

Opening up the HIV epidemic: a review of HIV seropositive status disclosure among people who inject drugs

ABSTRACTHIV status disclosure plays a crucial role in reducing risk behaviors of drug and sexual partners and thereby limiting HIV transmission. As people who inject drugs (PWID) bear a significant HIV burden and disclosure research among PWID is relatively few, we reviewed the literature to highlight what is known about disclosure among HIV-positive PWID. Searches of articles published from 2000 to 2015 yielded 17 studies addressing different aspects of disclosure, and results are presented by major themes. Our results suggest that despite the difficulties, most PWID (64–86%) disclose their HIV-positive status to trusted individuals (family members and intimate sexual partners) and to those who are known to be HIV-positive. Disclosure to non-intimate sexual partners and fellow drug users is relatively lower. Disclosure decision-making is primarily driven by the perceived positive and negative consequences of disclosure. Subsequent risk reduction practices following disclosure are influenced by the feeling of responsibility, as well as partners’ willingness to accept risk. Cultural family values, ethnicity, and different localities were several contextual factors that affect patterns of disclosure and risk behaviors of PWID. Areas for future research are recommended.

Prescription Opioid Injection Among HIV-Positive People Who Inject Drugs in a Canadian Setting.

Prescription opioids (POs) are commonly prescribed to patients living with HIV/AIDS, while the illicit use of POs remains a major public health concern throughout Canada and the United States. We sought to identify the prevalence and correlates of PO injection among HIV-positive people who inject drugs (PWID) in Vancouver, Canada, where HIV/AIDS treatment and care is offered at no cost. We examined data from 634 individuals from an ongoing prospective cohort of HIV-positive PWID. Between December 2005 and November 2013, the median prevalence of recent PO injection was 24.2% [interquartile range (IQR): 21.5-25.8%]. In a multivariable generalized estimating equation model, Caucasian ethnicity, heroin injection, and drug dealing were positively associated with PO injection, while older age and methadone maintenance treatment were negatively associated with PO injection (all p<0.05). Engagement on antiretroviral therapy was inversely associated with PO injection in a bivariable analysis, but did not remain significant after adjusting for heroin injection. These findings describe a particularly vulnerable sub-group of PWID who may benefit from targeted efforts to both minimize drug-related risk behaviors and support HIV/AIDS treatment.

No association between HIV status and risk of non-fatal overdose among people who inject drugs in Vancouver, Canada

BackgroundThe evidence to date on whether HIV infection increases the risk of accidental drug overdose among people who inject drugs (PWID) is equivocal. Thus, we sought to estimate the effect of HIV infection on risk of non-fatal overdose among two parallel cohorts of HIV-positive and –negative PWID. MethodsData were collected from a prospective cohort of PWID in Vancouver, Canada between 2006 and 2013. During biannual follow-up assessments, non-fatal overdose within the previous 6months was assessed. Bivariable and multivariable generalized mixed-effects regression models were used to determine the unadjusted and adjusted associations between HIV status, plasma HIV-1 RNA viral load, and likelihood of non-fatal overdose. ResultsA total of 1760 eligible participants (67% male, median age=42, and 42% HIV-positive at baseline) were included. Among 15,070 unique observations, 649 (4.3%) included a report of a non-fatal overdose within the previous 6months (4.4% among seropositive and 4.3% among seronegative individuals). We did not observe a difference in the likelihood of overdose by HIV serostatus in crude (odds ratio [OR]: 1.05, p=0.853) analyses or analyses adjusted for known overdose risk factors (adjusted OR [AOR]: 1.19, p=0.474). In a secondary analysis, among HIV-positive PWID, we did not observe an association between having a detectable viral load and overdose (AOR: 1.03, p=0.862). ConclusionsDespite the evidence that HIV infection is a risk factor for fatal overdose, we found no evidence for a relationship between HIV disease and non-fatal overdose. However, overdose remains high among PWID, indicating the need for ongoing policy addressing this problem, and research into understanding modifiable risk factors that predict non-fatal overdose.

High burden of hepatitis C & HIV co-infection among people who inject drugs in Manipur, Northeast India.

Background & objectives:It is well documented that the Northeast State of Manipur in India has been dealing with the dual problems of injecting drug use and HIV for the last two decades, but the hepatitis C problem has not been so well characterized. The aim of this study was to assess the prevalence of hepatitis C virus (HCV) infection and HCV/HIV co-infection among people who inject drugs (PWID) in Manipur, and identify factors associated with infection.Methods:Data were obtained from the Integrated Behavioural and Biological Assessment (2009-2010), a cross-sectional survey among 821 male PWID in two districts of Manipur (Churachandpur and Bishnupur). Information about drug use, sexual and injecting risk behaviours, and exposure to interventions was obtained, and biological specimens tested for HIV and HCV. Logistic regression analyses identified factors associated with HCV infection and HCV/HIV co-infection.Results:HCV prevalence was 74 per cent (91% Churachandpur, 56% Bishnupur), and HCV/HIV co-infection was 29 per cent (38% Churachandpur, 21% Bishnupur). Among the 31 per cent of HIV positive PWID, 95 per cent were co-infected. HCV infection was associated with district, longer duration of injecting, injecting at least once daily, generally injecting with a used needle and syringe, and having had an HIV test. HCV/HIV co-infection was associated with district, older age, being employed, being widowed/divorced, longer duration of injecting, and feeling at risk of HIV infection.Interpretation & conclusions:The HCV/HIV co-infection among PWID in Manipur was very high, highlighting the urgent need for effective prevention, diagnosis and treatment.

Association of patterns of methadone use with antiretroviral therapy discontinuation: a prospective cohort study

BackgroundMethadone maintenance therapy (MMT) is a proven treatment strategy for opioid dependent patients. Although studies have demonstrated that MMT increases contact with the medical system and improves adherence to antiretroviral therapy (ART) in HIV-positive people who inject drugs (PWID), the effect of MMT discontinuation on ART discontinuation has not been well described.MethodsWe examined the impact of continuous MMT use, MMT non-use and MMT discontinuation on the time to ART discontinuation (defined as 90 days of continuous non-use following previous enrolment) in a community-recruited prospective cohort of HIV-positive PWID followed between May 1996 and May 2013 in Vancouver, Canada. Multivariate Cox proportional hazards regression was used to examine the association between MMT use patterns and time to ART discontinuation while adjusting for socio-demographic confounders.ResultsA total of 794 HIV-positive PWID were included during the study period. In an adjusted analysis, in comparison to those who were continuously on MMT, MMT non-use (Adjusted Hazard Ratio [AHR] = 1.44, 95 % Confidence Interval [CI]: 1.19–1.73) as well as discontinuing MMT (AHR = 1.82, 95 % CI: 1.27–2.60) were both found to be independently associated with time to ART discontinuation.ConclusionsThis study reinforces the known benefits of MMT use on ART adherence and demonstrates how discontinuation of MMT is independently associated with an increased risk of ART cessation. These data highlight the importance of retaining PWID on MMT.

Time to act: Fast-Tracking the response for people who inject drugs in Asia and the Pacific.

Commentary Asia and the Pacific region is one of the world’s most vibrant places in terms of economic growth and social advancement. It captures many superlatives: the planet’s highest proportion of young people, the largest megacities in the world and Asia wins the crown of global growth leader again and again. However, despite the dynamism, some citizens are falling through the cracks. This is particularly true for people who inject drugs (PWID). With 3.15 million PWID, in terms of sheer numbers, East Asia and Southeast Asia has the largest injecting drug problem in the world and is home to one in four PWID globally [1]. People who inject drugs have multiple vulnerabilities—to HIV, hepatitis, tuberculosis and other infectious diseases; they account for an estimated 30 % of new HIV infections outside sub-Saharan Africa. About a third of PWID are living with HIV in Southwest Asia [1], and a number of countries have reported HIV prevalence higher than 10 % [2]. National figures often do not tell the full story, with some localities reporting significantly higher prevalence. In Cebu City, Philippines, HIV prevalence among PWID was estimated at 52.3 % in 2013 [3], and in Faisalabad, Pakistan, it was as high as 52.5 % in 2011 [4]. Scientific evidence shows that to respond to HIV and other health risks of people who inject drugs, it is important to develop programmes which cater to their needs. The Joint United Nations Programme on HIV/ AIDS (UNAIDS), the United Nations Office on Drugs and Crime (UNODC) and the World Health Organization (WHO) have recommended a package of nine interventions, commonly referred to as the comprehensive approach to injecting drug use [5]. The first four interventions—needle-syringe programmes (NSP), opioid substitution therapy (OST), HIV testing and counselling and the provision of antiretroviral therapy (ART)—are critical for effective national programmes. There is compelling evidence that NSP and OST are effective in reducing the sharing of injecting equipment and averting HIV infections. In combination with ART, these interventions diminish HIV transmission, decrease mortality, reduce drug dependency and improve quality of life. Several countries in the region have taken these recommendations to heart and implemented parts of the comprehensive harm reduction package. In the late 1990s, China had a fast-growing HIV epidemic among people who inject drugs and its health authorities began introducing OST sites and needle-syringe programmes. By the end of 2014, more than 700 OST sites were operating in China. HIV incidence rate dropped by 87.6 % from 0.95 % in 2006 to 0.12 % in 2014 among those registered in the clinics [6]. Recently, India and Myanmar have also increased their OST coverage. Despite these pockets of success, the coverage of harm reduction programmes remains inadequate in Asia and the Pacific region. High coverage of needle-syringe programmes is defined by WHO, UNAIDS and UNODC as more than 200 needles or syringes provided per PWID a year. Only four countries reported reaching high coverage in 2014, and five reported that less than 50 % of PWID used clean equipment for their last injection [2]. PWID frequently face stigma and discrimination when seeking health services and are far less likely to receive ART than others living with HIV due to social marginalization and the flawed perception that they are unable to adhere to treatment effectively. While current national monitoring systems are not designed to capture data on access to ART for PWID, a recent review suggests that less than five PWID received ART per 100 HIV-positive PWID [7]. Not only is coverage low, but there are worrying signs that some countries with a high HIV burden among PWID are scaling down harm reduction interventions [8]. This is undoubtedly due to the phasing out of support by international donors with little new funds * Correspondence: KrausS@unaids.org UNAIDS Regional Support Team for Asia and the Pacific, United Nations Building, Rajadamnern Nok Avenue, Bangkok 10200, Thailand Full list of author information is available at the end of the article

High prevalence of syringe lending among HIV-positive people who inject drugs in Bangkok, Thailand.

BackgroundSyringe sharing continues to be a major driver of the HIV pandemic. In light of efforts to enhance access to sterile syringes and promote secondary prevention among HIV-positive individuals, we sought to identify the prevalence and correlates of used syringe lending among self-reported HIV-positive people who inject drugs (PWID) in Bangkok, Thailand.FindingsWe used bivariable statistics to examine factors associated with self-reported syringe lending among self-reported HIV-positive PWID participating in the Mitsampan Community Research Project, a serial cross-sectional study of PWID in Bangkok, between June 2009 and October 2011. In total, 127 individuals were eligible for this analysis, including 25 (19.7 %) women. Twenty-one (16.5 %) participants reported syringe lending in the prior 6 months. Factors significantly associated with syringe lending included daily methamphetamine injection (odds ratio (OR) = 10.2, 95 % CI, 2.1–53.6), daily midazolam injection (OR = 3.1, 95 % CI, 1.1–8.7), use of drugs in combination (OR = 4.5, 95 % CI, 1.0–41.6), injecting with others on a frequent basis (OR = 4.25, 95 % CI, 1.3–18.3), and not receiving antiretroviral therapy (OR = 2.9, 95 % CI, 1.1–7.9).ConclusionsA high prevalence of syringe lending was observed among self-reported HIV-positive PWID in Bangkok, which was associated with high intensity drug use, polysubstance use, and frequently injecting with others. It is particularly concerning that individuals who lent syringes were more likely to be untreated for HIV disease given the known benefits of antiretroviral provision on the prevention of HIV transmission. These findings underscore the need to expand access to sterile syringes and HIV treatment among HIV-positive PWID in Thailand.

The causal effect of opioid substitution treatment on HAART medication refill adherence.

People who inject drugs (PWID) account for roughly 13% of the prevalent HIV/AIDS population outside of sub-Saharan Africa, and access to opioid substitution treatment (OST) is limited in many settings globally. OST likely facilitates access to HAART, yet sparse evidence is available to support this hypothesis. Our objective was to determine the causal impact of OST exposure on HAART adherence among HIV-positive PWID in a Canadian setting. We executed a retrospective cohort study using linked population-level data for British Columbia, Canada (January 1996-March 2010). We considered HIV-positive PWID after meeting HAART initiation criteria. A marginal structural model was estimated on a monthly timescale using inverse probability of treatment weights. The primary outcome was 95% HAART adherence, according to pharmacy refill compliance. Exposure to OST was defined as 95% of OST receipt, and we controlled for a range of fixed and time-varying covariates. Our study included 1852 (63.3%) HIV-positive PWID with a median follow-up of 5.5 years; 34% were female and 39% had previously accessed OST. The baseline covariate-adjusted odds of HAART adherence following OST exposure was 1.96 (95% confidence interval: 1.72-2.24), although the adjusted odds estimated within the marginal structural model was 1.68 (1.48-1.92). Findings were robust to sensitivity analyses on model specification. In a setting characterized by universal healthcare and widespread access to both office-based OST and HAART, OST substantially increased the odds of HAART adherence. This underlines the need to address barriers to OST globally to reduce the disease burden of both opioid dependence and HIV/AIDS.

Compulsory drug detention exposure is associated with not receiving antiretroviral treatment among people who inject drugs in Bangkok, Thailand: a cross-sectional study.

BackgroundThailand has experienced a longstanding epidemic of HIV among people who inject drugs (PWID). However, antiretroviral treatment (ART) coverage among HIV-positive PWID has historically remained low. While ongoing drug law enforcement involving periodic police crackdowns is known to increase the risk of HIV transmission among Thai PWID, the impact of such drug policy approaches on the ART uptake has been understudied. Therefore, we sought to identify factors associated with not receiving ART among HIV-positive PWID in Bangkok, Thailand, with a focus on factors pertaining to drug law enforcement.MethodsData were collected from a community-recruited sample of HIV-positive PWID in Bangkok who participated in the Mitsampan Community Research Project between June 2009 and October 2011. We identified factors associated with not receiving ART at the time of interview using multivariate logistic regression.ResultsIn total, 128 HIV-positive PWID participated in this study, with 58 (45.3%) reporting not receiving ART at the time of interview. In multivariate analyses, completing less than secondary education (adjusted odds ratio [AOR]: 3.32 ; 95% confidence interval [CI]: 1.48 – 7.45), daily midazolam injection (AOR: 3.22, 95% CI: 1.45 – 7.15) and exposure to compulsory drug detention (AOR: 3.36, 95% CI: 1.01 – 11.21) were independently and positively associated with not receiving ART. Accessing peer-based healthcare information or support services was independently and positively associated with receiving ART (AOR: 0.21, 95% CI: 0.05 – 0.84).ConclusionsApproximately half of our study group of HIV-positive PWID reported not receiving ART at the time of interview. Daily midazolam injectors, those with lower education attainment, and individuals who had been in compulsory drug detention were more likely to be non-recipients of ART whereas those who accessed peer-based healthcare-related services were more likely to receive ART. These findings suggest a potentially adverse impact of compulsory drug detention and highlight the need to expand interventions to facilitate access to ART among HIV-positive PWID in this setting.

Examining non-AIDS mortality among people who inject drugs.

Objective:To systematically review and analyse data from cohorts of people who inject drugs (PWID) to improve existing estimates of non-AIDS mortality used to calculate mortality among PWID in the Spectrum Estimates and Projection Package.Design:Systematic review and meta-analysis.Methods:We conducted an update of an earlier systematic review of mortality among PWID, searching specifically for studies providing data on non-AIDS-related deaths. Random-effects meta-analyses were performed to derive pooled estimates of non-AIDS crude mortality rates across cohorts disaggregated by sex, HIV status and periods in and out of opioid substitution therapy (OST). Within each cohort, ratios of non-AIDS CMRs were calculated and then pooled across studies for the following paired sub-groups: HIV-negative versus HIV-positive PWID; male versus female PWID; periods in OST versus out of OST. For each analysis, pooled estimates by country income group and by geographic region were also calculated.Results:Thirty-seven eligible studies from high-income countries and five from low and middle-income countries were found. Non-AIDS mortality was significantly higher in low and middle-income countries [2.74 per 100 person-years; 95% confidence interval (CI) 1.76–3.72] than in high-income countries (1.56 per 100 person-years; 95% CI 1.38–1.74). Non-AIDS CMRs were 1.34 times greater among men than women (95% CI 1.14–1.57; N = 19 studies); 1.50 times greater among HIV-positive than HIV-negative PWID (95% CI 1.15, 1.96; N = 16 studies); and more than three times greater during periods out of OST than for periods on OST (N = 7 studies).Conclusions:A comprehensive response to injecting drug must include efforts to reduce the high levels of non-AIDS mortality among PWID. Due to limitations of currently available data, including substantial heterogeneity between studies, estimates of non-AIDS mortality specific to geographic regions, country income level, or the availability of OST should be interpreted with caution.

Undiagnosed HIV among people who inject drugs in Manipur, India

Manipur is a geographically isolated state of India characterised by a high HIV prevalence among people who inject drugs (PWID). A low-to-moderate lifetime rate of HIV testing has been documented amongst PWID in Manipur. Little is known about the extent of undiagnosed HIV in this setting and whether uptake of HIV testing (and knowledge of a positive diagnosis) leads HIV-positive PWID to change their risk behaviours. The cross-sectional data (n = 821) analysed for this paper were collected in 2009 for the Integrated Behavioural and Biological Assessment (IBBA) using interviewer-administered questionnaires and the collection of de-linked blood and urine samples. Almost one-third (30.7%) of the participants tested HIV positive. The majority knew where to obtain a confidential HIV test (80.7%), however, half of the HIV-positive participants had either never had an HIV test (37.7%), or had undertaken a test without collecting the result (12.7%). Almost one-quarter (23.4%) of the HIV-positive participants and 17.4% of the HIV-negative participants had shared a needle/syringe with at least one other injector during the preceding month. Encouragingly, HIV-positive participants were significantly more likely than HIV-negative participants to use condoms with their regular sexual partners, however, there was still a high proportion of HIV-positive participants who did not use a condom at last sex with their regular (47.2%) or casual (48.0%) partners. Having taken an HIV test and collected the result was associated with a reduction in HIV-risk behaviours among HIV-positive participants, but not among HIV-negative participants. In conclusion, we found that a substantial proportion of the HIV-positive PWID in Manipur were not aware of their positive status, and risky injecting and sexual practices were commonplace. However, HIV-positive PWID appear to reduce their high-risk behaviours when they become aware of their HIV status highlighting the importance of taking HIV testing coverage to scale.

Availability of HIV prevention and treatment services for people who inject drugs: findings from 21 countries

BackgroundAbout a third of the global HIV infections outside sub-Saharan Africa are related to injecting drug use (IDU), and this accounts for a growing proportion of persons living with HIV. This paper is a response to the need to monitor the state of the HIV epidemic as it relates to IDU and the availability of HIV treatment and harm reduction services in 21 high epidemic countries.MethodsA data collection form was designed to cover questions on rates of IDU, prevalence and incidence of HIV and information on HIV treatment and harm reduction services available to people who inject drugs (PWID). National and regional data on HIV infection, IDU in the form of reports and journal articles were sought from key informants in conjunction with a systematic search of the literature.ResultsCompleted data collection forms were received for 11 countries. Additional country-specific information was sourced via the literature search. The overall proportion of HIV positive PWID in the selected countries ranged from 3% in Kazakhstan to 58% in Vietnam. While IDU is relatively rare in sub-Saharan Africa, it is the main driver of HIV in Mauritius and Kenya, with roughly 47% and 36% of PWID respectively being HIV positive. All countries had antiretroviral treatment (ART) available to PWID, but data on service coverage were mainly missing. By the end of 2010, uptake of needle and syringe programmes (NSP) in Bangladesh, India and Slovakia reached the internationally recommended target of 200 syringes per person, while uptake in Kazakhstan, Vietnam and Tajikistan reached between 100-200 syringes per person. The proportion of PWID receiving opioid substitution therapy (OST) ranged from 0.1% in Kazakhstan to 32.8% in Mauritius, with coverage of less than 3% for most countries.ConclusionsIn order to be able to monitor the impact of HIV treatment and harm reduction services for PWID on the epidemic, epidemiological data on IDU and harm reduction service provision to PWID needs to be regularly collected using standardised indicators.