Injection Risk Behaviors Research Articles

HIV epidemiology among female sex workers and their clients in the Middle East and North Africa: systematic review, meta-analyses, and meta-regressions

BackgroundHIV epidemiology among female sex workers (FSWs) and their clients in the Middle East and North Africa (MENA) region is poorly understood. We addressed this gap through a comprehensive epidemiological assessment.MethodsA systematic review of population size estimation and HIV prevalence studies was conducted and reported following PRISMA guidelines. Risk of bias (ROB) assessments were conducted for all included studies using various quality domains, as informed by Cochrane Collaboration guidelines. The pooled mean HIV prevalence was estimated using random-effects meta-analyses. Sources of heterogeneity and temporal trends were identified through meta-regressions.ResultsWe identified 270 size estimation studies in FSWs and 42 in clients, and 485 HIV prevalence studies in 287,719 FSWs and 69 in 29,531 clients/proxy populations. Most studies had low ROB in multiple quality domains. The median proportion of reproductive-age women reporting current/recent sex work was 0.6% (range = 0.2–2.4%) and of men reporting currently/recently buying sex was 5.7% (range = 0.3–13.8%). HIV prevalence ranged from 0 to 70% in FSWs (median = 0.1%) and 0–34.6% in clients (median = 0.4%). The regional pooled mean HIV prevalence was 1.4% (95% CI = 1.1–1.8%) in FSWs and 0.4% (95% CI = 0.1–0.7%) in clients. Country-specific pooled prevalence was < 1% in most countries, 1–5% in North Africa and Somalia, 17.3% in South Sudan, and 17.9% in Djibouti. Meta-regressions identified strong subregional variations in prevalence. Compared to Eastern MENA, the adjusted odds ratios (AORs) ranged from 0.2 (95% CI = 0.1–0.4) in the Fertile Crescent to 45.4 (95% CI = 24.7–83.7) in the Horn of Africa. There was strong evidence for increasing prevalence post-2003; the odds increased by 15% per year (AOR = 1.15, 95% CI = 1.09–1.21). There was also a large variability in sexual and injecting risk behaviors among FSWs within and across countries. Levels of HIV testing among FSWs were generally low. The median fraction of FSWs that tested for HIV in the past 12 months was 12.1% (range = 0.9–38.0%).ConclusionsHIV epidemics among FSWs are emerging in MENA, and some have reached stable endemic levels, although still some countries have limited epidemic dynamics. The epidemic has been growing for over a decade, with strong regionalization and heterogeneity. HIV testing levels were far below the service coverage target of “UNAIDS 2016–2021 Strategy.”

Measures of harm reduction service provision for people who inject drugs.

Coverage is an important dimension in measuring the effectiveness of needle and syringe programmes in providing sterile injecting equipment for people who inject drugs. The World Health Organization (WHO), the United Nations Office on Drugs and Crime (UNODC) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) currently recommend methods for measuring coverage at the population level, that is, across an estimated population of people who inject drugs within a given geographical area. However, population-level measures of coverage rely on highly uncertain population estimates and cannot capture the different levels of syringe acquisition and injecting episodes among individual users. Consequently, such measures only broadly evaluate the extent of programme service delivery, rather than describe how people who inject drugs as individuals and sub-groups interact with needle and syringe programmes. In response to these limitations, several researchers have proposed measuring coverage at the individual level, by the percentage of injecting episodes in relation to the number of sterile needles and syringes acquired. These measures evaluate coverage according to each individual’s needs. Such measures provide enhanced information for planning and monitoring of harm reduction programmes and have now been used in multiple international research studies. We advise that WHO, UNODC and UNAIDS add individual-level coverage measurement methods to their international monitoring guidelines for harm reduction programmes. By doing this, more responsive and effective programmes can be created to better reduce injecting risk behaviours and blood-borne virus transmission among people who inject drugs.

Injection risk norms and practices among migrant Puerto Rican people who inject drugs in New York City: The limits of acculturation theory

BackgroundAmong people who inject drugs (PWID) in New York City (NYC), racial minorities are disproportionately infected with HIV and hepatitis C (HCV). Prior research has shown that PWID who started injecting drugs in Puerto Rico (P.R.) tend to maintain the risky injection behaviors learned there. This study identifies the P.R.-native norms supporting the continued injection risk behavior of migrant Puerto Rican PWID in NYC to inform a culturally appropriate risk-reduction intervention. Methods40 migrant Puerto Rican PWID were recruited in NYC for a longitudinal qualitative study. The sample was stratified to include 20 migrants with <3 years in NYC and 20 migrants with >3-6 years in NYC. Time-location sampling was used to curb possible network bias in recruitment. Over 12 months, migrants completed semi-structured interviews at baseline, monthly follow-ups, and study exit. Analyses were guided by grounded theory. ResultsMost participants (90%) reported having had chronic HCV, and 22.5% reported being HIV-positive. Syringe- and cooker-/cotton-sharing were widespread in both P.R. and NYC. The ubiquitous practice of cleaning used syringes by “water-rinsing and air-blowing” was guided by a normative belief, learned in P.R., that “water and air kill HIV.” Sterile syringe use was not a priority. HCV was not a concern. P.R.-native abstinence-only narratives discouraged opioid agonist treatment (OAT) enrollment among recent migrants (≤3 years). Experiences with drug dealers, prison-power groups, and injection doctors (“Gancheros”) in P.R. influenced migrants’ injection risk behavior in NYC. Those who were Gancheros in P.R. continued working as Gancheros in NYC. ConclusionsInjection risks make migrant Puerto Rican PWID in NYC vulnerable to HIV/HCV. Harm reduction programs should pay closer attention to the rationales behind these injection risks. A risk-reduction intervention that incorporates the Ganchero figure may be a credible way to help migrants reduce injection risk and accept OAT and syringe exchange programs (SEP).

Injection and Heterosexual Risk Behaviors for HIV Infection Among Non-gay Identifying Men Who Have Sex with Men and Women.

Non-gay identifying men who have sex with men and women (MSMW) are an important subgroup of men who have sex with men (MSM) and have been underrepresented in studies of MSM that only use gay venues to draw their samples. We assessed heterosexual and drug use risks of MSMW who use drugs in a sample of male entrants to the Mount Sinai Beth Israel drug treatment programs from 2005 to 2018. Blood samples were collected and tested for HIV and HSV-2 infections. Among HIV seronegative participants, MSMW had significantly greater odds of sharing used needles with others, and reporting unprotected sex with female casual partners and female commercial sex partners, compared to their counterparts who reported sex with women exclusively (MSWE). Although not recruited from gay venues, MSMW had a significantly higher HIV prevalence than MSWE (23% vs. 10%, p < 0.001). Interventions that are specifically tailored to HIV prevention among MSMW are needed to ameliorate the prevalence of HIV risks and infection.

Young people who inject drugs in India have high HIV incidence and behavioural risk: a cross-sectional study.

IntroductionThere are limited data on young people who inject drugs (PWID) from low‐ and middle‐income countries where injection drug use remains a key driver of new HIV infections. India has a diverse injection drug use epidemic and estimates suggest that at least half of PWID are ≤30 years of age. We compared injection and sexual risk behaviours and HIV incidence between younger and older PWID and characterized uptake of HIV testing and harm reduction services to inform targeted HIV prevention efforts.MethodsWe analysed cross‐sectional data from 14,381 PWID recruited from cities in the Northeast and North/Central regions of India in 2013 using respondent driven sampling (RDS). We compared “emerging‐adult” (18 to 24 years, 26% of sample) and “young‐adult” PWID (25 to 30 years, 30% of sample) to older PWID (>30 years, 44% of sample) using logistic regression to evaluate factors associated with three recent risk behaviours: needle‐sharing, multiple sexual partners and unprotected sex. We estimated age‐stratified cross‐sectional HIV incidence using a validated multi‐assay algorithm.ResultsCompared to older adults, emerging‐adults in the Northeastern states were significantly more likely to share needles (males adjusted odds ratio [aOR] 1.82; females aOR 2.29, p < 0.01), have multiple sexual partners (males aOR 1.56; females aOR 3.75, p < 0.01), and engage in unprotected sex (males aOR 2.29, p < 0.01). In the North/Central states, young‐adult males were significantly more likely to needle‐share (aOR 1.23, p < 0.05) while emerging‐adult males were significantly more likely to have multiple sexual partners (aOR 1.74, p < 0.05). In both regions, emerging‐adults had the lowest HIV testing. Participation in harm reduction services was low across all age groups. Annual HIV incidence was higher in emerging‐ and young‐adult PWID in the North/Central region: emerging‐adults: 4.3% (95% confidence interval [CI] 3.0, 5.6); young‐adults: 4.9% (95% CI 3.7, 6.2); older adults: 2.1% (95% CI 1.4, 2.8).ConclusionsHigher HIV incidence and engagement in risky behaviours among younger PWID compared to older PWID, coupled with low utilization of harm reduction services highlight the importance of targeting this population in HIV programming. Age‐specific interventions focused on addressing the needs of young PWID are urgently needed to curb the HIV epidemic in this vulnerable population.

Comparative efficacy of interventions for reducing injection and sexual risk behaviours to prevent HIV in injection drug users: protocol for Bayesian network meta-analysis

IntroductionDrug users are more vulnerable to AIDS than the general population. While several interventions are effective for addressing HIV in injection drug users, no meta-analysis has yet been performed to...

Injection drug network characteristics as a predictor of injection behaviour

Social network characteristics of people who inject drugs (PWID) have previously been flagged as potential risk factors for HCV transmission such as increased injection frequency. To understand the role of the injecting network on injection frequency, we investigated how changes in an injecting network over time can modulate injecting risk behaviour. PWID were sourced from the Networks 2 Study, a longitudinal cohort study of PWID recruited from illicit drug street markets across Melbourne, Australia. Network-related correlates of injection frequency and the change in frequency over time were analysed using adjusted Cox Proportional Hazards and Generalised Estimating Equations modelling. Two-hundred and eighteen PWID followed up for a mean (s.d.) of 2.8 (1.7) years were included in the analysis. A greater number of injecting partners, network closeness centrality and eigenvector centrality over time were associated with an increased rate of infection frequency. Every additional injection drug partner was associated with an increase in monthly injection frequency. Similarly, increased network connectivity and centrality over time was also associated with an increase in injection frequency. This study observed that baseline network measures of connectivity and centrality may be associated with changes in injection frequency and, by extension, may predict subsequent HCV transmission risk. Longitudinal changes in network position were observed to correlate with changes in injection frequency, with PWID who migrate from the densely-connected network centre out to the less-connected periphery were associated with a decreased rate of injection frequency.

Identification of a Syndemic of Blood-Borne Disease Transmission and Injection Drug Use Initiation at the US-Mexico Border.

Efforts to prevent injection drug use (IDU) are increasingly focused on the role that people who inject drugs (PWID) play in the assistance with injection initiation. We studied the association between recent (ie, past 6 months) injection-related HIV risk behaviors and injection initiation assistance into IDU among PWID in the US-Mexico border region. Preventing Injecting by Modifying Existing Responses (PRIMER) is a multicohort study assessing social and structural factors related to injection initiation assistance. This analysis included data collected since 2014 from 2 participating cohorts in San Diego and Tijuana. Participants were 18 years and older and reported IDU within the month before study enrollment. Logistic regression analyses were conducted to assess the association between recent injection-related HIV risk behaviors (eg, distributive/receptive syringe sharing, dividing drugs in a syringe, and paraphernalia sharing) and recent injection initiation assistance. Among 892 participants, 41 (4.6%) reported recently providing injection initiation assistance. In multivariable analysis adjusting for potential confounders, reporting a higher number of injection-related risk behaviors was associated with an increased odds of recently assisting others with injection initiation (adjusted odds ratio per risk behavior: 1.3; 95% confidence interval: 1.0 to 1.6, P = 0.04). PWID who recently engaged in one or more injection-related HIV risk behavior were more likely to assist others in injection initiation. These results stress the syndemic of injection initiation and risk behaviors, which indicates that prevention of injection-related HIV risk behaviors might also reduce the incidence of injection initiation.

Comparing Injecting Risk Behaviors of Long-Term Injectors with New Injectors in Tehran, Iran

Background: Global estimates suggest there are 15.6 million people who inject drugs (PWID) of whom 17.8% are living with HIV.Few studies have characterized newly-onset injectors with long-term injectors and its association with injecting risk behaviors. Objectives: We examined the relationship between length of injection and risk behaviors among people who inject drugs (PWID) in Tehran, Iran. Methods: A cross-sectional study was conducted among PWID, from March to August 2016 in Tehran, Iran. PWID were recruited by convenience and snowball sampling from five Drop-in Centers (DIC) located in the south of Tehran. Our primary independent variable was length of injecting career, defined as the number of months since injecting initiation. Those defined as new injectors (were injecting for less than 18 months), and long-term injectors (as injecting drugs for more than 18 months). We reported the adjusted odds ratio (aOR) point estimate and 95% confidence interval (CI95%) as the effect measure. The level of significance used in multiple logistic regression model was 0.05. We used STATA v. 11 for all analyzes. Results: The analytical sample comprised of 500 participants (100% male). Mean (±SD) age of PWID with a length of injection history was 31.2 ± 7.2 years. Overall, 270 (54%) (CI95%: 49.6%, 58.4%) of participants were long-term injectors. The average age of drug use initiation among long-term injectors group was lower as compared to new injectors group (31.2 vs. 29.4, p < 0.001). The odds of distributive syringe sharing among new injectors were two times higher than long-term injectors (AOR = 2.1, 95% CI 1.4–4.7). The odds of receptive syringe sharing were lower among new injectors group (AOR = 0.7, CI95% 0.2–0.87), compared to long-term injectors. New injectors had higher odds of reusing their own syringes (OR = 2.8, 95% CI: 1.4–5.7; p = 0.01). Conclusions: Improvements in harm reduction service provision can occur through taregted risk reduction education for new injectors focusing on reducing distributive syringe sharing among them.

Increased Methamphetamine Use among Persons Who Inject Drugs in Hai Phong, Vietnam, and the Association with Injection and Sexual Risk Behaviors

ABSTRACTMethamphetamine use has increased significantly in Southeast Asia in the last 5–10 years, but there is little research on risk behaviors associated with the increase in this region. We evaluate injection and sexual risk behaviors associated with current methamphetamine use among heterosexual persons who inject drugs (PWID) in Hai Phong, Vietnam. We recruited 1336 PWID and assessed associations between methamphetamine use, injection and sexual risk behaviors, stratified by HIV serostatus. There were several statistically significant associations between methamphetamine use and sexual risk behaviors among HIV-positive PWID, but we did not find any associations between methamphetamine use and injection risk behaviors. Methamphetamine may increase the likelihood of PWID transmitting HIV to non-injecting primary sexual partners, as it can reduce ART adherence and can lead to weakening of the immune system and increased HIV viral loads. All participants were injecting heroin, and methamphetamine use may interfere with opiate use treatment. Public health efforts should focus on the large increase in methamphetamine use and the associated sexual risk behaviors. Emphasis on sexual risk behavior, particularly among those who are HIV-positive, in conjunction with continued monitoring of ART adherence and HIV viral loads, is critical.

Incidence and spontaneous clearance of hepatitis C virus (HCV) in people who inject drugs at the Stockholm Needle Exchange-Importance for HCV elimination.

The major transmission route for hepatitis C virus (HCV) is through sharing of unsterile injection equipment among people who inject drugs (PWID). The WHO strategy for HCV elimination by 2030 proposes increased efforts to treat PWID populations that drive the HCV epidemic. Among participants in the Stockholm needle exchange programme (NEP), the HCV prevalence is 60%. We aimed to study HCV incidence, spontaneous HCV clearance rate, and predictors associated with new HCV infections and reinfections in NEP participants. All 2320 patients enrolled in the programme between 8 April 2013 and 23 September 2016 were tested for HCV at baseline, and responded to a questionnaire regarding sociodemographic data and injection risk behaviour. Tests for HCV were repeated at an interval of 3-6months. The anti-HCV prevalence in the NEP participants at baseline was 77%, and the prevalence of HCV RNA was 57%. 24% of the anti-HCV positive were HCV RNA negative with a spontaneously cleared HCV infection. The overall HCV incidence rate was 22/100 PY. The HCV incidence rate in the HCV naive group was 26/100 PY, and in the spontaneously cleared group 19/100. Although there were no significant differences in becoming HCV infected between the two groups (31% vs 29%), the rate of spontaneous HCV clearance was significantly lower in the HCV naive group, 20% vs 44%, (P<0.05). A high HCV incidence rate was noted among the PWID indicating that treatment needs to be scaled up in conjunction with harm reduction measures to achieve HCV elimination goals set by WHO. This includes high coverage needle exchange programmes and effective addiction treatment for substance users, including opiate substitution treatment.

Effect of Alcohol Use on Injection and Sexual Behavior among People Who Inject Drugs in Tehran, Iran: A Coarsened Exact Matching Approach.

Many studies have recognized the importance of sexual and injection risk behaviors in HIV transmission among people who inject drugs (PWID). We aimed to examine effect of alcohol use on sexual and injection risky behavior using coarsened exact matching (CEM) approach among PWID in Tehran, Iran. A cross-sectional study. This study was conducted from Mar to Aug 2016 in Tehran, Iran. PWID were recruited by a convenience and snowball sampling from five of Drop-in Centers (DICs) in Tehran. We assessed three outcomes of interest, all treated as binary variables, including distributive and receptive sharing and inconsistent condom use with any type of sexual partner. We applied coarsened exact matching (CEM) to estimate the independent effect of alcohol use on injection and sexual risk behaviours. All data analysis was performed using Stata v.11. Overall, 550 PWID (all male) were enrolled. The prevalence of receptive sharing, distributive sharing, and inconsistent condom use was 32%, 15% and 55%, respectively. In the matched samples, last month drinkers were more likely to report receptive sharing (OR=2.12 95% CI: 1.31, 3.81; P=0.022), as compared to abstainer participants. Distributive sharing in last 30 d, was also significantly higher among last month drinkers group (OR=2.72 95% CI 1.72, 4.21; P=0.011), compared last month abstainers group. Finally, there was a statistically significant relationship between alcohol use and inconsistent condom use (OR=4.21 95% CI: 2.71, 7.52; P=0.013). The findings emphasize importance of addressing alcohol use in risk reduction interventions for Iranian PWID with alcohol use.

Feasibility of ecological momentary assessment to study mood and risk behavior among young people who inject drugs

AimsTo test the acceptability and feasibility of ecological momentary assessment (EMA) of mood and injection risk behavior among young people who inject drugs (PWID), using mobile phones. MethodsParticipants were 185 PWID age 18–35 recruited from two sites of a large syringe service program in Chicago. After completing a baseline interview, participants used a mobile phone app to respond to momentary surveys on mood, substance use, and injection risk behavior for 15 days. Participants were assigned to receive surveys 4, 5, or 6 times per day. ResultsParticipants were 68% male, 61% non-Hispanic white, 24% Hispanic, and 5% non-Hispanic Black. Out of 185 participants, 8% (n = 15) failed to complete any EMA assessments. Among 170 EMA responders, the mean number of days reporting was 10 (SD 4.7), the mean proportion of assessments completed was 0.43 (SD 0.27), and 76% (n = 130) completed the follow-up interview. In analyses adjusted for age and race/ethnicity, women were more responsive than men to the EMA surveys in days reporting (IRR = 1.33, 95% CI 1.13–1.56), and total number of surveys completed (IRR = 1.51, 95% CI 1.18–1.93). Homeless participants responded on fewer days (IRR = 0.76, 95% CI 0.64–0.90) and completed fewer surveys (IRR = 0.70, 95% CI 0.54–0.91), and were less likely to return for follow-up (p = 0.016). EMA responsiveness was not significantly affected by the number of assigned daily assessments. ConclusionsThis study demonstrated high acceptability and feasibility of EMA among young PWID, with up to 6 survey prompts per day. However, homelessness significantly hampered successful participation.

Longitudinal injecting risk behaviours among people with a history of injecting drug use in an Australian prison setting: The HITS-p study

BackgroundHCV transmission remains high in prisons globally. Understanding injecting risk behaviours in prisons is crucial to effectively develop and implement HCV prevention programs in this setting including treatment as prevention. MethodsHITS-p is a cohort study which enrolled people with a history of injecting drug use in prisons in NSW, Australia from 2005 to 2013. Participants completed an interview at enrolment and follow-up visits to determine injecting behaviours. Generalized estimating equation (GEE) and logistic regression methods were used to assess injecting risk behaviours prior to and following prison entry and to investigate injecting risk behaviours in prison. ResultsOverall, 499 participants with a history of injecting drug use were included (median age, 26 years; 65% male). Participants were significantly less likely to inject drugs following incarceration. Among injectors, participants were less likely to inject ≥weekly but more likely to share a needle/syringe. At enrolment, the proportion reporting any injecting, ≥weekly injecting, and needle/syringe sharing in prison was highest among younger individuals. Younger age was associated with both re-initiation and continuation of injecting drug use following prison entry. Among those continuously imprisoned, younger age was associated with increased odds of any injecting, ≥weekly injecting, and sharing a needle/syringe. ConclusionsUpon entry to prison, injecting drug use decreased but syringe sharing increased among injectors. Younger individuals are most likely to exhibit high-risk injecting behaviours in prison. These data highlight the need for improved HCV prevention strategies (including improved needle/syringe access and scale up of HCV therapy) for those at increased risk of HCV transmission in prison, including younger individuals.

Web-Based Survey Application to Collect Contextually Relevant Geographic Data With Exposure Times: Application Development and Feasibility Testing.

BackgroundAlthough studies that characterize the risk environment by linking contextual factors with individual-level data have advanced infectious disease and substance use research, there are opportunities to refine how we define relevant neighborhood exposures; this can in turn reduce the potential for exposure misclassification. For example, for those who do not inject at home, injection risk behaviors may be more influenced by the environment where they inject than where they live. Similarly, among those who spend more time away from home, a measure that accounts for different neighborhood exposures by weighting each unique location proportional to the percentage of time spent there may be more correlated with health behaviors than one’s residential environment.ObjectiveThis study aimed to develop a Web-based application that interacts with Google Maps application program interfaces (APIs) to collect contextually relevant locations and the amount of time spent in each. Our analysis examined the extent of overlap across different location types and compared different approaches for classifying neighborhood exposure.MethodsBetween May 2014 and March 2017, 547 participants enrolled in a Baltimore HIV care and prevention study completed an interviewer-administered Web-based survey that collected information about where participants were recruited, worked, lived, socialized, injected drugs, and spent most of their time. For each location, participants gave an address or intersection which they confirmed using Google Map and Street views. Geographic coordinates (and hours spent in each location) were joined to neighborhood indicators by Community Statistical Area (CSA). We computed a weighted exposure based on the proportion of time spent in each unique location. We compared neighborhood exposures based on each of the different location types with one another and the weighted exposure using analysis of variance with Bonferroni corrections to account for multiple comparisons.ResultsParticipants reported spending the most time at home, followed by the location where they injected drugs. Injection locations overlapped most frequently with locations where people reported socializing and living or sleeping. The least time was spent in the locations where participants reported earning money and being recruited for the study; these locations were also the least likely to overlap with other location types. We observed statistically significant differences in neighborhood exposures according to the approach used. Overall, people reported earning money in higher-income neighborhoods and being recruited for the study and injecting in neighborhoods with more violent crime, abandoned houses, and poverty.ConclusionsThis analysis revealed statistically significant differences in neighborhood exposures when defined by different locations or weighted based on exposure time. Future analyses are needed to determine which exposure measures are most strongly associated with health and risk behaviors and to explore whether associations between individual-level behaviors and neighborhood exposures are modified by exposure times.

Differences in risk behaviours and HIV status between primary amphetamines and opioid injectors in Estonia and Russia

Background and objectivePeople who inject drugs (PWID) account for over half of new HIV infections in Eastern Europe and central Asia, where opioids continue to be the dominant illicit drugs injected. Stimulants including amphetamines (ATS) have been associated with HIV infection risk in several settings. We sought to examine whether primary ATS injection was associated with greater HIV risk, compared to opioid injection in two European locales with significant HIV epidemics. MethodsPWID in Kohtla-Järve and St. Petersburg were recruited using respondent-driven sampling in 2012–2013. Survey data on demographic characteristics, service use, injecting and sexual risk behaviours and HIV-status (and HCV in Kohtla-Järve) were compared between primary opioid and ATS injectors using logistic regression models. ResultsOf 591 injectors recruited in Kohtla-Järve and 811 in St. Petersburg, 195 (33%) and 27 (4%) primarily injected ATS in each city. In both cities, ATS injectors were younger than opioid injectors, initiated injection later, injected less frequently and were more likely to have been paid for sex. In both cities, PWID had high levels of multiple sex partners. In Kohtla-Järve, ATS-injectors had lower odds of back-loading and greater odds of polydrug use than opioid-injectors. In St. Petersburg, where over half of PWID reported unsafe sharing practices, ATS-injectors were less likely to report these practices. ATS-injection was negatively associated with being HIV positive in Kohtla-Järve (aOR = 0.6; 95%CI: 0.5–0.8) and St. Petersburg (aOR = 0.3; 95%CI: 0.1–0.7). ATS-injection was negatively associated with HCV-reactivity in Kohtla-Järve (aOR = 0.5; 95%CI: 0.3–0.6). ConclusionsIn both locations, primary ATS injection was associated with lower injecting risk behaviours, lower odds of HIV and being paid for sex compared to opioid injection. Interventions targeting the characteristics and needs of ATS injectors are needed to increase contact with services and reduce sexual and injecting risk. Harm reduction services, including sexual risk reduction, need to be expanded for all PWID in St. Petersburg.

Impact of sex work on risk behaviours and their association with HIV positivity among people who inject drugs in Eastern Central Canada: cross-sectional results from an open cohort study

ObjectivesThe objectives of this study were: (1) to examine the correlates of HIV positivity among participants who injected drugs and engaged in sex work (PWID-SWs) in the SurvUDI network between...

RCT of an integrated CBT-HIV intervention on depressive symptoms and HIV risk.

Depression and depressive symptoms mediate the association between drug use and HIV risk. Yet, there are few interventions that target depressive symptoms and HIV risk for people who use drugs (PWUD). This study was a randomized controlled trial of an integrated cognitive behavioral therapy and HIV prevention intervention to reduce depressive symptoms, injection risk behaviors and increase condom use in a sample of urban people who used heroin or cocaine in the prior 6 months. A total of 315 individuals aged 18–55, who self-reported at least one HIV drug and sex risk behavior and scored ≥16 and <40 on the Centers for Epidemiologic Studies-Depression (CES-D) scale were randomized using a two-block design, stratified by sex to ensure equivalent numbers, to a 10 session intervention arm (n = 162) or a single session control arm (n = 153). The outcomes of interest were decreases in CES-D score and injection risk behaviors and increases in condom use. The sample was majority African American (85%) and unemployed (94%). Nearly half (47%) reported injection in the prior 6 months and only 19% were taking medication for depression. Follow-up assessments were conducted at 6 and 12 months. Retention at 12 months was 94%. Intervention arm was associated with statistically significantly lower CES-D score at 12 month compared to control. No differences were observed between arms in injection risk. At 6 month, intervention was associated with greater odds of condom use with non-main partner. These findings suggest the potential role of the integrated intervention in reducing depressive symptoms, but weak impact on HIV risk. This trial is registered with ClinicalTrials.gov under the title “Neighborhoods, Networks, Depression, and HIV Risk” number NCT01380613.

Preventing blood-borne virus infection in people who inject drugs in the UK: systematic review, stakeholder interviews, psychosocial intervention development and feasibility randomised controlled trial.

Opioid substitution therapy and needle exchanges have reduced blood-borne viruses (BBVs) among people who inject drugs (PWID). Some PWID continue to share injecting equipment. To develop an evidence-based psychosocial intervention to reduce BBV risk behaviours and increase transmission knowledge among PWID, and conduct a feasibility trial among PWID comparing the intervention with a control. A pragmatic, two-armed randomised controlled, open feasibility trial. Service users were Steering Group members and co-developed the intervention. Peer educators co-delivered the intervention in London. NHS or third-sector drug treatment or needle exchanges in Glasgow, London, Wrexham and York, recruiting January and February 2016. Current PWID, aged ≥ 18 years. A remote, web-based computer randomisation system allocated participants to a three-session, manualised, psychosocial, gender-specific group intervention delivered by trained facilitators and BBV transmission information booklet plus treatment as usual (TAU) (intervention), or information booklet plus TAU (control). Recruitment, retention and follow-up rates measured feasibility. Feedback questionnaires, focus groups with participants who attended at least one intervention session and facilitators assessed the intervention's acceptability. A systematic review of what works to reduce BBV risk behaviours among PWID; in-depth interviews with PWID; and stakeholder and expert consultation informed the intervention. Sessions covered improving injecting technique and good vein care; planning for risky situations; and understanding BBV transmission. Fifty-six per cent (99/176) of eligible PWID were randomised: 52 to the intervention group and 47 to the control group. Only 24% (8/34) of male and 11% (2/18) of female participants attended all three intervention sessions. Overall, 50% (17/34) of men and 33% (6/18) of women randomised to the intervention group and 47% (14/30) of men and 53% (9/17) of women randomised to the control group were followed up 1 month post intervention. Variations were reported by location. The intervention was acceptable to both participants and facilitators. At 1 month post intervention, no increase in injecting in 'risky' sites (e.g. groin, neck) was reported by participants who attended at least one session. PWID who attended at least one session showed a trend towards greater reduction in injecting risk behaviours, a greater increase in withdrawal planning and were more confident about finding a vein. A mean cost of £58.17 per participant was calculated for those attending one session, £148.54 for those attending two sessions and £270.67 for those attending all three sessions, compared with £0.86 in the control group. Treatment costs across the centres vary as a result of the different levels of attendance, as total session costs are divided by attendees to obtain a cost per attendee. The economic analysis suggests that a cost-effectiveness study would be feasible given the response rates and completeness of data. However, we have identified aspects where the service use questionnaire could be abbreviated given the low numbers reported in several care domains. No adverse events were reported. As only 19% of participants attended all three intervention sessions and 47% were followed up 1 month post intervention, a future definitive randomised controlled trial of the intervention is not feasible. Exposure to information on improving injecting techniques did not encourage riskier injecting practices or injecting frequency, and benefits were reported among attendees. The intervention has the potential to positively influence BBV prevention. Harm reduction services should ensure that the intervention content is routinely delivered to PWID to improve vein care and prevent BBVs. The intervention did not meet the complex needs of some PWID, more tailoring may be needed to reach PWID who are more frequent injectors, who are homeless and female. Intervention delivery proved more feasible in London than other locations. Non-attendance at the York trial site substantially influenced the results. Current Controlled Trials ISRCTN66453696 and PROSPERO 014:CRD42014012969. This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 72. See the NIHR Journals Library website for further project information.

Latent Risk Subtypes Based on Injection and Sexual Behavior Among People Who Inject Drugs in Rural Puerto Rico.

People who inject drugs (PWID) in Puerto Rico engage in high levels of injection and sexual risk behavior, and they are at high risk for HIV and hepatitis C (HCV) infection, relative to their US counterparts. Less is known, however, about the clustering of risk behavior conducive to HIV and HCV infection among rural Puerto Rican communities. The purpose of this study was to examine concurrent injection and sexual risk subtypes among a rural sample of PWID in Puerto Rico. Data were drawn from a respondent-driven sample collected in 2015 of 315 PWID in 4 rural communities approximately 30-40 miles from San Juan. Latent class analysis (LCA) was used to examine risk subtypes using 3 injection and 3 sexual risk indicators. In addition, demographic and other PWID characteristics were examined as possible predictors of latent class membership. Four LCA subtypes were identified: low risk (36%), high injection/low sexual risk (22%), low injection/high sexual risk (20%), and high risk (22%). Younger age and past year homelessness predicted high risk latent class membership, relative to the other classes. In addition, daily speedball use predicted membership in the high injection/low sexual risk class, relative to the low risk and low injection/high sexual risk classes. The findings suggest ways in which PWID risk clusters can be identified for targeted interventions.