Injection-related HIV Risk Behaviors Research Articles

HIV Risk Among Urban and Suburban People Who Inject Drugs: Elevated Risk Among Fentanyl and Cocaine Injectors in Maryland.

Drug overdose remains a leading cause of death in the US, with growing rates attributable to illicit fentanyl use. Recent HIV outbreaks among people who inject drugs (PWID) and service disruptions from COVID-19 have renewed concerns on HIV resurgence. We examined the relationship between fentanyl use and three injection-related HIV risk behaviors among PWID in Baltimore City (BC) and Anne Arundel Country (AAC), Maryland. PWID (N = 283) were recruited to the study through targeted sampling at street-based locations in BC and AAC from July 2018 to March 2020. Receptive syringe sharing (RSS) [adjusted odds ratio (AOR): 2.8, 95% confidence interval (CI): 1.2–6.3] and daily injecting (AOR: 1.9, 95% CI: 1.0–3.6) were associated with injecting fentanyl and cocaine together. Fentanyl availability and COVID-19 bring new HIV prevention challenges, particularly among those who inject fentanyl with cocaine, highlighting the importance to expand and sustain harm reduction, prevention, and treatment services for PWID to reduce HIV and overdose burden.

Policing Practices and HIV Risk Among People Who Inject Drugs - A Systematic Literature Review

Background: Laws and their enforcement act as structural determinants of health. Among people who inject drugs (PWID) in numerous global settings, police encounters (e.g. syringe confiscation, physical assault) have been associated with health harms. However, these relationships have not yet been systematically assessed. We conducted a systematic literature review to quantify the contribution of policing to HIV risk among PWID. Methods: We screened MEDLINE, sociological databases and grey literature for studies conducted from 1981-November 2018 that included estimates of HIV infection/risk behaviors and policing practices adversely related to PWID health. Abstracts containing valid associations were selected for further review. We extracted and summarized quantitative findings from eligible studies. Findings: We screened 8,201 abstracts, reviewed 175 full-text articles and included 27 eligible analyses from nine countries (Russia, Mexico, USA, Canada, Ukraine, Thailand, Malaysia, China and India). Heterogeneity in variable and endpoint selection precluded meta-analyses. In 6 (22%)% studies, HIV infection among PWID was significantly associated with policing, including syringe confiscation, reluctance to buy or carry syringes for fear of police, rushed injection due to police presence, fear of arrest, being arrested for planted drugs, and physical abuse. Examining injection-related HIV risk behaviors as analytical endpoints, 16 (59)% studies identified policing practices to be independently associated with syringe sharing, shooting gallery utilization, and seeking informal injection assistance. In 9 (33%), policing was associated with PWID avoidance of harm reduction services, including syringe exchange, methadone maintenance, and safe consumption facilities. Most studies focused on high-income settings. Interpretation: Globally, evidence suggests that policing substantially shapes the HIV risk environment for PWID, but lower-income settings are underrepresented in research. Curbing injection-related HIV risk may necessitate additional structural interventions. Methodological harmonization could facilitate knowledge generation on the role of police as a determinant of population health. Funding: This work was supported by the National Institute on Drug Abuse [grant numbers R01DA039073, K01DA043421(JC)] and the UCSD Center for AIDS Research (CFAR) [International Pilot Grant NIAID 5P30AI036214]. Declaration of Interests: The authors declare that they have no conflicts of interest. Ethics Approval Statement: The authors conducted a systematic literature review in accordance with PRISMA guidelines that has been registered with PROSPERO, the international prospective register of systematic reviews (PROSPERO Registration #CRD42018105967).

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.

Reduction of Injection-Related Risk Behaviors After Emergency Implementation of a Syringe Services Program During an HIV Outbreak.

To describe injection-related HIV risk behaviors preimplementation and postimplementation of an emergency syringe services program (SSP) in Scott County, Indiana, after an HIV outbreak among persons who inject drugs (PWID). Mixed methods retrospective pre-post intervention analysis. We analyzed routine SSP program data collected at first and most recent visit among clients with ≥2 visits, ≥7 days apart from April 4 to August 30, 2015, to quantify changes in injection-related risk behaviors. We also analyzed qualitative data collected from 56 PWID recruited in Scott County to understand factors contributing to these behaviors. SSP clients included in our analysis (n = 148, 62% of all SSP clients) reported significant (P < 0.001) reductions over a median 10 weeks (range 1-23) in syringe sharing to inject (18%-2%) and divide drugs (19%-4%), sharing other injection equipment (eg, cookers) (24%-5%), and number of uses of the same syringe [2 (interquartile range: 1-4) to 1 (interquartile range: 1-1)]. Qualitative study participants described access to sterile syringes and safer injection education through the SSP, as explanatory factors for these reductions. Injection frequency findings were mixed, but overall suggested no change. The number of syringes returned by SSP clients increased from 0 at first visit to median 57. All qualitative study participants reported using sharps containers provided by the SSP. Analyses of an SSP program and in-depth qualitative interview data showed rapid reduction of injection-related HIV risk behaviors among PWID post-SSP implementation. Sterile syringe access as part of comprehensive HIV prevention is an important tool to control and prevent HIV outbreaks.

The dynamic relationship between social norms and behaviors: the results of an HIV prevention network intervention for injection drug users

Social norms are a key source of influence on health behaviors. This study examined changes in social norms and relationships between HIV injection risk behaviors and social norms among injection drug users (IDUs) involved in an experimental intervention. Randomized clinical trial. An HIV Prevention Trials Network study, Philadelphia, USA. IDUs, called indexes, and their social network members, who were drug or sex partners, were recruited for an HIV prevention intervention and followed for up to 30 months (n = 652). Indexes were randomized into a peer education intervention or control condition. Outcomes of injection-related HIV risk behaviors (sharing needles, sharing cookers, sharing cotton, front-/back-loading) were measured every 6 months and the social norms of these four risk behaviors were assessed every 12 months. There was a statistically significant intervention effect on all four social norms of injection behaviors, with participants in the intervention reporting less risky social norms compared with controls (changes in mean score: needles, -0.24, P = 0.007; cookers, -0.33, P = .004; cottons, -0.28, P = .0165; front-/back-loading, -0.23, P = .002). There was also a statistically significant bidirectional association with social norms predicting injection risk behaviors at the next assessment and risk behaviors predicting social norms at the subsequent visit. Through social network interventions it is feasible to change both injection risk behaviors and associated social norms. However, it is critical that social network interventions focus on publically highlighting behavior changes, as changing social norms without awareness of behaviors change may lead to relapse of risk behaviors.

Community Reinforcement and Family Training for treatment retention and HIV behavioral risk reduction: A study protocol.

Drop-out from drug treatment following opiate detoxification represents a major health concern. This paper describes a study protocol for adapting Community Reinforcement and Family Training (CRAFT) to address treatment retention and HIV behavioral risk reduction. Study participants will include 52 dyads each consisting of one opiate dependent person recruited during a 13-day buprenorphine naloxone taper and their respective concerned significant other. Study procedures include development of a modified behavioral therapy and an initial randomized clinical trial. The primary outcome measure is the opiate dependent person’s retention in drug abuse treatment. A number of secondary outcomes will be measured, including both sexual- and drug injection-related HIV risk behavior reduction. This work was supported by the National Institute on Drug Abuse (1K23DA021512-01A2)

Contingency management reduces injection-related HIV risk behaviors in heroin and cocaine using outpatients

Intravenous drug use is a major vector of HIV transmission. We assessed whether contingency management (CM), in which participants earn reinforcers for drug abstinence, reduces HIV risk behaviors in methadone-maintained opiate- and cocaine-using outpatients. Participants ( n = 116) were randomly assigned to prize-based CM or to receipt of prize draws noncontingently on a schedule yoked to the CM group. Both groups received methadone and individual counseling throughout treatment. The HIV-Risk Taking Behaviour Scale was administered in written questionnaire form at 2-week intervals (HRBS; [Darke, S., Hall, W., Heather, N., Ward, J., & Wodak, A. (1991). The reliability and validity of a scale to measure HIV risk-taking behaviour among intravenous drug users. AIDS, 5, 181–185]). A mediation analysis was conducted to determine whether abstinence from opiates and cocaine mediated the effect of CM on HRBS scores. Changes in HRBS scores over time differed significantly by treatment ( F(9,334) = 2.4, p < 0.05), with HRBS scores decreasing over time in the CM group to a greater extent than in the noncontingent control group. Participants in the CM group had significantly lower rates of simultaneous cocaine/opiate-positive urine specimens than those in the noncontingent control group during CM treatment ( F(1,111) = 6.8, p = 0.01). The relationship between treatment condition and HRBS scores was mediated by abstinence. CM targeted toward cocaine and heroin use produces significant reductions in injection-related drug-taking behaviors associated with heightened risk for getting or transmitting HIV.

Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients

Objective To determine if adequate syringe coverage – “one shot for one syringe” – among syringe exchange program (SEP) clients is associated with injection-related HIV risk behaviors and syringe disposal. Design HIV risk assessments with 1577 injection drug users (IDUs) recruited from 24 SEPs in California between 2001 and 2003. Individual syringe coverage was calculated as a proportion of syringes retained from SEP visits to total number of injections in the last 30 days. Results Participants were divided into four groups based on syringe coverage: <50%, 50–99%, 100–149%, and 150% or more. In multivariate logistic regression, SEP clients with less than 50% syringe coverage had significantly higher odds of reporting receptive syringe sharing in the last 30 days (adjusted odds ratio [AOR] = 2.3; 95% confidence interval [CI] = 1.4, 3.6) and those with 150% or more coverage had lower odds of reporting receptive syringe sharing (AOR = 0.5; 95%CI = 0.3, 0.8) as compared to SEP clients with adequate syringe coverage of 100–149%. Similar associations were observed for other main outcomes of distributive syringe sharing and syringe re-use. No differences in safe syringe disposal were observed by syringe coverage. Conclusions Individual syringe coverage is strongly associated with safer injection behaviors without impacting syringe disposal among SEP clients. Syringe coverage is a useful measure for determining if IDUs are obtaining sufficient syringes to lower HIV risk.

Severe Anxiety Symptomatology and HIV Risk Behavior Among Hispanic Injection Drug Users in Puerto Rico

Despite an overall decrease in AIDS incidence in Puerto Rico, our studies continue to show high prevalence of HIV risk behaviors among injection drug users (IDUs). This study seeks to evaluate whether the occurrence of injection-related and sex-related HIV risk behaviors among IDUs in Puerto Rico varies with the presence of anxiety symptomatology. Subjects included 557 IDUs, recruited from street settings in poor neighborhoods in Puerto Rico. Symptoms of severe anxiety were reported by 37.1% of the study sample. Participants with severe anxiety symptoms were more likely to share needles, cotton, and rinse water; to pool money to buy drugs; and to engage in backloading, than those without severe anxiety symptoms. Participants with severe anxiety symptomatology were also more likely to practice unprotected vaginal or oral sex. The findings from this study alert HIV prevention and treatment programs to the need to address anxiety disorders within their programs.

Decreasing international HIV transmission: the role of expanding access to opioid agonist therapies for injection drug users

To examine the role of expanded access to opioid agonist treatment as a means to decrease international HIV transmission. Review of the English language literature via Medline. Estimates of prevalence rates for injection drug use, HIV infection and treatment effect sizes for changes in opioid use, opioid injection, needle-sharing, injection-related HIV risk behavior and cost. An estimated 12.6 million injection drug users internationally accounted for 10% of the 4.2 million new HIV infections in 2003. Ninety-three of the 136 countries (68%) that report injection drug use identify HIV infection related to this behavior. Observational studies of methadone treatment demonstrate decreases in opioid use, opioid injection, needle-sharing and lower rates of HIV prevalence and incidence. The effectiveness of buprenorphine in demonstrating similar findings is expected, although implementations and research are still emerging. The cost-effectiveness of opioid agonist treatment has been established. The barriers to international adoption of opioid agonist treatment, despite the research evidence and international guidelines, are discussed. Untreated opioid dependence leads to HIV transmission, on an international level. Opioid agonist treatments are associated with reductions in the frequency of opioid use, fewer injections and injection-related HIV risk behaviors and lower rates of HIV prevalence and incidence. Despite international recommendations, treatment for opioid-dependent injection drug users with methadone and buprenorphine is limited. Research, implementation efforts and political strategies to expand access to opioid agonist treatment are needed in order to combat the spread of HIV, especially in the developing world.

Factors Associated with Syringe Sharing Among Users of a Medically Supervised Safer Injecting Facility

Vancouver, Canada recently opened a medically supervised safer injecting facility (SIF) in an effort to reduce HIV and overdose risk and public injection drug use. We sought to examine factors associated with syringe sharing among SIF users. SIF users were randomly recruited into a prospective cohort of SIF users known as the Scientific Evaluation of Supervised Injecting (SEOSI) cohort. We examined the prevalence and correlates of used syringe borrowing among baseline HIV-negative participants and used syringe lending among baseline HIV-infected participants. Between 22 March 2004 and 22 October 2004, 479 baseline HIV-negative subjects (48 [10%] syringe borrowing events) and 103 baseline HIV-infected participants (17 [16.5%] syringe lending events) were recruited into the cohort. For baseline HIV negative participants, syringe borrowing was positively associated with public drug use (p<0.001) and requiring help injecting (p=0.001), whereas exclusive SIF use was inversely associated with syringe sharing (p=0.019). For baseline HIV-infected participants, syringe lending was positively associated with daily cocaine injection (p=0.022) and shooting gallery use (p=0.007). Although ongoing injection-related HIV risk behavior was reported among some SIF users, rates of syringe sharing were substantially lower than the rate observed previously in this community and it is noteworthy that exclusive SIF use was associated with reduced syringe sharing.

Effects of combined counseling and case management to reduce HIV risk behaviors among Hispanic drug injectors in Puerto Rico: A randomized controlled study

This study examined the effectiveness of a combined counseling and case management behavioral intervention, using motivational interviewing strategies, in engaging Hispanic injection drug users in treatment and reducing drug use and injection-related HIV risk behaviors. Follow up data are presented on 440 (79.0%) of 557 randomized participants, 6 months after the initial interview. Subjects in the experimental arm were significantly less likely to continue drug injection independent of entering drug treatment, and were also more likely to enter drug treatment. Subjects in both arms who entered drug treatment were less likely to continue drug injection. Among subjects who continued drug injection, those in the experimental arm were significantly less likely to share needles. Confirming the outcomes of this study in other Hispanic sites and populations could be a critical step towards reducing factors that contribute to the self-sustaining HIV/AIDS epidemic in Puerto Rico and communities in the U.S. mainland.

Migration and HIV risk behaviors: Puerto Rican drug injectors in New York City and Puerto Rico.

We compared injection-related HIV risk behaviors of Puerto Rican current injection drug users (IDUs) living in New York City and in Puerto Rico who also had injected in the other location with those who had not. We recruited Puerto Rican IDUs in New York City (n = 561) and in Puerto Rico (n = 312). Of the former, 39% were "newcomers," having previously injected in Puerto Rico; of the latter, 14% were "returnees," having previously injected in New York. We compared risk behaviors within each sample between those with and without experience injecting in the other location. Newcomers reported higher levels of risk behaviors than other New York IDUs. Newcomer status (adjusted odds ratio [OR] = 1.62) and homelessness (adjusted OR = 2.52) were significant predictors of "shooting gallery" use; newcomer status also predicted paraphernalia sharing (adjusted OR = 1.67). Returnee status was not related to these variables. Intervention services are needed that target mobile populations who are coming from an environment of high-risk behavior to one of low-risk behavior.

Drug Use and HIV Risks Among African-American, Mexican-American, and Puerto Rican Drug Injectors

This article documents the prevalence of injection-related HIV risk behaviors among a sample of 758 Mexican-American. Puerto Rican, and African-American drug injectors derived from the National Institute on Drug Abuse Cooperative Agreement database. The results show that the two Hispanic subgroups had higher injection-related risks than the African-American group. Further, among Hispanics, Puerto Ricans had higher rates of drug injection than Mexican-Americans, but Mexican-Americans had higher rates of sharing injection paraphernalia than Puerto Ricans. The research suggests that more aggressive HIV/AIDS intervention efforts be targeted to minority injection drug users, especially those that are contextualized by the racial/ethnic group targeted.

Injecting Drug Users who Want Treatment

This study examined characteristics of injecting drug users (IDUs) who want treatment and the features that differentiate them from IDUs who do not want treatment. Data were collected as part of a community-based HIV prevention project in San Antonio, Texas. Interviews were administered to 1,100 IDUs between February 1993 and May 1995. Interview topics included sociodemographics, drug use history, current drug use, treatment history, injection-related HIV risk behavior, sexual behavior, and previous contact related to HIV prevention. Multiple logistic regression analysis identified four factors independently associated with wanting treatment in the multivariate model. These were: (1) 30 or more injections per month; (2) being eligible for methadone maintenance; (3) 2 or more previous treatment admissions; and (4) being recruited after the first year of the project. Implications of these findings are discussed.

The Prevalence of Additional Injection-Related HIV Risk Behaviors Among Injection Drug Users

This study assesses the prevalence of injection-related behaviors that may facilitate HIV transmission even when syringes are not directly shared. Subjects who self-reported practicing these "indirect sharing" behaviors are described, the prevalence of these behaviors are compared with the direct sharing of syringes, and variables independently associated with indirect sharing are determined. Injection-related risks were assessed among 585 injection drug users (IDUs) in Denver, Colorado. Respondents were classified into three groups based on their self-reported injection behaviors: IDUs who directly and indirectly share syringes, IDUs who indirectly share only, and IDUs who neither directly or indirectly share. Indirect sharing was twice as prevalent as direct sharing. IDUs who injected heroin or speedballs were less safe in their injection behavior than those who did not. Drug treatment did not protect against injection-related risk behaviors; however, exposure to community HIV prevention efforts was protective. Indirect sharing behaviors are common, yet their link to HIV transmission remains unrecognized by many IDUs. IDUs must be informed about these additional risk behaviors.