Non-injection Drug Use Research Articles

Continued low uptake of treatment for hepatitis C virus infection in a large community‐based cohort of inner city residents

Despite advances in HCV treatment, recent data on treatment uptake is sparse. HCV treatment uptake and associated factors were evaluated in a community-based cohort in Vancouver, Canada. The CHASE study is a cohort of inner city residents recruited from January 2003-June 2004. HCV status and treatment were retrospectively and prospectively determined through data linkages with provincial virology and pharmacy databases. Logistic regression analyses were used to identify factors associated with HCV treatment uptake. Among 2913, HCV antibody testing was performed in 2405, 64% were HCV antibody-positive (n = 1533). Individuals with spontaneous clearance (18%, n = 276) were excluded. Among the remaining 1257 HCV antibody-positive participants (mean age 42, 71% male), 29% were Aboriginal. At enrolment, the majority reported recent injecting (60%) and non-injecting drug use (87%). Between January 1998 and March 2010, 6% (77 of 1257) initiated HCV treatment. In adjusted analyses, Aboriginal ethnicity [adjusted odds ratio (AOR) 0.23; 95% CI 0.10, 0.51] and crack cocaine use (AOR 0.61; 95% CI 0.37, 0.99) were associated with a decreased odds of receiving HCV treatment, while methamphetamine injecting (AOR 0.16; 95% CI 0.02, 1.18) trended towards a lower odds of receiving treatment. HCV treatment uptake ranged from 0.2 (95% CI 0.0, 0.7) per 100 person-years (PYs) in 2003 to 1.6 (95% CI 0.9, 2.6) per 100 PYs in 2009. HCV treatment uptake remains low in this large community-based cohort of inner city residents with a high HCV prevalence and access to universal healthcare.

Transitions from injecting to non-injecting drug use: Potential protection against HCV infection

Transitions from injecting to non-injecting drug use have been reported from many different areas, particularly in areas with large human immunodeficiency virus (HIV) epidemics. The extent to which such transitions actually protect against HIV and HCV has not been determined. A cross-sectional survey with HIV and hepatitis C (HCV) testing was conducted with 322 former injectors (persons who had injected illicit drugs but permanently transitioned to non-injecting use) and 801 current injectors recruited in New York City between 2007 and 2012. There were no differences in HIV prevalence, while HCV prevalence was significantly lower among former injectors compared to current injectors. Years injecting functioned as a mediating variable linking former injector status to lower HCV prevalence. Transitions have continued well beyond the reduction in the threat of AIDS to injectors in the city. New interventions to support transitions to non-injecting drug use should be developed and supported by both drug treatment and syringe exchange programs.

Employment predicts decreased mortality among HIV-seropositive illicit drug users in a setting of universal HIV care

ObjectiveGiven the link between employment and mortality in the general population, we sought to assess this relationship among HIV-positive people who use illicit drugs in Vancouver, Canada.MethodsData were derived from...

Prevalence and correlates of street-obtained buprenorphine use among current and former injectors in Baltimore, Maryland

ObjectivesThere are few systematic assessments of street-obtained buprenorphine use from community-based samples in the United States. The objective of this study was to characterize the prevalence, correlates, and reasons for street-obtained buprenorphine use among current and former injection drug users (IDUs) in Baltimore, Maryland. MethodsIn 2008, participants of the ALIVE (AIDS Linked to the IntraVenous Experience) study, a community-based cohort of IDUs, were administered a survey on buprenorphine. Street-obtained buprenorphine represented self-reported use of buprenorphine obtained from the street or a friend in the prior three months. ResultsSix hundred and two respondents were predominantly male (65%), African-American (91%), and 30% were HIV-positive. Overall, nine percent reported recent street-obtained buprenorphine use, and only 2% reported using to get high. Among active opiate users, 23% reported recent use of street-obtained buprenorphine. Use of buprenorphine prescribed by a physician, injection and non-injection drug use, use of street-obtained methadone and prescription opiates, homelessness, and opioid withdrawal symptoms were positively associated, while methadone treatment, health insurance, outpatient care, and HIV-infection were negatively associated with recent street-obtained buprenorphine use in univariate analysis. After adjustment, active injection and heroin use were positively associated with street-obtained buprenorphine use. Ninety-one percent reported using street-obtained buprenorphine to manage withdrawal symptoms. ConclusionsWhile 9% reported recent street-obtained buprenorphine use, only a small minority reported using buprenorphine to get high, with the majority reporting use to manage withdrawal symptoms. There is limited evidence of diversion of buprenorphine in this sample and efforts to expand buprenorphine treatment should continue with further monitoring.

HIV among female sex workers in the Central Asian Republics, Afghanistan, and Mongolia: Contexts and convergence with drug use

BackgroundCentral Asia is culturally and demographically diverse, both between and within its respective countries. That diversity is represented in the range of individual, network, community, and structural risks for female sex workers (FSWs) regionally. FSWs have several risk factors for HIV acquisition and transmission including behavioral, biological, and structural risk factors. Across Central Asia, sexual risks have become conflated with risks associated with injection and non-injection illicit drug use. MethodsPeer-reviewed literature databases and gray literature were searched for articles on sex work in Central Asia. The medial subject heading (MeSH) of “sex work” was cross-referenced with terms associated with Uzbekistan, Tajikistan, Turkmenistan, Kazakhstan, Kyrgyzstan, Mongolia, and Afghanistan. ResultsHIV prevalence data for FSWs suggest sustained or increasing prevalence in the region. There are increasing data directly linking HIV among FSWs to injection drug use; odds of HIV are up to 20 times higher among FSWs reporting injecting drug use. Though injecting drug use among FSWs is rare in some settings, recreational drugs and alcohol use limits other risk reduction behaviors, such as condom use. ConclusionsThe Central Asian HIV epidemic has traditionally been assumed to be driven nearly exclusively by drug use, resulting in surveillance systems focused on parenteral transmission. The reviewed data highlight limited attention to characterizing the burden of HIV and risk factors for HIV acquisition and transmission among FSWs who use drugs. Moving forward will require enhanced HIV surveillance and research to inform HIV prevention approaches to address all levels of HIV risks affecting FSWs in Central Asia.

Risk factors for progression to regular injection drug use among street-involved youth in a Canadian setting

BackgroundStreet-involved youth are at high risk for experimenting with injection drug use; however, little attention has been given to identifying the factors that predict progression to on-going injecting. MethodsLogistic regression was used to identify factors associated with progression to injecting weekly on a regular basis among a Canadian cohort of street-involved youth. ResultsAmong our sample of 405 youth who had initiated injecting at baseline or during study observation, the median age was 22 years (interquartile range [IQR]=21–24), and 72% (293) reported becoming a regular injector at some point after their first injection experience. Of these, the majority (n=186, 63%) reported doing so within a month of initiating injection drug use. In multivariate analysis, the drug used at the first injection initiation event (opiates vs. cocaine vs. methamphetamine vs. other; all p>0.05) was not associated with progression; however, younger age at first injection (adjusted odds ratio [AOR]=1.13), a history of childhood physical abuse (AOR=1.81), prior regular use of the drug first injected (AOR=1.77), and having a sexual partner present at the first injection event (AOR=2.65) independently predicted progression to regular injecting. ConclusionThese data highlight how quickly youth progress to become regular injectors after experimentation. Findings indicate that addressing childhood trauma and interventions such as evidence-based youth focused addiction treatment that could prevent or delay regular non-injection drug use, may reduce progression to regular injection drug use among this population.

Associations between drug use and sexual risks among heterosexual men in the Philippines

The relationship between drug use and sexual risk behaviours among 2272 men in the southern Philippines was assessed. Over 20% of participants used drugs. Logistic regression analyses adjusted for age, marital status, income, occupation and geographic region revealed that compared to non-drug users, men who used drugs had earlier sexual debuts (adjusted odds ratio = 1.73; 95% confidence interval = 1.38-2.17), were more likely to report two or more recent sexual partners (adjusted odds ratio = 2.22; 95% confidence interval = 1.59-3.11), and were more likely to report ever having sex with a female sex worker (adjusted odds ratio = 2.99; 95% confidence interval = 2.25-4.00). Condom use was noted to be low overall among the men in this study; however, the odds of more frequent condom use with a regular partner were greater for men who used drugs compared to non-drug users (adjusted odds ratio = 1.60; 95% confidence interval = 1.26-2.02). There were no significant differences in condom use during last sex or frequency of condom use with a sex worker. While injection drug use was not common (1%), use of oral or inhaled substances was prevalent, and associated with increased sexual risk for acquisition and transmission of STI/HIV. Efforts to decrease STI/HIV transmission should specifically target non-injection drug use as a risk factor.

P3.335 HIV and SYPHILIS Prevalence and Behaviour, Practises and Attitudes of the TRANS Population in Paraguay, 2011

Background The transgender population is highly affected by STI and HIV epidemic, with high stigma and social discrimination. In Paraguay there is a lack of information concerning HIV and syphilis prevalence in this population. Generally, data on this population is mixed with that of men who have sex with men (MSM). It is estimated there are 421 transgender citizens throughout the country. Methods Cross sectional observational study at subnational level, that included a survey and linked confidential serological tests from August to September 2011. HIV and syphilis were screened with rapid tests. HIV was confirmed with Western Blot and syphilis with TPHA for those reactive. The study population was people of male sex at birth that self-identify as females, with or without modification of their body and clothing according to said identity. A mapping of transgender was carried out, and subsequently the study was offered to all mapped people in the geographical areas of Capital, Itapua, Caaguazu, Parana and Amambay. Results 311 transgender participated in the study, 237 agreed to HIV testing and 247 to syphilis testing. HIV and syphilis prevalence was 27% (IC95% 21–32) and 12% (IC95% 8–16) respectively. HIV/syphilis co-infection occurred in 6% of cases. 89% were sexual workers. The associated risk factors for HIV infection were age, non-injectable drug use and sexual work time (p Conclusions HIV prevalence is high, similar to other Latin american countries. The prevalence of syphilis and syphilis/HIV co-infection is high. The high prevalence of non-injectable drug use implies the need for changing prevention strategies.

P3.310 Can MSM Attendees of a Municipal STD Clinic Serve as a Representative Sample For Behavioural Surveillance of HIV Practises and Risks?

BackgroundThe US National HIV Behavioral Surveillance (NHBS) system conducts venue-based sampling every three years of men who ever had a male sexual partner (i.e., men who have sex with men–MSM)....

O20.1 Two-Mode Analysis of HIV, HCV and Risk Behaviours: A Place-Based Analysis of Most At-Risk Populations in Winnipeg, Canada

BackgroundThe HIV epidemic has shown a considerable amount of heterogeneity, complicating the design and placement of prevention, intervention and treatment programmes. Place-based analyses providing specific information on pathogen prevalence, risk...

PTH-149 Successful Care for Patients with Chronic Hepatitis B Virus Infection in a Dedicated Drug and Alcohol Addiction Service in East London

IntroductionChronic Hepatitis B Virus (HBV) infection in persons attending drug addiction services has not been studied as thoroughly as infection with Hepatitis C Virus (HCV). The aim of this audit...

HIV Among Women in the District of Columbia: An Evolving Epidemic?

The epidemiology of HIV in urban centers of the United States such as the District of Columbia (DC) is dynamic with rates of new HIV and AIDS diagnoses as well as risk factors elevated. Correlates of HIV among heterosexual women extend beyond traditional, individual risk factors to structural factors. The purpose of this study was to compare proportions of HIV and correlates of HIV among women participating in National HIV behavioral surveillance (NHBS) system in 2006-7 (NHBS Cycle 1) and 2010 (NHBS Cycle 2). Analysis of 677 female participants at elevated risk for HIV revealed high prevalence of individual-level HIV-associated risk factors (e.g., sexual behavior) and socio-structural associated risk factors (e.g., homelessness, incarceration, lack of health insurance). While a greater proportion of women were HIV-infected in Cycle 2, after controlling for the distribution of demographic characteristics to adjust for a change in eligibility criteria, the pooled sample did not reveal a significantly increased proportion of HIV-infected women in Cycle 2. Homelessness and condom use were associated with greater relative odds of HIV after adjustment for confounders, and non-injection drug use was associated with reduced odds. Findings inform our understanding of the continuing HIV epidemic in DC and support development of effective interventions to slow the epidemic among women in DC and similar urban centers.

The Role of Drinking Severity on Sex Risk Behavior and HIV Exposure among Illicit Drug Users

The current study examined how drinking severity among injection and non-injection drug users is associated with sex risk behaviors and risk of HIV exposure. The study is a secondary analysis of an investigation of risk factors among drug users in Baltimore known as the NEURO-HIV epidemiologic study. Participants (N = 557) completed an interview, self-reported 30-day alcohol use, lifetime injection and non-injection drug use, and provided blood samples to screen for HIV. Participants were grouped into one of three drinking severity conditions: abstinent (no reported alcohol use in prior 30 days), moderate alcohol use (≤30 drinks for females, or ≤60 drinks for males), or problematic alcohol use (>30 drinks for females, or >60 drinks for males). Drinking severity groups were significantly different on lifetime injection drug use, heroin injection, snorting/sniffing cocaine, and smoking crack. Logistic regression analyses found problematic alcohol users to be more likely than alcohol abstainers to inject drugs before or during sex (AOR = 5.78; 95% CI = 2.07-16.10), and more likely than moderate alcohol users to use alcohol before/during sex (AOR = 4.96; 95% CI = 2.09-11.81), inject drugs before/during sex (AOR = 2.96; 95% CI = 1.29-6.80), and to be HIV+ among Black participants (AOR = 2.72; 95% CI = 1.14-6.49). These results outline the necessity for research and clinical intervention among this population to reduce sex risk behaviors and potential HIV exposure, while highlighting the need to examine drinking severity as a predictor of sex risk behaviors.

Retention among North American HIV-infected persons in clinical care, 2000-2008.

Retention in care is key to improving HIV outcomes. The goal of this study was to describe 'churn' in patterns of entry, exit, and retention in HIV care in the United States and Canada. Adults contributing ≥1 CD4 count or HIV-1 RNA (HIV-lab) from 2000 to 2008 in North American AIDS Cohort Collaboration on Research and Design clinical cohorts were included. Incomplete retention was defined as lack of 2 HIV-laboratories (≥90 days apart) within 12 months, summarized by calendar year. Beta-binomial regression models were used to estimate adjusted odds ratios (OR) and 95% confidence intervals (CI) of factors associated with incomplete retention. Among 61,438 participants, 15,360 (25%) with incomplete retention significantly differed in univariate analyses (P < 0.001) from 46,078 (75%) consistently retained by age, race/ethnicity, HIV risk, CD4, antiretroviral therapy use, and country of care (United States vs. Canada). From 2000 to 2004, females (OR = 0.82, CI: 0.70 to 0.95), older individuals (OR = 0.78, CI: 0.74 to 0.83 per 10 years), and antiretroviral therapy users (OR = 0.61, CI: 0.54 to 0.68 vs. all others) were less likely to have incomplete retention, whereas black individuals (OR = 1.31, CI: 1.16 to 1.49, vs. white), those with injection drug use HIV risk (OR = 1.68, CI: 1.49 to 1.89, vs. noninjection drug use), and those in care longer (OR = 1.09, CI: 1.07 to 1.11 per year) were more likely to have incomplete retention. Results from 2005 to 2008 were similar. From 2000 to 2008, 75% of the North American AIDS Cohort Collaboration on Research and Design population was consistently retained in care with 25% experiencing some changes in status or churn. In addition to the programmatic and policy implications, the findings of this study identify patient groups who may benefit from focused retention efforts.

Beyond injecting drug use: investigation of a Victorian cluster of hepatitis C among HIV‐infected men who have sex with men

To examine increased notifications of hepatitis C virus (HCV) in men who have sex with men (MSM) infected with HIV in Victoria, and evaluate HCV transmission risk factors other than injecting drug use. Case series through retrospective review of all HCV cases in Victoria from 1 April 2010 to 30 June 2011, with clinical and laboratory data examined in likely MSM to identify a co-infected cohort. Patients with newly acquired HCV with HIV co-infection were invited to complete a questionnaire exploring novel risk factors for HCV transmission (non-injecting drug use, sexual practices with increased likelihood of trauma, and presence of genital ulcers). Sequencing was performed to determine the local molecular epidemiology of HCV co-infection. Demographics of newly co-infected MSM, traditional versus novel risk factors for HCV acquisition, prior knowledge of potential for sexual transmission of HCV, and association between viral sequences. Thirty-one patients with HIV were identified from 3365 notifications of hepatitis C. The median age was 42 years, and median time from HIV to HCV diagnosis was 22 months. Most patients were asymptomatic, with abnormal liver function tests prompting HCV testing. Interviews with 14 patients identified a high prevalence of novel risk factors and limited knowledge of HCV risk. Two clusters of matching viral sequences were identified. Novel HCV transmission routes have emerged in Victoria. These data reinforce the need for targeted testing and prevention strategies among HIV-infected MSM.

Prevalent and Incident Hepatitis C Virus Infection Among HIV-Infected Men Who Have Sex With Men Engaged in Primary Care in a Boston Community Health Center

Sexually transmitted hepatitis C virus (HCV) infection is an emerging epidemic among human immunodeficiency virus (HIV)-infected men who have sex with men (MSM). HCV may be underrecognized in this population, historically thought to be at low risk. We determined the prevalence and incidence of HCV among HIV-infected men at Fenway Health between 1997 and 2009. We describe characteristics associated with HCV. Of 1171 HIV-infected men, of whom 96% identify as MSM, 1068 (91%) were screened for HCV and 64 (6%) had a positive HCV antibody (Ab) result at initial screening. Among the 995 men whose initial HCV Ab result was negative, 62% received no further HCV Ab testing. Among the 377 men who had ≥1 additional HCV Ab test, 23 (6%) seroconverted over 1408 person-years, for an annualized incidence of 1.63 per 100 person-years (95% confidence interval, .97-2.30). Among the 87 HIV-infected MSM diagnosed with prevalent or incident HCV, 33% reported history of injection drug use, 46% noninjection drug use (NIDU), and 70% sexually transmitted infections (STIs). Sixty-four (74%) of HCV-infected MSM developed chronic HCV; 22 (34%) initiated HCV treatment and 13 (59%) of treated persons achieved a sustained virologic response (SVR). Prevalent and incident HCV, primarily acquired through nonparenteral means, was common in this HIV-infected population despite engagement in care. STIs and NIDU were common among HIV/HCV-coinfected MSM. SVR rates were high among those who underwent HCV treatment. All sexually active and/or substance-using HIV-infected MSM should receive routine and repeated HCV screening to allow for early diagnosis and treatment of HCV.

HIV Incidence and Associated Risk Factors Among Female Sex Workers in a High HIV-Prevalence Area of China

Heterosexual sex is replacing injection drug use as the main mode of HIV transmission in China. The objective of this study is to determine HIV incidence and associated risk factors among female sex workers (FSWs) in China. From March 2006 to November 2009, FSWs in Kaiyuan City, Yunnan were recruited into an open cohort study. Participants were interviewed and tested for HIV and sexually transmitted infections every 6 months. A multivariate Cox proportional hazards regression model with time-dependent variables was used to measure associations between independent variables and HIV seroconversion. During 3.5 years of follow-up, 19 incident cases of HIV infection were diagnosed, yielding an overall incidence of 1.44 per 100 person-years (95% confidence interval [CI]: 0.87-2.24). In the multivariate Cox proportional hazards regression model, noninjection drug use (adjusted hazard ratio [AHR]: 6.7, 95% CI: 2.25-19.93), inconsistent condom use with clients in the previous week (AHR: 2.9, 95% CI: 1.03-8.34), and number of clients in the previous week ≥7 (AHR: 4.9, 95% CI: 1.81-13.13) were all independent risk factors for HIV seroconversion. These results underscore the urgency for preventive interventions on sexual and drug use behaviors among FSWs, including condom promotion as well as sexually transmitted infection screening and treatment.

Factors associated with specific clinical forms of oral candidiasis in HIV-infected Brazilian adults

ObjectiveThis study assesses the association among factors related with specific clinical forms of oral candidiasis (OC) in HIV-infected Brazilian adults. DesignThis study was conducted with 590 HIV-infected adults from 1997 to 2004. The OC diagnosis was based in accordance with the EC-Clearinghouse classification. Multivariate logistic regression analyses were performed to measure the association between HAART and OC, with pseudomembranous [PC], erythematous [EC], and angular cheilitis [AC]) adjusted for HIV-related diseases, smoking, alcohol consumption, injecting and non-injecting drug use. ResultsTwo hundred and eighteen (37.0%) individuals were undergoing HAART. The prevalence of PC, EC and AC was 21.2%, 15.7% and 8.8%, respectively. Approximately 64% of the individuals with PC and EC, and 76.5% with AC had absolute CD4 levels ≤200cells/mm3. The results of the multivariate analysis showed that subjects not undergoing HAART had a significantly higher odds ratio for PC [OR 3.67 (95% CI: 1.97–6.80)] and EC [OR 1.88 (95% CI: 1.04–3.39)], and AC [OR 4.56 (95% CI: 1.58–13.19)]. In addition, smoking [OR 2.58 (95% CI: 1.43–4.68)] and pneumocystis pneumonia [OR 1.92 (95% CI: 1.07–3.42)] were associated with PC, while high alcohol consumption [OR 3.40 (95% CI: 1.13–10.18)] and cytomegalovirus infection [OR 2.34 (95% CI: 1.06–5.15)] were associated with EC. ConclusionThe data indicates that the odds of having all clinical forms of OC are higher in HIV-infected adults not receiving HAART.

Childhood sexual abuse and risk for initiating injection drug use: A prospective cohort study

ObjectiveThis study examined whether childhood sexual abuse predicts initiation of injection drug use in a prospective cohort of youth. MethodFrom October 2005 to November 2010, data were collected from the At Risk Youth Study (ARYS), a prospective cohort study of street-involved youth in Vancouver, Canada. Inclusion criteria were age 14–26years, no lifetime drug injection, and non-injection drug use in the month preceding enrollment. Participants were interviewed at baseline and semiannually thereafter. Cox regression was employed to identify risk factors for initiating injection. ResultsAmong 395 injection-naïve youth, 81 (20.5%) reported childhood sexual abuse. During a median follow-up of 15.9months (total follow-up 606.6 person-years), 45 (11.4%) youth initiated injection drug use, resulting in an incidence density of 7.4 per 100 person-years. In univariate analyses, childhood sexual abuse was associated with increased risk of initiating injection (unadjusted hazard ratio [HR], 2.38; 95% confidence interval [CI], 1.29–4.38; p=0.006), an effect that persisted in multivariate analysis despite adjustment for gender, age, aboriginal ancestry and recent non-injection drug use (adjusted HR, 2.71; 95% CI, 1.42–5.20; p=0.003). ConclusionChildhood sexual abuse places drug users at risk for initiating injection. Addiction treatment programs should incorporate services for survivors of childhood maltreatment.

Risk Factors for HIV and Unprotected Anal Intercourse among Men Who Have Sex with Men (MSM) in Almaty, Kazakhstan

IntroductionMen who have sex with men (MSM) are at high risk for HIV infection. MSM in Central Asia, however, are not adequately studied to assess their risk of HIV transmission. Methods: This study used respondent driven sampling methods to recruit 400 MSM in Almaty, the largest city in Kazakhstan, into a cross-sectional study. Participation involved a one-time interviewer-administered questionnaire and rapid HIV screening test. Prevalence data were adjusted for respondent network size and recruitment patterns. Multivariate logistic regression was used to investigate the association between HIV and selected risk factors, and unprotected anal intercourse (UAI) and selected risk factors.ResultsAfter respondent driven sampling (RDS) weighted analysis, 20.2% of MSM were HIV-positive, and 69.0% had unprotected sex with at least one male partner in the last 12 months. Regression analysis showed that HIV infection was associated with unprotected receptive anal sex (AOR: 2.00; 95% CI: 1.04–3.84). Having unprotected anal intercourse with male partners, a measure of HIV risk behaviors, was associated with being single (AOR: 0.38; 95% CI: 0.23–0.64); very difficult access to lubricants (AOR: 11.08; 95% CI: 4.93–24.91); STI symptoms (AOR: 3.45; 95% CI: 1.42–8.40); transactional sex (AOR: 3.21; 95% CI: 1.66–6.22); and non-injection drug use (AOR: 3.10; 95% CI: 1.51–6.36).ConclusionsThis study found a high HIV prevalence among MSM in Almaty, and a population of MSM engaging in multiple high-risk behavior in Almaty. Greater access to HIV education and prevention interventions is needed to limit the HIV epidemic among MSM in Almaty.