Non-injection Users Research Articles

Commentary: Can mortality rates among adult antiretroviral therapy patients in Europe reach levels similar to those experienced in the general population?

Since 1996, widespread availability of combination antiretroviral therapy (ART) has significantly improved survival of HIV-infected persons in industrialized countries. This has prompted researchers in Europe and North America to investigate whether mortality among HIV-infected persons receiving ART might reach levels similar to those in the general population. In this paper by Lewden et al., more than 80 000 patients from 31 European countries are included in an analysis to estimate crude ART patient mortality rates for persons 518 years of age, who initiated ART during 1998–2008, had a known gender and date of birth, known baseline CD4þ T-cell (CD4) count, and 51 follow-up visit. The standardized mortality ratio (SMR) is used to compare mortality between ART patients and the general population. The SMR is the ratio of the observed number of deaths in the ART cohorts to the expected number of deaths if ART cohorts had experienced general population country-, calendar-year-, gender-, and age-specific mortality. SMRs were estimated using random effects Poisson models, adjusted for age, gender, HIV transmission group and history of AIDS at ART start. The overall ART patient mortality rate of 1.2 per 100 person years (PY) is similar to that recently reported for 13 cohorts from nine countries in Europe and North America (0.95/100 PY for the period 2001– 2009) and 23 cohorts from 10 European countries, Australia and Canada (0.86/100 PY for the period 2004–2006), supporting previous estimates that average annual risk of death for ART patients has declined since 1996–2001, when estimates of about 3/100 PY were reported. The authors were specifically interested in assessing whether ART patient mortality could reach levels similar to those experienced in the general population, if ART patients achieved and maintained CD4 counts 5500/mm. This article builds on previous work by Lewden et al. in 2007, which reported that ART patients in a French cohort, who maintained CD4 counts 5500/mm, had mortality rates similar to those of the general population 6 years after ART start. In this analysis, only certain subgroups of patients who achieved CD4 counts 5500/mm reached mortality rates similar to those observed in the general population. First, among all male ART patients, who achieved and maintained a CD4 count 5500/mm for 53 years, mortality was similar to that of males in the general population [SMR 1.0, 95% confidence interval (CI) 0.8–1.4]. In contrast, mortality among all female ART patients, who achieved a CD4 count 5500/mm, was always higher than that of females in the general population, even after 5 years with a CD4 count 5500/mm. Higher SMRs among females compared with males has been documented in other studies. Authors suggest that differences in the prevalence of low socio-economic status (SES) and/ or smoking between HIV-infected and uninfected persons may be more pronounced for females than males and this might explain the higher SMRs for females. Adjustment of SMRs for SES indicators and smoking burden, variables not available to authors for this analysis, would be needed to further investigate SMR differences by sex. Secondly, among the subgroup of non-injection drug users (non-IDUs) with a CD4 count 5500/mm, males immediately on achieving this CD4 threshold (SMR 0.9, 95% CI 0.7–1.2), and females after 3 years in this CD4 stratum (SMR 1.1, 95% CI 0.7–1.7), had similar mortality rates to those in the Published by Oxford University Press on behalf of the International Epidemiological Association 2012. International Journal of Epidemiology 2012;1–2

Hepatitis C virus‐specific immune responses in noninjecting drug users

Noninjection drug use, although recognized as an emerging risk factor for acquisition of other blood-born pathogens, is still unconfirmed as a route of hepatitis C virus (HCV) transmission. Our goal was to measure HCV exposure and prevalence in noninjection drug users (NIDUs). Fifty-seven NIDUs were screened by extensive questionnaire to exclude prior injection drug use and evaluated for HCV-specific serologic and cellular immune responses. HCV-specific T-cell responses were measured using interferon-gamma (IFN-γ) enzyme-linked immunospot (ELISpot) assay with overlapping HCV peptides covering the entire HCV genome. Fifteen individuals who never used illicit drugs served as negative controls. Eleven people with no history of injecting drug use (19.3%) were HCV seropositive: seven with chronic HCV infection and four with previously resolved infection. Of 51 NIDUs with ELISpot results, HCV-specific cellular immunity was detected in 5 (9.8%). These responses were relatively weak and narrow. We did not find significant associations between HCV-specific immune responses and noninjection drug use practices. Subjects with HCV-specific immunity, however, were significantly more likely to have bought sex in the past 6 months, to have had more casual partners of the opposite sex in the last 6 months, and those partners were more likely to have ever injected drugs compared to subjects without HCV-specific immunity. In summary, we found serologic or cellular HCV-specific immune responses in 27.5% of NIDUs. Our results suggest that sexual behaviour associated with noninjection drug use might be a risk factor for HCV acquisition. Additional studies are needed to precisely determine the practices that lead to HCV exposure among this population.

Problem recognition, intention to stop use, and treatment use among regular heroin injectors

This study investigated frequency of recent use as an explanatory variable in problem recognition and intention to stop use among regular injection heroin users. Data from the NEURO-HIV Epidemiologic Study, an investigation of neuropsychological and social–behavioral risk factors for HIV and hepatitis A, B, and C among injection and noninjection drug users, were used in the analyses. Participants (N = 337) consisted of those who reported injecting heroin daily or nearly daily for a period of 3 months. Multiple linear regression analysis revealed that frequency of recent injection drug use predicted problem recognition (β = .17), but not intention to stop use; although marginal, being female (β = .15), and homeless (β = .14) contributed to intention to stop use. Past 6-month treatment participation was 48%, and current treatment enrollment was 26% among study participants. This study highlights the importance of capitalizing on injection drug users' recent use as a mechanism for treatment interventions.

Prevalence of Human Immunodeficiency Virus (HIV), Risk Behavior, and Recent Substance Use in a Sample of Urban Drug Users: Findings by Race and Sex

The aim of the current study was to examine the prevalence of HIV, past six-month illicit drug use, and risk behaviors among a population of heavy drug users living in an urban setting. Although many studies investigate substance use, sex-risk behavior, and HIV by race and gender, no studies have examined these variables simultaneously. The current study seeks to fill this gap in the literature by exploring HIV prevalence among a predominantly heterosexual sample of recent substance users by injection drug use (IDU) status, race, and sex. Baseline data from the Baltimore site of the NEURO-HIV epidemiologic study was used in this study. This study examines neuropsychological and social-behavioral risk factors of HIV, hepatitis A, hepatitis B, and hepatitis C among both injection and non-injection drug users. Descriptive statistics and chi-square statistics were used in data analyses. Blood and urine samples were obtained to test for the presence of recent drug use, viral hepatitis, HIV, and other sexually transmitted diseases (STDs). Findings presented here have several important implications for HIV prevention and care among substance users. Intervention programs that incorporate substance use treatment in addition to HIV education, particularly with respect to substance use and sex risk behavior are imperative.

Non-injection drug use and hepatitis C among drug treatment clients in west central Mexico

BackgroundResearch on hepatitis C virus (HCV) prevalence among non-injecting drug treatment clients in the United States, Europe and Asia indicate substantial differences by place. To date, little or no research on HCV and non-injection drug use (NIDU) has been conducted in Mexico. MethodsWe examined the prevalence of HCV, hepatitis B virus (HBV), and HIV among non-injecting drug users (NIDUs) in community-based drug treatment (N=122) and NIDUs in a prison-based drug treatment program (N=30), both located in west central Mexico. ResultsAmong the community clients, prevalence was 4.1% (95% confidence interval [CI]: 1.8–9.2) for HCV, 5.7% for HBV (95% CI: 2.8–11.4), and 1.6% for HIV (95% CI: 0.4–5.8). Among the in-prison clients, prevalence was 40.0% (95% CI: 24.6–57.7) for HCV, 20.0% for HBV (95% CI: 9.5–37.3), and 6.7% for HIV (95% CI: 1.9–21.3). None of the clients were aware of being infected. ConclusionThe HCV prevalence found for the NIDU community treatment clients ranks among the lower HCV estimates published for NIDUs in treatment to date. The prevalence found for the in-prison clients ranks among the higher, raising a concern of possible elevated HCV infection among NIDUs in the west central Mexico prison—one compounded by the finding that none of this study's clients knew they were HCV positive.

Role of Sexual Transmission of HIV Among Young Noninjection and Injection Opiate Users: A Respondent-Driven Sampling Study

Sexual transmissibility of HIV among young drug users in China has been investigated in few studies. The objective of this study was to examine the role of sexual transmission on HIV infection among injection drug users (IDUs) and noninjection drug users (NIDUs). Respondent-driven sampling (RDS) was used to recruit 426 young heroin/opium drug users in Yunnan, China. Logistic regression modeling was performed to examine interrelationships among risky sexual behaviors, drug-use modes, and drug-use practices. Substantial proportions of NIDUs and IDUs reported engagement in risky sexual behaviors including: (1) multiple sexual partners (42% of NIDUs vs. 37% of IDUs), (2) concurrent sexual partnerships (48% vs. 46%), (3) commercial sex partners (23% vs. 24%), and sex partners who were NIDUs (14% vs. 17%). Both NIDUs and IDUs reported low levels of condom use with nonregular partners (48% vs. 42%) and regular partner (24% vs. 27%), and having a history of recent methamphetamine use (21% vs. 18%). Compared to IDUs, NIDUs reported having had fewer sex partners who were IDUs, fewer IDU network peers, more NIDU network peers, and having lower levels of HIV knowledge and self-perceived HIV risk. Generalization of the HIV epidemic from high-risk groups to the general population may be driven by risky sexual behavior among drug users. Reducing sexual transmission of HIV among both IDUs and NIDUs is the next major challenge for HIV intervention among drug users in China.

Early onset of drug and polysubstance use as predictors of injection drug use among adult drug users

Early onset of alcohol, marijuana, and cigarette use is an indicator of later substance use problems in adulthood such as alcohol or other drug dependence. This paper seeks to address the association between early onset alcohol, marijuana, cigarette, and polysubstance use with injection drug use among recent illicit drug users. The current study used baseline data from the Baltimore site of the NEURO-HIV Epidemiologic Study, an investigation of neuropsychological and social–behavioral risk factors of HIV, hepatitis A, hepatitis B, and Hepatitis C among both injection and non-injection drug users in Baltimore, Maryland. The present study used a subset (N=651) of the larger parent study that identified as White or Black, and reported any drug use in the past 6months. In the full sample slightly more than half (52.5%) of study participants were IDUs. IDUs differed from non-IDUs on age of initiation for cigarettes, marijuana, and alcohol, with IDUs initiating the use of all three substances significantly earlier than non-IDUs. IDUs also had significantly greater proportions of early onset of alcohol (χ2=19.71, p<.01), cigarette (χ2=11.05, p<.01), marijuana (χ2=10.83, p<.01), and polysubstance use (χ2=23.48, p<.01) than non-IDUs. After adjusting for age, gender, and race/ethnicity, only participants identified as early onset alcohol users (AOR=1.47, 95% CI: 1.00–2.18) and early onset polysubstance users (AOR=1.62, 95% CI: 1.10–2.38) were more likely to have IDU status than those who reported initiating substance use later. IDU status was then stratified by race/ethnicity. After controlling for age and gender, only early polysubstance use was a significant predictor of IDU status for Whites (AOR=2.06, 95% CI: 1.07–3.93). Consistent with literature on early substance initiation and later illicit substance use, early onset of alcohol and polysubstance use is an important risk factor for IDU in adulthood.

Latent classes of heroin and cocaine users predict unique HIV/HCV risk factors

BackgroundPatterns of heroin and cocaine use vary and may be associated with unique risk factors for bloodborne infections. MethodsLatent class analysis identified sub-populations of 552 heroin and cocaine users in Baltimore, Maryland. Using latent class regression, these classes were analyzed for associations with demographic characteristics, risky behaviors, Hepatitis C, and HIV. ResultsThree classes were found: Crack/Nasal-Heroin users (43.5%), Polysubstance users (34.8%), and Heroin Injectors (21.8%). Compared to Polysubstance users, Crack/Nasal-Heroin users were almost 7 times more likely to identify as Black (OR=6.97, 95% CI=4.35–11.2). Sharing needles was over 2.5 times more likely among Polysubstance users than among Heroin Injectors (OR=2.66, 95% CI=1.49–4.75). Crack/Nasal-Heroin users were 2.5 times more likely than Polysubstance users to exchange drugs for sex (OR=2.50, 95% CI=1.22–5.13). Crack/Nasal-Heroin users were less likely than Heroin Injectors to have Hepatitis C (OR=0.10, 95% CI=0.06–0.18), but no significant differences were found for HIV. ConclusionsSubpopulations of cocaine and heroin users differed in demographic classifications, HIV-risk behaviors, and Hepatitis C infection. All subpopulations included substantial numbers of HIV-positive individuals. Findings provide further evidence that non-injection drug users face significant infectious disease risk.

Prevention of mother-to-child transmission of human immunodeficiency virus among pregnant women using injecting drugs in Ukraine, 2000-10.

AimsTo compare clinical status, mother-to-child transmission (MTCT) rates, use of prevention of (PMTCT) interventions and pregnancy outcomes between HIV-infected injecting drug users (IDUs) and non-IDUs.Design and settingProspective cohort study conducted in seven human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) Centres in Ukraine, 2000–10.ParticipantsPregnant HIV-infected women, identified before/during pregnancy or intrapartum, and their live-born infants (n = 6200); 1028 women followed post-partum.MeasurementsMaternal and delivery characteristics, PMTCT prophylaxis, MTCT rates, preterm delivery (PTD) and low birth weight (LBW).FindingsOf 6200 women, 1111 (18%) reported current/previous IDU. The proportion of IDUs diagnosed with HIV before conception increased from 31% in 2000/01 to 60% in 2008/09 (P < 0.01). Among women with undiagnosed HIV at conception, 20% of IDUs were diagnosed intrapartum versus 4% of non-IDUs (P < 0.01). At enrolment, 14% of IDUs had severe/advanced HIV symptoms versus 6% of non-IDUs (P < 0.001). IDUs had higher rates of PTD and LBW infants than non-IDUs, respectively, 16% versus 7% and 22% versus 10% (P < 0.001). IDUs were more likely to receive no neonatal or intrapartum PMTCT prophylaxis compared with non-IDUs (OR 2.81, p < 0.001). MTCT rates were 10.8% in IDUs versus 5.9% in non-IDUs; IDUs had increased MTCT risk (adjusted odds ratio 1.32, P = 0.049). Fewer IDUs with treatment indications received HAART compared with non-IDUs (58% versus 68%, P = 0.03).ConclusionsPregnant human immunodeficiency virus-infected injecting drug users in Ukraine have worse clinical status, poorer access to prevention of mother-to-child transmission prophylaxis and highly active antiretroviral therapy, more adverse pregnancy outcomes and higher risk of mother-to-child transmission than non-injecting drug user women.

Commentary for Li et al., "Sexual transmissibility of HIV among opiates users with concurrent sexual partnerships: An egocentric network study in Yunnan, China."

It has now been 30 years since the Centers for Disease Control and Prevention reported the first case of HIV. In that time, tremendous advances have been made in HIV treatments, care, testing, and prevention. Today, all people of economic means and many without such means have access to life saving HIV treatments. Further, HIV prevention education and practical prevention tools like condoms and sterile syringes are increasingly available. Yet, between 2 and 3 million people will become HIV positive this year, mostly due to unprotected sexual contact. As Li and colleagues remind us, sexual risk is an important component of the HIV epidemic among injection and non-injection drug users.(1) In fact, as early as ten years ago, HIV incidence studies among injection drug users (IDUs) found sex behaviors to be an important independent predictor of seroconversion. (2–4) Further, Li and colleagues highlight the role that multiple concurrent sexual partnerships, particularly in the connection with drug use, can play in the spread of HIV.(1) At the same time, it is hard not to be struck by the clinical terminology and limited approach that characterize much of the research on HIV-related sex risk. It is as though none of us researchers have ever had sex. An important next step in building a more sophisticated, dare we say “real,” approach to sex risk is to consider not merely the sexual preferences and positioning (i.e., tops or bottoms), nor the temporal overlap and sequencing of sexual partners, but to capture the motivations and contexts for this most fundamental human behavior. Important highlights of such an approach include documenting, quantitatively and qualitatively, by partner, the socio-emotional (including intimacy, desire, and pleasure), biological and developmental, economic, and situational factors that drive consensual sexual decision making and behaviors. Recent efforts at the US Centers for Disease Control and Prevention (CDC) and elsewhere in the area of sexual health are speaking to the increased awareness of the need to approach HIV-related sexual risk within a broader and more comprehensive framework.(5, 6) Research on HIV risk and infection among drug users would certainly benefit from this more inclusive and multifaceted approach. An important outcome of this new research must be better targeting of individuals, couples, and groups with interventions that are sensitive and responsive to both limits and opportunities for change within varied sexual relationships as called for by Li and colleagues among others.(1, 7, 8) But it must also include consideration of other social forces that contribute to risk and inhibit protective behaviors as they relate to sex risk among drug users such as economic and social support, law enforcement activities, gender relations, and the multitude of other structural forces that increase sexual risk among drug users. One area where this latter approach has shown promise is in interventions that address the context of sex behavior and risk. Such interventions have been developed most commonly with sex workers, and recognize the complex interplay of economic need, gender norms, sexual desire and pleasure, trust and intimacy, violence, stigma and other factors in which sex work is embedded. (9, 10) A prime example is the Songachi Project -- a successful HIV-prevention intervention that took a comprehensive, rights-based, multilevel approach with sex workers in India. The Songachi Project created a peer education program; offered literacy training (recognizing that education components would not work if women could not read materials); established high level advocates for sex workers; addressed economic barriers (set up a loan program from which sex workers could borrow money in financial crisis situations so that they were not tempted to skip condom use in order to be paid more) and other environmental barriers (e.g., selling condoms rather than giving them away to increase perceived value); changed social relationships not only among sex workers but also between sex workers and key powerful community members, and; built individual HIV/STI prevention and treatment skills.(11) Recent global trends indicate: (1) the continued spread of injection drug use, (12) (2) the increased availability and use of stimulant drugs such as methamphetamine that are likely to lead to an escalation in sex related HIV risk among drug users, (13) and (3) the continued need for more and better HIV prevention intervention and strategies for injecting drug using populations. (14) Moving forward, HIV prevention efforts among drug using populations must focus on sex risk and involve interventions and strategies that address the range of motivations and context of sexual behavior, from those that arise for intimate and emotional factors to those that occur in sex work. And while promising models exist for the latter type of sex risk, new models and approaches are urgently needed to address the much more common sex risk that arise from the human needs for affection, support, child bearing, and physical pleasure among drug using populations.

A Simple New Method to Triangulate Self-Reported Risk Behavior Data—The Bean Method

Human immunodeficiency virus (HIV)/sexually transmitted disease (STD)-related interventions rely on self-reported risk behavioral data, which are biased toward social desirability. It is warranted to develop methods for data triangulation. Some questions on HIV/STD-related behaviors that were asked in 5 face-to-face (FTF) surveys were repeated at the end of the surveys, using the newly developed bean method (BM), which requested participants to transfer a bean of a particular color from a large jar to a smaller one, depending on whether the answer was affirmative (yellow, white, green, or red) or not (black); both jars contained 500 mixed-up colored beans. At the end of each day, the number of beans for each color was counted and was compared with the results of the FTF interviews. Participants were ensured that the researchers would not trace their responses. Among female sex workers who were noninjecting drug users, the BM as compared with the FTF interviews, reported higher prevalence of inconsistent condom use in the last 6 months, unprotected sex with the last client, and STD in the last 6 months. Among men who have sex with men in Hong Kong, the BM as compared to the FTF interviews, reported higher prevalence of unprotected sex with another man and having >3 sex partners in the last 12 months. No statistically significant between-method differences were reported among injecting drug users. Results of HIV/STD-related behaviors are dependent on mode of data collection. The simple BM can be used regularly to triangulate self-reported HIV-related behavioral data obtained from FTF interviews.

Comparison of Abacavir/Lamivudine and Tenofovir/Emtricitabine Among Treatment-Naive HIV-Infected Patients Initiating Therapy

Controversy about the relative performance of abacavir (ABC)/lamivudine (3TC) and tenofovir (TDF)/emtricitabine (FTC) in initial combination antiretroviral therapy (cART) exists. We compared the times to regimen failure (composite of virologic failure or switching/stopping nucleosides for any reason) according to nucleoside backbone in treatment-naive patients starting cART in a retrospective observational cohort study. Additional endpoints included virologic failure, switching/stopping nucleosides for nonvirologic reasons, and virologic suppression. Treatment-naive noninjection drug user individuals in the Canadian Observational Cohort initiating ABC/3TC-containing or TDF/FTC-containing cART with efavirenz, nevirapine, lopinavir/ritonavir, or atazanavir/ritonavir with ≥6 months follow-up were included. Multivariable proportional hazards regression models accounting for competing risks were used to model outcomes. One thousand seven hundred sixty-four individuals (588 ABC/3TC, 1176 TDF/FTC) were included. Median (interquartile range) follow-up times were 34 (23-50) and 20 (13-30) months, respectively. Time to regimen failure was similar for ABC/3TC versus TDF/FTC [adjusted hazard ratio, (aHR) = 0.96, 95% CI = 0.80 to 1.17] after adjusting for baseline viral load (VL), sex, province, third antiretroviral agent, year of cART initiation, HLA-B*5701 test availability, and rate of VL testing. No differences were observed in time to virologic failure (aHR = 0.84, 95% CI = 0.58 to 1.20), switching/stopping nucleosides for nonvirologic reasons (aHR = 1.02, 95% CI = 0.81 to 1.28), or virologic suppression (aHR = 0.96, 95% CI = 0.83 to 1.10). There was no statistical interaction between backbone and baseline VL for any outcome. Results were similar when stratified by baseline VL ≤ 100,000 or > 100,000 copies per milliliter. In our naive noninjection drug user HIV-infected patients starting cART, there was no difference in time to regimen failure, virologic failure, switching/stopping nucleosides, or virologic suppression with ABC/3TC versus TDF/FTC.

Comparing Injection and Non-Injection Routes of Administration for Heroin, Methamphetamine, and Cocaine Users in the United States

ABSTRACT Research examining the demographic and substance use characteristics of illicit drug use in the United States has typically failed to consider differences in routes of administration or has exclusively focused on a single route of administration—injection drug use. Data from National Survey on Drug Use and Health were used to compare past-year injection drug users and non-injection drug users' routes of administration of those who use the three drugs most commonly injected in the United States: heroin, methamphetamine, and cocaine. Injection drug users were more likely than those using drugs via other routes to be older (aged 35 and older), unemployed, possess less than a high school education, and reside in rural areas. IDUs also exhibited higher rates of abuse/dependence, perceived need for substance abuse treatment, and co-occurring physical and psychological problems. Fewer differences between IDUs and non-IDUs were observed for heroin users compared with methamphetamine or cocaine users.

Determinants of health-related quality of life in adults living with HIV in Vietnam

Health-related quality of life (HRQL) is a good indicator to monitor and evaluate healthcare services for adults with HIV/AIDS. This study described HRQL of adults with HIV and its determinants, and compared it with HRQL for the general population. A cross-sectional study with a national multistage sampling of households with and without HIV-positive people was conducted in 2008. Six provinces were purposively selected to represent areas of the country and progressions of HIV epidemics. Households were sampled with probability-proportional-to-size, following the selection of rural and urban districts. A total of 820 HIV-positive and HIV-negative adults (mean age: 32.5; 38.7% female) were interviewed. Among 400 HIV-positive people, 52.3% had a history of injecting drugs, and 56.3% were at AIDS stage and receiving antiretroviral treatment (ART). HRQL was measured using the EuroQOL five-dimension questionnaire (EQ-5D). Multiple regression models were purposefully constructed to examine the determinants of HRQL. The EQ-5D index and visual analog scale (VAS) score in less advanced HIV people (0.90, 69.3) and AIDS patients (0.88, 65.2) were significantly lower than those of the general population (0.96, 81.6) (p<0.001). The frequency of reported problems across EQ-5D dimensions in the HIV population (2.4–30.9%) was significantly higher than in the general population (0.7–12.1%). Compared to ART patients, those at earlier HIV stages reported having problems at similar proportions across four HRQL dimensions, except pain/discomfort, where ART patients had a significantly higher proportion. Injecting drug users taking ART perceived lower HRQL score than non-injecting drug users. Multiple regression determined that joblessness (p<0.01) and inaccessibility to health services (p<0.05) were associated with lower HRQL. In addition, involvements in self-help groups significantly improved HRQL among HIV-positive participants (p<0.05). The findings highlight the need to improve the health service referral system and enhance psychological and social supports for patients in early stages of HIV infection in Vietnam.

Factors related to past HIV testing among South African non-injection drug users

South Africa has some of the highest estimates of human immunodeficiency virus (HIV) in the world, with a prevalence of 21.5%. Despite this, based on population-level data, 39% of sexually active South Africans have never been tested for HIV. Non-injection drug users (NIDUs) are a high-risk and increasingly prevalent group in South Africa. However, few studies have examined HIV test utilization among high-risk groups such as drug users in South Africa. The study was conducted in Pretoria, South Africa between 2002 and 2006. Of the 382 individuals surveyed, 31% had been tested for HIV in the past. Results indicate that females and older individuals were significantly more likely to have been tested for HIV at some point in the past, while individuals who did not know someone with HIV/AIDS as well as individuals who are unsure of their risk of HIV infection were significantly less likely to have ever accessed testing. Identification of these subgroups has implications for the development of targeted interventions to promote greater HIV testing among at-risk groups in South Africa.

Sexual transmissibility of HIV among opiate users with concurrent sexual partnerships: an egocentric network study in Yunnan, China

To investigate the patterns of concurrent sexual partnerships among young opiate users and sexual transmissibility of human immunodeficiency virus (HIV) in concurrent sexual partnerships in drug-use and sexual networks. Cross-sectional design. A total of 426 young opiate users in Yunnan, China. Young opiate users recruited from their network ties. Respondent-driven sampling (RDS) was used to recruit participants. Multiple logistic regressions were performed to analyze the relationships of concurrent sexual partnerships with egocentric social network components, risky sexual behavior for HIV and drug-use practices. The RDS-adjusted prevalence of concurrent sexual partners was 42.9% among opiate users. Opiate users with concurrent sexual partnerships were more likely to engage in risky HIV-related sexual behavior, compared to those without. Specifically, they were more likely to report having had four or more sexual partners (26.3% versus 2.0%), having had a spouse or boy/girlfriends who also had concurrent sexual partnerships (28.1% versus 8.2%), having exchanged drug for sex (12.4% versus 3.8%), having had sexual partners who were non-injection drug users (22.6% versus 10.1%), having had sexual partners who were injection drug users (25.3% versus 13.5%) and having used club drugs (26.3% versus 13.5%). There were no significant differences in consistent condom use between opiate users with sexual concurrency and those without. The same proportion (25.8%) of opiate users in the two groups reported having consistently used condoms when having sex with regular partners, and 46.3% of opiate users with sexual concurrency and 36.4% of those without such concurrency consistently used condoms with non-regular partners. The expansion of the human immunodeficiency virus epidemic from high-risk populations to the general population in China may be driven by concurrent sexual partnerships. Behavioral interventions targeting safer sex should be integrated into harm reduction programmes.

HIV prevalence and sexual risk behaviour among non-injection drug users in Tijuana, Mexico

Prior studies estimate HIV prevalence of 4% among injection drug users (IDUs), compared with 0.8% in the general population of Tijuana, Mexico. However, data on HIV prevalence and correlates among non-injecting drug users (NIDUs) are sparse. Individuals were recruited through street outreach for HIV testing and behavioural risk assessment interviews to estimate HIV prevalence and identify associated sexual risk behaviours among NIDUs in Tijuana. Descriptive statistics were used to characterise ‘low-risk’ NIDUs (drug users who were not commercial sex workers or men who have sex with men). Results showed that HIV prevalence was 3.7% among low-risk NIDUs. During the prior six months, 52% of NIDUs reported having >1 casual partner; 35% reported always using condoms with a casual partner; and 13% and 15%, respectively, reported giving or receiving something in exchange for sex. Women were significantly more likely than men to have unprotected sex with an IDU (p<0.01). Conclusions: The finding that HIV prevalence among NIDUs was similar to that of IDUs suggests that HIV transmission has occurred outside of traditional core groups in Tijuana. Broad interventions including HIV testing, condom promotion and sexual risk reduction should be offered to all drug users in Tijuana.

Mortality by causes in HIV-infected adults: comparison with the general population

BackgroundWe compared mortality by cause of death in HIV-infected adults in the era of combined antiretroviral therapy with mortality in the general population in the same age and sex groups.MethodsMortality by cause of death was analyzed for the period 1999-2006 in the cohort of persons aged 20-59 years diagnosed with HIV infection and residing in Navarre (Spain). This was compared with mortality from the same causes in the general population of the same age and sex using standardized mortality ratios (SMR).ResultsThere were 210 deaths among 1145 persons diagnosed with HIV (29.5 per 1000 person-years). About 50% of these deaths were from AIDS. Persons diagnosed with HIV infection had exceeded all-cause mortality (SMR 14.0, 95% CI 12.2 to 16.1) and non-AIDS mortality (SMR 6.9, 5.7 to 8.5). The analysis showed excess mortality from hepatic disease (SMR 69.0, 48.1 to 78.6), drug overdose or addiction (SMR 46.0, 29.2 to 69.0), suicide (SMR 9.6, 3.8 to 19.7), cancer (SMR 3.2, 1.8 to 5.1) and cardiovascular disease (SMR 3.1, 1.3 to 6.1). Mortality in HIV-infected intravenous drug users did not change significantly between the periods 1999-2002 and 2003-2006, but it declined by 56% in non-injecting drug users (P = 0.007).ConclusionsPersons with HIV infection continue to have considerable excess mortality despite the availability of effective antiretroviral treatments. However, excess mortality in the HIV patients has declined since these treatments were introduced, especially in persons without a history of intravenous drug use.

Harm reduction intensity—Its role in HAART adherence amongst drug users in Amsterdam

BackgroundOpioid substitution treatment seems to improve adherence to highly active antiretroviral therapy (HAART) in drug users (DU). DU in Amsterdam receive methadone within a harm reduction programme. We hypothesized that not only receiving methadone, but joining this complete comprehensive programme would improve HAART adherence. MethodsIncluded were 102 HIV-positive DU attending the Amsterdam Cohort Study (ACS), reporting HAART use at multiple visits between 1999 and 2009. Non-adherence was defined as taking less than 95% of medication in the past 6 months (self-reported). Harm reduction intensity (HR) was measured by combining injecting drug use, methadone dosage and needle exchange, in different levels of participation, ranging from no/incomplete HR, complete HR to low or no dependence on HR. We studied the association between non-adherence and harm reduction intensities with logistic regression models adjusted for repeated measurements. ResultsNon-adherence was reported in 11.9% of ACS visits. Non-injecting DU with low dependence on HR were less adherent than DU with complete HR (aOR 1.78; CI 95% 1.00–3.16), although there was no overall effect of HR. No difference was demonstrated in adherence between DU with complete HR and incomplete HR. Unsupervised housing (no access to structural support at home) (aOR 2.58; CI 95% 1.40–4.73) and having a steady partner (aOR 0.48; CI 95% 0.24–0.96) were significantly associated with respectively more and less non-adherence. ConclusionsIn Amsterdam, still-injecting DU who are exposed to systematic and integrated care, although not practising complete harm reduction, can be just as adherent to HAART as DU who make use of complete harm reduction and non-injecting DU with no dependence on harm reduction. These findings suggest the importance of a systematic and comprehensive support system including supervised housing and social and medical support to increase HAART adherence rates amongst all HIV-infected DU. When such programmes are introduced in settings where injecting drug use is highly prevalent, access to HAART for drug users in these settings can and should be increased.

The relationship between injection and noninjection drug use and HIV disease progression

Background Injection drug use is associated with poor HIV outcomes even among persons receiving highly active antiretroviral therapy (HAART), but there are limited data on the relationship between noninjection drug use and HIV disease progression. Methods We conducted an observational study of HIV-infected persons entering care between January 1, 1999, and December 31, 2004, with follow-up through December 31, 2005. Results There were 1,712 persons in the study cohort: 262 with a history of injection drug use, 785 with a history of noninjection drug use, and 665 with no history of drug use; 56% were White, and 24% were females. Median follow-up was 2.1 years, 33% had HAART prior to first visit, 40% initiated first HAART during the study period, and 306 (17.9%) had an AIDS-defining event or died. Adjusting for gender, age, race, prior antiretroviral use, CD4 cell count, and HIV-1 RNA, patients with a history of injection drug use were more likely to advance to AIDS or death than nonusers (adjusted hazard ratio [HR] = 1.97, 95% confidence interval [CI] = 1.43–2.70, p < .01). There was no statistically significant difference of disease progression between noninjection drug users and nonusers (HR = 1.19, 95% CI = 0.92–1.56, p = .19). An analysis among the subgroup who initiated their first HAART during the study period ( n = 687) showed a similar pattern (injection drug users: HR = 1.83, 95% CI = 1.09–3.06, p = .02; noninjection drug users: HR = 1.21, 95% CI = 0.81–1.80, p = .35). Seventy-four patients had active injection drug use during the study period, 768 active noninjection drug use, and 870 no substance use. Analyses based on active drug use during the study period did not substantially differ from those based on history of drug use. Conclusions This study shows no relationship between noninjection drug use and HIV disease progression. This study is limited by using history of drug use and combining different types of drugs. Further studies ascertaining specific type and extent of noninjection drug use prospectively, and with longer follow-up, are needed.