People Who Inject Drugs Programs Research Articles

Incidence and molecular epidemiology of hepatitis C virus reinfection in prisons in Catalonia, Spain (Re-HCV study)

Hepatitis C virus (HCV) reinfection may hamper HCV elimination in prisons. We aimed to (i) determine the reinfection rate in people treated for HCV in Catalan prisons, (ii) measure reinfection in people entering prisons, and (iii) characterize the molecular epidemiology of HCV in prisons and people who inject drugs (PWID) in the community. Re-HCV was a prospective study in eight prisons (2019–2020) including two groups: (1) people cured with treatment in prison and followed-up every 6 months, and (2) people testing HCV-RNA positive at incarceration. Bio-behavioral data were collected. HCV isolates were sequenced and phylogenetically analyzed with those of PWID in the community. Reinfection follow-up after treatment was achieved in 97 individuals (103.05 person-years). Two reinfections were detected, resulting in an incidence ≤ 10/100 person-years. Among people entering prison, 2% (359/17,732) were viremic, of which 334 (93.0%) were included, and 44 (13.5%) presented with reinfection (84.7% being PWID). Frequently, HCV isolates in prisons and PWID in the community were phylogenetically related. Although HCV reinfection is low after treatment, it is common in people entering Catalan prisons. To maintain a low HCV prevalence in prisons, harm-reduction services and test-and-treat programs for PWID should be strengthened both inside and outside prisons.

Prevalence, risk factors, treatment uptake and treatment outcome of hepatitis C virus in people who inject drugs at the needle and syringe program in Uppsala, Sweden

BackgroundThe World Health Organization has set a goal to reach world elimination of hepatitis C virus (HCV) by 2030. Needle and syringe programs (NSP) for people who inject drugs (PWID) are crucial to achieve this goal. The NSP in Uppsala, Sweden, was opened in 2016 and has since 2018 provided HCV treatment for PWID. The aim of this study was to investigate HCV prevalence, risk factors and treatment uptake and outcome in NSP participants.MethodsData from 450 PWID registered at the Uppsala NSP between 2016-11-01 and 2021-12-31 were collected from the national quality registry InfCare NSP. Data from the 101 PWID treated for HCV at the Uppsala NSP were collected through patient journal review. Descriptive and inferential analysis was performed. Ethical approval was obtained from the Ethical Review Board in Uppsala (dnr 2019/00215).ResultsThe mean age was 35 years. 75% were males (336/450), and 25% were females (114/450). The overall HCV prevalence was 48% (215/450) with a declining trend over time. Factors associated with a higher risk of HCV were older age at registration (OR 1.025, 95% CI 1.004–1.046), lower age at injection drug debut (OR 0.963, 95% CI 0.932–0.996), lower education level (OR 1.829, 95% CI 1.185–2.821) and higher number of total visits at the NSP (OR 1.005, 95% CI 1.001–1.009). The overall HCV treatment uptake was 47% (101/215), of which 77% (78/101) completed HCV treatment. The HCV treatment compliance was 88% (78/89). 99% (77/78) were cured with a sustained virologic response 12 weeks after completed treatment. The reinfection rate over the study period was 9/77 (11.7%); all were male with mean age of 36.ConclusionsHCV prevalence, treatment uptake and treatment outcome have improved since the opening of the Uppsala NSP. However, further measures are needed to reach the HCV elimination goal. Outreach HCV treatment programs for PWID should be explored and evaluated in combination with further implementation of low-threshold programs.

Social Network Strategy improves access to HIV testing and harm reduction programs for PWID and their partners in Kazakhstan.

The region of Eastern Europe and Сentral Asia has a growing HIV epidemic. Kazakhstan is a country in Central Asia with an estimated 33,000 people living with HIV. The new HIV infections have increased by 29% since 2010. Evidence suggests that HIV testing strategies focused on social networks are effective methods to identify more people with undiagnosed HIV. We conducted a study to describe the optimized HIV case finding (OCF) intervention for people who inject drugs (PWID) and their partners in Kazakhstan. The OCF is based on recruitment of the extended risk social networks of HIV-positive PWID, using a two-step recruitment algorithm. There were 5,983 PWIDs and their partners tested for HIV, of those 149 (2.5%) received HIV-positive test results and the majority 145 (97%) were newly identified HIV-positive. The characteristics which had a statistically significant positive association with HIV-positive test results included: age group 15-19 (OR 4.12, 95% CI 1.44-11.7); age group 20-24 (OR 1.97, 95% CI 1.03-3.8); age group 50+ (OR 2.45, 95% CI 1.48-4.1); male sex (OR 1.78; 95% CI 1.2-2.6), participants who have previously received harm reduction services (OR 1.48; 95% CI 1.0-2.2); partners from "other groups" (OR 2.31, 95% CI 1.3-4.2). Low-threshold HIV testing and harm reduction services, like OCF using directly assisted self-testing and social network strategies are essential in reaching key populations with HIV prevention, increasing access to HIV testing and care.

690. High Mortality and Over-representation of Young Women Amongst People Who Inject Drugs Admitted with Infective Endocarditis in Saskatchewan, Canada from 2013-2018

BackgroundThe province of Saskatchewan has had the highest rates of HIV and Hepatitis C in Canada for over 10 years, the majority of which is related to People who inject drugs (PWID) and with higher proportion of young women. However, the most severe complications of injection drug use (IDU) are infective endocarditis (IE) and its associated sequelae. While high rates of IE have been noted, no data exists to show the burden of infective endocarditis and its clinical outcomes. Thus, we looked to determine the mortality and impact of IE amongst PWID and also establish the epidemiology while comparing to non-PWID IE. MethodsThis is a retrospective chart review of consecutive adult patients (age > 18) admitted for IE, as defined by Duke’s IE Criteria, at tertiary care hospitals in Regina, the capital city of Saskatchewan, between January 1, 2013 and December 31, 2018. PWID were identified through chart documentation of self-reported IV drug use. Outcomes included 1-year mortality, surgical intervention and referral to addiction services. ResultsOf the total 227 patients in our cohort, 130 (57.3%) were female, and the 1-year mortality was 39.2%. PWID related IE comprised 132 (58.1%) of the cohort. In comparison to non-PWID related IE, PWID were younger (median age 38.0, compared to 68.0 for non-PWID), more likely to be female (RR 2.06; 95% CI [1.44-3.04]; p< 0.001), to suffer right-sided disease (RR 9.14; 95% CI [4.74-15.14]; p< 0.001) and less likely to receive surgical management (RR 0.30; 95% CI [0.27-0.77]; p< 0.001). Surgical management was associated with lower mortality (RR 0.40; 95% CI [0.11-0.65]; p< 0.001). Addiction support and treatment also was protective (RR 0.89; 95% CI [0.34-1.21]; p=0.051). ConclusionThis cohort study of IE episodes shows for the first time the devastating impact of IDU in Saskatchewan and identifies PWID as having a 39% mortality at 1 year, which coupled with their younger age translates into an enormous years of life lost. Additionally, the over-representation of young women amongst PWID IE is consistent with the higher percentage of young women with HIV and HCV infections, and identifies them as a group that is particularly vulnerable to complications of IDU. Targeted programs for PWID, particularly towards young women at risk are urgently needed. Disclosures All Authors: No reported disclosures

Challenges of sexually transmitted infections and sexual health among people who inject drugs.

This review provides a summary of recently published research on sexually transmitted infections (STI) and related behaviors among people who inject drugs (PWID), covering three major areas: sexual behavior and its role in STI transmission among PWID, multilevel factors associated with STI risk, and strategies addressing sexual health of PWID. This review is timely given the growing priority of combination prevention approaches and integrated care for PWID. Modern research improves the understanding that PWID have an increased risk of STI, which varies by gender, setting, type of substance used, and presence of mental disorders. Major socioeconomic and structural factors, specific and nonspecific to PWID, facilitate inequality and sexual risk behavior. Sexual transmission continues to contribute substantially to the spread of bloodborne infections among PWID, accounting for at least 10% of new HIV cases according to epidemiological modeling. Despite the substantial evidence that behavioral interventions can improve sexual health and reduce sex-related risks among PWID, there is a research-practice gap, reflected in the scarcity of implementation studies published recently. Integration of sexual health into prevention programs for PWID is essential to curb transmission of STI, including HIV, among PWID and their sexual partners.

Sustainable Harm Reduction Needle and Syringe Programs for People Who Inject Drugs: A Scoping Review of Their Implementation Qualities

While substance use disorders (SUD) continue to be a global concern, harm reduction approaches can provide sustainable harm minimization to people who inject drugs (PWID) without requiring abstinence. Yet, the evidence for the sustainable implementation of harm reduction approaches is newly emerging. This scoping review sought to map the evidence on implementation qualities of sustainable harm reduction needle and syringe programs (NSPs). We searched the Cochrane Database of Systematic Reviews, PubMed, ProQuest Central, and Directory of Open Access Journals for empirical studies (a) with an explicit focus on harm minimization NSPs, (b) with a clearly identified study population, (c) that described the specific NSP implementation protocol, (d) that provided information on accessibility, affordability, and feasibility, and (e) were published in English between 2000–2020. Following narrative qualitative synthesis, the evidence suggests individual implementer characteristics directly influenced sustainable availability and scope of NSP provision while implementation processes explained the predictability and continuity of service provision across services. External factors including community perceptions of NSPs and policing activity influenced the sustainability of NSP implementation. The emerging evidence suggests that sustainable NSP programs for PWID require provider, consumer, and community engagement, supported by enabling health policies.

Perspectives of clients and providers on factors influencing opioid agonist treatment uptake among HIV-positive people who use drugs in Indonesia, Ukraine, and Vietnam: HPTN 074 study

BackgroundOpioid agonist treatment (OAT) is an effective method of addiction treatment and HIV prevention. However, globally, people who inject drugs (PWID) have insufficient OAT uptake. To expand OAT access and uptake, policymakers, program developers and healthcare providers should be aware of barriers to and facilitators of OAT uptake among PWID.MethodsAs a part of the HPTN 074 study, which assessed the feasibility of an intervention to facilitate HIV treatment and OAT in PWID living with HIV in Indonesia, Ukraine, and Vietnam, we conducted in-depth interviews with 37 HIV-positive PWID and 25 healthcare providers to explore barriers to and facilitators of OAT uptake. All interviews were audio-recorded, transcribed, translated into English, and coded in NVivo for analysis. We developed matrices to identify emergent themes and patterns.ResultsDespite some reported country-specific factors, PWID and healthcare providers at all geographic locations reported similar barriers to OAT initiation, such as complicated procedures to initiate OAT, problematic clinic access, lack of information on OAT, misconceptions about methadone, financial burden, and stigma toward PWID. However, while PWID reported fear of drug interaction (OAT and antiretroviral therapy), providers perceived that PWID prioritized drug use over caring for their health and hence were less motivated to take up ART and OAT. Motivation for a life change and social support were reported to be facilitators.ConclusionThese results highlight a need for support for PWID to initiate and retain in drug treatment. To expand OAT in all three countries, it is necessary to facilitate access and ensure low-threshold, financially affordable OAT programs for PWID, accompanied with supporting interventions. PWID attitudes and beliefs about OAT indicate the need for informational campaigns to counter misinformation and stigma associated with addiction and OAT (especially methadone).

Access to and use of health and social services among people who inject drugs in two urban areas of Mozambique, 2014: qualitative results from a formative assessment

BackgroundPrior to 2014, data about health seeking behaviors or service uptake for People who inject drugs (PWID) in Mozambique did not exist. We present the results from the formative assessment component of the Biological and Behavioral Survey (BBS).MethodsStandardized interview guides were used during key informant interviews (KII) and focus group discussions (FGD) in Maputo and Nampula/Nacala to discuss issues related to risk behaviors and access to and utilization of health and social services by PWID. The target sample size was not defined a priori, but instead KII and FGD were conducted until responses reached saturation. Data analysis was based on the principles of grounded theory related to qualitative research.ResultsEighty-eight respondents, ages 15 to 60, participated in KIIs and FGDs. Participants were majority male from diverse income and education levels and included current and former PWID, non-injection drug users, health and social service providers, peer educators, and community health workers. Respondents reported that PWID engage in high-risk behaviors such as needle and syringe sharing, exchange of sex for drugs or money, and low condom use. According to participants, PWID would rather rent, share or borrow injection equipment at shooting galleries than purchase them due to stigma, fear of criminalization, transportation and purchase costs, restricted pharmacy hours, personal preference for needle sharing, and immediacy of drug need. Barriers to access and utilization of health and social services include distance, the limited availability of programs for PWID, lack of knowledge of the few programs that exist, concerns about the quality of care provided by health providers, lack of readiness as a result of addiction and perceived stigma related to the use of mental health services offering treatment to PWID.ConclusionsMozambique urgently needs to establish specialized harm reduction programs for PWID and improve awareness of available resources. Services should be located in hot spot areas to address issues related to distance, transportation and the planning required for safe injection. Specific attention should go to the creation of PWID-focused health and social services outside of state-sponsored psychiatric treatment centers.

HIV- and hepatitis C-related risk behaviors among people who inject drugs in Uganda: implications for policy and programming

BackgroundThere is a dearth of evidence on injecting drug use and associated HIV and hepatitis C virus (HCV) infections in Uganda. As such, policy and programming for people who inject drugs (PWID) is limited due to scarcity of epidemiological data. We therefore conducted this study to assess the injecting drug and sexual practices among PWID in Kampala Capital City and Mbale Municipality.MethodsUsing a rapid situation assessment framework, we conducted semi-structured interviews among 125 PWID (102 males and 23 females)—recruited through outreach and snowball sampling. We assessed their injecting drug and sexual practices. We also conducted 12 focus group discussions among PWID and 30 in-depth interviews among key informants.ResultsA total of 125 PWID (81.6% males and 18.4% females) were recruited into the study. Approximately three quarters of PWID started injecting before the age of 25. More females (21.7%) compared to males (13.7%) started injecting by the age of 17. Fifty-seven percent of the PWID in Kampala and 50% in Mbale shared injecting equipment in the last 3 months prior to the study. There was an emerging practice of mixing drugs with blood and sharing it among different PWID as a sign of oneness. Heroin was being injected by 72% of the participants. Less than one half of the PWID had used a condom during the last casual sex, and 42.7% did not use a condom the last time they engaged in sex work. Seventy-six percent of the PWID had undertaken an HIV test in the last 12 months, and 9.2% self-reported to be HIV positive.ConclusionsThis study highlights the need for introducing harm reduction policies and services including increased access to sterile injecting equipment and education around safer injecting and sexual practices. Programs for PWID should also address the specific needs of female sex workers who inject drugs.

Allocative and implementation efficiency in HIV prevention and treatment for people who inject drugs

BackgroundEstimated global new HIV infections among people who inject drugs (PWID) remained stable over the 2010–2015 period and the target of a 50% reduction over this period was missed. To achieve the 2020 UNAIDS target of reducing adult HIV infections by 75% compared to 2010, accelerated action in scaling up HIV programs for PWID is required. In a context of diminishing external support to HIV programs in countries where most HIV-affected PWID live, it is essential that available resources are allocated and used as efficiently as possible. MethodsAllocative and implementation efficiency analysis methods were applied. Optima, a dynamic, population-based HIV model with an integrated program and economic analysis framework was applied in eight countries in Eastern Europe and Central Asia (EECA). Mathematical analyses established optimized allocations of resources. An implementation efficiency analysis focused on examining technical efficiency, unit costs, and heterogeneity of service delivery models and practices. ResultsFindings from the latest reported data revealed that countries allocated between 4% (Bulgaria) and 40% (Georgia) of total HIV resources to programs targeting PWID — with a median of 13% for the eight countries. When distributing the same amount of HIV funding optimally, between 9% and 25% of available HIV resources would be allocated to PWID programs with a median allocation of 16% and, in addition, antiretroviral therapy would be scaled up including for PWID. As a result of optimized allocations, new HIV infections are projected to decline by 3–28% and AIDS-related deaths by 7–53% in the eight countries. Implementation efficiencies identified involve potential reductions in drug procurement costs, service delivery models, and practices and scale of service delivery influencing cost and outcome. A high level of implementation efficiency was associated with high volumes of PWID clients accessing a drug harm reduction facility. ConclusionA combination of optimized allocation of resources, improved implementation efficiency and increased investment of non-HIV resources is required to enhance coverage and improve outcomes of programs for PWID. Increasing efficiency of HIV programs for PWID is a key step towards avoiding implicit rationing and ensuring transparent allocation of resources where and how they would have the largest impact on the health of PWID, and thereby ensuring that funding spent on PWID becomes a global best buy in public health.

HIV incidence among people who inject drugs (PWIDs) in Ukraine: results from a clustered randomised trial

SummaryBackgroundIn this study, we sought to assess whether a social network intervention was superior to HIV testing and counseling in impacting HIV incidence among PWID. Although this was not a primary study aim, it is associated with reducing drug and sex risk behaviors, which were primary aims.MethodsPWID were recruited from street settings in Odessa, Donetsk, and Nikolayev, Ukraine for a clustered randomized clinical trial (RCT). “Index” or peer leaders, along with two of their network members, were randomly assigned to testing and counseling block (N=589) or testing and counseling plus a social network intervention block (N=611). Participants in the network intervention received 5-sessions to train their network members in risk reduction. Those assigned testing and counseling received no further intervention following counseling. Employing an intent to treat analyses, the primary outcome was HIV sero-conversion using Cox regression and incorporating a gamma frailty term to account for clustering. No stratification or minimization was utilized. The trail was registered with ClinicalTrial.gov, NCT01159704.FindingsBetween July 12, 2010 and November 23, 2012, 2,304 PWID were recruited, 1,200 of whom were HIV negative and included in the present study. At baseline, there were no significant differences between groups. Of the 1,200 HIV negative participants, 1,085 (90.4%) were retained at 12 months. Incidence density revealed 18.45 (95% CI 14.87 – 22.03, 102 events in 553.0 py) per 100 person years (py) for those in the intervention group and 31.78 (95% CI 26.83–36.74, 158 events in 497.1 py) per 100 py among control arm participants. This corresponded to a reduced hazard in the intervention group, HR= 0.53 (95% CI 0.38, 0.76, p =0.0003). There were no study-related adverse events.InterpretationThese data provide strong support for integrating peer education into comprehensive HIV prevention programs for PWID and suggest the value in developing and testing peer-led interventions for improving access and adherence to PrEP and ART.FundingThis study was funded by the National Institute on Drug Abuse (RO1 DA026739).

People who inject drugs in prison: HIV prevalence, transmission and prevention

In 2011, over 10.1 million people were held in prisons around the world. HIV prevalence is elevated in prison and this is due to the over representation of people who inject drugs (PWID). Yet HIV prevention programs for PWID are scarce in the prison setting. With a high proportion of drug users and few prevention programs, HIV transmission occurs and sometimes at an alarming rate.This commentary focuses primarily on drug users in prison; their risk behaviours and levels of infection. It also comments on the transmission of HIV including outbreaks and the efforts to prevent transmission within the prison setting.The spread of HIV in prison has substantial public health implications as virtually all prisoners return to the community. HIV prevention and treatment strategies known to be effective in community settings, such as methadone maintenance treatment, needle and syringe programs, condoms and antiretroviral therapy should be provided to prisoners as a matter of urgency.

Drug use, HIV, HCV and TB: major interlinked challenges in Eastern Europe and Central Asia.

Eastern Europe and Central Asia have the largest drug epidemic globally and the fastest and still expanding HIV epidemic. The Russian Federation and Ukraine together account for over 90% of the reported AIDS cases in the region. If small in absolute numbers, the epidemics are however significant in prevalence rate in most countries of Central Asia. Most heroin and many of the new synthetic or home-made drugs are injected, which has led to high prevalence levels (up to 90%) of HCV infection in people who inject drugs (PWID). The two epidemics of HIV and HCV are in turn interlinked with TB and MDR-TB that are highly prevalent among marginalized populations in the region. Despite progress in the last two years, access to antiretroviral treatment remains far below global levels and increases more slowly than new reported cases of HIV. Access to prevention is limited with low coverage of needle exchange programs and very low or inexistent access to opioid substitutive therapy. There are few exceptions to this situation, including Ukraine where harm reduction programs are being scaled up together with significant peer outreach programs for PWIDs. This is likely to be the reason why the epidemic curves in the Russian Federation and Ukraine are now diverging. The region faces many structural, cultural, societal and political obstacles in responding to these quadruple epidemics. Without a significantly expanded and strengthened response, these epidemics will remain major causes of illness and premature deaths in the region.

Male-to-male sex among men who inject drugs in Delhi, India: Overlapping HIV risk behaviours

BackgroundHIV among people who inject drugs (PWID) is a major public health challenge in India. This paper examines PWID in Delhi who also have male-to-male sex with a focus on overlapping HIV risk behaviours and the psychosocial correlates of a history of male-to-male anal sex. MethodsWe analysed data collected in April–May of 2012 from a community-based sample of 420 male PWID in Delhi obtained using time location sampling. ResultsOne third (37%) of the men reported a history of anal sex with men, among whom just 16% used a condom at last anal sex. Almost all (93%) participants who had a history of anal sex with men also had sex with women. Chi-square tests revealed that a history of anal sex with men was associated with a higher number of female sexual partners and sharing of needles and syringes. Additionally, unprotected sex at last sex with a male partner was significantly associated with unprotected sex at last sex with regular and paid female partners. Multivariate binary logistic regression revealed that the psychosocial correlates of a history of anal sex with other men were: being aged 18–24 (OR=2.4, p=0.014), illiteracy (OR=1.9, p=0.033), having never been married (OR=2.6, p=0.007), a main source of income of crime/begging (OR=3.1, p=0.019), a duration of injecting drug use greater than 20 years (OR=3.4, p=0.035) and suicidal ideation (OR=1.7, p=0.048). ConclusionMale-to-male sex was associated with psychosocial vulnerability, including a longer history of injecting drug use, suicidal ideation and socio-economic disadvantage. Given the extent of overlapping HIV risk behaviours, HIV programs for PWID would benefit from a strong focus on prevention of sexual HIV transmission, especially among male injectors who also have sex with other men.

Do metropolitan HIV epidemic histories and programs for people who inject drugs and men who have sex with men predict AIDS incidence and mortality among heterosexuals?

PurposeWe focus on a little-researched issue—how human immunodeficiency virus (HIV) epidemics and programs in key populations in metropolitan areas affect epidemics in other key populations. We consider (1) How are earlier epidemics among people who inject drugs (PWID) and men who have sex with men (MSM) related to later AIDS incidence and mortality among heterosexuals?; (2) Were prevention programs targeting PWID or MSM associated with lower AIDS incidence and mortality among heterosexuals?; and (3) Was the size of the potential bridge population of noninjecting drug users (NIDUs) in a metropolitan area associated with later AIDS incidence and mortality among heterosexuals? MethodsUsing data for 96 large U.S. metropolitan areas, Poisson regression assessed associations of population prevalences of HIV-infected PWID and MSM (1992); NIDU population prevalence (1992–1994); drug use treatment coverage for PWID (1993); HIV counseling and testing coverage for MSM and for PWID (1992); and syringe exchange presence (2000) with CDC data on AIDS incidence and mortality among heterosexuals in 2006–2008, with appropriate socioeconomic controls. ResultsPopulation density of HIV+ PWID and of NIDUs were positively related, and prevention programs for PWID negatively related to later AIDS incidence among heterosexuals and later mortality among heterosexuals living with AIDS. HIV+ MSM population density and prevention programs for MSM were not associated with these outcomes. ConclusionsEfforts to reduce HIV transmission among PWID and NIDUs may reduce AIDS and AIDS-related mortality among heterosexuals. More research is needed at metropolitan area, network, and individual levels into HIV bridging across key populations and how interventions in one key population affect HIV epidemics in other key populations.

Perception of Hepatitis C Risk among Injecting Drug Users Who Obtain Injecting Equipment from Pharmacies in Western Australia

This study describes perceptions of hepatitis C (HCV) risk among people who inject drugs (PWID) in Western Australia (WA), and seeks to determine the relationship between perceptions of risk and injecting equipment sharing practices. One hundred and forty five participants recruited from 30 high-distributing pharmacies throughout WA completed surveys during a two-week period. Respondents reported that they did not see themselves as highly susceptible to HCV and did not believe HCV was a severe condition. Forty-three percent of respondents reported sharing injecting equipment in the past month. In multivariate analysis, sharing injecting equipment was associated with lower self-efficacy for sterile equipment use, being unemployed, and being male. These findings suggest that high self-efficacy protects against sharing injecting equipment with others. Psychosocial factors warrant close scrutiny and attention in future research and HCV prevention programs for PWID.