Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness

The impact of blood-borne viruses on cause-specific mortality among opioid dependent people: An Australian population-based cohort study

BACKGROUND

Blood-borne viruses (BBV) are prevalent among people with opioid dependence but their association with cause-specific mortality has not been examined at the population-level.

METHODS

We formed a population-based cohort of 29,571 opioid substitution therapy (OST) registrants in New South Wales, Australia, 1993-2007. We ascertained notifications of infection and death by record linkage between the Pharmaceutical Drugs of Addiction System (OST data), registers of hepatitis C (HCV), hepatitis B (HBV) and human immunodeficiency virus (HIV) diagnoses, and the National Death Index. We used competing risks regression to quantify associations between notification for BBV infection and causes of death. BBV status, age, year, OST status, and OST episodes were modelled as time-dependent covariates; sex was a fixed covariate.

RESULTS

OST registrants notified with HCV infection were more likely to die from accidental overdose (subdistribution hazard ratio, 95% Confidence Interval: 1.7, 1.5-2.0), cancer (2.0, 1.3-3.2) and unintentional injury (1.4, 1.0-2.0). HBV notification was associated with a higher hazard of mortality due to unintentional injury (2.1, 1.1-3.9), cancer (2.8, 1.5-5.5), and liver disease (2.1, 1.0-4.3). Liver-related mortality was higher among those notified with HIV only (11, 2.5-50), HCV only (5.9, 3.2-11) and both HIV and HCV (15, 3.2-66). Registrants with an HIV notification had a higher hazard of cardiovascular-related mortality (4.0, 1.6-9.9).

CONCLUSIONS

Among OST registrants, BBVs are a direct cause of death and also a marker of behaviours that can result in unintended death. Ongoing and enhanced BBV prevention strategies and treatment, together with targeted education strategies to reduce risk, are justified.

Trends and characteristics of heroin overdoses in Wisconsin, 2003-2012

BACKGROUND

Heroin abuse has increased substantially during the past decade in the United States. This study describes trends and demographic shifts of heroin overdoses and heroin-related fatalities in Wisconsin and contrasts these with prescription opioid overdoses.

METHODS

This study was cross-sectional using databases of emergency department (ED) visits, hospital admissions, and death certificates in Wisconsin, United States, during 2003-2012. Cases were Wisconsin residents treated for heroin or prescription opioid overdose, and residents who died of heroin-related drug poisoning. Primary measurements were rates over time and by geographic region, and rates and rate ratios for selected demographic characteristics.

RESULTS

During 2003-2012, age-adjusted rates of heroin overdoses treated in EDs increased from 1.0 to 7.9/100,000 persons; hospitalized heroin overdoses increased from 0.7 to 3.5/100,000. Whites accounted for 68% of hospitalized heroin overdoses during 2003-2007 but 80% during 2008-2012. Heroin-related deaths were predominantly among urban residents; however, rural fatalities accounted for zero deaths in 2003 but 31 (17%) deaths in 2012. Among patients aged 18-34 years, those hospitalized with heroin overdose were more often men (73.0% versus 54.9%), uninsured (44.2% versus 29.9%), and urban (84.3% versus 73.2%) than those with prescription opioid overdose. Rates of ED visits for heroin overdose in this age group exceeded rates for prescription opioid overdose in 2012 (26.1/100,000 versus 12.6/100,000 persons, respectively).

CONCLUSIONS

An epidemic of heroin abuse is characterized by demographic shifts toward whites and rural residents. Rates of heroin overdose in younger persons now exceed rates of prescription opioid overdose.

Randomized controlled trial of motivational interviewing for reducing injection risk behaviours among people who inject drugs

AIM

We tested the efficacy of a brief intervention based on motivational interviewing (MI) to reduce high-risk injection behaviours over a 6-month period among people who inject drugs (PWID).

DESIGN

A single-site two-group parallel randomized controlled trial comparing MI with a brief educational intervention (EI).

SETTING

A study office located in downtown Montréal, Canada, close to the community-based harm reduction programmes where PWID were recruited.

PARTICIPANTS

PWID who had shared drug injection equipment or shared drugs by backloading or frontloading in the month prior to recruitment were randomized to either the MI (112) or EI (109) groups.

INTERVENTION

The MI aimed to (1) encourage PWID to voice their desires, needs and reasons to change behaviours; (2) boost motivation to change behaviours; and (3) when the person was ready, support the plan he or she chose to reduce injection risk behaviours. The EI consisted of an individual session about safe injection behaviours.

MEASUREMENTS

The primary outcome was defined as having any of these risk behaviours at 6 months: having shared syringes, containers, filters or water to inject drugs in the previous month and backloading/frontloading; each behaviour was examined separately, as secondary outcomes.

FINDINGS

The probability of reporting a risk injection behaviour decreased in both the MI and the EI groups. At 6-month follow-up, participants who reported any risk behaviours were 50% [odds ratio (OR) = 0.50; confidence interval (CI) = 0.13-0.87] less likely to be in the MI group than in the EI group as well as those who reported sharing containers (OR = 0.50; CI = 0.09-0.90). PWID who reported sharing equipment excluding syringes were 53% less likely to be in the MI group (OR = 0.47; CI = 0.11-0.84).

CONCLUSIONS

A brief motivational interviewing intervention was more effective than a brief educational intervention in reducing some high risk injecting behaviours up in the subsequent 6 months.

Hepatitis C Virus seroconversion among persons who inject drugs in relation to primary care physician visiting: The potential role of primary healthcare in a combined approach to Hepatitis C prevention

BACKGROUND

Meaningful reductions in Hepatitis C Virus (HCV) transmission rates among persons who inject drugs (PWID) require a comprehensive prevention approach, including access to harm reduction measures and to healthcare-related interventions, such as HCV screening, testing and antiviral treatment. Little is known, however, about the role of visiting a primary care physician (PCP) in relation to HCV infection risk among PWID, when integrated within a combined prevention approach. This study assessed the association between PCP visiting and HCV seroconversion among PWID attending needle exchange programs (NEP).

METHODS

A prospective cohort study, HEPCO, was conducted among active PWID in Montréal (2004-2013). Interviews scheduled at 3- or 6-month intervals included completion of an interviewer-administered questionnaire, and collection of blood samples for HCV antibody testing. HCV-seronegative participants who reported NEP attendance at baseline and had at least one follow-up visit were eligible for this study. HCV incidence was calculated using the person-time method. Time-varying Cox regression modeling was conducted to evaluate the relationship between self-reported recent PCP visiting and HCV incidence.

RESULTS

At baseline assessment, of 226 participants (80.5% male; median age: 30.6 years), 37.2% reported having recently visited a PCP. During 449.6 person-years of follow-up, 79 participants seroconverted to HCV [incidence rate: 17.6 per 100 person-years, 95% confidence interval (CI): 14.0-21.8]. Covariate-adjusted analyses indicated that visiting a PCP was associated with a lower risk of HCV infection [Adjusted Hazard Ratio: 0.54, 95% CI: 0.31-0.93]. Other independent predictors of HCV infection included unstable housing, cocaine injection and prescription opioid injection.

CONCLUSION

Among PWID attending NEP, visiting a PCP was associated with a lower risk of HCV infection. Yet, only a minority of participants reported PCP visiting. Efforts to intensify engagement with PCP among PWID could potentially contribute to lower HCV transmission when integrated within a combined approach to prevention.

National income inequality and declining GDP growth rates are associated with increases in HIV diagnoses among people who inject drugs in Europe: a panel data analysis

Background

There is sparse evidence that demonstrates the association between macro-environmental processes and drug-related HIV epidemics. The present study explores the relationship between economic, socio-economic, policy and structural indicators, and increases in reported HIV infections among people who inject drugs (PWID) in the European Economic Area (EEA).

Methods

We used panel data (2003–2012) for 30 EEA countries. Statistical analyses included logistic regression models. The dependent variable was taking value 1 if there was an outbreak (significant increase in the national rate of HIV diagnoses in PWID) and 0 otherwise. Explanatory variables included the growth rate of Gross Domestic Product (GDP), the share of the population that is at risk for poverty, the unemployment rate, the Eurostat S80/S20 ratio, the Gini coefficient, the per capita government expenditure on health and social protection, and variables on drug control policy and drug-using population sizes. Lags of one to three years were investigated.

Findings

In multivariable analyses, using two-year lagged values, we found that a 1% increase of GDP was associated with approximately 30% reduction in the odds of an HIV outbreak. In GDP-adjusted analyses with three-year lagged values, the effect of the national income inequality on the likelihood of an HIV outbreak was significant [S80/S20 Odds Ratio (OR) = 3.89; 95% Confidence Interval (CI): 1.15 to 13.13]. Generally, the multivariable analyses produced similar results across three time lags tested.

Interpretation

Given the limitations of ecological research, we found that declining economic growth and increasing national income inequality were associated with an elevated probability of a large increase in the number of HIV diagnoses among PWID in EEA countries during the last decade. HIV prevention may be more effective if developed within national and European-level policy contexts that promote income equality, especially among vulnerable groups.

Influence of different drugs on HIV risk in people who inject: systematic review and meta-analysis

AIMS

To assess systematically the risk of HIV acquisition by type of drug injected across different settings.

METHODS

A systematic review and meta-analysis were conducted. Databases were searched for studies of HIV incidence in people who inject different drugs (PWID). Pooled HIV incidence rate ratio (IRR) was used to compare HIV risk between injecting and not-injecting a given drug, when possible, or otherwise with those reported not to have injected the substance. Pooled estimates of crude IRR were derived using random-effects models. Variations in IRR were assessed in subgroup analyses, by drug and geographical region.

RESULTS

Of 5779 studies screened, 15 were included. HIV incidence was reported for people injecting cocaine (eight: North America, Europe), amphetamine-type stimulants (ATS) (four: Western and Eastern Europe, Asia), heroin (11: all settings), opiate-stimulants (four: North America, Western and Eastern Europe) and opiates-sedatives (five: Europe, Asia). HIV risk in cocaine injectors was 3.6 times 95% confidence interval (CI) = 2.8-4.7, I(2)  = 0%; n = 4) that of non-injectors and 3.0 for ATS injectors (95% CI = 2.2-4.1, I(2)  = 0%; n = 2). Higher sexual risk was reported in cohorts injecting stimulants. Compared to not-injecting, HIV IRR was 2.8 (95% CI = 1.7-4.7, I(2)  = 77%; n=6) for all heroin injectors and 3.5 (95% CI = 2.3-5.2, I(2)  = 40%; n=5) for heroin injectors in Asia and Europe.

CONCLUSION

The risk of HIV acquisition in people who inject drugs appears to vary by drug type but differences are not statistically significant, precluding conclusive grading of risk.

Opioid substitution therapy is associated with increased detection of hepatitis C virus infection: a 15-year observational cohort study

BACKGROUND

Strategies are needed to enhance screening of hepatitis C virus (HCV) infection among people who inject drugs to improve engagement in HCV treatment, and stem the growing burden of HCV-related morbidity and mortality.

METHODS

We linked routinely collected data on enrolment in opioid substitution therapy (OST) and HCV notifications. We calculated rates of incident HCV notifications, and compared rates in and out of OST.

RESULTS

Following adjustment for sex, age and calendar period, rates of incident HCV notification were significantly higher during periods of OST, compared to periods out of OST (adjusted incident rate ratio: 1.91; 95% confidence interval: 1.86, 1.97). This effect was seen across multiple treatment periods.

CONCLUSIONS

HCV screening in OST settings increases detection of HCV infection among people who inject drugs.

Tailored combination prevention packages and PrEP for young key populations

INTRODUCTION

Young key populations, defined in this article as men who have sex with men, transgender persons, people who sell sex and people who inject drugs, are at particularly high risk for HIV. Due to the often marginalized and sometimes criminalized status of young people who identify as members of key populations, there is a need for HIV prevention packages that account for the unique and challenging circumstances they face. Pre-exposure prophylaxis (PrEP) is likely to become an important element of combination prevention for many young key populations.

OBJECTIVE

In this paper, we discuss important challenges to HIV prevention among young key populations, identify key components of a tailored combination prevention package for this population and examine the role of PrEP in these prevention packages.

METHODS

We conducted a comprehensive review of the evidence to date on prevention strategies, challenges to prevention and combination prevention packages for young key populations. We focused specifically on the role of PrEP in these prevention packages and on young people under the age of 24, and 18 in particular.

RESULTS AND DISCUSSION

Combination prevention packages that include effective, acceptable and scalable behavioural, structural and biologic interventions are needed for all key populations to prevent new HIV infections. Interventions in these packages should meaningfully involve beneficiaries in the design and implementation of the intervention, and take into account the context in which the intervention is being delivered to thoughtfully address issues of stigma and discrimination. These interventions will likely be most effective if implemented in conjunction with strategies to facilitate an enabling environment, including increasing access to HIV testing and health services for PrEP and other prevention strategies, decriminalizing key populations' practices, increasing access to prevention and care, reducing stigma and discrimination, and fostering community empowerment. PrEP could offer a highly effective, time-limited primary prevention for young key populations if it is implemented in combination with other programs to increase access to health services and encourage the reliable use of PrEP while at risk of HIV exposure.

CONCLUSIONS

Reductions in HIV incidence will only be achieved through the implementation of combinations of interventions that include biomedical and behavioural interventions, as well as components that address social, economic and other structural factors that influence HIV prevention and transmission.

Disinfection of syringes contaminated with hepatitis C virus by rinsing with household products

PWID “disinfect” used syringes with readily available household products when new syringes are inaccessible. Household products tested were more effective in fixed-needle syringes (low residual volume) than in syringes with detachable-needles (high residual volume). Bleach was the most effective disinfectant.

Background. Hepatitis C virus (HCV) transmission among people who inject drugs (PWID) is associated with the sharing of injection paraphernalia. People who inject drugs often “disinfect” used syringes with household products when new syringes are unavailable. We assessed the effectiveness of these products in disinfecting HCV-contaminated syringes.

Methods. A genotype-2a reporter virus assay was used to assess HCV infectivity in syringes postrinsing. Hepatitis C virus-contaminated 1 mL insulin syringes with fixed needles and 1 mL tuberculin syringes with detachable needles were rinsed with water, Clorox bleach, hydrogen peroxide, ethanol, isopropanol, Lysol, or Dawn Ultra at different concentrations. Syringes were either immediately tested for viable virus or stored at 4°C, 22°C, and 37°C for up to 21 days before viral infectivity was determined.

Results. Most products tested reduced HCV infectivity to undetectable levels in insulin syringes. Bleach eliminated HCV infectivity in both syringes. Other disinfectants produced virus recovery ranging from high (5% ethanol, 77% ± 12% HCV-positive syringes) to low (1:800 Dawn Ultra, 7% ± 7% positive syringes) in tuberculin syringes.

Conclusions. Household disinfectants tested were more effective in fixed-needle syringes (low residual volume) than in syringes with detachable needles (high residual volume). Bleach was the most effective disinfectant after 1 rinse, whereas other diluted household products required multiple rinses to eliminate HCV. Rinsing with water, 5% ethanol (as in beer), and 20% ethanol (as in fortified wine) was ineffective and should be avoided. Our data suggest that rinsing of syringes with household disinfectants may be an effective tool in preventing HCV transmission in PWID when done properly.

Can HIV and Hepatitis C Virus Infection be Eliminated Among Persons Who Inject Drugs?

HIV and hepatitis C virus (HCV) infection are readily transmitted among persons who inject drugs. The HIV and HCV epidemics have expanded rapidly, becoming global health issues. Combined prevention has been implemented to reduce injection and sexual transmission of HIV and HCV among persons who inject drugs. Reductions in risky injection and sexual behavior have led to dramatic reductions in HIV in many countries. Whether comparable reductions in HCV transmission can be achieved has yet to be determined. Eliminating HIV and HCV among persons who inject drugs will require considerable resources and commitment, particularly in low and middle income countries.

[Emergence of novel psychoactive substances among clients of a needle exchange program in Budapest, Hungary]

In this paper the authors summarize experience of a drug service provider with the injecting use of novel psychoactive substances. Among clients of the needle exchange programme of Blue Point Drug Counselling and Outpatient Centre, the authors observed the spread of the novel substances since 2009. The extensive spread of the novel substances caused substantial change in injecting use patterns, thus in the usage of the needle exchange programme. The novel psychoactive substances appeared consecutively, so that this setting gave a unique opportunity to observe and track the emergence of these substances. The authors summarize the characteristics which are important for medical practice (risks, frequent use, severe psychopathological conditions) as well as special risks associated with these substances (substances with unknown composition and effect). They highlight the importance and role of the early warning system, monitoring the online sources of information and testing of samples containing novel psychoactive substances.

Addressing the HIV/AIDS epidemic among Puerto Rican people who inject drugs: the need for a multiregion approach

High levels of HIV risk behaviors and prevalence have been reported among Puerto Rican people who inject drugs (PRPWID) since early in the HIV epidemic. Advances in HIV prevention and treatment have reduced HIV among people who inject drugs (PWID) in the United States. We examined HIV-related data for PRPWID in Puerto Rico and the US Northeast to assess whether disparities continue. Injection drug use as a risk for HIV is still overrepresented among Puerto Ricans. Lower availability of syringe exchanges, drug abuse treatment, and antiretroviral treatment for PWID in Puerto Rico contribute to higher HIV risk and incidence. These disparities should be addressed by the development of a federally supported Northeast-Puerto Rico collaboration to facilitate and coordinate efforts throughout both regions.

Rapid decline in HCV incidence among people who inject drugs associated with national scale-up in coverage of a combination of harm reduction interventions

Background

Government policy has precipitated recent changes in the provision of harm reduction interventions – injecting equipment provision (IEP) and opiate substitution therapy (OST) – for people who inject drugs (PWID) in Scotland. We sought to examine the potential impact of these changes on hepatitis C virus (HCV) transmission among PWID.

Methods and Findings

We used a framework to triangulate different types of evidence: ‘group-level/ecological’ and ‘individual-level’. Evidence was primarily generated from bio-behavioural cross-sectional surveys of PWID, undertaken during 2008-2012. Individuals in the window period (1–2 months) where the virus is present, but antibodies have not yet been formed, were considered to have recent infection. The survey data were supplemented with service data on the provision of injecting equipment and OST. Ecological analyses examined changes in intervention provision, self-reported intervention uptake, self-reported risk behaviour and HCV incidence; individual-level analyses investigated relationships within the pooled survey data. Nearly 8,000 PWID were recruited in the surveys. We observed a decline in HCV incidence, per 100 person-years, from 13.6 (95% CI: 8.1–20.1) in 2008–09 to 7.3 (3.0–12.9) in 2011–12; a period during which increases in the coverage of OST and IEP, and decreases in the frequency of injecting and sharing of injecting equipment, were observed. Individual-level evidence demonstrated that combined high coverage of needles/syringes and OST were associated with reduced risk of recent HCV in analyses that were unweighted (AOR 0.29, 95%CI 0.11–0.74) and weighted for frequency of injecting (AOR_w 0.05, 95%CI 0.01–0.18). We estimate the combination of harm reduction interventions may have averted 1400 new HCV infections during 2008–2012.

Conclusions

This is the first study to demonstrate that impressive reductions in HCV incidence can be achieved among PWID over a relatively short time period through high coverage of a combination of interventions.

A comparative study of opioid substitution therapy utilisation among opioid-dependent men and women

INTRODUCTION AND AIMS

Few population-based studies have examined differences in opioid substitution therapy (OST) treatment utilisation between men and women. Using a population of opioid-dependent people in New South Wales, Australia, first-episode and long-term OST treatment utilisation profiles were compared between men and women, differentiating between treatment initiation in the community and in custody.

DESIGN AND METHODS

Retrospective data linkage study using records of new OST entrants (2001-2010) and custody episodes (2000-2012). First OST treatment episode and overall treatment utilisation characteristics were compared between men and women initiating treatment in the community or in custody. Treatment retention was evaluated at 3, 6, 9 and 12 months after first commencing OST and overall, as the median proportion of follow-up time spent in treatment.

RESULTS

There were 15,600 new OST entrants in the cohort--10,930 were men (70.1%) and 4670 women (29.9%); 12,584 (80.7%) initiated treatment in the community and 3016 (19.3%) in custody. More men initiated OST in custody (24.0% vs. 8.3%, P < 0.001) and only received OST in custody (57.5% vs. 41.8%, P < 0.001). Women were retained longer in their first OST treatment episode at all four time points in both treatment settings and in treatment overall (community: 46.6% vs. 39.1%, P < 0.001; custody: 41.3% vs. 30.8%, P < 0.001).

DISCUSSION AND CONCLUSIONS

There are a number of key differences in OST treatment utilisation profiles between men and women. Whereas men commonly initiate and only receive OST in custody, treatment retention is higher among women, independent of the setting treatment is initiated.

Changes in HIV incidence among people who inject drugs in Taiwan following introduction of a harm reduction program: a study of two cohorts

BACKGROUND

Harm reduction strategies for combating HIV epidemics among people who inject drugs (PWID) have been implemented in several countries. However, large-scale studies using sensitive measurements of HIV incidence and intervention exposures in defined cohorts are rare. The aim of this study was to determine the association between harm reduction programs and HIV incidence among PWID.

METHODS AND FINDINGS

The study included two populations. For 3,851 PWID who entered prison between 2004 and 2010 and tested HIV positive upon incarceration, we tested their sera using a BED HIV-1 capture enzyme immunoassay to estimate HIV incidence. Also, we enrolled in a prospective study a cohort of 4,357 individuals who were released from prison via an amnesty on July 16, 2007. We followed them with interviews at intervals of 6-12 mo and by linking several databases. A total of 2,473 participants who were HIV negative in January 2006 had interviews between then and 2010 to evaluate the association between use of harm reduction programs and HIV incidence. We used survival methods with attendance at methadone clinics as a time-varying covariate to measure the association with HIV incidence. We used a Poisson regression model and calculated the HIV incidence rate to evaluate the association between needle/syringe program use and HIV incidence. Among the population of PWID who were imprisoned, the implementation of comprehensive harm reduction programs and a lower mean community HIV viral load were associated with a reduced HIV incidence among PWID. The HIV incidence in this population of PWID decreased from 18.2% in 2005 to 0.3% in 2010. In an individual-level analysis of the amnesty cohort, attendance at methadone clinics was associated with a significantly lower HIV incidence (adjusted hazard ratio: 0.20, 95% CI: 0.06-0.67), and frequent users of needle/syringe program services had lower HIV incidence (0% in high NSP users, 0.5% in non NSP users). In addition, no HIV seroconversions were detected among prison inmates.

CONCLUSIONS

Although our data are affected by participation bias, they strongly suggest that comprehensive harm- reduction services and free treatment were associated with reversal of a rapidly emerging epidemic of HIV among PWID. Please see later in the article for the Editors' Summary.