Prevalence and correlates of hepatitis C virus infection among street-recruited injection drug users in San Juan, Puerto Rico

Harms associated with injecting in public spaces: a global systematic review and meta-analysis

BACKGROUND

Despite increasing backlash against harm reduction efforts and the need to understand the risk environments encountered by people who inject drugs (PWID), a quantitative systematic review on public injecting and associated health and drug-related outcomes is lacking. We aimed to summarize the global evidence on the prevalence and harms associated with injecting in public spaces.

METHODS

We searched MEDLINE, Embase, PsycINFO, CINAHL, Scopus, Global Health, and Web of Science from inception to March 21, 2024. We pooled data from included studies using random-effects meta-analyses to quantify the associations between recent (i.e., current or within the last year) public injecting and associated outcomes. Public injecting was defined as injecting in public or semi-public spaces, including streets, parks, and abandoned buildings. Risk of bias was assessed using the Joanna Briggs Institute's critical appraisal tool.

RESULTS

Of the 6144 initial records, 84 studies were eligible for inclusion. The pooled prevalence of recent public injecting was 48.85 % (95 % confidence intervals [CI] 43.87, 53.85). Public injecting was associated with increased odds of recent non-fatal overdose (odds ratio [OR] 2.51, 95 % CI 2.01, 3.13), HCV infection (OR 1.55, 95 % CI 1.18, 2.02), recent needle/syringe sharing (OR 2.41, 95 % CI 1.97, 2.94), recent sex work (OR 1.75, 95 % CI 1.03, 2.97), recent incarceration (OR 2.10, 95 % CI 1.78, 2.47), and recent unstable housing/homelessness (OR 4.23, 95 % CI 3.17, 5.65). Public injecting showed a statistically non-significant association with HIV infection (OR 1.41, 95 % CI 0.80, 2.46). Public injecting was also associated with a higher willingness to use supervised injection facilities (OR 2.66, 95 % CI 1.86, 3.80).

CONCLUSION

Public injecting is prevalent among PWID and associated with various adverse drug- and health-related outcomes, highlighting the need for increased access to safe injection spaces. Findings support developing interventions to reduce harms from public injecting, such as addressing structural risks from law enforcement, expanding naloxone programs, and establishing overdose prevention centers. Housing interventions, in particular, could serve as an effective upstream strategy to reduce public injecting and related harms.

Prevalence and associated risk factors of hepatitis C antibody and RNA among people who inject drugs in Puerto Rico

INTRODUCTION

As a public health crisis, hepatitis C viral infection (HCV) is highly prevalent among people who inject drugs (PWID). We aimed to assess factors associated with HCV antibody (Ab) and HCV ribonucleic acid (RNA) positivity among PWID in Puerto Rico.

METHODS

The study recruited a total of 150 persons in rural and peri-urban community settings through the respondent-driven sampling method and administered a structured questionnaire. We conducted HIV and HCV testing using dried blood spots (DBS). We examined correlates of HCV infection with sociodemographics, drug use patterns, and injection practices using regression in bivariate and multivariable analysis.

RESULTS

Of the 150 participants, 89 % were male; 11 % were female; 72 % identified as mixed race; and the median duration of drug injection was 17.8 years. The mean age was 43.1 years, with 64 % of the population being from 23 to 45 years old. Among study participants (n = 150), the prevalence of HCV Ab was 73 %, and HCV RNA was 53 %. Factors significantly associated with HCV Ab and RNA included older age, increasing years of injection, incarceration, injecting other people, and identifying as Black. The belief that syringe air blowing reduces HCV transmission was also independently associated with HCV Ab positivity.

CONCLUSIONS

Our findings regarding risk factors associated with HCV infection show the need to enhance prevention and control strategies for reducing transmission among PWID. Direct-acting antiviral treatment, sustained access to harm reduction, and culturally tailored services will be required to substantially reduce rates of HCV. Community-based treatment models and treatment in correctional settings are needed.

Hepatitis C virus infection and co-infection with HIV among persons who inject drugs in 10 U.S. cities-National HIV Behavioral Surveillance, 2018

BACKGROUND

Characterizing acute and chronic hepatitis C virus (HCV) infection and HIV/HCV co-infection among persons who inject drugs (PWID) can inform elimination efforts.

METHODS

During 2018 National HIV Behavioral Surveillance in 10 U.S. metropolitan statistical areas (MSAs), PWID were recruited using respondent-driven sampling and offered a survey, HIV testing, and HCV antibody and RNA testing. We examined prevalence and associated characteristics of HCV infection and HIV/HCV co-infection. Associations were assessed using log-linked Poisson regression models with robust standard errors accounting for clustering by recruitment chain and adjusting for MSA and network size.

RESULTS

Overall, 44.2% had current HCV infection (RNA detected), with 3.9% classified as acute infection (HCV antibody non-reactive/RNA detected) and 40.3% as chronic (HCV antibody reactive/RNA detected). Four percent had HIV/HCV co-infection. Current HCV infection was significantly higher among PWID who were male, White, injected >1 time/day, shared syringes in past year, and shared injection equipment in past year. PWID who were transgender, injecting >5 years, and most often injected speedball (heroin and cocaine together) or stimulants alone were more likely to have HIV/HCV co-infection. Among PWID who never previously had HCV infection, 9.9% had acute HCV infection. Among PWID who started injecting ≤5 years ago, 41.5% had already acquired HCV infection.

CONCLUSIONS

Acute and chronic HCV infections were substantial among a sample of PWID in 10 U.S. MSAs. Accessibility to HCV RNA testing, promoting safer practices, and intervening early with harm reduction programs for recent injection initiates will be critical to disease elimination efforts for PWID.

Hepatitis C virus care cascade among people who inject drugs in puerto rico: Minimal HCV treatment and substantial barriers to HCV care

Background

People who inject drugs (PWID) in Puerto Rico are disproportionately affected by the hepatitis C virus (HCV) epidemic. However, there is a scarcity of data on the HCV care cascade among PWID in Puerto Rico. This study aims to describe the HCV cascade of care among PWID in Puerto Rico, identify gaps, and explore barriers to HCV care.

Methods

Participants were recruited using respondent-driven sampling and tested for both HCV antibodies (Ab) and RNA (ribonucleic acid) using rapid testing and dried blood spot samples (DBS). The cascade of care was estimated based on the DBS HCV Ab and RNA results, as well as self-reported data on HCV screening, linkage to care, treatment uptake and sustained virologic response collected through a questionnaire. The cascade was constructed sequentially, with each step using the number of people from the preceding step as the base denominator. The survey also assessed participants' perceived barriers to HCV care.

Results

Out of 150 participants, 126 (84%) had previously been HCV screened, 87% (109/126) were HCV Ab positive, 72% (79/109) were RNA positive,48% (38/79) were linked to care, 32% (12/38) initiated treatment, 58% (7/12) finished treatment, and 71% (5/7) achieved SVR. Barriers to HCV care included concerns about drug abstinence requirements, access to transportation, stigma in healthcare settings, and lack of knowledge about HCV treatment sites.

Conclusion

This study provides insights into the HCV cascade of care among PWID in Puerto Rico for the first time and highlights limited diagnosis, treatment uptake, and barriers to care.

Seroprevalence and Genotype Diversity of Hepatitis C Virus in the Caribbean-A Review

Hepatitis C (HCV) continues to present a global public health challenge, with no vaccine available for prevention. Despite the availability of direct-acting antivirals (DAAs) to cure HCV, it remains prevalent in many regions including the Caribbean. As efforts are made to eliminate HCV from the region, existing barriers, such as the high cost of DAAs and lack of an established database of HCV cases within the Caribbean, must be addressed. This review seeks to assess epidemiologic trends (seroprevalence and genotypic diversity) of HCV in the Caribbean and identify gaps in surveillance of the disease. The literature for the period 1 January 2005 to October 2022 was reviewed to gather country-specific data on HCV across the Caribbean. References were identified through indexed journals accessed through established databases using the following keywords: Caribbean, genotype distribution, and general epidemiologic characteristics. The usage pattern of HCV drugs was determined from information obtained from pharmacists across the Caribbean including Jamaica. The prevalence of HCV in the Caribbean was 1.5%; the region should therefore be considered an area of moderate HCV prevalence. The prevalence of HCV among intravenous drug users (21.9-58.8%), persons living with HIV/AIDS (0.8 to 58.5%), prisoners (32.8-64%), and men who have sex with men (MSM) (0.8-6.9%) was generally higher than in the general population (0.8-2.3%). Genotype 1 (83%) was most prevalent followed by genotypes 2 (7.2%) and 3 (2.1%), respectively. Less than 50% of countries in the Caribbean have reliable or well-curated surveillance data on HCV. Drugs currently being used for treatment of HCV infections across the Caribbean include Epclusa (sofosbuvir/velpatasvir) and Harvoni (ledipasvir/sofosbuvir). Some of these drugs are only available in the private sector and are sourced externally whenever needed. While trends point to a potentially higher prevalence of HCV, it will require well-designed random surveys to obtain better estimates of the infection seroprevalence, supported by strong public health laboratory systems. DAAs that are pan-genotypic should translate into treatments that are affordable, accessible, and available to improve cure rates and reduce the HCV burden in the population.

Seroprevalence and risk factors associated with hepatitis C: a cross-sectional study of persons who inject drugs in Puerto Rico, 2018

BACKGROUND

People Who Inject Drugs (PWID) are at a higher risk of acquiring bloodborne infections. We aimed to estimate the seroprevalence of the Hepatitis C Virus (HCV) in PWID and identify correlates and risk factors using data from the Puerto Rico National HIV Behavioral Surveillance System, PWID cycle 5, conducted in 2018.

METHODS

A total of 502 San Juan Metropolitan Statistical Area participants were recruited through the Respondent Driven Sampling method. Sociodemographic, health-related, and behavioral characteristics were assessed. Testing for HCV antibodies was completed after the face-to-face survey. Descriptive and logistic regression analyses were performed.

RESULTS

Overall seroprevalence of HCV was 76.5% (95% CI: 70.8-81.4%). A significantly (p < 0.05) higher HCV seroprevalence was observed among PWID with the following characteristics: heterosexuals (78.5%), high school graduates (81.3%), tested for sexually transmitted infections (STI) in the past 12 months (86.1%), frequent speedball injection (79.4%), and knowing the HCV serostatus of the last sharing partner (95.4%). Adjusted logistic regression models showed that having completed high school and reported STI testing in the past 12 months were significantly associated with HCV infection (OR_a = 2.23; 95% CI: 1.06-4.69; OR_a = 2.14; 95% CI: 1.06-4.30, respectively).

CONCLUSIONS

We report a high seroprevalence of HCV infection in PWID. Social health disparities and potential missed opportunities validate the continuing call for local action for public health and prevention strategies.

"Caballo": risk environments, drug sharing and the emergence of a hepatitis C virus epidemic among people who inject drugs in Puerto Rico

BACKGROUND

Sharing drug injection equipment has been associated with the transmission of HCV among PWID through blood contained in the cooker and cotton used to prepare and divide up the drug solution. While epidemiologists often subsume this practice under the sharing of "ancillary equipment," more attention should be paid to the fact that indirect sharing takes place within the process of joint drug acquisition and preparation.

METHODS

We employed an ethnographic approach observing active PWID (N = 33) in four rural towns in Puerto Rico in order to document drug sharing arrangements involved in "caballo", as this practice is locally known. We explored partners' motivation to engage in drug sharing, as well as its social organization, social roles and existing norms.

FINDINGS

Findings suggest that drug sharing, is one of the main drivers of the HCV epidemic in this population. Lack of financial resources, drug packaging, drug of choice and the desire to avoid the painful effects of heroin withdrawal motivates participants' decision to partner with somebody else, sharing injection equipment-and risk-in the process. Roles are not fixed, changing not only according to caballo partners, but also, power dynamics.

CONCLUSION

In order to curb the HCV epidemic, harm reduction policies should recognize the particular sociocultural contexts in which people inject drugs and make decisions about risk. Avoiding sharing of injection equipment within an arrangement between PWID to acquire and use drugs is more complex than assumed by harm reduction interventions. Moving beyond individual risk behaviors, a risk environment approach suggest that poverty, and a strict drug policy that encourage users to carry small amounts of illicit substances, and a lack of HCV treatment among other factors, contribute to HCV transmission.

Predicting HCV Incidence in Latinos with High-Risk Substance Use: A Data Science Approach

Hepatitis C virus (HCV) in the U.S. has tripled in the prior five years, and injecting drug use is the primary risk for HCV, with up to 90% of older and former people who inject drugs (PWIDs) testing positive. Laboratory testing of HCV for any PWIDs is the gold standard, however many PWIDs lack access to health treatment or services. Identifying risks of HCV via a data science approach would aid community health workers (CHW) to rapidly link those most at risk of infection with treatment. This study employed a data-science approach to determine the strongest risk factors of HCV in a sample of Mexican-Americans WIDs n = 221 (96 negative/125 positive). Data included 238 demographic and psychosocial predictors. A Random Forest machine learning algorithm demonstrated significant prediction improvement over baseline no information rate comparison. Strongest risks for positive HCV included sharing drug-use equipment and younger age at first heroin use; receiving drug-education during incarceration was protective. A ROC curve fit to the prediction yielded an area under the curve of 0.77. Predictive variables of HCV in the present analysis can be obtained via screening by CHW. Identification of patients most at risk of HCV within community settings can maximize treatment utilization.

Establishing trust in HIV/HCV research among people who inject drugs (PWID): Insights from empirical research

BACKGROUND

The establishment of trust between researchers and participants is critical to advance HIV and HCV prevention particularly among people who inject drugs (PWID) and other marginalized populations, yet empirical research on how to establish and maintain trust in the course of community health research is lacking. This paper documents ideas about trust between research participants and researchers amongst a sub-sample of PWID who were enrolled in a large, multi-year community health study of social networks and HIV/HCV risk that was recently conducted in rural Puerto Rico.

METHODS

Qualitative research was nested within a multi-year Social Network and HIV/HCV Risk study involving N = 360 PWID > 18 years of age living in four small, rural Puerto Rican communities. Semi-structured interviews were conducted between March 2017 and April 2017 with a subset of 40 active PWID who had been enrolled in the parent study. Interview questions invited participants to draw upon their recent experience as research participants to better understand how PWID perceive and understand participant-researcher trust within the context of HIV/HCV-related epidemiological research.

RESULTS

Fear of police, stigma and concerns regarding confidentiality and anonymity were identified as structural factors that could compromise participation in HIV/HCV-related research for PWID. While monetary compensation was an important motivation, participants also valued the opportunity to learn about their HIV/HCV status. During their participation in the study, gaining knowledge of safe injection practices was perceived as a valuable benefit. Participant narratives suggested that PWID may adopt an incremental and ongoing approach in their assessment of the trustworthiness of researchers, continuously assessing the extent to which they trust the research staff throughout the course of the research. Trust was initially generated through peer Respondent Driven Sampling recruitment. Research staff who maintained a presence in the community for the entire duration of the prospective study reinforced trust between participants and the research team.

CONCLUSION

Although PWID face numerous structural barriers to research-related trust in HIV/HCV research, we found that using a peer-based recruitment method like RDS, and employing a research staff who are knowledgeable about the targeted population, culturally sensitive to their needs, and who maintain a long-term presence in the community may help mitigate many of these barriers. The reputation of the research is built incrementally as participants join the study. This contributes to a "street reputation" that grows as current or former participants vouch for the study. Establishing trust was identified as only the first step towards building a collaborative relationship with participants, and our findings suggest that steps to address criminalization and stigmatization also are necessary to support research trust.

"Money Helps": People who inject drugs and their perceptions of financial compensation and its ethical implications

This study documents how people who inject drugs (PWID) in rural Puerto Rico perceive payments for participating in HIV epidemiological studies. In-depth interviews were conducted among a subset (n = 40) of active PWID older than 18 years of age who had been previously enrolled in a much larger study (N = 360). Findings suggest that financial compensation was the main motivation for initially enrolling in the parent study. Then, as trust in the researchers developed, participants came to perceive compensation as part of a reciprocal exchange in which they assisted researchers by providing a trustful account of their experiences and researchers reciprocated with financial support.

Prevalence of hepatitis C virus in young people who inject drugs in four Colombian cities: A cross-sectional study using Respondent Driven Sampling

BACKGROUND

Colombia has a growing population of young people who inject drugs (PWID). Despite the previously reported association of injection drug use with hepatitis c virus (HCV) in other countries, studies on HCV prevalence in PWID in Colombia are lacking. The objective of this study is to determine the prevalence, demographics, and correlations of risky injection behaviours in HCV seropositive PWID in four Colombian cities (Armenia, Bogotá, Cúcuta and Pereira).

METHODS

This was a cross-sectional study carried out between January and June of 2014 that included 918 PWID from four Colombian cities, recruited by Respondent Driven Sampling. A survey was administered to each participant, and blood samples were collected. Binary logistic regression and multivariate analyses for each city were conducted.

RESULTS

Average participant age was 26 years (SD 6.5). Of all participants, 27.3% of PWID were HCV seropositive, of which 52% were 25 years old or younger. In Pereira, increased risk of HCV infection was found for PWID that: had a history of injection drug use of 5 years or more (AOR: 3.0, CI: 1.7-7.8); were between 25 and 28 years of age (AOR: 5.2, CI: 1.0-26.3); had higher injection frequency (AOR: 2.5, CI: 1.4-4.2), and daily use of gifted, sold, or rented needles or syringes (AOR: 4.5, CI: 1.0-7.1). Additionally, in Cucuta, being HIV seropositive appeared to be greatly associated with risk of HCV seropositivity (AOR: 16.9, CI: 3.5-81.5).

CONCLUSION

Although prevalence of HCV in PWID in Colombia is lower than that reported for other countries, the described demographic characteristics and diverse risky injection behaviors on each city, in the context of a young PWID population with a short injection drug use history, should be taken into account in order to guide efforts towards preventing and reducing risk of HCV infection in PWID in Colombia.

Injection Partners, HCV, and HIV Status among Rural Persons Who Inject Drugs in Puerto Rico

BACKGROUND

The prevalence of hepatitis C (HCV) and HIV among persons who inject drugs (PWID) and the ability of these diseases to spread through injection networks are well documented in urban areas. However, less is known about injection behaviors in rural areas.

OBJECTIVES

This study focuses on the association between the number of self-reported injection partners with the PWID's self-reported HCV and HIV status. Injection networks provide paths for infection and information to flow, and are important to consider when developing prevention and intervention strategies.

METHODS

Respondent driven sampling was used to conduct 315 interviews with PWID in rural Puerto Rico during 2015. Negative binomial regression was used to test for associations between the number of self-reported injection partners and self-reported HCV and HIV statuses. Multinomial logistic regression was used to test for associations with the participant's self-reported HCV and HIV statuses.

RESULTS

Self-reported HCV status is significantly associated with injection risk network size. Injection partner networks of self-reported HCV- respondents are half what is reported by those with a positive or unknown status. Self-reported HIV statuses are not associated with different numbers of injection partners.

CONCLUSIONS

Smaller injection networks among those who self-report a HCV- status suggests that those who believe their status to be negative may take protective action by reducing their injection network compared to those have a self-reported HCV+ or an unknown status. Although the cross-sectional design of the study makes it difficult verify, such behavior has implications for prevention programs attempting to prevent HCV transmission.

Substance Abuse and HIV/AIDS in the Caribbean

The Caribbean and Central America represent a formidable challenge for researchers and policy makers in the HIV field, due to their pronounced heterogeneity in terms of social, economic, and cultural contexts and the different courses the HIV epidemic has followed in the region. Such contrasting contexts and epidemics can be exemplified by 2 countries that share the island of Hispaniola, the French Creole-speaking Haiti, and the Spanish-speaking Dominican Republic. Haiti has experienced the worst epidemics outside of sub-Saharan Africa. Following a protracted economic and social crisis, recently aggravated by a devastating earthquake, the local HIV epidemic could experience resurgence. The region, strategically located on the way between coca-producing countries and the profitable North American markets, has been a transshipment area for years. Notwithstanding, the impact of such routes on local drug scenes has been very heterogeneous and dynamic, depending on a combination of local mores, drug enforcement activities, and the broad social and political context. Injecting drug use remains rare in the region, but local drug scenes are dynamic under the influence of increasing mobility of people and goods to and from North and South America, growing tourism and commerce, and prostitution. The multiple impacts of the recent economic and social crisis, as well as the influence of drug-trafficking routes across the Caribbean and other Latin American countries require a sustained effort to track changes in the HIV risk environment to inform sound drug policies and initiatives to minimize drug-related harms in the region.

Hepatitis C infection and other drug-related harms among inpatients who injected drugs in Turkey

Hepatitis C virus (HCV) is easily spread among those who share drug injection equipment. Due to the ease of contraction and growing prevalence of HCV in Eastern Europe, the aims of this study focused on describing risky injection practices as well as the prevalence of HCV, HIV and hepatitis B virus (HBV) among people who inject drugs (PWID) who were admitted to public and private drug treatment centres in Turkey from 2012 to 2013. Other aims included identifying correlates of needle sharing and HCV infection. Of the 4694 inpatients who ever injected drugs and the 3914 who injected in the past 30 days, nearly all (98%) reported heroin as their drug of choice, the vast majority reported ever sharing a needle (73.4% and 79.3%), and the mean age at first injection was 23 years. Of current PWID, 51.9% were HCV-positive, 5.9% were HBV-positive and only 0.34% of lifetime PWID were HIV-positive. Predictors of increased needle sharing include younger age, being unemployed, having lesser education and reporting heroin as a drug of choice. Significant predictors of HCV infection included being 40 years or older, receiving treatment in the Mediterranean region of Turkey, reporting heroin as a primary substance, a longer duration of drug use and sharing needles. With this information, it is essential to improve access to clean injection equipment in Turkey, to focus on improving education on clean injection practices and to enhance efforts in testing and treating HCV-positive PWID.

Social Determinants of HIV/HCV Co-Infection: A case Study from People Who Inject Drugs in Rural Puerto Rico

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Co-infection correlates with age, longer period of drug use, medical insurance coverage and sexual identity.

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LGBT PWID are vulnerable to co-infection. Stigma, commercial sex and violence compounds risk.

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Culturally sensitive prevention strategies focused on this particular population should be implemented to avoid co-infection.

Correlates of injection drug use among individuals admitted to public and private drug treatment facilities in Turkey

BACKGROUND

The number of individuals seeking treatment for drug use has been increasing in recent years in Turkey. However, existing research on patterns and risk factors for drug use and how they vary by age and location in Turkey is limited.

METHODS

We examined the socio-demographic characteristics, drug use behaviors, and treatment history of citizens admitted to inpatient substance use treatment at public and private facilities in Turkey during 2012 and 2013 and identified correlates of lifetime and current injection drug use.

RESULTS

Of the 11,247 patients at the 22 public treatment centers in 2012-2013, a majority were male, lived with family, were unemployed, and had an average age of 27 years. Within private clinics (n=663), a higher proportion was female (9.7% private vs. 5.7% public), aged 11-17 years old (13% vs. 7.4%), used cannabis as their primary drug (18.4% vs. 13.2%), and had previously received drug treatment (57% vs. 47.2%). Within public centers, 40.4% reported ever injecting drugs and 33.7% reported injecting in the past 30 days; the corresponding percentages at private clinics were 22.5% and 18.1%. Significant predictors of injection drug use included being homeless, being a temporal employee or unemployed, having higher education, heroin as a preferred drug, having a longer duration of drug use, and prior drug treatment.

CONCLUSION

Prevention and intervention efforts are needed to reduce the transition to heroin and injection drug use among youth as well as improve access to a variety of drug treatment options for people who use substances in Turkey.

Time Since Migration and HIV Risk Behaviors Among Puerto Ricans Who Inject Drugs in New York City

BACKGROUND

Among people who inject drugs (PWID) in the United States, those who initiated drug injection in Puerto Rico (immigrant Puerto Rican PWID) engage in more injection and sexual risk behaviors, and have higher HIV incidence than non-Hispanic whites.

OBJECTIVE

Understand the persistence of these HIV behaviors.

METHODS

In a cross-sectional study conducted in New York City (NYC) in 2012 (National HIV Behavioral Surveillance), PWID aged ≥18 years were recruited using Respondent-Driven Sampling, interviewed, and tested for HIV. Participants were categorized into 5 different groups: (1) US-born non-Hispanic PWID, (2) US-born Puerto Rican PWID, (3) recent immigrant Puerto Rican PWID (≤3 years in NYC), (4) medium-term immigrant Puerto Rican PWID (>3 and ≤10 years in NYC), and (5) long-term immigrant Puerto Rican PWID (>10 years in NYC). We examined the relationship between time since migrating on sexual and injection risk behaviors among immigrant Puerto Rican PWID, compared with U.S.-born Puerto Rican PWID and US-born non-Hispanic PWID. Adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were estimated using logistic regression.

RESULTS

A total of 481 PWID were recruited. In adjusted analyses using US-born non-Hispanic PWID as the comparison group, syringe sharing was significantly more likely among medium-term immigrants; and unprotected sex with casual partners was more likely among recent and long-term immigrants.

CONCLUSIONS

The risk-acculturation process for immigrant Puerto Rican PWID may be nonlinear and may not necessarily lead to risk reduction over time. Research is needed to better understand this process.

Understanding differences in HIV/HCV prevalence according to differentiated risk behaviors in a sample of PWID in rural Puerto Rico

BACKGROUND

Blood contained in needles and injection equipment has been identified as a vector for HIV and HCV transmission among people who inject drugs (PWID). Yet, there is often a wide discrepancy in prevalence for both viruses. While microbiological differences between viruses influence prevalence, other variables associated with the way drugs are acquired and used, also play a role.

METHODS

Respondent-driven sampling (RDS) methods recruited a sample of 315 current intravenous drug users in rural Puerto Rico. Information about type and frequency of use, HIV and HVC risk behaviors (sharing needles, cookers, cotton, and water), sexual behaviors, and alcohol use was collected. HIV and HCV statuses were assessed via rapid antibody tests. T tests compare means of participants who tested positive (reactive) to those who tested negative. Logistic regression analyses were used to validate the association of the risk factors involved.

RESULTS

Tests showed a significant difference in HIV (6%) and HCV (78.4%) prevalence among a population of current PWID. The main risk behaviors in HCV transmission are the sharing of injection "works", (e.g., cookers, cotton, and water). Sharing works occurred more than twice as often as the sharing of needles, and HCV+ and HCV- individuals reported the same needle sharing habits.

CONCLUSIONS

Washing and rinsing injection works with water seems to prevent HIV transmission, but it is unable to prevent HCV infection. While education about the need to clean injection equipment with bleach might be beneficial, equipment sharing--and the subsequent risk of HVC--might be unavoidable in a context where participants are forced to pool resources to acquire and use intravenous drugs.

Hepatitis C in key populations in Latin America and the Caribbean: systematic review and meta-analysis

Objectives

Summarize hepatitis C virus (HCV) prevalence in injecting (IDU) and non-injecting drug users (NIDU), men who have sex with men (MSM), sex workers, and prison inmates in Latin America and the Caribbean (LAC).

Methods

Systematic review on HCV prevalence in sub-populations in LAC. Databases searched from 1-1-2000 to 10-30-2013. Inclusion criteria: prevalence studies in sub-populations in LAC. HCV-antibody was marker for prevalence of current/past HCV infection and HCV-RNA for prevalence of HCV current infection.

Results

IDU HCV current/past infection presented highest prevalence, from 1.7 % in Colombia to over 95 % in Ciudad Juarez and Tijuana, Mexico and pooled regional anti-HCV prevalence was 49 % (CI 95 % 22.6–76.3 %). NIDU, MSM and sex workers anti-HCV prevalence was below 10 %, and pooled regional prevalence of 4 % (CI 95 % 2.6–4.5 %), 3 % (CI 95 % 1.7–4.5 %) and 2 % (CI 95 % 1.0–3.4 %), respectively. Prison inmates presented higher values, but prevalence decreased over the 15-year time span (p < 0.001). Current HCV infection from three countries showed prevalence under 10 % in prison inmates and 1–46 % among drug users.

Conclusions

Disease burden is high and surveillance, prevention and treatment should target these groups in LAC.

Electronic supplementary material

The online version of this article (doi:10.1007/s00038-015-0708-5) contains supplementary material, which is available to authorized users.

Factors Correlated With Hepatitis C and B Virus Infections Among Injecting Drug Users in Tehran, IR Iran

BACKGROUND

In Iran, the number of injecting drug users (IDUs) has increased in recent years. The rates of hepatitis C virus (HCV) and hepatitis B virus (HBV) infections among IDUs are reportedly high.

OBJECTIVES

The purpose of this study was to assess factors correlated with HCV and HBV infections among IDUs in Tehran.

PATIENTS AND METHODS

A cross-sectional study included 899 IDUs recruited from the community, drug treatment centers, and drop-in-centers. The study involved interviews conducted using an adapted version of the WHO Drug Injection Study Phase II (Version 2b) questionnaire and blood testing for the HCV antibody, hepatitis B surface antigen, and hepatitis B core antibody. A logistic regression model was used to identify independent factors correlated with HCV and HBV infections.

RESULTS

HCV infection was found to be primarily associated with female gender [odds ratio (OR) 5.0, 95% confidence interval (CI) 2.0-10.0)], unmarried status (OR 2.9, 95% CI 1.9-4.4), drug use for more than 10 years (OR 2.7, 95% CI 1.8-3.9), drug injection frequency of more than once per day (OR 2.6, 95% CI 1.6-4.2), history of imprisonment (OR 2.5, 95% CI 1.6-4.0)], and a history of shared injection needles in prison (OR 2.3, 95% CI 1.5-3.6). HBV infection was mainly correlated with a history of imprisonment (OR 1.9, 95% CI 1.4-2.7) and drug use for more than 10 years (OR 1.4, 95% CI 1.1-1.9).

CONCLUSIONS

Because a considerable number of IDUs in Iran are receiving reduction services, tailoring services for prevention of hepatitis infection are necessary.

Prevalence of HCV risk behaviors among prison inmates: tattooing and injection drug use

Hepatitis C virus (HCV) is the most common blood-borne chronic viral infection in the United States and it is over represented in incarcerated populations. This study estimates if in prison tattooing is associated with self reported HCV infection in a probabilistic sample of 1,331 sentenced inmates in Puerto Rico prisons anonymously surveyed in 2004, who had previously been tested for HCV. Analysis were carried out with the total sample and among non-injectors (n=796) to control for injection drug use (IDU) and other confounders. Nearly 60% of inmates had acquired tattoos in prison. HCV was reported by 27% of subjects in the total sample and by 12% of non-injectors who had undergone tattoos in prison. IDU was the strongest predictor of HCV in the total sample (OR=5.6, 95% CI=3.2-9.7). Among non injectors, tattooing with reused needles or sharp objects and/ or reusing ink was positively associated with HCV self-report (OR=2.6, 95% CI=1.3-5.5). Tattooing is a common occurrence in this prison setting. Findings suggest that preventive interventions are required to reduce the risk of HCV transmission through unsterile tattooing and injection practices.

Trends and projections of hepatitis C virus epidemiology in Latin America

BACKGROUND AND AIM

The purpose of the present investigation is to provide an analysis of previous works on the epidemiology of the hepatitis C virus (HCV) infection from six countries throughout Latin America, to forecast the future HCV prevalence trends in Argentina, Brazil, Mexico and Puerto Rico, and to outline deficiencies in available data, highlighting the need for further research.

METHODS

Data references were identified through indexed journals and non-indexed sources. Overall, 1080 articles were reviewed and 150 were selected based on their relevance to this work. When multiple data sources were available for a key assumption, a systematic process using multi-objective decision analysis (MODA) was used to select the most appropriate sources. When data were missing, analogues were used. Data from other countries with similar risk factors and/or population compositions were used as a proxy to help predict the future trends in prevalence.

RESULTS

The review indicates that the dominant genotype is type 1. HCV prevalence in the analysed countries ranges from 1 to 2.3%. The Latin American countries have been very proactive in screening their blood supplies, thus minimizing the risk of transmission through transfusion. This suggests that other risk factors are set to play a major role in continued new infections. The number of diagnosed and treated patients is low, thereby increasing the burden of complications such as liver cirrhosis or hepatocellular carcinoma. The HCV prevalence, according to our modelling is steady or increasing and the number of infected individuals will increase.

CONCLUSIONS

The results herein reported should provide a foundation for informed planning efforts to tackle hepatitis.

Behind the Bars of Paradise: HIV and Substance Use among Incarcerated Populations in Puerto Rico

For those who are incarcerated in jails and prisons, the correctional setting represents a unique context for health care access and utilization. In Puerto Rico, over 16 000 persons pass each year through a correctional facility, approximately 6.9% of the incarcerated population present HIV infection, and 73.8% and 27.1% evidence a previous history of drug and alcohol use, respectively. In addition, HIV-infected populations have comorbidity with other diseases that are associated with substance use. Several approaches have been considered to prevent, treat, and provide a continuum of care for HIV and substance disorders among incarcerated populations. Nearly 30 years of legally regulated practices for correctional health care have produced recommendations for addressing the needs of those with HIV and substance disorders within the correctional facilities in Puerto Rico. These recommendations include making prevention services available, building capacity among health care providers, and understanding the cultural and political contexts.

Seroepidemiology of viral hepatitis, HIV and herpes simplex type 2 in the household population aged 21-64 years in Puerto Rico

BACKGROUND

Viral hepatitis and sexually transmitted infections (STIs) are key public health problems that pose an enormous risk for disease transmission in the general population. This study estimated, for the first time, prevalence estimates of serologic markers of HCV, HBV, HAV, HIV and HSV-2 in the adult population of Puerto Rico and assessed variations across sociodemographic and behavioral characteristics.

METHODS

A seroepidemiologic survey was employed using a stratified cluster probability sample of households in Puerto Rico. Participants completed a face-to-face interview, a self-administered questionnaire using an ACASI system, and provided blood specimens for antibody testing. Prevalence estimates of viral hepatitis, HIV and HSV-2 were estimated using a logistic regression model weighting for the probability of participation in each household block and the inverse of the probability of selection according to geographic strata, households' blocks, and sex distribution.

RESULTS

A total of 1,654 adults participated in the study. Seroprevalence estimates for HCV (2.3%, 95% CI: 1.3%-4.2%), HBV (3.1%, 95% CI: 2.0%-4.7%), and HSV-2 (22.3%, 95% CI: 18.5%-26.7%) in Puerto Rico are roughly in agreement with estimates obtained in the US population; however, HAV (41.3%, 95% CI: 36.9%-45.8%) and HIV (1.1%, 95% CI: 0.5%-2.3%) seroprevalence estimates in Puerto Rico were higher. The proportion of individuals that were unaware of their serostatus was as follows: 80% for HCV, 98.3% for HBV, 96.4% for HAV, 36.4% for HIV, and 97.8% for HSV-2. Post-stratification estimates of seroprevalence varied significantly by demographic and risk related characteristics.

CONCLUSION

This data underscore the disproportionate impact of some viral infections across selected population subgroups in Puerto Rico. A concerted island-wide effort is needed to strengthen viral hepatitis and STIs prevention and control strategies, support surveillance to monitor chronic infections, and ensure appropriate counseling, testing, and medical management of infected persons. Integration of HCV, HBV, and HSV-2 counseling into HIV existing prevention services and outreach through social networks might represent a valuable approach to reach high-risk individuals.

Meta-regression of hepatitis C virus infection in relation to time since onset of illicit drug injection: the influence of time and place

The authors examined the relation between time since onset of illicit drug injection (time at risk) and rates of hepatitis C virus (HCV) infection by using meta-regression. In 72 prevalence studies, median time since onset of injection was 7.24 years and median prevalence was 66.02%. The model showed statistically significant linear and quadratic effects of time at risk on HCV prevalence and significantly higher prevalence in developing and transitional countries and in earlier samples (1985-1995). In developed countries post-1995, mean fitted prevalence was 32.02% (95% confidence interval: 25.31, 39.58) at 1 year of injection and 53.01% (95% confidence interval: 40.69, 65.09) at 5 years. In developing/transitional countries post-1995, mean fitted HCV prevalence was 59.13% (95% confidence interval: 30.39, 82.74) at 1 year of injection. In 10 incidence studies, median time at risk was 5.29 years and median cumulative HCV incidence was 20.69%. Mean fitted cumulative incidence was 27.63% (95% confidence interval: 16.92, 41.70) at 1 year of drug injection. The authors concluded that time to HCV infection in developed countries has lengthened. More rapid onset of HCV infection in drug injectors in developing/transitional countries resembles an earlier era of the HCV epidemic in other regions.

Latinos and chronic hepatitis C: a singular population

Latinos are the largest minority in the USA and have higher rates of HCV infection. The course of chronic hepatitis C in Latinos is more aggressive, with higher risk to develop cirrhosis than any other ethnic group or race. Available information suggests that more rapid progression of liver disease is aggravated by decreased efficacy to treatment with available therapies. The causes for more aggressive progression and decreased efficacy of treatment are complex. Factors related to metabolic syndrome, insulin resistance, and hepatic steatosis are important, as well as genetic differences, not only for metabolic syndrome but for immune responses to interferon. In addition, there are substantial barriers for Latinos to access medical care. Language, cultural differences, and socioeconomic factors, including lack of medical insurance, more frequent use of alcohol, and possible medical care provider bias, are significant obstacles to diagnosis and treatment. The severity of the liver disease and the association to metabolic syndrome medical conditions justify that Latinos be considered a special population with urgent need of intervention strategies. In this article we present all the available evidence on epidemiology, natural history of chronic hepatitis C, and efficacy of anti-HCV therapy in Latinos infected with HCV.

Designing an experimental HIV/HCV intervention to promote the safe re-use of drug preparation materials by injection drug users in Puerto Rico

Injection drug users (IDUs) in San Juan, Puerto Rico are characterized by high rates of daily injecting, injection of shared drugs, re-use of injection syringes, and use of shooting galleries. They lack adequate access to new injection syringes and drug preparation equipment, and experience elevated rates of HIV and HCV infection. Between April and August, 2006, researchers and active IDUs collaborated in the development of an experimental HIV/HCV intervention aimed at identifying drug preparation items and practices that will enable IDUs to make drug solutions without potentially contaminated injection syringes contacting materials used to prepare drugs. The collaboration involved discussing and testing a variety of drug preparation items and practices in office and community settings. The process was repeated until concerns that had been raised were resolved, and a tentative set of intervention items and practices to be evaluated in a community field trial was identified. Throughout, a strong emphasis was placed on the capacity of an item or practice to address common problems confronted by IDUs (blunted needles, clogged syringes, injected particles) in addition to the core aim of reducing contamination of preparation materials by blood in injection syringes. This report describes the final selection of items and practices: 1) A small water bottle that permits IDUs to add approximately .05 cc water drops directly to drug powder in cookers; 2) A preparation syringe (a type of ancillary equipment not used for injecting) that permits IDUs to pull up a measurable amount of water to add to drug powder, an alternative to producing water drops; 3) A filtering device, the Sterifilt filter, attached to a preparation syringe, which eliminates the need for cotton or cigarette filters; 4) Use of a preparation syringe to distribute drug solution by backloading to injection syringe(s); 5) A small water bottle enabling IDUs to clean injection syringes by backload rinsing. The overarching aim of this experimental HIV/HCV intervention was to promote the safe re-use of drug preparation and injection items, and to impact the large number of IDUs in San Juan who maintain personal injection syringes, but currently use communal ancillary equipment in shooting galleries and inject drug solutions prepared with other IDUs' injection syringes.

The law (and politics) of safe injection facilities in the United States

Safe injection facilities (SIFs) have shown promise in reducing harms and social costs associated with injection drug use. Favorable evaluations elsewhere have raised the issue of their implementation in the United States. Recognizing that laws shape health interventions targeting drug users, we analyzed the legal environment for publicly authorized SIFs in the United States. Although states and some municipalities have the power to authorize SIFs under state law, federal authorities could still interfere with these facilities under the Controlled Substances Act. A state- or locally-authorized SIF could proceed free of legal uncertainty only if federal authorities explicitly authorized it or decided not to interfere. Given legal uncertainty, and the similar experience with syringe exchange programs, we recommend a process of sustained health research, strategic advocacy, and political deliberation.

Seroprevalence of hepatitis C virus and associated risk behaviours: a population-based study in San Juan, Puerto Rico

BACKGROUND

Limited information about the epidemiology of hepatitis C virus (HCV) infection is available in Puerto Rico, one of the areas hardest hit by the human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) epidemic. We estimated the prevalence of HCV infection and identified correlates of seropositivity in the municipality of San Juan, Puerto Rico.

METHODS

A probability cluster design was employed to select a sample of households representative of the population aged 21-64 years in San Juan during 2001-2002. All 964 subjects completed a face-to-face interview to gather data on demographics and self-reported risk behaviours followed by venipuncture for HCV antibody testing. Variables that were at least marginally associated with HCV seroprevalence (P < 0.10) in the bivariate analyses were considered for inclusion into the multiple logistic regression model to estimate the adjusted prevalence odds ratio (POR).

RESULTS

Overall weighted prevalence of HCV infection was 6.3% (95% CI 3.6-10.9%). A significant (P < 0.05) higher prevalence was observed among subjects with the following characteristics: age 30-49 (9.5%), male sex (10.6%), < or =12 years of education (9.6%), no health coverage (12.6%), lifetime heroin use (39.2%), lifetime cocaine use (39.6%), tattooing practices (34.2%), history of imprisonment (32.8%), and self-reported histories of hepatitis B virus infection (30.4%) and HIV/AIDS (92.1%). Multivariate logistic regression revealed that tattooing practices (POR = 8.9; 95% CI 1.7-44.7), lifetime cocaine use (POR = 5.5; 95% CI 2.2-13.5), blood transfusions prior to 1992 (POR = 4.0; 95% CI 1.6-10.1), lifetime heroin use (POR = 3.3; 95% CI 1.4-7.8), and history of imprisonment (POR = 2.3; 95% CI 1.1-4.9) remained significantly associated with HCV seropositivity.

CONCLUSIONS

The large prevalence of HCV infection observed in Puerto Rican adults residing in San Juan suggest that HCV infection is an emerging public health concern and merits further investigation.