Measuring injecting risk behaviour in the second decade of harm reduction: a survey of injecting drug users in England

English and American Drug Clients' Views of the Acceptability, Advantages, and Disadvantages of Treatment and Harm Reduction Interventions

Although drug abusers present to clinics and drop-in centers requesting various treatments and harm reduction interventions, clinicians and administrators have little direct empirical evidence of the degree to which clients find various therapies acceptable or the perceived advantages and disadvantages of specific interventions. A structured interview was administered to 48 male and female outpatient or detoxification ward clients in Nottingham, England, and 40 female residential treatment program clients in Northwest Ohio, to assess the acceptability of and related attitudes regarding a broad range of interventions. Large proportions of respondents in both samples, and especially in the English sample, reported somewhat or complete acceptance of various abstinence-oriented treatments and harm reduction interventions for those still taking drugs. Respondents also discriminated among these interventions, as evidenced by differing levels of acceptance of many and outright rejection of other interventions. Although there were differences in acceptance and experience of the specific interventions between the two samples, respondents in both countries provided balanced appraisals of the advantages and disadvantages of each intervention.

Mind the gap! Failure in understanding key dimensions of a drug user's life

This article discusses the failure to succeed in the treatment of the heterogeneous population of substance users, in terms of too little, or a total absence of, necessary available knowledge from an ethnographic perspective of the user's mental geographies. I suggest three dimensions that are critical to be knowledgeable about at the beginning planning stages of any intervention and on any level of policy, namely, insights into time, space, and bodily perceptions of drug users. In these scopes, barriers are drawn and upheld between caregiver and intervention planners, on the one hand, and the client, on the other. In cases when treatment has proven successful, however success is defined, the gap between the addict's mental geography and the surrounding world has been overcome to some degree. Previous research in the area of substance users' perspective of time, space, and body, and estimates of its value for success in and posttreatment, support, and care of people with severe drug-use-related problems, are discussed.

Problem drug use the public health imperative: what some of the literature says

Background

With more than 200,000 problem drug users is contact with structured treatment services in England the public health imperative behind drug treatment is great. Problem drug use for many is a chronic and relapsing condition, where "cure" is often neither a reasonable or appropriate expectation and it can further be argued that in these circumstances problem drug use is no different from any number of chronic and enduring health conditions that are managed in the health care system and therefore should be conceptualised as such.

Discussion

A public health approach to drug treatment emphasises the need for drug users in or accessing treatment, to reduce their harmful drug use, reduce drug use related risks such as sepsis and overdose and stay alive for longer. However a public health perspective in relation to problem drug use isn't always either apparent or readily understood and to that end there is still a significant need to continue the arguments and debate that treatment and interventions for problem and dependent drug users need to extend beyond an individualistic approach. For the purposes of discussion in this article public and population health will be used interchangeably.

Summary

A recognition and acceptance that a public and population health approach to the management of problem drug users is sound public health policy also then requires a long term commitment in terms of staffing and resources where service delivery mirrors that of chronic condition management.

Multilevel analysis of HIV related risk behaviors among heroin users in a low prevalence community

BACKGROUND

Injecting drug users (IDU) are at increased risk of human immunodeficiency virus (HIV) infection. Their HIV prevalence however varies from place to place and may not be directly linked with the level of individual risk. This study explores the relative importance of individual and community level characteristics in the practice of HIV-related risk behaviors in IDU in Hong Kong where the HIV prevalence has remained low at below 1%.

METHODS

Methadone clinics were used as the channel for accessing drug users in Hong Kong. HIV-related risk factors in drug users attending these clinics were retrieved from a questionnaire routinely administered to newly admitted and readmitted clients, and assessed using logistic regression and multilevel analyses.

RESULTS

Between 1999 and 2005, a total of 41,196 person-admissions were recorded by 20 methadone clinics. Male gender, older age and new admissions in bigger clinics located in districts with older median age were more likely to have engaged in HIV related risk behaviors including heroin injection, needle sharing, unprotected sex and having multiple sex partners (p < 0.05).

CONCLUSION

Multilevel analysis is a useful adjunct for determining the association between risk behaviors and both individual and community factors in IDUs, which can be demonstrated even in low HIV prevalence settings.

Hepatitis C virus acquisition among injecting drug users: a cohort analysis of a national repeated cross-sectional survey of needle and syringe program attendees in Australia, 1995-2004

High hepatitis C virus (HCV) prevalence has been documented among many injecting drug user (IDU) populations worldwide; however, there is limited published data on trends in incidence of infection in these epidemics over time. To address this, we used a novel method of analyzing data collected via repeat, cross-sectional sero-surveys by injection initiation cohorts to investigate trends in HCV seropositivity among a population of needle and syringe program (NSP) attendees in Australia between 1995 and 2004, and thereby infer annual incidence trends. Injection initiation cohorts were defined by their time of entry into the IDU population. We also investigated the associations between HCV antibody seroprevalence and risk factor data, and trends in risk factor data over the decade. Approximately 20,000 NSP attendees participated in the study over the 10-year period. Within each injection initiation cohort, we found an increase in HCV prevalence over time, with prevalence appearing to reach saturation around 90%. There was little indication that the slopes of increase had changed with more recent initiation cohorts. While duration of injecting was most strongly associated with HCV seropositivity in this study, we also found that self-reported history of needle and syringe sharing and imprisonment were independently associated with higher HCV prevalence regardless of duration of injecting, with the exception of IDUs who have 15 or more years injecting experience. In this group, recent risk behavior had no relationship to prevalence. In summary, our findings suggest a persistent HCV epidemic despite significant harm reduction efforts in Australia since the mid-1980s, with HIV incidence effectively constant in successive initiation cohorts.

Quantifying hepatitis C transmission risk using a new weighted scoring system for the Blood-Borne Virus Transmission Risk Assessment Questionnaire (BBV-TRAQ): applications for community-based HCV surveillance, education and prevention

Background

The hepatitis C virus (HCV) is a major cause of drug-related morbidity and mortality, with incidence data implicating a wide range of HCV transmission risk practices. The Blood-Borne Virus Transmission Risk Assessment Questionnaire (BBV-TRAQ) is a content valid instrument that comprehensively assesses HCV risk practices. This study examines the properties of a new weighted BBV-TRAQ designed to quantify HCV transmission risk among injecting drug users (IDU).

Methods

Analyses of cross-sectional surveys of Australian IDU (N = 450) were used to generate normative data and explore the properties of a weighted BBV-TRAQ. Items weights were assigned according to expert key informant ratings of HCV risk practices performed during the development stages of the BBV-TRAQ. A range of item weights was tested and psychometric properties explored. A weighting scheme was recommended based on the plausibility of normative subscale data in relation to research evidence and the ability of BBV-TRAQ scores to discriminate between HCV positive and negative participants.

Results

While retaining the psychometric properties of the unweighted scale and demonstrating good internal reliability. By taking into account the relative transmission risk of a broad range of putative HCV practices, the weighted BBV-TRAQ produced promising predictive validity results among IDU based on self-report HCV status, particularly among young and less experienced injectors.

Conclusion

Brief, easy to administer and score, and inexpensive to apply, the utility of the BBV-TRAQ for community based education and prevention is enhanced by the application of item weights, potentially offering a valid surrogate measure for HCV infection among IDU.

Health systems' responses to 25 years of HIV in Europe: inequities persist and challenges remain

Europe is currently experiencing the fastest rate of growth of HIV of any region of the world. An analysis of policy and health system responses to the HIV epidemic in Europe and central Asia (hereafter referred to as Europe) over the last 25 years reveals considerable heterogeneity. In general, while noting hazards of broad generalisations and the differences that exist across countries in a particular grouping, effective policies to control HIV have been implemented more widely in western than in central and eastern Europe. However, the evidence suggests persistence of inequalities in access to preventive and treatment services, with those at highest risk, such as commercial sex workers, prisoners, intravenous drug users, and migrants often particularly disadvantaged, despite many targeted programmes. Responses in individual countries, especially in the early stages of the epidemic, were influenced by specific cultural and political factors. Strong leadership and active involvement by civil society organisations emerge as important factors for success but also a limiting factor to the response observed in eastern Europe, where civil society or NGO culture is weak as compared to western Europe. Scaling up of effective responses in many countries in eastern Europe will be challenging-where increased financial resources will have to be accompanied by broader changes to health system organization with greater involvement of the civil society in planning and delivery of client-focused services.

Injecting alone among young adult IDUs in five US cities: evidence of low rates of injection risk behavior

Illicit drug injection typically occurs in private or semi-public settings where two or more injectors are present. In a large sample of young adult injectors (aged 15-30) in five US cities, we describe those who reported consistently injecting by themselves in a recent period. Among 3199 eligible subjects, 85% were male, median age was 24 years, and median number of years injecting was four. Fifteen percent (n=467) who reported always injecting alone in the previous 3 months were compared to other IDUs to understand the relationship between this practice and injection risk behavior. IDUs who reported injecting alone were substantially less likely to report injection with a syringe (AOR=0.16, 95% CI 0.1-0.2) or other drug preparation equipment (AOR=0.17, 95% CI 0.13-0.2) previously used by another injector. Markedly low rates of injection risk behavior were observed in IDUs who reported injecting alone; this practice may facilitate safe injection by granting the individual greater control over the injection setting. However, risks may include accidental overdose with severe consequences.

High hepatitis C incidence in new injecting drug users: a policy failure?

OBJECTIVE

Evidence of ongoing hepatitis C (HCV) transmission among injecting drug users (IDUs) suggests a need for a better understanding of seroconversion characteristics among new IDUs and other vulnerable subgroups. This study aimed to determine incidence of HCV and associated risk factors among new IDUs in Sydney.

METHODS

IDUs who had injected drugs in the past six months and who were unaware of their antibody HCV status or knew their serostatus to be negative were recruited through street-based outreach, methadone clinics and needle and syringe programs in south-western Sydney. Anti-HCV negative IDUs (n = 215) were enrolled and followed-up at 3-6 monthly intervals. New IDUs (n = 204) were defined as aged below 30 years or injecting for < or = 6 years at baseline.

RESULTS

A total of 61 seroconversions were observed and incidence was 45.8 per 100 person years. Independent predictors of seroconversion were duration of injecting < 1 year (IRR = 3.10; 95% CI 1.47-6.54), female gender (IRR = 2.0; 95% CI 1.16-3.45), culturally and linguistically diverse background (CALDB) (IRR = 2.03; 95% CI 1.06-3.89) and intravenous cocaine use (IRR = 2.37; 95% CI 1.26-4.44). While new IDUs shared common risk factors, strong associations were observed between HCV seroconversion and sharing syringes, sharing other injecting equipment and backloading in CALDB new IDUs.

CONCLUSION

Incidence of HCV infection among new IDUs in Sydney is unacceptably high.

IMPLICATIONS

Extremely high rates of incident infection among newly initiated CALDB IDUs indicate an urgent need for enhanced policy and resource commitments to reduce the vulnerability of this group to HCV and other blood-borne infections.

HIV risk behaviors among female IDUs in developing and transitional countries

BACKGROUND

A number of studies suggest females may be more likely to engage in injection and sex risk behavior than males. Most data on gender differences come from industrialized countries, so data are needed in developing countries to determine how well gender differences generalize to these understudied regions.

METHODS

Between 1999 and 2003, 2512 male and 672 female current injection drug users (IDUs) were surveyed in ten sites in developing countries around the world (Nairobi, Beijing, Hanoi, Kharkiv, Minsk, St. Petersburg, Bogotá, Gran Rosario, Rio, and Santos). The survey included a variety of questions about demographics, injecting practices and sexual behavior.

RESULTS

Females were more likely to engage in risk behaviors in the context of a sexual relationship with a primary partner while males were more likely to engage in risk behaviors in the context of close friendships and casual sexual relationships. After controlling for injection frequency, and years injecting, these gender differences were fairly consistent across sites.

CONCLUSION

Gender differences in risk depend on the relational contexts in which risk behaviors occur. The fact that female and male risk behavior often occurs in different relational contexts suggests that different kinds of prevention interventions which are sensitive to these contexts may be necessary.

Methods to recruit hard-to-reach groups: comparing two chain referral sampling methods of recruiting injecting drug users across nine studies in Russia and Estonia

Evidence suggests rapid diffusion of injecting drug use and associated outbreaks of HIV among injecting drug users (IDUs) in the Russian Federation and Eastern Europe. There remains a need for research among non-treatment and community-recruited samples of IDUs to better estimate the dynamics of HIV transmission and to improve treatment and health services access. We compare two sampling methodologies "respondent-driven sampling" (RDS) and chain referral sampling using "indigenous field workers" (IFS) to investigate the relative effectiveness of RDS to reach more marginal and hard-to-reach groups and perhaps to include those with the riskiest behaviour around HIV transmission. We evaluate the relative efficiency of RDS to recruit a lower cost sample in comparison to IFS. We also provide a theoretical comparison of the two approaches. We draw upon nine community-recruited surveys of IDUs undertaken in the Russian Federation and Estonia between 2001 and 2005 that used either IFS or RDS. Sampling effects on the demographic composition and injecting risk behaviours of the samples generated are compared using multivariate analysis. Our findings suggest that RDS does not appear to recruit more marginalised sections of the IDU community nor those engaging in riskier injecting behaviours in comparison with IFS. RDS appears to have practical advantages over IFS in the implementation of fieldwork in terms of greater recruitment efficiency and safety of field workers, but at a greater cost. Further research is needed to assess how the practicalities of implementing RDS in the field compromises the requirements mandated by the theoretical guidelines of RDS for adjusting the sample estimates to obtain estimates of the wider IDU population.

Effects of sex work on the prevalence of syphilis among injection drug users in 3 Russian cities

OBJECTIVES

We examined risk factors for syphilis infection among injection drug users in 3 Russian Federation cities, focusing particular attention on the potential roles of gender and sex work.

METHODS

We conducted a cross-sectional survey of injection drug users in Moscow, Volgograd, and Barnaul, collecting behavioral data and testing for antibodies to Treponema pallidum. Associations between presence of antibodies to T pallidum and covariates were explored.

RESULTS

Overall, the prevalence of antibodies to T pallidum was 11% (95% confidence interval=9.7%, 13.1%). Syphilis was associated with involvement in sex work and with gender in Moscow and Barnaul but not in Volgograd. Female injection drug users not involved in sex work were more likely than men to be younger and to have recently begun to inject; female injection drug users involved in sex work were more likely than those not involved in sex work to inject daily.

CONCLUSIONS

Syphilis transmission dynamics varied by region. Sex work can increase syphilis risk among injection drug users, potentially feeding the momentum of sexually transmitted HIV and syphilis among noninjectors. Targeted interventions are needed to reduce both sexual and injection risk behaviors among injection drug users.

Incidence and risk factors for hepatitis C seroconversion in injecting drug users in Australia

AIMS

To determine the incidence of hepatitis C virus (HCV) infection and identify risk factors for seroconversion.

DESIGN

Prospective cohort study. Participants were recruited through direct approaches, street-based outreach, methadone and sexual health clinics and needle and syringe programmes.

SETTING

Urban, regional and rural settings in New South Wales, Australia.

PARTICIPANTS

Injecting drug users (IDUs) (n = 584) were screened and tested for exposure to HCV. Between 1999 and 2002 antibody HCV negative IDUs (n = 368) were enrolled and followed-up every 3-6 months until seroconversion or study completion.

MEASUREMENTS

Interviewer-administered baseline and follow-up questionnaires consisted of 131 items and included demographics, drug use and risk behaviour. Approximately 10 cc of whole blood was drawn at each visit. Specimens were stored at -70C and serology performed using one or two third-generation enzyme-linked immunosorbent assays and polymerase chain reaction testing.

FINDINGS

Sixty-eight seroconversions were observed and incidence was 30.8 per 100 person-years, with incidence in IDUs injecting < 1 year, 133 per 100 person-years. Independent predictors of seroconversion were female gender, duration of injecting, injecting cocaine, shared use of filters and recruitment strategy.

CONCLUSIONS

Women, new initiates and IDUs recruited via outreach appear to be at increased risk of infection. Results confirm the significance of cocaine injection as a risk factor and provide the first evidence outside North America of the link between shared use of drug preparation equipment and incident HCV infection. Prevention efforts should attempt to raise awareness of the risks associated with drug sharing and, in particular, the role of potentially contaminated syringes in HCV infection.

A review of the evidence for the effectiveness of primary prevention interventions for hepatitis C among injecting drug users

BACKGROUND

Hepatitis C (HCV) prevalence is most common amongst injecting drug users where up to 98% of the population can be infected despite a low prevalence of HIV. This review considers the evidence for the effectiveness of primary prevention interventions to reduce incidence or prevalence of hepatitis C.

METHODS

Systematic review of the major electronic medical databases: Medline, EMBASE, PsycINFO, CINAHL and the Cochrane Library (Evidence Based Health). Either intervention or observational studies were included if they described an intervention targeting injecting drug using populations with the outcome to reduce either the prevalence or incidence of hepatitis C infection.

RESULTS

18 papers were included in the final review from 1007 abstracts. Needle exchange programmes reduce the prevalence of HCV though prevalence remains high. Similarly the effectiveness of methadone maintenance treatment is only marginally effective at reducing HCV incidence. There is limited evidence evaluating either the effectiveness of behavioural interventions, bleach disinfectants, or drug consumption rooms.

CONCLUSION

Primary prevention interventions have led to a reduction in HIV incidence, have been less effective at reducing HCV incidence. Global prevalence of HCV remains disturbingly high in injecting drug users. A robust response to the global health problem of HCV will require provision of new interventions. Behavioural interventions; distribution of bleach disinfectant; other injecting paraphernalia alongside sterile needle distribution; and evaluation of drug consumption rooms merit further expansion internationally and research activity to contribute to the emerging evidence base. Whilst the prevalence of HCV remains high, nevertheless many current interventions aimed at primary HCV prevention have been shown to be cost-effective due to their significant positive impact upon prevalence of HIV.

Evidence for a substantial role of sharing of injecting paraphernalia other than syringes/needles to the spread of hepatitis C among injecting drug users

In industrialized countries, transmission of hepatitis C occurs primarily through injecting drug use. Transmission of hepatitis C in injecting drug users is mainly associated with the sharing of contaminated syringes/needles, although evidence for risk of hepatitis C infection through sharing of other injecting paraphernalia is increasing. In this paper, the independent effects of sharing paraphernalia other than syringes/needles have been estimated. The prevalence and force of infection were modelled using three serological data sets from drug users in three centres in Belgium as a function of the sharing behaviour. It was found that sharing of materials other than syringes/needles indeed seemed to contribute substantially to the spread of hepatitis C among injecting drug users.

Prevalence of, and risk factors for, hepatitis C virus infection among recent initiates to injecting in London and Glasgow: cross sectional analysis

Our aim was to compare the prevalence of antibody to hepatitis C virus (anti-HCV) among recently initiated injecting drug users (IDUs) in London and Glasgow, and to identify risk factors which could explain differences in prevalence between the cities. Complementary studies of community recruited IDUs who had initiated injection drug use since 1996 were conducted during 2001-2002. Data on HCV risk behaviours were gathered using structured questionnaires with identical core questions and respondents were asked to provide an oral fluid specimen which was tested anonymously for anti-HCV but was linked to the questionnaire. Sensitivities of the anti-HCV assays for oral fluid were 92-96%. Prevalence of anti-HCV was 35% (122/354) in London and 57% (207/366) in Glasgow (P < 0.001). Multifactorially, factors significantly associated with raised odds of anti-HCV positivity were increasing length of injecting career, daily injection, polydrug use, having had a needlestick injury, and having served a prison sentence. In addition lower odds of anti-HCV positivity were associated with non-injection use of crack cocaine and recruitment from drug agencies. After adjustment for these factors, the increased odds of anti-HCV associated with being a Glasgow IDU were diminished but remained significant. HCV continues to be transmitted among the IDU population of both cities at high rates despite the availability of syringe exchange and methadone maintenance. Effectiveness of harm reduction interventions may be compromised by inadequate coverage and failure to reduce sufficiently the frequency of sharing different types of injecting equipment, as well as the high background prevalence of HCV, and its high infectivity. Comprehensive action is urgently required to reduce the incidence of HCV among injectors.

HIV prevalence among injecting drug users in England and Wales 1990 to 2003: evidence for increased transmission in recent years

OBJECTIVE

To describe trends in HIV prevalence among injecting drug users in England and Wales between 1990 and 2003.

METHODS

Analysis of surveillance data from voluntary unlinked anonymous cross-sectional surveys collecting oral fluid samples and behavioural information from injecting drug users recruited from both drug agency (n = 24,304) and community settings (n = 3628).

RESULTS

HIV prevalence in England and Wales declined from 5.9% in 1990 to 0.6% in 1996 and then remained stable until 1999, after which it increased to 1.4% in 2003. Few HIV infections were detected among short-term injectors between 1994 and 1999, but in recent years prevalence among this group has increased. Other factors associated with higher odds of HIV infection were being recruited in London and from community settings, and ever having had a voluntary confidential HIV test. Incidence estimated through a force of infection model was 2.8% per annum among those injecting for less than a year in London between 1998 and 2003.

CONCLUSIONS

These data suggest that incidence and prevalence of HIV may have increased, whereas other indicators suggest an increase in risk behaviour. It is critical that harm reduction measures are reinvigorated, and evolve in response to changes in drug use risk behaviours and policy.

Injecting drug use in Brighton, Liverpool, and London: best estimates of prevalence and coverage of public health indicators

STUDY OBJECTIVE

To estimate the prevalence of injecting drug use (IDU) in three cities in England and to measure the coverage of key public health indicators.

DESIGN

Capture-recapture techniques with covariate effects.

SETTING

Liverpool, Brighton, and 12 London boroughs, 2000/01.

PARTICIPANTS

IDU collated and matched across five data sources-community recruited survey, specialist drug treatment, arrest referral, syringe exchange, and accident and emergency-896 in Brighton, 1224 in Liverpool, and 6111 in London.

MAIN RESULTS

It is estimated that in 2000/01 the number and prevalence of IDU aged 15-44 was 2300 (95%CI 1500 to 3700) and 2.0% (95%CI% 1.3% to 3.2%) in Brighton; 2900 (95%CI 2500 to 5000) and 1.5% (95%CI 1.3% to 2.6%) in Liverpool; 16 700 (95%CI 13 800 to 21 600) and 1.2% (95%CI 1.0% to 1.6%) in 12 London boroughs; with a prevalence of 1.7% (95%CI 1.2% to 3.3%) in inner London. It is estimated that: less than one in four IDU are in treatment in the three areas; syringe exchange programmes covered about 25% of injections in Brighton and Liverpool and 20% in London; and that the annual opioid mortality rate among IDU was 2% in Brighton compared with less than 1% in Liverpool and London.

CONCLUSIONS

Credible estimates of the prevalence of injecting drug use (and key public health indicators) can be determined using covariate capture-recapture techniques. These suggest that: targets to double the number in treatment are possible: syringe distribution should be increased; and further attention, especially in Brighton, given to reducing overdose mortality.

Preventing hepatitis C: 'common sense', 'the bug' and other perspectives from the risk narratives of people who inject drugs

There is little published research about how people who inject drugs are responding to the hepatitis C epidemic. This study seeks to address the prevention of hepatitis C using qualitative interviews with people who inject drugs in London. We explored narratives about risk reduction and hepatitis C in the social and historical context of other risks such as HIV, vein damage and overdose. Themes of the narratives included: the importance of autonomy in the acquisition of safer injecting skills; that safer injection was regarded as 'common sense', normalised and predicated on the risk of HIV; that hepatitis C risk was relativised with HIV risk and thereby seen as less important; and that hepatitis C infection was also seen as unavoidable. These narrative forms represent significant challenges for the management of the hepatitis C epidemic, both in terms of the existing risk reduction efforts designed for HIV and in terms of the articulation of risk reduction for injectors with general public health policy.

Hepatitis A virus and injecting drug misuse in Aberdeen, Scotland: a case-control study

To describe an epidemiological investigation of an outbreak of hepatitis A virus (HAV) infection among injecting drug users in Aberdeen, Scotland. A case-control study to determine whether transmission was facilitated by poor personal hygiene or through sharing injecting equipment. Cases were more likely to report not washing their hands after using the toilet [odds ratio (OR) = 12.9, 95% confidence interval (CI) = 1.58-105.89] or before preparing food (OR = 4.0, 95% CI = 1.01-15.8), and less likely to have washed their hands prior to preparing drugs (OR = 10.67, 95% CI = 2.14-53.07). Cases were also more likely to report recipient sharing of needles/syringes (OR = 8.27, 95% CI = 1.68-40.57), and to have had injecting contact with someone who was jaundiced (OR = 29.4, 95% CI = 3.18-271.44). The results indicate that the lack of hygiene within the context of individuals gathering to prepare and inject drugs provides ample opportunity for the transmission of HAV. Although the promotion of good hygiene and the avoidance of sharing injecting equipment are important measures in preventing HAV transmission, they are unlikely to effect major behavioural change. Such measures should, therefore, be reinforced by routinely offering HAV vaccine to injectors.

Interventions de prévention efficaces contre le VIH et l’hépatite C chez les jeunes utilisateurs de drogues par injection (UDI)

La dernière décennie a été marquée par une augmentation importante du nombre de pays rapportant que l’injection de drogues est présente dans leur population. Et, dans plusieurs pays, particulièrement dans ceux en voie de développement, la plupart des nouveaux injecteurs ont entre 15 et 24 ans. De nombreuses conséquences sociales et sanitaires sont associées à l’injection de drogues, les principales conséquences de type infectieux étant l’hépatite C et l’infection par le virus de l’immunodéficience humaine (VIH). Nous présenterons dans cet article les comportements d’injection et les comportements sexuels des injecteurs adolescents et jeunes adultes qui en font des personnes à risque pour ces deux infections. Nous y décrirons également des caractéristiques de ces jeunes injecteurs, qui sont liées à leur âge, dont il faut tenir compte dans l’élaboration de programmes de prévention : besoins liés au développement cognitif, physique et psychologique et aux contraintes d’ordre légal. Finalement, nous exposerons les résultats d’une vaste recherche que nous avons menée dans la littérature en vue de trouver des projets de prévention de l’infection par le VIH et de l’hépatite C qui ont répondu aux besoins spécifiques des jeunes injecteurs et qui ont fait l’objet d’une évaluation. Cette recherche a démontré qu’il existe très peu d’interventions satisfaisantes dans ce domaine. Selon nous, il est urgent que de telles interventions soient développées, évaluées et diffusées afin de contrer les épidémies de VIH et d’hépatite C qui sévissent chez les jeunes injecteurs.

Reduction or cessation of injecting risk behaviours? Treatment outcomes at 1-year follow-up

This paper investigates changes in injecting and shared use of needles and syringes among 732 drug misusers recruited to residential and community treatment programmes as part of the National Treatment Outcome Research Study (NTORS). Specifically, it investigates whether reductions in these behaviours were due to a move away from injecting among drug users or whether they could be accounted for by drug users becoming abstinent. Injecting and sharing of injecting equipment were substantially reduced after treatment. Outcomes were due to reduced sharing among injectors, reduced injecting among continuing users and to users becoming abstinent. Clients from residential programmes were more likely to be abstinent at follow-up: methadone clients were more likely to be injecting but not sharing. Abstinence and intermediate risk reduction outcomes were achieved by many drug injectors from both treatment settings. Both outcomes confer benefits, though the benefits of abstinence are greater. Users who were injectors at intake but who had stopped injecting at follow-up consistently achieved superior outcomes across a range of problem behaviours.

Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study

OBJECTIVE

Illicit drug use is identified in Healthy People 2010 as a leading health indicator because it is associated with multiple deleterious health outcomes, such as sexually transmitted diseases, human immunodeficiency virus, viral hepatitis, and numerous social problems among adolescents and adults. Improved understanding of the influence of stressful or traumatic childhood experiences on initiation and development of drug abuse is needed.

METHODS

We examined the relationship between illicit drug use and 10 categories of adverse childhood experiences (ACEs) and total number of ACEs (ACE score). A retrospective cohort study of 8613 adults who attended a primary care clinic in California completed a survey about childhood abuse, neglect, and household dysfunction; illicit drug use; and other health-related issues. The main outcomes measured were self-reported use of illicit drugs, including initiation during 3 age categories: <or=14 years, 15 to 18 years, or as an adult (>or=19 years); lifetime use for each of 4 birth cohorts dating back to 1900; drug use problems; drug addiction; and parenteral drug use.

RESULTS

Each ACE increased the likelihood for early initiation 2- to 4-fold. The ACE score had a strong graded relationship to initiation of drug use in all 3 age categories as well as to drug use problems, drug addiction, and parenteral drug use. Compared with people with 0 ACEs, people with >or=5 ACEs were 7- to 10-fold more likely to report illicit drug use problems, addiction to illicit drugs, and parenteral drug use. The attributable risk fractions as a result of ACEs for each of these illicit drug use problems were 56%, 64%, and 67%, respectively. For each of the 4 birth cohorts examined, the ACE score also had a strong graded relationship to lifetime drug use.

CONCLUSIONS

The ACE score had a strong graded relationship to the risk of drug initiation from early adolescence into adulthood and to problems with drug use, drug addiction, and parenteral use. The persistent graded relationship between the ACE score and initiation of drug use for 4 successive birth cohorts dating back to 1900 suggests that the effects of adverse childhood experiences transcend secular changes such as increased availability of drugs, social attitudes toward drugs, and recent massive expenditures and public information campaigns to prevent drug use. Because ACEs seem to account for one half to two third of serious problems with drug use, progress in meeting the national goals for reducing drug use will necessitate serious attention to these types of common, stressful, and disturbing childhood experiences by pediatric practice.

Psychometric properties of the Blood-borne Virus Transmission Risk Assessment Questionnaire (BBV-TRAQ)

AIMS

To develop a standard measure of blood-borne virus transmission risk behaviour, and examine the underlying psychometric properties.

DESIGN

The Blood-borne Virus Transmission Risk Assessment Questionnaire (BBV-TRAQ) was developed over three consecutive phases of the original BBV-TRAQ study in adherence to classical scale development procedures, culminating in the recruitment of a development sample of current injecting drug users via convenience and snowball sampling.

SETTING

Needle and syringe programmes (NSPs), medical clinics, alcohol/drug agencies, peer-based and outreach organizations across inner and outer metropolitan Melbourne.

PARTICIPANTS

Two hundred and nine current injecting drug users. The mean age was 27 years, 68% were male, 65% unemployed, 36% with prison history and 25% in methadone maintenance.

MEASUREMENTS

BBV-TRAQ items cover specific injecting, sexual and skin penetration risk practices. BBV-TRAQ characteristics were assessed via measures of internal and test-retest reliability; collateral validation; and principal components analyses.

FINDINGS

The BBV-TRAQ has satisfactory psychometric properties. Internal (a=0.87), test-retest (r=0.84) and inter-observer reliability results were high, suggesting that the instrument provides a reliable measure of BBV risk behaviour and is reliable over time and across interviewers. A principal components analysis with varimax rotation produced a parsimonious factor solution despite modest communality, and indicated that three factors (injecting, sex and skin penetration/hygiene risks) are required to describe BBV risk behaviour.

CONCLUSIONS

The BBV-TRAQ is reliable and represents the first risk assessment tool to incorporate sufficient coverage of injecting, sex and other skin penetration risk practices to be considered truly content valid. The questionnaire is indicated for use in addictions research, clinical, peer education and BBV risk behaviour surveillance settings.

Injection drug use in North America

Injection drug use of psychotropic agents for nontherapeutic purposes is associated with some of the most pernicious infectious diseases seen in the United States. There is an inextricable link between infection, injection drug use (IDU) and other risk behaviors, especially those related to sexual activity. A number of national surveys now provide excellent databases to track the breadth, scope and impact of IDU across the United States. The prevalence of heroin use has increased over the past decade with larger numbers of users presenting for treatment of drug use disorders. A host of serious infections can result from IDU. Prevention and early intervention with evidence-based harm-reduction strategies are crucial to reducing and eliminating these odious consequences.

Prevalence of hepatitis C among injection drug users in England and Wales: is harm reduction working?

OBJECTIVES

This study sought to establish the prevalence of hepatitis C antibodies (anti-HCV) and hepatitis B antibodies (anti-HBc) among injection drug users in England and Wales.

METHODS

A voluntary cross-sectional survey collected oral fluid samples and behavioral information; 2203 injectors were recruited through drug agencies, and 758 were recruited in the community.

RESULTS

Prevalence was 30% for anti-HCV, 21% for anti-HBc, and 0.9% for HIV antibodies. Anti-HCV prevalence rates were significantly greater among those with longer injecting careers, those in older age groups, those residing in London, those recruited in drug agencies, those positive for anti-HBc, and those with a previous voluntary HIV test.

CONCLUSIONS

Anti-HCV prevalence rates among injectors in England and Wales, where comprehensive harm reduction programs exist, are lower than rates in other industrialized countries.