Continuing HIV risk in New York City injection drug users: the association of syringe source and syringe sharing

Housing-based syringe services programs to improve access to safer injecting equipment for people who inject drugs in Vancouver, Canada: a spatially oriented qualitative study

BACKGROUND

Housing environments shape injection drug-related risks and harms and thus represent a critical implementation setting for syringe services programs (SSPs). As critical harm reduction measures, SSPs provide safe injecting equipment to people who inject drugs (PWID). Vancouver, Canada, has well-established syringe distribution programs through which PWID have low-threshold access to unlimited syringes and related injecting equipment, including through non-profit operated supportive housing and single-room occupancy hotels. This study examines the role of housing-based SSPs in distributing injecting equipment to PWID in Vancouver.

METHODS

Between January and March 2020, semi-structured, in-depth interviews were conducted in Vancouver with 26 PWID. Interviews were audio-recorded, transcribed, and coded. Salient themes were identified using inductive and deductive approaches.

RESULTS

Many participants accessed SSPs in housing facilities and expressed preference for these programs over those offered at other locations and through other health and social services. Three major themes emerged to explain this preference. First, most participants injected in the buildings where they resided, and housing-based SSPs made injecting equipment available when and where it was most needed. Second, many participants preferred to avoid carrying syringes outside of the places where they inject due to fears that syringe possession may lead to criminal charges or confiscation of syringes and/or illicit drugs by police. Third, for some participants, anti-drug user stigma and concerns over unwillingly disclosing their drug use hindered access to SSPs outside of housing settings. Programs operated within housing facilities often offered greater client anonymity along with more supportive and less stigmatizing environments, particularly in the presence of peer staff.

CONCLUSION

The current study advances understanding of access to injecting equipment in a setting with city-wide syringe distribution programs. Our findings underscore the benefits of housing-based SSPs and encourage the expansion of such services to maximize access to harm reduction supports for PWID.

Consider the Source: Associations between Syringe Sources and Risky Injection Behaviors in California's Central Valley

BACKGROUND

Sterile syringe access is critical to prevent serious viral and bacterial infections among people who inject drugs (PWID) but many areas across the United States lack sufficient access. Although California law allows nonprescription pharmacy syringe sales and syringe services programs (SSPs), access gaps remain in the largely rural Central Valley.

OBJECTIVE

The purpose of this study was to examine syringe access and related injection behaviors among PWID in Fresno, California.

METHODS

We used respondent driven sampling to recruit 494 individuals for a survey about syringe access and injection behaviors between April and September 2016. Participants were ≥18 years old and injected at least twice in the past 30 days. Descriptive statistics examined syringe access and logistic regression determined if discrete syringe source categories were significantly associated with syringe sharing and/or reuse.

RESULTS

A majority (67%) obtained syringes from an authorized source; SSPs were most common (59%), while few reported pharmacy purchase (14%). Unauthorized sources were even more common (79%), primarily friends (64%) or someone on the street (37%). Compared to PWID who used only authorized sources, those using only unauthorized sources had a higher odds of syringe sharing (AOR = 3.40, 95% CI: 1.66, 6.95) and syringe reuse (AOR = 6.22; 95% CI: 2.24, 17.29), as did those who reported mixed sources (AOR = 3.78; 95% CI: 1.90, 7.54 and AOR = 4.64; 95% CI: 2.08, 10.35).

CONCLUSIONS

Our findings demonstrate a need to expand syringe access in nonurban California to prevent the syringe sharing and reuse that contributes to serious viral and bacterial infections among PWID.

Estimating Hidden Population Sizes with Venue-based Sampling: Extensions of the Generalized Network Scale-up Estimator

BACKGROUND

Researchers use a variety of population size estimation methods to determine the sizes of key populations at elevated risk of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), an important step in quantifying epidemic impact, advocating for high-risk groups, and planning, implementing, and monitoring prevention, care, and treatment programs. Conventional procedures often use information about sample respondents' social network contacts to estimate the sizes of key populations of interest. A recent study proposes a generalized network scale-up method that combines two samples-a traditional sample of the general population and a link-tracing sample of the hidden population-and produces more accurate results with fewer assumptions than conventional approaches.

METHODS

We extended the generalized network scale-up method from link-tracing samples to samples collected with venue-based sampling designs popular in sampling key populations at risk of HIV. Our method obviates the need for a traditional sample of the general population, as long as the size of the venue-attending population is approximately known. We tested the venue-based generalized network scale-up method in a comprehensive simulation evaluation framework.

RESULTS

The venue-based generalized network scale-up method provided accurate and efficient estimates of key population sizes, even when few members of the key population were sampled, yielding average biases below ±6% except when false-positive reporting error is high. It relies on limited assumptions and, in our tests, was robust to numerous threats to inference.

CONCLUSIONS

Key population size estimation is vital to the successful implementation of efforts to combat HIV/AIDS. Venue-based network scale-up approaches offer another tool that researchers and policymakers can apply to these problems.

Web-Based Eligibility Quizzes to Verify Opioid Use and County Residence Among Rural Young Adults: Eligibility Screening Results from a Feasibility Study

Background

Web-based methods can be used to collect data from hidden populations, including people who use drugs (PWUD). These methods might be especially advantageous among PWUD in rural areas, where transportation barriers are prevalent, stigma may heighten concerns about confidentiality, and internet access is improving. However, Web-based research with PWUD can be challenging, especially in verifying eligibility. Administering quizzes to verify residential and substance use eligibility could prove valuable in online research among PWUD, yet the utility of this approach is currently unknown.

Objective

This study describes the implementation of online eligibility quizzes about the local community to verify residence in the target study area along with drug dose, appearance, and price to verify opioid misuse.

Methods

To be eligible, individuals had to live in 1 of 5 eastern Kentucky counties, report using opioids to get high in the past 30 days, and be 18 to 35 years old. Participants recruited from August 2017 to July 2018 were asked questions about their opioid use followed by a quiz about drug dose, appearance, and price to verify substance use eligibility. Residential eligibility was verified with 5-question quizzes assessing knowledge of the county where they reported living. Questions tested knowledge about towns, festivals, and landmarks; local school mascots and colors; and presence of certain retail stores, restaurants, and facilities (eg, jails). A subsample that reported using opioids in the past 24 hours was randomly selected to complete urine drug testing (UDT). Nonparametric tests were performed to explore differences across demographic subgroups.

Results

Of the 410 entries assessed for eligibility, 39.3% (161/410) were ineligible as they reported no substance use, being outside the age range, or living outside the study area. Of the remaining 249 who met the eligibility criteria based on age, residency, and opioid misuse, 94.0% (234/249) passed the eligibility quizzes. Among those who passed the heroin quiz, 99.4% (167/168) recognized the image of powdered heroin, 94.6% (159/168) answered the cap size (ie, the purchase unit) question correctly, and 97.0% (163/168) answered the street price question correctly. Among those who passed the drug quiz for prescription opioids, 95% (36/38) answered the dose question correctly, and 82% (31/38) selected the correct image. In a random sample of participants who completed UDT within 3 days of their online screening, 74% (25/34) tested positive for an opioid.

Conclusions

This study demonstrated the utility of using online eligibility screening quizzes to verify opioid misuse and residence. Participants accurately recognized heroin and prescription opioid doses, prices, and images and correctly answered questions about features of their county. Online quizzes to screen and enroll PWUD hold promise for future research as an alternative to more time- and resource-intensive approaches that could offset the advantages of Web-based methods.

Syringe sharing among people who inject drugs in London, Canada

OBJECTIVES

London, Ontario, is facing an outbreak of HIV among people who inject drugs (PWID), as well as persistently high levels of hepatitis C virus (HCV). Syringe sharing is the primary driver of HIV and HCV transmission risks among PWID, however, little is known about factors contributing to syringe sharing in this setting. Therefore, we sought to characterize syringe sharing and its correlates among London PWID.

METHODS

Between March and April, 2016, PWID participated in a survey administered by peer research associates as part of the Ontario Integrated Supervised Injection Services Feasibility Study. Bivariable and multivariable logistic regression models examined associations with syringe sharing (borrowing or lending previously used syringes) over the previous 6 months. A sub-analysis described patterns of borrowing and lending by self-reported HIV and HCV statuses.

RESULTS

Of 198 PWID, 44 (22%) reported syringe sharing in the past 6 months. In the multivariable analysis, selling drugs (adjusted odds ratio; AOR = 1.92, 95% CI = 1.20-3.08), daily crystal methamphetamine injection (AOR = 1.66, 95% CI = 1.07-2.59), and identifying as HIV-positive (AOR = 3.11, 95% CI = 1.61-6.01) were independently associated with increased syringe sharing. While not independently associated with syringe sharing, problems accessing syringes were common (13-50%). Self-reported HIV-positive respondents were more likely to report syringe borrowing (p < 0.001), but not lending (p = 0.26).

CONCLUSION

We observed a high rate of syringe sharing among London PWID, with sharing being associated with high-intensity injection of crystal methamphetamine, as well as with involvement in drug sales. Considering the current HIV outbreak in London, multi-level prevention efforts are urgently needed.

Optimal allocation of HIV prevention funds for state health departments

OBJECTIVE

To estimate the optimal allocation of Centers for Disease Control and Prevention (CDC) HIV prevention funds for health departments in 52 jurisdictions, incorporating Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program funds, to improve outcomes along the HIV care continuum and prevent infections.

METHODS

Using surveillance data from 2010 to 2012 and budgetary data from 2012, we divided the 52 health departments into 5 groups varying by number of persons living with diagnosed HIV (PLWDH), median annual CDC HIV prevention budget, and median annual HRSA expenditures supporting linkage to care, retention in care, and adherence to antiretroviral therapy. Using an optimization and a Bernoulli process model, we solved for the optimal CDC prevention budget allocation for each health department group. The optimal allocation distributed the funds across prevention interventions and populations at risk for HIV to prevent the greatest number of new HIV cases annually.

RESULTS

Both the HIV prevention interventions funded by the optimal allocation of CDC HIV prevention funds and the proportions of the budget allocated were similar across health department groups, particularly those representing the large majority of PLWDH. Consistently funded interventions included testing, partner services and linkage to care and interventions for men who have sex with men (MSM). Sensitivity analyses showed that the optimal allocation shifted when there were differences in transmission category proportions and progress along the HIV care continuum.

CONCLUSION

The robustness of the results suggests that most health departments can use these analyses to guide the investment of CDC HIV prevention funds into strategies to prevent the most new cases of HIV.

Drug and sexual HIV risk behaviours related to knowledge of HIV serostatus among injection drug users in Houston, Texas

This study examines the association between drug and sexual HIV risk behaviours and knowledge of HIV serostatus among a sample of injection drug users, recruited into the 2009 National HIV Behavioral Surveillance project. We calculated prevalence ratios and associated 95% confidence intervals of reporting a given risk behaviour comparing injection drug users unaware of their serostatus and HIV-negative to HIV-positive injection drug users. Of 523 participants, 21% were unaware of their HIV serostatus. The three groups were not different from each other in terms of drug-use behaviours; however, injection drug users unaware of their HIV serostatus were 33% more likely to report having more than three sexual partners in the past 12 months and 45% more likely to report having unprotected sex compared to HIV-positive injection drug users. We observed markedly higher prevalence of sexual risk behaviours among injection drug users unaware of their serostatus, but drug-use risk behaviours were similar across the groups.

Novel use of surveillance data to detect HIV-infected persons with sustained high viral load and durable virologic suppression in New York City

BACKGROUND

Monitoring of the uptake and efficacy of ART in a population often relies on cross-sectional data, providing limited information that could be used to design specific targeted intervention programs. Using repeated measures of viral load (VL) surveillance data, we aimed to estimate and characterize the proportion of persons living with HIV/AIDS (PLWHA) in New York City (NYC) with sustained high VL (SHVL) and durably suppressed VL (DSVL).

METHODS/PRINCIPAL FINDINGS

Retrospective cohort study of all persons reported to the NYC HIV Surveillance Registry who were alive and ≥12 years old by the end of 2005 and who had ≥2 VL tests in 2006 and 2007. SHVL and DSVL were defined as PLWHA with 2 consecutive VLs ≥100,000 copies/mL and PLWHA with all VLs ≤400 copies/mL, respectively. Logistic regression models using generalized estimating equations were used to model the association between SHVL and covariates. There were 56,836 PLWHA, of whom 7% had SHVL and 38% had DSVL. Compared to those without SHVL, persons with SHVL were more likely to be younger, black and have injection drug use (IDU) risk. PLWHA with SHVL were more likely to die by 2007 and be younger by nearly ten years, on average.

CONCLUSIONS/SIGNIFICANCE

Nearly 60% of PLWHA in 2005 had multiple VLs, of whom almost 40% had DSVL, suggesting successful ART uptake. A small proportion had SHVL, representing groups known to have suboptimal engagement in care. This group should be targeted for additional outreach to reduce morbidity and secondary transmission. Measures based on longitudinal analyses of surveillance data in conjunction with cross-sectional measures such as community viral load represent more precise and powerful tools for monitoring ART effectiveness and potential impact on disease transmission than cross-sectional measures alone.

Potential role of safer injection facilities in reducing HIV and hepatitis C infections and overdose mortality in the United States

BACKGROUND

Safer injection facilities (SIFs) reduce risks associated with injecting drugs, particularly public injection and overdose mortality. They exist in many countries, but do not exist in the United States. We assessed several ethical, operational, and public health considerations for establishing SIFs in the United States.

METHOD

We used the six-factor Kass framework (goals, effectiveness, concerns, minimization of concerns, fair implementation, and balancing of benefits and concerns), summarized needs of persons who inject drugs in the United States, and reviewed global evidence for SIFs.

RESULTS

SIFs offer a hygienic environment to inject drugs, provide sterile injection equipment at time of injection, and allow for safe disposal of used equipment. Injection of pre-obtained drugs, purchased by persons who inject drugs, happens in a facility where trained personnel provide on-site counseling and referral to addiction treatment and health care and intervene in overdose emergency situations. SIFs provide positive health benefits (reducing transmission of HIV and viral hepatitis, bacterial infections, and overdose mortality) without evidence for negative health or social consequences. SIFs serve most-at-risk persons, including those who inject in public or inject frequently, and those who do not use other public health programs. It is critical to address legal, ethical, and local concerns, develop and implement relevant policies and procedures, and assess individual- and community-level needs and benefits of SIFs given local epidemiologic data.

CONCLUSIONS

SIFs have the potential to reduce viral and bacterial infections and overdose mortality among those who engage in high-risk injection behaviors by offering unique public health services that are complementary to other interventions.

Current and emerging research needs in studying the NYC HIV-drug use epidemic

As we begin the fourth decade of the epidemic, it is clear that, as demonstrated by the articles in this Special Issue, much has been learned about factors contributing to the decline in HIV prevalence among drug users in New York. However, there are a number of outstanding research questions that remain or are emerging. Following is a summary of some of the topics requiring further research. While this summary does not represent a comprehensive list, it is based on many of the questions raised in the articles in this Special Issue and identifies some of the directions to be investigated during the next decade.