Positive effects of community attachment on internalised stigma and wellbeing among people who inject drugs

BACKGROUND

Internalised stigma experienced by people who inject drugs (PWID) is known to have negative health consequences. Research has explored factors that may protect or buffer individuals from the negative consequences of internalised stigma. Community attachment, or perceived connection to a community of like people, can have numerous health-related benefits. However, this relationship may be complex for PWID; being part of a social network of PWID may provide opportunity for more frequent drug use and equipment sharing. This study investigated the relationships between community attachment, internalised stigma, and wellbeing among PWID, while also addressing potential health risks associated with PWID community attachment.

METHODS

PWID (n=603) were recruited through nine peer-based drug user organisations across Australia with assistance from the peak consumer organisation. Participants completed a survey measuring community attachment, internalised stigma, personal wellbeing, injecting frequency, and equipment sharing.

RESULTS

Greater attachment to a PWID community was associated with lower internalised stigma, but also with sharing of injecting equipment and increased frequency of injecting behaviour. The relationship between community attachment and personal wellbeing was mediated by internalised stigma, however this was only the case for PWID who reported no sharing of injecting equipment.

CONCLUSIONS

This research highlights the significance of community attachment for PWID while also noting the complexity of this relationship and the potential negative consequences. It is important to view networks of PWID communities as sources of positive social capital, where norms about health behaviours and harm reduction can be promoted and which can buffer community members from the harms associated with stigma.

Baseline prevalence and correlates of HIV and HCV infection among people who inject drugs accessing a syringe services program; Miami, FL

Background

Blood-borne viral infections, such as HIV and hepatitis C (HCV), are common infections among people who inject drugs (PWID). This study aims to determine the prevalence of HIV and HCV infection among PWID accessing the first legal syringe services program (SSP) in the state of Florida, along with examining baseline correlates of HIV and HCV infection.

Methods

Baseline behavioral enrollment assessments of 837 participants accessing an SSP for the first time were analyzed. Patients self-reporting or testing HIV or HCV positive at the enrollment visit were included. Socio-demographic, drug use, and injection-related risk behaviors in the last 30 days were compared across groups defined by all combinations of HIV and HCV serostatus.

Bivariate and multivariable logistic regression models were used to assess correlates of baseline HCV and HIV infection independently.

Results

Overall prevalence for HCV and HIV infection were 44.4% and 10.2%, respectively. After adjusting for confounders, the most significant correlates of baseline HCV infection were age (aOR = 1.01), lower education level (aOR = 1.13), currently homeless (aOR = 1.16), injecting more than seven times a day (aOR = 1.14), reusing syringes (aOR = 1.18), and sharing injection equipment (aOR = 1.13). The most significant predictors of baseline HIV infection were age (aOR = 1.01), non-Hispanic Black race (aOR = 1.28), Hispanic ethnicity (aOR = 1.12), gay or bisexual orientation (aOR = 1.22), and methamphetamine injection (aOR = 1.22). In addition, heroin injection (aOR = 0.92) was significantly associated with a lower odds of HIV infection.

Discussion/conclusion

Baseline behavioral predictors differed between HIV infection and HCV infection among participants accessing syringe services. Understanding the risk factors associated with each infection should be considered when developing additional harm reduction interventions tailored for diverse PWID populations served at SSPs.

Maintaining the healthy body: Blood management and hepatitis C prevention among men who inject performance and image-enhancing drugs

Australia's ambitious aim to 'eliminate' hepatitis C as a public health concern by 2030 requires researchers, policy makers and health practitioners to engage with populations rarely identified as a priority. Men who inject performance and image-enhancing drugs (PIEDs) are one such population, yet research suggests they have low rates of knowledge about hepatitis C. Although rates of needle-sharing in this group are thought to be low, other risks of blood-to-blood contact exist due to the use of large-gauge needles, intramuscular injecting, hard-to-reach injection sites, repeated injecting and peer-to-peer injecting. How should health initiatives engage people who might not customarily consider themselves vulnerable to hepatitis C? Drawing on the work of body theorist Margrit Shildrick, this article considers how men who inject PIEDs understand their bodies, with a particular focus on injecting practices, blood awareness and infection control, in order to inform hepatitis C prevention efforts. In our analysis, we draw on qualitative interviews with 60 men who inject PIEDs, which we conducted for an Australian Research Council-funded project focused on better understanding PIED injecting to improve health and minimise hepatitis C transmission. The interviews suggest that men who inject PIEDs closely monitor potential external infection risks, such as dirt and bacteria that might intrude upon the 'purity and security' of the body. However, less attention appears to be paid to what might be transferred out of the body and potentially to others, such as blood. Notions of trust and cleanliness, and normative perceptions of intravenous drug use, also shaped injecting practices and cursory attention to blood management. While environmental transmission poses a smaller transmission risk than needle-sharing, educating PIED consumers about it is nevertheless warranted. Focusing targeted health promotion materials on environmental blood as a potential route of hepatitis C transmission may help engage this population in prevention, and encourage more frequent hepatitis C testing.

High HIV seroconversion rate in hepatitis C virus-infected drug users followed in a harm reduction unit: a lost opportunity for preexposure prophylaxis

OBJECTIVES

Current harm reduction strategies will probably remain insufficient to eliminate HIV transmission among drug users. We aimed to estimate the HIV seroconversion rate among drug users followed at a harm reduction unit (HRU) to evaluate the potential use of preexposure prophylaxis as a prevention tool.

DESIGN AND METHODS

A cohort of drug users has been followed at an HRU in Madrid between 2013 and 2016. Individuals who were HIV negative at baseline and who had at least one retest for HIV infection were eligible. Kaplan-Meier methods were employed to estimate the incidence density.

RESULTS

A total of 954 drug users had at least an HIV test. At baseline, 260 were HIV negative and had at least one follow-up HIV test. After 330.89 person-years of risk for HIV infection, 10 (3.8%) seroconverted. Overall incidence density of HIV seroconversion was 3.02 [95% confidence interval (CI); 1.4-5.5] per 100 person-years, with differences according to hepatitis C virus (HCV) serostatus: 1.17 (95% CI; 0.1-4.2) per 100 person-years in negative HCV individuals and 4.98 (95% CI; 2.1-9.8) per 100 person-years in positive HCV individuals. In the multivariable analysis, infection with HCV remained independently associated with time to HIV seroconversion (adjusted hazard ratio = 6.43; 95% CI; 1.1-36.5, P = 0.035).

CONCLUSION

Despite efforts in HIV prevention in a HRU, a high incidence of HIV was found among active drug users. Positive HCV status is a strong predictor of HIV seroconversion. In this context, preexposure prophylaxis implementation should be considered as an additional tool for HIV prevention in this population.

Evaluation of a hepatitis C education intervention with clients enrolled in methadone maintenance and needle/syringe programs in Malaysia

BACKGROUND

Approximately 40%-90% of people who inject drugs (PWID) in Malaysia have hepatitis C (HCV). PWID continue to be disproportionately affected by HCV due to their lack of knowledge, perceived risk and interest in HCV treatment. Education interventions may be an effective strategy for increasing HCV knowledge in PWID, and harm reduction services are uniquely positioned to implement and deploy such interventions.

METHODS

We recruited 176 clients from methadone maintenance treatment (MMT: N=110) and needle/syringe programs (NSP: N=66) between November 2015 and August 2016. After baseline knowledge assessments, clients participated in a standardized, 45-min HCV education program and completed post-intervention knowledge assessments to measure change in knowledge and treatment interest.

RESULTS

Participants were mostly male (96.3%), Malay (94.9%), and in their early 40s (mean=42.6years). Following the intervention, overall knowledge scores and treatment interest in MMT clients increased by 68% and 16%, respectively (p<0.001). In contrast, NSP clients showed no significant improvement in overall knowledge or treatment interest, and perceived greater treatment barriers. Multivariate linear regression to assess correlates of HCV knowledge post-intervention revealed that optimal dosage of MMT and having had an HIV test in the past year significantly increased HCV knowledge. Having received a hepatitis B vaccine, however, was not associated with increased HCV knowledge after participating in an education session.

CONCLUSION

Generally, HCV knowledge and screening is low among clients engaged in MMT and NSP services in Malaysia. Integrating a brief, but comprehensive HCV education session within harm reduction services may be a low-cost and effective strategy in improving overall HCV knowledge and risk behaviors in resource-limited settings. In order to be an effective public health approach, however, education interventions must be paired with strategies that improve social, economic and political outcomes for PWID. Doing so may reduce HCV disparities by increasing screening and treatment interest.

Value of Comprehensive HCV Treatment among Vulnerable, High-Risk Populations

OBJECTIVES

The objective of this study was to explore the trade-offs society and payers make when expanding treatment access to patients with chronic hepatitis C virus (HCV) infection in early stages of disease as well as to vulnerable, high-risk populations, such as people who inject drugs (PWID) and HIV-infected men who have sex with men (MSM-HIV).

METHODS

A discrete time Markov model simulated HCV progression and treatment over 20 years. Population cohorts were defined by behaviors that influence the risk of HCV exposure: PWID, MSM-HIV, an overlap cohort of individuals who are both PWID and MSM-HIV, and all other adults. Six different treatment scenarios were modeled, with varying degrees of access to treatment at different fibrosis stages and to different risk cohorts. Benefits were measured as quality-adjusted life-years and a $150,000/quality-adjusted life-year valuation was used to assess social benefits.

RESULTS

Compared with limiting treatment to METAVIR fibrosis stages F3 or F4 and excluding PWID, expanding treatment to patients in all fibrosis stages and including PWID reduces cumulative new infections by 55% over a 20-year horizon and reduces the prevalence of HCV by 93%. We find that treating all HCV-infected individuals is cost saving and net social benefits are over $500 billion greater compared with limiting treatment. Including PWID in treatment access saves 12,900 to 41,200 lives.

CONCLUSIONS

Increased access to treatment brings substantial value to society and over the long-term reduces costs for payers, as the benefits accrued from long-term reduction in prevalent and incident cases, mortality, and medical costs outweigh the cost of treatment.

The Role of Civil Disobedience in Drug Policy Reform: How an Illegal Safer Injection Room Led to a Sanctioned, ‘Medically Supervised Injection Center

In shooting galleries, drug users are able to illegally rent cubicles to inject drugs. Established in Kings Cross, Sydney in the early 1990s, police grudgingly tolerated several such galleries. In 1997, a royal commission recommended that a parliamentary inquiry consider establishing an official medically supervised injecting center (MSIC). Despite strong evidence supporting an MSIC, a majority of the committee voted against a trial facility. As an act of civil disobedience, a group of concerned citizens established an unsanctioned MSIC. However, police soon closed the facility. At a subsequent parliamentary drug summit, delegates voted to support an official trial of an MSIC and invited a congregation of Roman Catholic nuns to establish the facility. When the nuns were instructed to withdraw, the Uniting Church was invited to establish the project. The MSIC opened in May 2001. It can be concluded that public health practitioners wishing to improve appalling outcomes from drug policies sometimes have to resort to civil disobedience in order to achieve their goals.

‘You Sort of Switch Off’: Exploring Mindlessness in Injecting Drug Users’ Accounts of Blood

Risk of blood borne virus among injecting drug users is high and is a significant challenge for public health efforts. Mindlessness/mindfulness theory provides an alternative lens through which to understand social phenomena. Interview transcripts of 32 current and former injectors were explored for evidence of mindless injecting (or automatic behaviour). Mindlessness in injecting practices can be important as opportunities to reduce injecting risk can emerge from understanding ‘expert’ approaches to injecting. Further work is required to generate fuller understandings of this construct on injecting drug use and to incorporate carefully and sensitively this tool into health promotion efforts.

Hepatitis C virus and HIV seroprevalences, sociodemographic characteristics, behaviors and access to syringes among drug users, a comparison of geographical areas in France, ANRS-Coquelicot 2011 survey

BACKGROUND

People who use drugs (PWUDs) are at a high risk for hepatitis C virus (HCV) and human immunodeficiency virus (HIV), but they have different characteristics depending on the local context. In France, seroprevalence, sociodemographic, and behavior information have only been studied at a national level rather than at a local level. The aim of this study was to describe and examine profile and drug use practice differences in seven French cities and departments and to assess whether these differences can explain HCV and HIV seroprevalence variations between French geographical areas.

METHODS

Data were collected from the cross-sectional ANRS-Coquelicot survey conducted for the second time in 2011 among drug users having injected or snorted drugs at least once in their life. Professional interviewers administrated a face-to-face questionnaire in six different areas in France: Paris, Marseille, Bordeaux, Lille, Strasbourg and the Seine-Saint-Denis department (Paris suburbs). Participants were asked to self-collect a fingerpick blood sample in order to search for the presence of anti-HIV and anti-HCV antibodies and to estimate seroprevalence in PWUDs.

RESULTS

Overall, HCV and HIV seroprevalence was 44% [95% CI: 39.6-47.9] and 10% [95% CI: 7.5-12.6] respectively. The highest HCV seroprevalence was 56% in Marseille and the lowest was 24% in Bordeaux and for HIV the highest was 18% in Seine-Saint-Denis and the lowest was 0% in Lille. The population's age differed between areas and could mostly explain HCV seroprevalence variation but not exclusively. Profiles and practices, different in each area, can also explain this variation. In multivariate analysis, HCV seroprevalence was lower in Bordeaux (prevalence ratio [PR]=0.64), Strasbourg (PR=0.76), and Seine-Saint-Denis (PR=0.8) than in Paris. Nearly one-third of injectors declared having had difficulties to obtain syringes in the 6 previous months, but disparities existed between areas.

CONCLUSION

HCV risk exposure in PWUDs remains high in France and varies between different areas. Innovative harm reduction strategies including educative programs about safe injecting and supervised consumption rooms need to be developed.

Políticas de redução de danos no Brasil

Considerando a disseminação da epidemia de HIV e o controle de sua transmissão entre usuários de drogas injetáveis (UDI), estratégias de redução de danos foram incorporadas em diversos países, incluindo o Brasil. Considerando a emergência das drogas como tema central na agenda governamental, especialmente o crack, o presente artigo registra e discute as práticas observadas em um programa de pesquisa e atenção aos UDI: o UFO. Foram considerados aspectos tais como acesso e adesão do usuário, dificuldades de financiamento, sustentabilidade e avaliação de resultados. As etapas do estudo envolveram pesquisa documental, observação sistemática e entrevistas com informantes-chave. Destacamos características do UFO que poderiam contribuir para políticas de redução de danos no cenário brasileiro. O programa estudado se apresenta como um exemplo exitoso de iniciativas de redução de danos, obtendo sucesso no acesso e adesão desse grupo, favorecendo seu acesso aos serviços de saúde e prevenção de riscos associados ao uso de drogas.

The relationship between alcohol use and injecting drug use: impacts on health, crime and wellbeing

BACKGROUND AND OBJECTIVES

People who inject drugs (PWID) are at risk of a variety of adverse outcomes. Previous research suggests that alcohol, when consumed with opioids, is a risk factor for overdose, but there has been less investigation of the effects of alcohol consumption on other health, criminogenic or life satisfaction outcomes. In this paper we explore the effects of alcohol on outcomes for PWID across a variety of life domains.

METHODS

Baseline data were drawn from the Melbourne Injecting Drug User cohort study, which is a cohort of 688 PWID. Drinking scores were generated from the AUDIT-C (0, 1-7, 8+) and associations between them and health (recent heroin overdose, Emergency Department use), criminogenic (violent and nonviolent crime) and life satisfaction (personal wellbeing) outcomes were examined using logistic and linear regression.

RESULTS

While around 36% of the cohort reported past-month abstinence from alcohol, 44% scored between 1 and 7 and 20% above 7 on the AUDIT-C. A score above 7 was associated with perpetration of violent crime and lower personal wellbeing ratings than a score of 0, after adjusting for potential confounders. There was no association between alcohol and other outcomes examined, after adjustment for confounders.

CONCLUSION

Cohort participants who drink heavily were more likely to report engaging in violent crime and poorer life satisfaction. The relationship between alcohol and the offending behaviours of the cohort was consistent with the effects of alcohol on violent offending in the broader community.

Alcohol and other drug use, club drug dependence and treatment seeking among lesbian, gay and bisexual young people in Sydney

INTRODUCTION AND AIMS

Substance use and substance use problems are often more prevalent in same-sex attracted young people (SSAY), yet little to date has been published about substance use and problems in this population in Australia. This paper aimed to characterise patterns of alcohol use, club drug use and dependence, injecting drug use and engagement with treatment services, comparing lesbians, gay men, bisexual women and bisexual men.

DESIGN AND METHODS

A cross-sectional, online survey was conducted with 572 SSAY in Sydney, aged 18 to 25 years. The Alcohol Use Disorders Identification Test--Consumption questions (AUDIT-C) assessed hazardous alcohol use, and the Severity of Dependence Scale assessed club drug dependence.

RESULTS

Seventy per cent of respondents had AUDIT-C scores indicative of hazardous alcohol use, and 29% of respondents had used club drugs in the previous 6 months. Multivariate logistic regression showed that male respondents had a lower odds of hazardous alcohol use (adjusted odds ratio = 0.6, 95% confidence interval 0.4-0.9), but a higher odds of recent club drug use (adjusted odds ratio = 1.8, 95% confidence interval 1.2-2.7). Methamphetamine dependence was reported among half of respondents who reported use in the previous 6 months. Bisexual women were more likely than other respondents to have sought treatment for alcohol and other drug use, and overall treatment utilisation was low (6%).

DISCUSSION AND CONCLUSIONS

This study reports high rates of drinking and club drug use, and a possible underutilisation of alcohol and other drug treatment. The findings suggest that SSAY in Sydney may be at a high risk of alcohol- and drug-related harm.

Low dead-space syringes for preventing HIV among people who inject drugs: promise and barriers

PURPOSE OF REVIEW

This review examines evidence regarding the differential effects of high dead-space syringes (HDSS) and low dead-space syringes (LDSS) on HIV transmission among people who inject drugs (PWID). It also identifies areas for additional research and examines potential barriers to interventions that promote LDSS.

RECENT FINDINGS

Results of laboratory experiments and cross-sectional bio-behavioral surveys provide circumstantial evidence that the probability of HIV transmission associated with sharing LDSS is less than the probability of HIV transmission associated with sharing HDSS. Mathematical models suggest that LDSS may prevent injection-related HIV epidemics among PWID.

SUMMARY

Circumstantial evidence suggests that LDSS may substantially reduce HIV transmission among PWID, who share syringes. Additional research that links LDSS to reductions in HIV incidence is needed. Most currently available LDSS are 1 ml or smaller and have fixed needles. These cannot be used by PWID 'injecting' larger volumes of fluid and they may be rejected by PWID, who prefer syringes with detachable needles. Nonetheless, LDSS represent a potentially promising intervention that deserves serious consideration.

Individual-level syringe coverage among Needle and Syringe Program attendees in Australia

BACKGROUND

Harm associated with injecting drug use is a significant public health issue and a major cause of morbidity and mortality, with global estimates of 3 million injectors infected with HIV and 8 million living with chronic hepatitis C virus (HCV) infection. Estimates of program coverage are widely used in the context of HIV prevention and are critical in determining the effectiveness of interventions such as Needle and Syringe Programs (NSPs).

METHODS

Data from a national cross-sectional study of NSP attendees in Australia were used to estimate individual-level syringe coverage as a proportion of monthly injections covered by a new syringe. Univariate and multivariate logistic regressions modelled associations between demographics, injecting risk, anti-HIV and HCV prevalence and syringe coverage. The median number of syringes retained per NSP attendee per annum was also estimated.

RESULTS

Twenty percent of participants had insufficient new syringes for all injections. Syringe reuse (including reuse of one's own syringe) was independently associated with syringe coverage of <100%. Conversely, procurement of syringes from an NSP was independently associated with syringe coverage ≥100%, with a greater protective effect occurring when NSP utilisation was combined with current engagement in opiate substitution therapy. The median number of syringes retained per participant per annum was 720, equivalent to 2 per day.

CONCLUSIONS

While Australian NSP attendees report high syringe coverage by international standards, prevention efforts could be scaled up. Syringe reuse was associated with syringe coverage of <100%, suggesting the utility of reuse as a proxy for individual-level syringe coverage.

Minimal transmission of HIV despite persistently high transmission of hepatitis C virus in a Swedish needle exchange program

The aim of this study was to examine the prevalence and incidence of HIV and hepatitis B and C (HBV and HCV) among injecting drug users in a Swedish needle exchange programme (NEP) and to identify risk factors for blood-borne transmission. A series of serum samples from NEP participants enrolled from 1997 to 2005 were tested for markers of HIV, HBV and HCV (including retrospective testing for HCV RNA in the last anti-HCV-negative sample from each anti-HCV seroconverter). Prevalence and incidence were correlated with self-reported baseline characteristics. Among 831 participants available for follow-up, one was HIV positive at baseline and two seroconverted to anti-HIV during the follow-up of 2433 HIV-negative person-years [incidence 0.08 per 100 person-years at risk (pyr); compared to 0.0 in a previous assessment of the same NEP covering 1990-1993]. The corresponding values for HBV were 3.4/100 pyr (1990-1993: 11.7) and for HCV 38.3/100 pyr (1990-1993: 27.3). HCV seroconversions occurred mostly during the first year after NEP enrolment. Of the 332 cases testing anti-HCV negative at enrolment, 37 were positive for HCV RNA in the same baseline sample (adjusted HCV incidence 31.5/100 pyr). HCV seroconversion during follow-up was significantly associated with mixed injection use of amphetamine and heroin, and a history of incarceration at baseline. In this NEP setting, HIV prevalence and incidence remained low and HBV incidence declined because of vaccination, but transmission of HCV was persistently high. HCV RNA testing in anti-HCV-negative NEP participants led to more accurate identification of timepoints for transmission.

Saúde pública, redução de danos e a prevenção das infecções de transmissão sexual e sanguínea: revisão dos principais conceitos e sua implementação no Brasil

Este artigo aborda o contexto histórico e o marco conceitual da implantação dos programas de redução de danos no campo da saúde pública, com ênfase nos programas brasileiros. A presente revisão teve como objetivo principal investigar a pertinência atual de tais programas no enfrentamento das infecções de transmissão sexual e sanguínea, em especial, a AIDS e a hepatite C. Os resultados sistematizados pela literatura nacional e internacional indicam que as ações práticas de redução de danos são mais efetivas quando integradas a outras medidas de saúde pública, guiadas por princípios em comum. Iniciativas de redução de danos afinadas com princípios de saúde pública não se prendem a modelos, nem se esgotam em cuidados de saúde propriamente ditos. Abrangem diversas modalidades de ações pragmáticas, com base em políticas públicas, devem estar em sintonia com a comunidade desde seu planejamento, e serem executadas em parceria com esta.

Qualitative accounts of needle and syringe cleaning techniques among people who inject drugs in Sydney, Australia

INTRODUCTION AND AIMS

Cleaning needles/syringes is an important second-line harm reduction strategy, yet there is limited information on practices employed by people who inject drugs in Australia. This study attempts to identify and assess cleaning practices in terms of the techniques involved and the social contexts in which cleaning takes place.

DESIGN AND METHODS

As part of an exploratory qualitative study in south-west Sydney, in-depth interviews and simulated cleaning exercises were conducted with 12 people who inject drugs. Interviews were digitally recorded and transcribed verbatim. Open coding was used to inductively classify data into themes, and data were examined for patterns and variations in the relationships within and between themes.

RESULTS

Data indicate that cleaning and reuse of needles/syringes was common in this small sample. The most frequently utilised reagent was cool water. While all participants reported cleaning and reusing only their own equipment, none of the techniques demonstrated would have been sufficient to deactivate human immunodeficiency virus or hepatitis C virus.

DISCUSSION AND CONCLUSIONS

Results suggest that even where cleaning of needles and syringes is widespread, people who inject drugs may not engage in efficacious cleaning. The combination of the complexity of current cleaning messages and a lack of accurate information about efficacious techniques are likely to contribute to poor cleaning practice. Australia could benefit from the development of a nationally consistent cleaning message; however, the evidence would suggest that this would need to be accompanied by strategies designed to simplify and disseminate this information in order to increase the uptake of efficacious cleaning methods by people who inject drugs.

Hospitalization rates associated with hepatitis B and HIV co-infection, age and sex in a population-based cohort of people diagnosed with hepatitis C

To determine the extent age, sex and co-infection affect morbidity in people infected with hepatitis C virus (HCV), we performed a population-based study linking HCV notifications in New South Wales, Australia with their hospital (July 2000 to June 2006), hepatitis B virus (HBV) and HIV notification, and death records. Poisson models were used to calculate hospitalization rate ratios (RRs) for all-cause, illicit drug and liver-related admissions. Co-infection RRs were used to estimate attributable risk (AR). The 86 501 people notified with HCV contributed 422 761 person-years of observation; 0·8% had HIV, 3·7% HBV, and 0·04% had both. RRs for males were equal to or lower than for females in younger ages, but higher in older ages (Pfor interaction ⩽0·013). HBV/HIV co-infection resulted in ARs of over 70% for liver disease and 30–60% otherwise. However, at the cohort level the impact was minimal (population ARs 1·3–8·7%). Our findings highlight the importance and success of public health measures, such as needle and syringe exchange programmes, which have helped to minimize the prevalence of co-infection in Australia. The findings also suggest that the age of study participants needs to be considered whenever the burden of HCV-related morbidity is reported by sex. The results are likely to be representative of patterns in hospital-related morbidity for the entire HCV-infected population in Australia and the ARs generalizable to other developed countries.

Candidate hepatitis C vaccine trials and people who inject drugs: challenges and opportunities

People who inject drugs (PWID) are at high risk of HCV. Limited evidence of the effectiveness of prevention interventions and low uptake of treatment in this group highlight the need for increased investment in biomedical interventions, notably safe and efficacious vaccines. While several candidates are currently in development, field trials in PWID present challenges, including ethical issues associated with trial literacy, informed consent and standards of care. Significant biological and social factors and differences between HIV and HCV suggest that HCV warrants targeted vaccine preparedness research to lay the groundwork for successful implementation of future trials.

"Fitness for duty": social, organisational and structural influences on the design and conduct of candidate hepatitis C vaccine trials involving people who inject drugs

Several candidate vaccines for hepatitis C are currently in preclinical development or the early stages of clinical trials. Implementing trials of these vaccines among people who inject drugs will be challenging. Previous research, particularly willingness to participate studies in relation to HIV vaccines in marginalized groups, has focused on the modifiable characteristics of individual participants. This qualitative research with people who inject drugs, health staff and clinicians focuses on social, organisational and structural elements of vaccine trial designs which may exclude or reduce the participation of people who inject drugs.

Hepatitis C infection among intravenous drug users attending therapy programs in Cyprus

The most high-risk population for HCV transmission worldwide today are intravenous drug users. HCV genotypes in the general population in Cyprus demonstrate a polyphyletic infection and include subtypes associated with intravenous drug users. The prevalence of HCV, HBV, and HIV infection, HCV genotypes and risk factors among intravenous drug users in Cyprus were investigated here for the first time. Blood samples and interviews were obtained from 40 consenting users in treatment centers, and were tested for HCV, HBV, and HIV antibodies. On the HCV-positive samples, viral RNA extraction, RT-PCR and sequencing were performed. Phylogenetic analysis determined subtype and any relationships with database sequences and statistical analysis determined any correlation of risk factors with HCV infection. The prevalence of HCV infection was 50%, but no HBV or HIV infections were found. Of the PCR-positive samples, eight (57%) were genotype 3a, and six (43%) were 1b. No other subtypes, recombinant strains or mixed infections were observed. The phylogenetic analysis of the injecting drug users' strains against database sequences observed no clustering, which does not allow determination of transmission route, possibly due to a limitation of sequences in the database. However, three clusters were discovered among the drug users' sequences, revealing small groups who possibly share injecting equipment. Statistical analysis showed the risk factor associated with HCV infection is drug use duration. Overall, the polyphyletic nature of HCV infection in Cyprus is confirmed, but the transmission route remains unknown. These findings highlight the need for harm-reduction strategies to reduce HCV transmission.

Representations and coverage of non-English-speaking immigrants and multicultural issues in three major Australian health care publications

BACKGROUND

No recent Australian studies or literature, provide evidence of the extent of coverage of multicultural health issues in Australian healthcare research. A series of systematic literature reviews in three major Australian healthcare journals were undertaken to discover the level, content, coverage and overall quality of research on multicultural health. Australian healthcare journals selected for the study were The Medical Journal of Australia (MJA), The Australian Health Review (AHR), and The Australian and New Zealand Journal of Public Health (ANZPH). Reviews were undertaken of the last twelve (12) years (1996-August 2008) of journal articles using six standard search terms: 'non-English-speaking', 'ethnic', 'migrant', 'immigrant', 'refugee' and 'multicultural'.

RESULTS

In total there were 4,146 articles published in these journals over the 12-year period. A total of 90 or 2.2% of the total articles were articles primarily based on multicultural issues. A further 62 articles contained a major or a moderate level of consideration of multicultural issues, and 107 had a minor mention.

CONCLUSIONS

The quantum and range of multicultural health research and evidence required for equity in policy, services, interventions and implementation is limited and uneven. Most of the original multicultural health research articles focused on newly arrived refugees, asylum seekers, Vietnamese or South East Asian communities. While there is some seminal research in respect of these represented groups, there are other communities and health issues that are essentially invisible or unrepresented in research. The limited coverage and representation of multicultural populations in research studies has implications for evidence-based health and human services policy.

A national cross-sectional study among drug-users in France: epidemiology of HCV and highlight on practical and statistical aspects of the design

Background

Epidemiology of HCV infection among drug users (DUs) has been widely studied. Prevalence and sociobehavioural data among DUs are therefore available in most countries but no study has taken into account in the sampling weights one important aspect of the way of life of DUs, namely that they can use one or more specialized services during the study period. In 2004–2005, we conducted a national seroepidemiologic survey of DUs, based on a random sampling design using the Generalised Weight Share Method (GWSM) and on blood testing.

Methods

A cross-sectional multicenter survey was done among DUs having injected or snorted drugs at least once in their life. We conducted a two stage random survey of DUs selected to represent the diversity of drug use. The fact that DUs can use more than one structure during the study period has an impact on their inclusion probabilities. To calculate a correct sampling weight, we used the GWSM. A sociobehavioral questionnaire was administered by interviewers. Selected DUs were asked to self-collect a fingerprick blood sample on blotting paper.

Results

Of all DUs selected, 1462 (75%) accepted to participate. HCV seroprevalence was 59.8% [95% CI: 50.7–68.3]. Of DUs under 30 years, 28% were HCV seropositive. Of HCV-infected DUs, 27% were unaware of their status. In the month prior to interview, 13% of DUs shared a syringe, 38% other injection parapharnelia and 81% shared a crack pipe. In multivariate analysis, factors independently associated with HCV seropositivity were age over 30, HIV seropositivity, having ever injected drugs, opiate substitution treatment (OST), crack use, and precarious housing.

Conclusion

This is the first time that blood testing combined to GWSM is applied to a DUs population, which improve the estimate of HCV prevalence. HCV seroprevalence is high, indeed by the youngest DUs. And a large proportion of DUs are not aware of their status. Our multivariate analysis identifies risk factors such as crack consumption and unstable housing.

A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs

Harm reduction is both a policy approach and used to describe a specific set of interventions. These interventions aim to reduce the harms associated with drug use. Employing a strict definition of harm reduction, evidence for the efficacy and effectiveness of alcohol, tobacco and illicit drug harm reduction interventions were reviewed. Systematic searches of the published literature were undertaken. Studies were included if they provided evaluation data (pre-post, or control group comparisons). More than 650 articles were included in the review. The majority of the literature concerned illicit drugs. For alcohol, harm reduction interventions to reduce road trauma are well-founded in evidence. Otherwise, there is limited research to support the efficacy and effectiveness of other alcohol harm reduction interventions. For tobacco, the area is controversial but promising new products that reduce the harms associated with smoking are being developed. In the area of illicit drugs there is solid efficacy, effectiveness and economic data to support needle syringe programmes and outreach programmes. There is limited published evidence to date for other harm reduction interventions such as non-injecting routes of administration, brief interventions and emerging positive evidence for supervised injecting facilities. There is sufficient evidence to support the wide-spread adoption of harm reduction interventions and to use harm reduction as an overarching policy approach in relation to illicit drugs. The same cannot be concluded for alcohol or tobacco. Research at a broad policy level is required, especially in light of the failure by many policy makers to adopt cost-effective harm reduction interventions.

Maternal and neonatal effects of substance abuse during pregnancy: our ten-year experience

PURPOSE

The aim of the study was to assess perinatal outcome of pregnancy burdened with maternal addiction in comparison with an unselected population from a European transition country.

MATERIALS AND METHODS

Data on pregnancies complicated by illicit drug abuse (n = 85) managed during a 10-year period (1997-2007) at Split University Hospital were analyzed. Data on the type of drug, course of gestation and labor, and on perinatal outcome were considered. Data on all non-dependence pregnancies recorded during the study period were used as a control group.

RESULTS

During the study period, there were 85 dependence-complicated pregnancies (0.2%). Use of heroin alone during pregnancy was recorded in 51 women (50%), methadone alone in 6 (7%), and a combination of heroin and methadone in 9 (11%). Premature delivery was significantly more common in the group of pregnant addicts (21% vs. 6%); 49% of pregnant addicts were carriers of hepatitis C virus (HCV) and 14% of hepatitis B virus (HBV). Neonatal abstinence syndrome developed in 61 infants (7%) born to addicted mothers. There were 4 cases (4.6%) of early neonatal death; 7 neonates had 5-minute Apgar score < or = 7 (8%); 29 neonates had low birth weight for age (33%); and 7 neonates had congenital anomalies (8%). The risk of various congenital anomalies was 3-fold in the group of children born to addicted mothers.

CONCLUSION

Addiction pregnancies present a small but high-risk group according to perinatal outcome. Appropriate obstetric and neonatal care can reduce the rate of complications in these pregnancies and improve perinatal outcome.

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.

Risk of hepatitis C virus transmission through drug preparation equipment: a systematic and methodological review

The use of blood-contaminated drug preparation equipment is believed to be associated with the transmission of hepatitis C virus (HCV) among injection drug users (IDUs), but the extent of HCV infection risk is unclear. The objective of this review was to appraise the evidence regarding HCV incidence associated with the use of drug preparation equipment such as drug mixing containers, filters and water. In June 2007, cohort and case-control studies examining the association of HCV incidence with the sharing of drug preparation equipment were identified by searching electronic reference databases as well as the reference lists of published papers. Ten studies (seven cohort and three nested case-control) met the inclusion criteria for the review. The relative risk of HCV infection associated with drug preparation equipment were mainly between 2.0 and 5.9; however, the precision of the estimates from individual studies were marked by wide confidence intervals. Few studies exist to allow an adequate assessment of the individual contributions of containers, filters and water to HCV incidence. The major methodological limitations of reviewed studies were short follow-up times, inadequate control of confounders and lack of exclusion of periods when IDUs were not at risk for HCV infection through drug injection. Current evidence implicating the association of drug preparation equipment with HCV incidence is limited by several methodological concerns.

The 2004 Australian prison entrants' blood-borne virus and risk behaviour survey

OBJECTIVES

To assess the prevalence of blood-borne viruses and associated risk factors among prison entrants at seven Australian prisons across four States.

DESIGN

Consecutive cross-sectional design. Voluntary confidential testing of all prison entrants for serological markers of human immunodeficiency virus (HIV), hepatitis C (HCV) and hepatitis B (HBV) over 14 consecutive days in May 2004. Demographic data and data related to risks for blood-borne virus transmission, such as sexual activity, body piercing, tattooing, and injecting drug use, were collected.

RESULTS

National prevalence for HIV was 1%, hepatitis B core antibody 20%, and hepatitis C antibody 34%. Fifty-nine per cent of participants had a history of injecting drug use. Among injecting drug users, the prevalence of HIV was 1%, hepatitis C antibody 56%, and hepatitis B core antibody 27%. Forty-one per cent of those screened reported a previous incarceration. In the multivariate model, Queensland and Western Australian (WA) prison entrants were significantly less likely to test positive to HCV than those in New South Wales (NSW). Amphetamine was the most commonly injected drug in Queensland, Tasmania and WA. In NSW, heroin was the most common drug injected. In the multivariate analysis a history of injecting drug use, being aged 30 years or more, and a prior incarceration were positively associated with hepatitis C infection. For hepatitis B core antibody, age over 30 years and a history of injecting drug use were associated with an increased risk.

CONCLUSIONS

The findings support the view that prisoner populations are vulnerable to blood-borne virus infection, particularly hepatitis B and C. Prisoner populations should be included in routine surveillance programs so as to provide a more representative picture of blood-borne virus epidemiology in Australia.

Factors associated with reported hepatitis C and HIV among injecting drug users in ten European cities

BACKGROUND

To analyze self-reported prevalence of HCV and HIV in a sample of socially excluded injecting drug users, as well as factors associated with the presence of these diseases.

METHODS

Cross-sectional study. Data were collected with a structured, face-to-face questionnaire by outreach workers and privileged access interviewers in 1131 participants who had injected heroin and/or cocaine over the past year (71.5% men; mean age, 30 years) from Seville and Granada, Spain; Cologne, Germany; Vienna, Austria; Brussels, Belgium; Athens, Greece; Dublin, Ireland; London, England; Lisbon, Portugal and Perugia, Italy.

RESULTS

Among the total sample, 595 (52.6%) participants reported HCV-positive status and 143 (12.6%) HIV-positive status. Multivariate analysis for HCV showed that women are at less risk than men, and that longer drug use, injecting while in prison, sharing needles, and reported positive status for tuberculosis, HBV, HIV or sexually-transmitted disease are positively associated with HCV. Participants reporting positive HIV status were generally older, had injected drugs while in prison, had completed less than 8 years of schooling, were divorced, had no regular employment, and declared infection with tuberculosis, sexually-transmitted disease and HCV.

CONCLUSIONS

The highest incidences of HCV and HIV were reported by participants in a poorer social and health situation. Drug addicts must cope not only with their addiction but also with the process of social exclusion they are immersed in. To the greatest extent possible, any course of action for this group should be built into integrated, coordinated plans that take a broad approach to the main issues involved.

National survey of HIV and hepatitis testing and vaccination services provided by drug and alcohol agencies in Australia

OBJECTIVES

To identify the prevalence of blood-borne viruses (BBVs) testing, counselling and vaccination services by drug and alcohol services for injecting drug users in Australia.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional survey of drug and alcohol agencies throughout Australia.

OUTCOME MEASURES

Current availability of testing, counselling and vaccination services for hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV; availability of medical coverage; and barriers to greater provision of services.

RESULTS

Survey responses were provided by 222 agencies nationally (61% response rate). About three-quarters of agencies provided some access to HIV, HBV, and HCV testing and HBV vaccinations, but only a third offered these services routinely on site. HBV vaccination availability differed depending on the primary function of the agency, with drug dependence units and needle and syringe programs more likely to provide vaccination on site. The major barriers preventing agencies from providing routine on-site BBV services are lack of access to medical staff and trained personnel; the cost of providing these services; and a lack of facilities.

CONCLUSIONS

The restricted provision of BBV services represents missed opportunities to reduce individual and community morbidity and to maximise the potential savings from preventable disease in relation to HBV infection. To address key barriers and patient retention issues, it is necessary to expand the role of non-medical staff, increase the use of shorter HBV vaccination schedules, and identify and maintain local clinical partnerships between public and private service providers.

Significant reductions of HIV prevalence but not of hepatitis C virus infections in injection drug users from metropolitan Barcelona: 1987-2001

OBJECTIVES

To characterize trends from 1987 to 2001 in the prevalence of HIV and HCV infections among 2219 injection drug users (IDUs) starting treatment for substance abuse in two large hospitals in metropolitan Barcelona.

METHODS

The study population comprised IDUs with HIV tests completed from 1987 to 2001 and admitted for detoxification. Testing for HCV started in 1991 (n=1132). Characterization of temporal trends was carried out using logistic regression methods. Stratification was used to describe possible heterogeneities of the temporal trends.

RESULTS

The overall prevalence of HIV, HCV, and HBV (HBsAg+) was 55%, 88%, and 7%, respectively. Adjusted by duration of IDU, sex, and age at initiation, the prevalence of HIV infection declined significantly (p<0.001) from 1989 to 2004. The substantially higher prevalence of HCV showed a decline (p=0.065) of lesser magnitude. The decline of HIV infection was consistently observed among those with duration of IDU of less than 10 years. In turn, the decline of HCV was restricted to those with short duration of IDU (<4 years) because the prevalence of HCV infection was close to 100% for durations longer than 4 years in all calendar periods.

CONCLUSIONS

Preventive interventions and treatment for substance abuse might have contributed to the waning of the HIV epidemic in Spain. However, the extremely high levels of HCV infection and the underlying prevalence of HIV might lead to a large health burden of liver disease.

Do needle syringe programs reduce HIV infection among injecting drug users: a comprehensive review of the international evidence

This first international review of the evidence that needle syringe programs reduce HIV infection among injecting drug users found that conservative interpretation of the published data fulfills six of the nine Bradford Hill criteria (strength of association, replication of findings, temporal sequence, biological plausibility, coherence of evidence, and reasoning by analogy) and all six additional criteria (cost-effectiveness, absence of negative consequences, feasibility of implementation, expansion and coverage, unanticipated benefits, and application to special populations). The Bradford Hill criteria are often used to evaluate public health interventions. The principal finding of this review was that there is compelling evidence of effectiveness, safety, and cost-effectiveness, consistent with seven previous reviews conducted by or on behalf of U.S. government agencies. Authorities in countries affected or threatened by HIV infection among injecting drug users should carefully consider this convincing evidence now available for needle syringe programs with a view to establishing or expanding needle syringe programs to scale.

Fulfilling prophecy? Sexually transmitted infections and HIV in Indigenous people in Western Australia

OBJECTIVE

To compare trends and rates of HIV and sexually transmitted infections in Indigenous and non-Indigenous people of Western Australia.

DESIGN AND SETTING

Analysis of WA notification data for chlamydia, gonorrhoea, and primary and secondary syphilis in 2002, and for HIV infections from 1983 to 2002.

MAIN OUTCOME MEASURES

Rates of HIV and sexually transmitted infection by Indigenous status.

RESULTS

In 2002, there were 3046 notifications for chlamydia, 1380 for gonorrhoea and 64 for syphilis. When information on Indigenous status was available, Indigenous people accounted for 41% of chlamydia and 76% of gonorrhoea notifications, with Indigenous:non-Indigenous age-standardised rate ratios of 16 (95% CI, 14-17) and 77 (95% CI, 67-88), respectively. Indigenous people accounted for 90.6% of syphilis notifications (age-standardised Indigenous:non-Indigenous rate ratio, 242 [95% CI, 104-561]). From 1985 to 2002, HIV notification rates for non-Indigenous people in WA declined and rates for Indigenous people increased. From 1994 to 2002, there were 421 notifications of HIV infection in WA residents, 52 (12.4%) in Indigenous people and 369 (87.6%) in non-Indigenous people. Indigenous people accounted for 39% and 6.2% of all notifications in WA females and males, respectively. The Indigenous:non-Indigenous rate ratios were 18 (95% CI, 12-29) for females and 2 (95% CI, 1-3) for males.

CONCLUSIONS

Indigenous Western Australians are at greater risk of HIV transmission than non-Indigenous people. Strategies to prevent further HIV infection in Indigenous Australians should include control of sexually transmitted infections.

Treatment for Hepatitis C Virus Infection among Current Injection Drug Users in Australia

An estimated 210,000 people were living with hepatitis C virus (HCV) infection in Australia at the end of 2001, and the number of people developing cirrhosis was projected to increase 4-fold by 2020. Eighty percent of prevalent and 90% of incident HCV infections are related to injection drug use. Current injection drug use was an exclusion criterion for access to government-funded treatment for HCV infection until May 2001. Despite the removal of this barrier to treatment access for current injection drug users (IDUs), the number of IDUs receiving treatment remains extremely low. Treatment outcomes among IDUs with chronic HCV infection treated at 2 public hospital-based hepatitis clinics are presented. These data demonstrate that IDUs who continue to inject infrequently during treatment for HCV infection can achieve a sustained virological response. Further studies are under way to examine outcomes of treatment for HCV among clients undergoing treatment for drug dependency who have chronic HCV infection and among current IDUs with acute and newly acquired HCV infection.

The hepatitis C virus epidemic among injecting drug users

Given the economic and health costs of hepatitis C virus (HCV) infection, and the ongoing transmission within the injecting drug user (IDU) population, there is a need for improved understanding of HCV epidemiology within this risk group. We employed a recently developed method based on phylogenetic analysis to infer HCV epidemic history and to provide the first estimates of the rate of spread of subtypes 1a and 3a circulating within injecting drug user populations. The data indicates that HCV subtype 1a entered the IDU population on at least three separate occasions. Both subtypes demonstrate exponential population growth during the 20th century, with a doubling time of 7-8 years. The results provide a baseline for prediction of the future course of the HCV epidemic, and its likely response to transmission control policies.