A Hazard Analysis of Risk Factors of Mortality in Individuals Who Inject Drugs in Denver CO

Mortality among HIV-Positive and HIV-Negative People Who Inject Drugs in Mizoram, Northeast India: A Repeated Cross-Sectional Study (2007-2021)

Background: HIV and drug overdose continue to be the leading causes of death among people who inject drugs (PWID). Mizoram, a small state in the northeast of India, has the highest prevalence of HIV in India and a high HIV prevalence among PWID. Objective: To estimate the mortality among HIV-positive and HIV-negative PWID and to describe its associated factors. Methods: Cross-sectional datasets from the 2007-2021 Mizoram State AIDS Control Society (MSACS) data comprising 14626 PWID were analyzed. Logistic regression analysis was conducted to examine the factors associated with mortality among HIV-negative and HIV-positive PWID after adjusting for potential confounding factors. Results: Mortality among HIV-negative PWID declined by 59% between 2007 and 2021. The mortality rate among HIV-positive PWID also declined by 41% between 2007 and 2021. The multiple logistic regression analysis revealed that being divorced/separated/widowed (AOR = 1.41, 95% CI 1.03-1.94) remained positively associated with mortality among HIV-positive PWID. Mortality among HIV-negative PWID remained positively associated with ages of 24-34 years (AOR = 1.54, 95% CI 1.29-1.84) and above 35 years (AOR = 2.08, 95% CI 1.52-2.86), being divorced/separated/widowed (AOR = 1.28, 95% CI 1.02-1.61), and the sharing of needles/syringes (AOR = 1.28, 95% CI 1.34-2.00). Mortality among HIV-negative PWID was negatively associated with being married (AOR = 0.72, 95% CI 0.57-0.90), being employed (AOR = 0.77, 95% CI 0.64-0.94), and having a monthly income. Conclusions: The mortality rate among HIV-negative and HIV-positive PWID declined significantly between 2007 and 2021 in Mizoram. To further reduce mortality among PWID, interventions should target those sharing needles/syringes, those above 24 years of age, and unmarried participants.

Mortality among people who inject drugs - the interwoven roles of fentanyl and HIV: a community-based cohort study

BACKGROUND

Excess all-cause mortality is a key indicator for assessing direct and indirect consequences of injection drug use and data are warranted to delineate sub-populations within people who inject drugs at higher risk of death. Our aim was to examine mortality and factors associated with mortality among people who inject drugs in Estonia.

METHODS

Retrospective cohort study using data from people who inject drugs recruited in the community with linkage to death records. Standardized mortality ratios were used to compare the cohort mortality to the general population and potential predictors of death were examined through survival analysis (Cox regression). The cohort include a total of 1399 people who inject drugs recruited for cross-sectional surveys using respondent driven sampling between 2013 and 2018 in Estonia. A cohort with follow-up through 2019 was formed with linkage to national causes of death registry.

RESULTS

Among 1399 participants with 4684 person-years of follow-up, 10% were deceased by 2019. The all-cause mortality rate in the cohort was 28.9 per 1000 person-years (95% confidence interval 25.3-35.3). Being HIV positive, injecting mainly opioids (fentanyl), living in the capital region and the main source of income other than work were associated with greater mortality risk.

CONCLUSIONS

While low-threshold services have been available for a long time for people who inject drugs, there is still a need to widen the availability and integration of services, particularly the integration of HIV and opioid treatment.

The Tsunamic Model of LGBTQ+ Deaths of Despair: A Systemic Review to Identify Risk Factors for Deaths of Despair Among LGBTQ+ People

The term Deaths of Despair (DOD) was introduced to capture the phenomenon of mortality associated with suicide, drug overdose, and alcoholic liver disease. The LGBTQ+ population consistently evidences disproportionately high rates of DOD. This study reviewed the literature on DOD within this community to create a conceptual model that identifies risk factors that work together to potentiate DOD in the LGBTQ+ community. Ten DOD-Related Factors were identified and used to create The Tsunamic Model of LGBTQ+ Deaths of Despair. DOD-Related Factors include: (1) Stigma, (2) Demographics, (3) Identity Development, (4) Internalized Homophobia, (5) Depression, (6) Victimization, (7) Isolation/Rejection, (8) Sensation Seeking, (9) Risky Behavior, and (10) Uninformed Care. Each factor is associated with increased risk for DOD among the LGBTQ+ community. This model can help health professionals by providing a framework for prevention and early intervention programs.

Health risk associated with residential relocation among people who inject drugs in Los Angeles and San Francisco, CA: a cross sectional study

Background

Given the housing instability and frequent residential relocation (both volitional and hegemonic) of people who inject drugs, we sought to determine whether residential relocation (defined as sleeping in a different place in the past 30 days) is associated with health outcomes in a sample of people who inject drugs (PWID).

Methods

We recruited 601 PWID using targeted sampling and interviewed them between 2016 and 2018 in San Francisco and Los Angeles, CA about housing, drug use practices, and service utilization. We then developed multivariable regression models to investigate how residential relocation is associated with violence, health outcomes, and social service access. We analyzed our data between June 2018 and October 2019.

Results

Participants who relocated in the past 30 days had lower odds of being in substance use treatment (Adjusted Odds Ratio [AOR] = 0.62, 95% Confidence Interval [CI] = 0.42, 0.89) and higher odds of nonfatal overdose (AOR = 2.50, CI = 1.28, 4.90), receptive syringe sharing (AOR = 2.26, CI = 1.18, 4.32), severe food insecurity (AOR = 1.69, CI = 1.14, 2.50), having belongings stolen (AOR = 2.14, CI = 1.42, 3.21), experiencing physical assault (AOR = 1.58, CI = 1.03, 2.43), arrest (AOR = 1.64, CI = 1.02, 2.65), and jail (AOR = 1.90, CI = 1.16, 3.13) in the past 6 months when compared to those who did not relocate.

Conclusions

PWID who have relocated in the past 30 days have higher odds of experiencing violence and life- threatening adverse outcomes, and policies that disrupt living circumstances of PWID should be ended in favor of those that support housing stability.

A cohort study revealed high mortality among people who inject drugs in Hai Phong, Vietnam

OBJECTIVE

To estimate the residual mortality rate among people who inject drugs (PWID) in a Low-Middle Income Countries context where the HIV epidemic has been controlled and methadone coverage is high.

STUDY DESIGN AND SETTING

PWID from Haiphong, Vietnam, were recruited through three annual respondent-driven sampling surveys that fueled two cohorts of PWID with HIV (n = 761) and without HIV (n = 897), with bi-annual follow-up. Presumed causes of death were ascertained from medical records and/or interviews of participants family.

RESULTS

Among the 1658 participants with a median follow-up of 2 years, 67 and 36 died in the HIV-positive and HIV-negative cohort, respectively, yielding crude mortality rates of 4.3 (95% Confidence interval (CI): 3.3-5.4) per 100 person-years of follow-up (PYFU) and 1.9 (CI: 1.4-2.6) per 100 PYFU. In the HIV-positive cohort, in which 81% of participants had undetectable viral load, the two main causes of death were tuberculosis and HIV-related diseases. In the HIV-negative cohort, the two main causes of death were liver-related diseases and overdose. In a time-dependent multivariable model, "unsuppressed viral load" was associated with increased risk of mortality, whereas "being on methadone" or "being employed" was associated with a lower risk.

CONCLUSION

Despite a very successful HIV and methadone program, the mortality remains high among PWID in Vietnam, largely due to curable infectious diseases such as tuberculosis and viral hepatitis.

Drugs, discipline and death: Causes and predictors of mortality among people who inject drugs in Tijuana, 2011-2018

BACKGROUND

People who inject drugs (PWID) experience multiple risk factors for mortality; yet, we know little about causes of death among PWID in Tijuana, Mexico, an area with high levels of injecting and changes in policy/law enforcement responses to substance use. This study examines rates, causes, and predictors of mortality among Tijuana PWID.

METHODS

Data come from a community-based cohort of PWID aged ≥18 who injected drugs in the past month. Mortality was confirmed by death certificate over 78 months during 2011-2018. Predictors of mortality were identified using time-updated Cox regression, controlling for age.

RESULTS

Among 734 participants, there were 130 deaths (54 confirmed, 76 unconfirmed), with an incidence rate of 17.74 deaths per 1000 person-years for confirmed deaths (95% Confidence Interval (CI)=13.01, 22.48) and 39.52 for unconfirmed deaths (CI=32.72, 46.31). Confirmed deaths resulted from homicide/trauma (26%), overdose (26%), septic shock (18%) and HIV-related causes (9%). In multivariable analysis of confirmed deaths, baseline HIV seropositivity (adjusted Hazard Ratio [aHR]=6.77, CI=1.98, 23.17), incident HIV infection (aHR=3.19, CI=1.02, 9.96), and number of times being beaten by police in the past 6 months at baseline (aHR=1.08 per time, CI=1.04, 1.12) were predictive of death; whereas, injection cessation for 6+ months during time at risk (aHR=0.25, CI=0.33, 0.79) was protective.

CONCLUSION

In addition to overdose and HIV prevention efforts, attention to structural conditions that potentiate mortality is needed, including improved access to medication-assisted treatment to support injection cessation and a shift from police as a source of harm to harm reduction.

Association of History of Injection Drug Use with External Cause-Related Mortality Among Persons Linked to HIV Care in an Urban Clinic, 2001-2015

High mortality rates among persons with HIV with a history of injection drug use (PWID) are thought to be driven in part by higher rates of external cause-related mortality. We followed 4796 persons aged 18-70 engaged in continuity HIV care from 2001 to 2015 until death or administrative censoring. We compared cause-specific (csHR) and subdistribution hazards (sdHR) of death due to external causes among PWID and persons who acquired their HIV infection through other routes (non-IDU). We standardized estimates on age, sex, race, and HIV-related health status. The standardized csHR for external cause-related death was 3.57 (95% CI 2.39, 5.33), and the sdHR was 3.14 (95% CI 2.16, 4.55). The majority of external cause-related deaths were overdose-related and standardized sdHR was 4.02 (95% CI 2.40, 6.72). Absolute rate of suicide was low but the csHR for PWID compared to non-IDU was most elevated for suicide (6.50, 95% CI 1.51, 28.03). HIV-infected PWID are at a disproportionately increased risk of death due to external causes, particularly overdose and suicide.

Rising role of prescription drugs as a portal to injection drug use and associated mortality in Baltimore, Maryland

INTRODUCTION

Prescription drug abuse is a major public health problem in rural and suburban areas of the United States, however its emergence in large urban settings with endemic injection drug use remains understudied. We examined temporal trends in injection drug use initiation and mortality among people who inject drugs (PWID) in Baltimore, Maryland.

METHODS

Data were derived from the baseline assessment of PWID enrolled in a community-based cohort study with longitudinal follow-up for mortality assessment. PWID were recruited from 2005-2008 (N = 1,008) and 2015-2018 (N = 737). We compared characteristics by birth cohort (before/after 1980) and type of drug initiated (prescription opioids, prescription non-opioids, non-injection illicit drugs, or injection drugs). We calculated standardized mortality ratios (SMR) using the US general population as the reference.

RESULTS

PWID born after 1980 were more likely to initiate drug use with prescription opioids and non-opioids and had higher levels of polysubstance prior to injection initiation, compared to individuals born before 1980. Overall mortality was high: 2.59 per 100 person-years (95% CI: 2.27-2.95 per 100 person-years). Compared to the US population, the highest SMRs were observed among participants between 40-44 years of age, with especially high mortality among women in this age group (SMR:29.89, 95% CI: 15.24-44.54).

CONCLUSIONS

Mirroring national trends, the profile of PWID in Baltimore has changed with increased prescription drug abuse and high levels of polysubstance use among younger PWID. Interventions need to reach those using prescription drugs early after initiation of use in order to reduce transition to injecting. Urgent attention is warranted to address premature mortality, particularly among middle-aged and female PWID.

The relationship between parental heavy drinking and non-fatal overdose among people who inject drugs in Vancouver, Canada

BACKGROUND

Despite the acute drug-related and behavioural risk factors for experiencing a drug overdose, few remote childhood experiences have been examined as risk factors for subsequent later life overdose risk. Parental heavy drinking has been associated with some later life negative outcomes, but little is known regarding the impact on drug overdoses, especially among people who inject drugs. Given the current overdose crisis in North America, we sought to evaluate the impact of parental heavy drinking on later life non-fatal overdose among people who inject drugs in Vancouver, Canada.

METHODS

Data were derived from two prospective cohort studies of community-recruited people who inject drugs in Vancouver between December 2012 and May 2016. We employed multivariable generalized estimating equations to examine the relationship between parental heavy drinking and non-fatal overdose in the past six months.

RESULTS

Among 327 eligible participants, 111 (33.9%) reported parental heavy drinking and 95 (29.1%) reported a non-fatal overdose at least once during the study period. In a multivariable analysis, experiencing parental heavy drinking remained independently associated with non-fatal overdose (adjusted odds ratio: 1.69; 95% confidence interval: 1.07-2.66) after adjustment for a range of socio-demographic and drug using confounders.

CONCLUSIONS

These findings suggest long-term negative impacts of parental heavy drinking, on subsequent risk taking or other mechanisms associated with overdose. Current overdose prevention efforts may benefit from the evaluation of life course vulnerabilities that may be amenable to earlier interventions.

Collecting Sexual Orientation and Gender Identity Information at Death

Currently, no US jurisdiction or agency routinely or systematically collects information about individuals' sexual orientation and gender identity (SOGI) at the time of death. As a result, little is known about causes of death in people having a minority sexual orientation or gender identity. These knowledge gaps have long impeded identification of mortality disparities in sexual and gender minority populations and hampered the development of targeted public health interventions and prevention strategies. We offer observations about the possibilities and challenges of collecting and reporting accurate postmortem SOGI information on the basis of our past four years of working with death investigators, coroners, and medical examiners. This work was located primarily in New York, New York, and has extended from January 2015 to the present. Drawing on our experiences, we make recommendations for future efforts to include SOGI among the standard demographic variables used to characterize individuals at death.