Substance use and risk of HIV infection among Men who have Sex with Men in India: Analysis of National IBBS data, India

HIV prevalence is higher among Men who have Sex with Men (MSM), owing to their unsafe sexual behavior. Further, MSM indulge in behaviors such as consumption of alcohol/oral drugs and/or injecting during/before sex that poses the risk of unsafe behaviors, thereby increasing their vulnerability to HIV. The study aims to analyze the factors associated with HIV infection among the multi-risk MSM using any substances with those MSM who do not use substances.Community-based cross-sectional survey design using probability-based sampling between October 2014 and November 2015.For the nation-wide Integrated Biological and Behavioral Surveillance (IBBS), 23,081 MSM were recruited from 4067 hotspots in 108 districts across India. Information on demographics, sexual behaviors, substance use, sexual partners, and awareness on HIV and its management was collected from the consented respondents using computer-assisted personal interview (CAPI) by trained personnel. Blood samples were tested for HIV. Statistical analyses were done, to study the associations between substance use and its influence on high-risk sexual behaviors and HIV infection.One in 3 MSM (33.88%) in India were substance users, thus exhibiting "multi-risk" (MR) behaviors. Significantly higher HIV prevalence (3.8%, P < .05) was reported among MR-MSM, despite 97.2% of them being aware of HIV. Higher HIV prevalence among MSM exhibiting homosexual behavior for ≤1 year is of specific concern, as this accounts to recent infections and indicates the increased vulnerability of the infection among the new entrants.Substance-use resulting in high-risk sexual behavior was significantly associated with higher HIV prevalence among MR-MSM. Integrated targeted interventions focusing on safe sex and safe-IDU practices among MR-MSM are required to end the disease transmission.

The contribution of injection drug use to hepatitis C virus transmission globally, regionally, and at country level: a modelling study

BACKGROUND

WHO aims to eliminate the hepatitis C virus (HCV) as a public health threat by 2030. Injection drug use is an important risk factor for HCV transmission, but its contribution to country-level and global epidemics is unknown. We estimated the contribution of injection drug use to risk for HCV epidemics globally, regionally, and at country level.

METHODS

We developed a dynamic deterministic HCV transmission model to simulate country-level HCV epidemics among people who inject drugs and the general population. Each country's model was calibrated using country-specific data from UN datasets and systematic reviews on the prevalence of HCV and injection drug use. The population attributable fraction of HCV transmission associated with injection drug use was estimated-defined here as the percentage of HCV infections prevented if additional HCV transmission due to injection drug use was removed between 2018 and 2030.

FINDINGS

The model included 88 countries (85% of the global population). The model predicted 0·23% (95% credibility interval [CrI] 0·16-0·31) of the global population were injection drug users in 2017, and 8% (5-12) of prevalent HCV infections were among people who currently inject drugs. Globally, if the increased risk for HCV transmission among people who inject drugs was removed, an estimated 43% (95% CrI 25-67) of incident HCV infections would be prevented from 2018 to 2030, varying regionally. This population attributable fraction was higher in high-income countries (79%, 95% CrI 57-97) than in countries of low and middle income (38%, 24-64) and was associated with the percentage of a country's prevalent HCV infections that are among people who inject drugs.

INTERPRETATION

Unsafe injecting practices among people who inject drugs contribute substantially to incident HCV infections globally. Any intervention that can reduce HCV transmission among people who inject drugs will have a pronounced effect on country-level incidence of HCV.

FUNDING

None.

HIV incidence and behavioral correlates of HIV acquisition in a cohort of injection drug users in St Petersburg, Russia

The aim of the project was to study human immunodeficiency virus (HIV) incidence, sociodemographic and behavioral correlates of HIV acquisition among injection drug users (IDUs).A total of 717 IDUs were recruited, tested, and counseled for HIV-1; 466 HIV-negative participants were enrolled and followed-up at 6 and 12 months. Sociodemographic and behavioral data were collected during each study visit. The association of sociodemographic and behavioral factors to HIV-1 incidence was assessed.During the 9-month recruitment period, 717 IDUs were screened and 466 participants were enrolled. HIV-1 prevalence at baseline was 35%. Most enrolled subjects were young (median age 30), male (75%), injected heroin in the previous 3 months (86%), about 50% had shared syringes and other paraphernalia, and 44% had unprotected sex in the last month. The retention rate at the 12-month follow-up was 72% and the adjusted retention rate was 88%. The HIV incidence rate was 7.2/100 person-years. HIV incidence was significantly associated with specific drug risk behaviors, including injecting the mixture of heroin and psychostimulants, the frequency of injecting in groups with other people, and having more drug dealers.The St Petersburg IDUs cohort demonstrates one of the highest HIV incidence rates in the world. In 2004 to 2006, the HIV incidence was 4.5, in 2005 to 2007-19.6, and in 2008 to 2009-7.2/100 person-years. The peak of HIV epidemic among IDUs in St Petersburg, as determined by 3 independent cohort studies, was in 2006 to 2007. Interventions targeting IDUs with long experience of heroin injection and high levels of injection risk behaviors are urgently needed.

Structural reorganization of pyramidal neurons in the medial prefrontal cortex of alcohol dependent rats is associated with altered glial plasticity

In rodents, chronic intermittent ethanol vapor exposure (CIE) produces alcohol dependence, alters the activity of pyramidal neurons and decreases the number of glial progenitors in the medial prefrontal cortex (mPFC). Adult male Wistar rats were exposed to CIE and were injected with mitotic markers to label and phenotype proliferating cells to test the hypothesis that CIE produces concurrent alterations in the structure of pyramidal neurons and the cell cycle kinetics and developmental stages of glial progenitors in the mPFC. Medial prefrontal cortical tissue was processed for Golgi-Cox staining, immunohistochemistry and Western blotting analysis. CIE increased dendritic arborization and spine densities within basal and apical dendrites of pyramidal neurons via aberrant reorganization of actin cytoskeleton-associated molecules. CIE concomitantly increased the expression of total NR2B subunits without affecting phosphorylation of NR2B at Tyr-1472 or levels of PSD-95. CIE reduced the length of S-phase of the cell cycle of glial progenitors and reduced proliferation and differentiation of progenitors into bHLH transcription factor Olig2-expressing premyelinating oligodendrocyte progenitor cells (OPCs). CIE also produced a corresponding hyperphosphorylation of Olig2, and reduced expression of myelin basic protein. Our findings demonstrate that CIE-induced alterations in OPCs and myelin-related proteins are associated with profound alterations in the structure of pyramidal neurons. In sum, our results not only provide evidence that alcohol dependence leads to pathological changes in the mPFC, which may in part define a cellular basis for cognitive impairments associated with alcoholism, but also show dependence-associated morphological changes in the PFC at the single neuron level.

A reexamination of connectivity trends via exponential random graph modeling in two IDU risk networks

Patterns of risk in injecting drug user (IDU) networks have been a key focus of network approaches to HIV transmission histories. New network modeling techniques allow for a reexamination of these patterns with greater statistical accuracy and the comparative weighting of model elements. This paper describes the results of a reexamination of network data from the SFHR and P90 data sets using Exponential Random Graph Modeling. The results show that "transitive closure" is an important feature of IDU network topologies, and provides relative importance measures for race/ethnicity, age, gender, and number of risk partners in predicting risk relationships.

Understanding correlates of hepatitis C virus infection among homeless recently paroled men

This cross-sectional study assessed predictors of Hepatitis C virus (HCV) positivity with baseline data collected on recently released male parolees (N = 157) participating in a randomized trial focused on reduction of drug use, recidivism, and risk for hepatitis and HIV infections. In this sample, the prevalence of HCV was 25%. The logistic regression analysis revealed that being an injection drug user was significantly related to HCV infection. However, contrary to most of the current literature, being Black had significantly lower odds of contracting HCV than their White counterparts. Moreover, having lived on the streets, not being part of a close family in childhood, and being older were also associated with HCV infection. These findings highlight the need for skilled assessments that target the vulnerabilities of homeless adults, especially those who have been incarcerated. Understanding drug use patterns, childhood networks, and family relationships, may assist in the design of interventions to reduce risky drug use and address behaviors derived from disadvantaged childhood.

Neighborhoods and HIV: a social ecological approach to prevention and care

Neighborhood factors have been linked to HIV risk behaviors, HIV counseling and testing, and HIV medical care. However, the social-psychological mechanisms that connect neighborhood factors to HIV-related behaviors have not been fully determined. In this article we review the research on neighborhood factors and HIV-related behaviors, approaches to measuring neighborhoods, and mechanisms that may help to explain how the physical and social environment within neighborhoods may lead to HIV-related behaviors. We then discuss organizational, geographic, and social network approaches to intervening in neighborhoods to reduce HIV transmission and facilitate HIV medical care with the goal of reducing morbidity and mortality and increasing social and psychological well-being.

Pharmacy syringe purchase test of nonprescription syringe sales in San Francisco and Los Angeles in 2010

The two main legal sources of clean needles for illicit injection drug users (IDUs) in California are syringe exchange programs (SEPs) and nonprescription syringe sales (NPSS) at pharmacies. In 2004, California became one of the last states to allow NPSS. To evaluate the implementation of NPSS and the California Disease Prevention Demonstration Project (DPDP), we conducted syringe purchase tests in San Francisco (SF) and Los Angeles (LA) between March and July of 2010. Large differences in implementation were observed in the two cities. In LA, less than one-quarter of the enrolled pharmacies sold syringes to our research assistant (RA), and none sold a single syringe. The rate of successful purchase in LA is the lowest reported in any syringe purchase test. In both sites, there was notable variation among the gauge size available, and price and quantity of syringes required for a purchase. None of the DPDP pharmacies in LA or SF provided the requisite health information. The findings suggest that more outreach needs to be conducted with pharmacists and pharmacy staff. The pharmacies' failure to disseminate the educational materials may result in missed opportunities to provide needed harm reduction information to IDUs. The varied prices and required quantities may serve as a barrier to syringe access among IDUs. Future research needs to examine reasons why pharmacies do not provide the mandated information, whether the omission of disposal options is indicative of pharmacies' reluctance to serve as disposal sites, and if the dual opt-in approach of NPSS/DPDP is a barrier to pharmacy enrollment.

Differing HIV risks and prevention needs among men and women injection drug users (IDU) in the District of Columbia

Washington, DC has among the highest HIV/AIDS rates in the US. Gender differences among injection drug users (IDUs) may be associated with adoption of prevention opportunities including needle exchange programs, HIV testing, psychosocial support, and prevention programming. National HIV Behavioral Surveillance data on current IDUs aged ≥18 were collected from 8/09 to 11/09 via respondent-driven sampling in Washington, DC. HIV status was assessed using oral OraQuick with Western Blot confirmation. Weighted estimates were derived using RDSAT. Stata was used to characterize the sample and differences between male and female IDU, using uni-, bi-, and multivariable methods. Factors associated with HIV risk differed between men and women. Men were more likely than women to have had a history of incarceration (86.6 % vs. 66.8 %, p < 0.01). Women were more likely than men to have depressive symptoms (73.9 % vs. 47.4 %, p < 0.01), to have been physically or emotionally abused (66.1 % vs. 16.1 %, p < 0.0001), to report childhood sexual abuse (42.7 % vs. 4.7 %, p < 0.0001), and pressured or forced to have sex (62.8 % vs. 4.0 %, p < 0.0001); each of these differences was significant in the multivariable analysis. Despite a decreasing HIV/AIDS epidemic among IDU, there remain significant gender differences with women experiencing multiple threats to psychosocial health, which may in turn affect HIV testing, access, care, and drug use. Diverging needs by gender are critical to consider when implementing HIV prevention strategies.

Injection drug users' perspectives on placing HIV prevention and other clinical services in pharmacy settings

In their role as a source of sterile syringes, pharmacies are ideally situated to provide additional services to injection drug users (IDUs). Expanding pharmacy services to IDUs may address the low utilization rates of healthcare services among this population. This qualitative study of active IDUs in San Francisco explored perspectives on proposed health services and interventions offered in pharmacy settings, as well as facilitators and barriers to service delivery. Eleven active IDUs participated in one-on-one semistructured interviews at a community field site and at a local syringe exchange site between February and May 2010. Results revealed that most had reservations about expanding services to pharmacy settings, with reasons ranging from concerns about anonymity to feeling that San Francisco already offers the proposed services in other venues. Of the proposed health services, this group of IDUs prioritized syringe access and disposal, clinical testing and vaccinations, and provision of methadone. Pharmacists' and pharmacy staff's attitudes were identified as a major barrier to IDUs' comfort with accessing services. The findings suggest that although IDUs would like to see some additional services offered within pharmacy settings, this is contingent upon pharmacists and their staff receiving professional development trainings that cultivate sensitivity towards the needs and experiences of IDUs.

Expectancy and readiness-based predictors of treatment uptake among the urban poor living with HIV

There is growing evidence that early treatment with antiretroviral therapy (ART) confers benefit to HIV-infected persons and may reduce the risk of transmission. Among an urban poor sample living with HIV who meet guidelines for but are not taking ART, we explored treatment beliefs at baseline and subsequent ART uptake over the following 12 months. Most demographic/background characteristics did not differ between ART initiators and noninitiators, but baseline beliefs of expectancies about treatment ease, efficacy, and readiness sensitively predicted ART initiation. Treatment-related stigma/social concerns did not. Results offer direction for interventions to optimize treatment among those most in need.

Residential trajectory and HIV high-risk behaviors among Montréal street youth--a reciprocal relationship

Evidence has linked residential instability and engagement in high-risk behaviors. This paper longitudinally examines the relationship between changes in residential stability and changes in HIV risk behaviors among Montréal street youth (SY). Between April 2006 and May 2007, 419 SY (18-25 years old) were recruited in a cohort study. SY (using Montréal street youth agencies services) were eligible if they had had at least one 24-hour episode of homelessness in the previous 30 days. Baseline and follow-up interviews, carried out every 3 months, included completion of a questionnaire (based on Life History Calendar Technique) assessing daily sleeping arrangements since the last interview, and monthly sexual and drug use behaviors. Using mixed-effects logistic regression method, we examined the association between various risk behaviors and residential stability, reached when a youth resided in any of the following settings for a whole month: own place; friends'/partner's/parent's place; any types of housing service (excluding emergency shelters). Analyses were carried out controlling for gender, age, education level, lifetime duration of homelessness, childhood sexual trauma, and lifetime mental health disorders. As of January 2009, 360 SY (79% boys) had completed at least one follow-up interview, representing 4,889 months of follow-up. Residential stability was significantly associated with the following: sex exchange (adjusted odd ratio [AOR], 0.25; 95% confidence interval [CI], 0.14-0.37), drug injection (AOR, 0.55; CI, 0.33-0.76), daily alcohol consumption (AOR, 0.58; CI, 0.42-0.74), polydrug consumption (AOR, 0.61; CI, 0.50-0.73), polydrug consumption excluding marijuana (AOR, 0.55; CI, 0.45-0.65), and multiple sex partners (≥3 partners; AOR, 0.57; CI, 0.40-0.74). Our results suggest a reciprocal relationship between residential instability and HIV risk behaviors. This calls for more integrated services combining both individual and structural-level interventions to improve the health of street youth.

Drug network characteristics and HIV risk among injection drug users in Russia: the roles of trust, size, and stability

We investigated the influence of drug network characteristics including trust, size, and stability on HIV risk behaviors and HIV testing among injection drug users (IDUs) in St. Petersburg, Russia. Overall, male and female IDUs who reported having high levels of trust in their drug networks were significantly more likely to share syringes than those with lower levels of trust (OR [95% CI]) 2.87 [1.06, 7.81] and 4.89 [1.05, 21.94], respectively). Male and female IDUs in larger drug networks were more likely to share syringes than those in smaller networks (4.21 [1.54, 11.51] and 4.80 [1.20, 19.94], respectively). Characteristics that were significantly associated with not having been HIV tested included drug network instability among men and larger network size among women. High trust, large size, and instability were positively and significantly associated with syringe sharing and not having been HIV tested. Effectiveness of interventions in Russia to reduce the risk of HIV infection may be enhanced if network characteristics are addressed.

HIV prevalence and risk among heterosexual methamphetamine injectors in California

This study funded by Centers for Disease Control compares HIV prevalence and risk behavior among heterosexual methamphetamine (n = 428) and nonmethamphetamine (n = 878) injectors in California, USA, during 2001-2003. While HIV was not highly prevalent among methamphetamine injectors (3%), sexual and injection risk behaviors were highly prevalent (ranging from 21% to 72%). In multivariate analyses, methamphetamine injectors had higher odds than nonmethamphetamine injectors of unprotected vaginal intercourse and sex with five or more sexual partners in the past 6 months and of distributive and receptive syringe sharing in the past 30 days. There was no significant difference in HIV sero-status by methamphetamine use. Suggestions are made for designing HIV prevention programs. The study's limitations are noted.

Health and oral health care needs and health care-seeking behavior among homeless injection drug users in San Francisco

Few existing studies have examined health and oral health needs and treatment-seeking behavior among the homeless and injection drug users (IDUs). This paper describes the prevalence and correlates of health and oral health care needs and treatment-seeking behaviors in homeless IDUs recruited in San Francisco, California, from 2003 to 2005 (N = 340). We examined sociodemographic characteristics, drug use patterns, HIV status via oral fluid testing, physical health using the Short Form 12 Physical Component Score, self-reported needs for physical and oral health care, and the self-reported frequency of seeking medical and oral health care. The sample had a lower health status as compared to the general population and reported a frequent need for physical and oral health care. In bivariate analysis, being in methadone treatment was associated with care-seeking behavior. In addition, being enrolled in Medi-Cal, California's state Medicaid program, was associated with greater odds of seeking physical and oral health care. Methamphetamine use was not associated with higher odds of needing oral health care as compared to people who reported using other illicit drugs. Homeless IDUs in San Francisco have a large burden of unmet health and oral health needs. Recent cuts in Medi-Cal's adult dental coverage may result in a greater burden of oral health care which will need to be provided by emergency departments and neighborhood dental clinics.

Comparing respondent-driven sampling and targeted sampling methods of recruiting injection drug users in San Francisco

The objective of this article is to compare demographic characteristics, risk behaviors, and service utilization among injection drug users (IDUs) recruited from two separate studies in San Francisco in 2005, one which used targeted sampling (TS) and the other which used respondent-driven sampling (RDS). IDUs were recruited using TS (n = 651) and RDS (n = 534) and participated in quantitative interviews that included demographic characteristics, risk behaviors, and service utilization. Prevalence estimates and 95% confidence intervals (CIs) were calculated to assess whether there were differences in these variables by sampling method. There was overlap in 95% CIs for all demographic variables except African American race (TS: 45%, 53%; RDS: 29%, 44%). Maps showed that the proportion of IDUs distributed across zip codes were similar for the TS and RDS sample, with the exception of a single zip code that was more represented in the TS sample. This zip code includes an isolated, predominantly African American neighborhood where only the TS study had a field site. Risk behavior estimates were similar for both TS and RDS samples, although self-reported hepatitis C infection was lower in the RDS sample. In terms of service utilization, more IDUs in the RDS sample reported no recent use of drug treatment and syringe exchange program services. Our study suggests that perhaps a hybrid sampling plan is best suited for recruiting IDUs in San Francisco, whereby the more intensive ethnographic and secondary analysis components of TS would aid in the planning of seed placement and field locations for RDS.

Acceptability of a safer injection facility among injection drug users in San Francisco

OBJECTIVE

Research has shown that safer injection facilities (SIFs) are successful at reducing public nuisance and enhancing public health. Since 2007 support for implementation of a SIF in San Francisco has been building. The objective of this study is to assess the acceptability of a SIF among injection drug users (IDUs) in San Francisco.

METHODS

IDUs were recruited in San Francisco using targeted sampling and interviewed using a quantitative survey (N=602). We assessed the prevalence of willingness to use a SIF as well as correlates of willingness among this group.

RESULTS

Eighty-five percent of IDUs reported that they would use a SIF, three quarters of whom would use it at least 3 days per week. In multivariate analysis, having injected in public and having injected speedballs were associated with intent to use a SIF. The majority of IDUs reported acceptability of many potential rules and regulations of a pilot SIF, except video surveillance, and being required to show identification.

CONCLUSIONS

Building on the success of SIFs in various international settings, IDUs in San Francisco appear interested in using a SIF should one be implemented.

Non-prescription syringe sales in California: a qualitative examination of practices among 12 local health jurisdictions

Legislation permitting non-prescription syringe sales (NPSS) was passed in 2004 in California as a structural intervention designed to expand access to syringes for injection drug users. As of December 2009, 19 of California's 61 local health jurisdictions (LHJs) have approved policies to authorize pharmacies to sell non-prescription syringes. The legislation faces termination in 2010 if current evaluation efforts fail to demonstrate outcomes defined in the legislation. Using qualitative methods, we examined the systems and procedures associated with implementation; identified facilitators and barriers to implementation among 12 LHJs, and documented the role of public health in initiating and sustaining local programs. We identified consistent activities that led to policy implementation among LHJs and discovered several barriers that were associated with failure to implement local programs. Factors leading to NPSS were public health leadership; an inclusive planning process, marketing the program as a public health initiative; learning from others' efforts, successes, and failures; and identifying acceptable syringe disposal options in advance of program implementation. Health departments that were confronted with political and moral arguments lost momentum and ultimately assigned a lower priority to the initiative citing the loss of powerful public health advocates or a lack of human resources. Additional barriers were law enforcement, elected officials, and pharmacy opposition, and failure to resolve syringe disposal options to the satisfaction of important stakeholders. The lessons learned in this study should provide useful guidance for the remaining LHJs in California without NPSS programs.

Primary and secondary analysis of local elected officials' decisions to support or oppose pharmacy sale of syringes in California

Under California law, local governments may authorize pharmacies within their jurisdictions to sell ten or fewer syringes to an adult without prescription, proof of identity, or proof of medical need. Local governments may simultaneously exempt adults from prosecution for violation of state drug paraphernalia codes for possession of ten or fewer syringes for personal use. Both of these provisions are temporary and sunset on December 31, 2010, unless subsequent state legislation amends that date. The objective of our study was to ascertain how and why local policymakers made their decisions regarding non-prescription syringe sale (NPSS). We examined influences on their decisions, including specific messengers and the arguments that were most salient to their decision making. We selected jurisdictions that were geographically representative of California counties; those with and without syringe exchange programs, and those that had passed or rejected NPSS. We conducted nine semi-structured interviews in five jurisdictions. To enrich primary data collection, we analyzed secondary data by reviewing audio, video, and written transcripts of public hearings and newspaper coverage in five jurisdictions, including three jurisdictions without primary interview data. Among proponents of NPSS, we identified common themes, including: (1) public health research provided conclusive evidence for reduction in HIV and hepatitis transmission without problems of crime, drug use, or unsafe discard of syringes; (2) the local health officer was the key to influencing local policymakers; (3) recall of prior debates over syringe exchange served to inform their decision making; and (4) a lack of local opposition or controversy. Common concerns among opponents of NPSS included: (1) that there would be an increase in unsafe discard of syringes; (2) loss of an important law enforcement tool; (3) that drug users were incapable of desired behavior change; and (4) that research was inconclusive, or proved that syringe access would not work in reducing rates of disease. Themes held in common by proponents and opponents of NPSS were identified as well. Syringe access through NPSS is in fact supported by a robust body of public health research and is considered an important component of a comprehensive strategy to reduce HIV and hepatitis transmission. Our study highlights the importance of understanding the perspectives of elected officials in order to ameliorate their concerns without undermining the public health goal of reducing death, disease, and suffering in at-risk communities.

Reducing HIV risks among active injection drug and crack users: the safety counts program

The efficacy of Safety Counts, a CDC-diffused intervention, was reanalyzed. In a quasi experimental, cross-over design, injection drug users (IDU) and crack users in two neighborhoods were assigned by neighborhood to receive individual Voluntary HIV Counseling and Testing or Safety Counts and 78% were reassessed at 5-9 months. Drug users in the Safety Counts program reported significantly greater reductions in risky sex, crack and hard drug use, and risky drug injection. The more sessions of Safety Counts attended, the greater were the reductions in risky acts. Different analytic decisions result in very different findings for the same intervention. Safety Counts is an effective intervention for IDU and crack users. Analytic decision of intervention outcomes is highly related to evaluations of an intervention's efficacy.

HIV prevention needs of sex-trading injection drug-using black men who have sex with both men and women

This study examined HIV prevention program needs from the perspective of injection drug-using men who have sex with both men and women involved in sex trade. Focus groups were conducted involving an exploratory sample (N = 105) of men who met the following parameters: African American, injection drug-using behavior, men who have sex with men and women, and men who frequent parks and other areas for sex trade in Baltimore City and surrounding areas, aged between 18 and 40 years. Data suggest that an HIV prevention program is needed that includes a safe space specifically for the IDU-MSM/W sex-trade community, comprehensive services including treatment for substance abuse and job assistance, and methods for improving HIV-prevention, such as communication skills to increase condom use during sex. These findings provide a better understanding of a population for which little is known, and identifies HIV prevention program needs for the IDU-MSM/W community involved in sex trade.

Mental health in HIV seronegative and seropositive IDUs in South Florida

About one-third of HIV-infected people in the USA have a history of injection-drug use. Injecting drugs are a primary vector for HIV transmission. Drug and alcohol use are significant contributors to sexual transmission of the virus. In South Florida, urban injection-drug users (IDUs) represent a substantial population at risk for infection. Substance use management in this group is critical. As part of a larger study of at-risk populations in South Florida, we examined mental health differences among IDUs (n=117), HIV seropositive IDUs (n=130), and HIV seronegative non-IDUs (n=169). We explored factors associated with depression and anxiety between groups, and found HIV seronegative and seropositive IDUs not receiving antiretroviral (ARV) treatment to have poorer overall mental health than both HIV seropositive participants on ARVs and non-IDU participants. Our data support systems enhancement to meet the various psychosocial and health care needs among IDUs and highlight the need for resource allocation to target community-based integrated mental health services in urban populations. In addition, our data underscore the need for primary and secondary HIV prevention interventions to address the drug-use risk behaviors among IDUs to reduce the likelihood of HIV infection and transmission in this population.

Simultaneous recruitment of drug users and men who have sex with men in the United States and Russia using respondent-driven sampling: sampling methods and implications

The Sexual Acquisition and Transmission of HIV Cooperative Agreement Program (SATHCAP) examined the role of drug use in the sexual transmission of the human immunodeficiency virus (HIV) from traditional high-risk groups, such as men who have sex with men (MSM) and drug users (DU), to lower risk groups in three US cities and in St. Petersburg, Russia. SATHCAP employed respondent-driven sampling (RDS) and a dual high-risk group sampling approach that relied on peer recruitment for a combined, overlapping sample of MSM and DU. The goal of the sampling approach was to recruit an RDS sample of MSM, DU, and individuals who were both MSM and DU (MSM/DU), as well as a sample of sex partners of MSM, DU, and MSM/DU and sex partners of sex partners. The approach efficiently yielded a sample of 8,355 participants, including sex partners, across all four sites. At the US sites-Los Angeles, Chicago, and Raleigh-Durham-the sample consisted of older (mean age = 41 years), primarily black MSM and DU (both injecting and non-injecting); in St. Petersburg, the sample consisted of primarily younger (mean age = 28 years) MSM and DU (injecting). The US sites recruited a large proportion of men who have sex with men and with women, an important group with high potential for establishing a generalized HIV epidemic involving women. The advantage of using the dual high-risk group approach and RDS was, for the most part, the large, efficiently recruited samples of MSM, DU, and MSM/DU. The disadvantages were a recruitment bias by race/ethnicity and income status (at the US sites) and under-enrollment of MSM samples because of short recruitment chains (at the Russian site).

The harm inside: injection during incarceration among male injection drug users in Tijuana, Mexico

Limited access to sterile syringes and condoms in correctional facilities make these settings high risk environments for HIV transmission. Although incarceration among injection drug users (IDUs) is common, there is limited information regarding specific IDU risk behaviors inside. We examined correlates of incarceration, injection inside and syringe sharing inside among male IDUs recruited in Tijuana, Mexico, using respondent driven sampling (RDS) (n=898). An interviewer administered survey collected data on sociodemographic, behavioral and contextual characteristics. Associations with (a) history of incarceration, (b) injection inside, and (c) syringe sharing inside were identified using univariate and multiple logistic regression models with RDS adjustment. Seventy-six percent of IDUs had been incarcerated, of whom 61% injected inside. Three quarters (75%) of those who injected shared syringes. U.S. deportation [adjusted odds ratio (AOR)=1.61; 95% confidence interval (CI): 1.07, 2.43] and migration (AOR=1.81; 95% CI: 1.12, 2.95) were independently associated with incarceration. Injection inside was independently associated with recent receptive syringe sharing (AOR=2.46; 95% CI: 1.75, 3.45) and having sex with a man while incarcerated (AOR=3.59; 95% CI: 1.65, 7.83). Sharing syringes inside was independently associated with having sex with a man while incarcerated (AOR=6.18; 95% CI: 1.78, 21.49). A majority of incarcerated IDUs reported injecting and syringe sharing during incarceration, and these IDUs were more likely to engage in sex with other men. Corrections-based interventions to reduce injection and syringe sharing are urgently needed, as are risk reduction interventions for male IDUs who have sex with men while incarcerated.

Greater drug injecting risk for HIV, HBV, and HCV infection in a city where syringe exchange and pharmacy syringe distribution are illegal

Comparing drug-injecting risk between cities that differ in the legality of sterile syringe distribution for injection drug use provides a natural experiment to assess the efficacy of legalizing sterile syringe distribution as a structural intervention to prevent human immunodeficiency virus (HIV) and other parenterally transmitted infections among injection drug users (IDUs). This study compares the parenteral risk for HIV and hepatitis B (HBV) and C (HCV) infection among IDUs in Newark, NJ, USA, where syringe distribution programs were illegal during the period when data were collected, and New York City (NYC) where they were legal. IDUs were nontreatment recruited, 2004-2006, serotested, and interviewed about syringe sources and injecting risk behaviors (prior 30 days). In multivariate logistic regression, adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) for city differences are estimated controlling for potential city confounders. IDUs in Newark (n = 214) vs. NYC (n = 312) were more likely to test seropositive for HIV (26% vs. 5%; AOR = 3.2; 95% CI = 1.6, 6.1), antibody to the HBV core antigen (70% vs. 27%; AOR = 4.4; 95% CI = 2.8, 6.9), and antibody to HCV (82% vs. 53%; AOR = 3.0; 95% CI = 1.8, 4.9), were less likely to obtain syringes from syringe exchange programs or pharmacies (AOR = 0.004; 95% CI = 0.001, 0.01), and were more likely to obtain syringes from street sellers (AOR = 74.0; 95% CI = 29.9, 183.2), to inject with another IDU's used syringe (AOR = 2.3; 95% CI = 1.1, 5.0), to reuse syringes (AOR = 2.99; 95% CI = 1.63, 5.50), and to not always inject once only with a new, sterile syringe that had been sealed in a wrapper (AOR = 5.4; 95% CI = 2.9, 10.3). In localities where sterile syringe distribution is illegal, IDUs are more likely to obtain syringes from unsafe sources and to engage in injecting risk behaviors. Legalizing and rapidly implementing sterile syringe distribution programs are critical for reducing parenterally transmitted HIV, HBV, and HCV among IDUs.

Income generating activities of people who inject drugs

BACKGROUND

Injection drug users (IDU) commonly generate income through prohibited activities, such as drug dealing and sex trade work, which carry significant risk. However, little is known about the IDU who engage in such activities and the role of active drug use in perpetuating this behavior.

METHODS

We evaluated factors associated with prohibited income generation among participants enrolled in the Vancouver Injection Drug Users Study (VIDUS) using logistic and linear regression. We also examined which sources of income respondents would eliminate if they did not require money to pay for drugs.

RESULTS

Among 275 IDU, 145 (53%) reported engaging in prohibited income generating activities in the past 30 days. Sex work and drug dealing accounted for the greatest amount of income generated. Non-aboriginal females were the group most likely to report prohibited income generation. Other variables independently associated with prohibited income generation include daily heroin injection (AOR=2.3) and daily use of crack cocaine (AOR=3.5). Among these individuals, 68 (47%) indicated they would forgo these earnings if they did not require money for illegal drugs, with those engaged in sex trade work (62%) being most willing to give up their illegal source of income.

CONCLUSION

These findings suggest that the costs associated with illicit drugs are compelling IDU, particularly those possessing markers of higher intensity addiction, to engage in prohibited income generating activities. These findings also point to an opportunity to explore interventions that relieve the financial pressure of purchasing illegal drugs and reduce engagement in such activities, such as low threshold employment and expansion of prescription and substitution therapies.

A situational picture of HIV/AIDS and injection drug use in Vinnitsya, Ukraine

BACKGROUND

New and explosive HIV epidemics are being witnessed in certain countries of Eastern Europe, including Ukraine, as well as a rapid and dramatic increase in the supply, use, and negative public health consequences of illicit drugs. A majority of registered HIV cases in Ukraine occur among injection drug users (IDUs), large numbers of whom report HIV risk behaviors such as needle sharing. The purpose of this study was to apply the World Health Organization's Rapid Assessment and Response on Injection Drug Use (IDU-RAR) guide to create a situational picture in the Vinnitsya Oblast, Ukraine, a region with very scarce information about the HIV/AIDS and injection drug use (IDU) epidemics.

METHODS

The IDU-RAR uses a combination of qualitative data collection techniques commonly employed in social science and evaluation research to quickly depict the extent and nature of the given health problem and propose locally relevant recommendations for improvement. The investigators focused their assessment on the contextual factors, drug use, and intervention and policy components of the IDU-RAR. A combination of network and block sampling techniques was used. Data collection methods included direct observation, review of existing data, structured and unstructured interviews, and focus group discussions. Key informants and locations were visited until no new information was being generated.

RESULTS

The number of registered HIV cases in Vinnitsya has increased from 3 (1987-1995) to 860 (1999-10/2004), 57 of whom have already died. Ten percent of annual admissions to the area's Regional Narcological Dispensary were for opiate disorders, and the number of registered IDUs rose by 20% from 1999 to 2000. The level of HIV/AIDS awareness is generally poor among the general population but high among high-risk populations. Both HIV/AIDS and injection drug use carry a strong stigma in the community, even among medical professionals. There was very little evidence of primary HIV/AIDS prevention efforts, and IDU prevention efforts focused on promotion of anti-drug messages in the schools.

CONCLUSION

Given that Ukraine has sparse resources to be devoted to this problem, action recommendations should be prioritized, realistic, and initially targeted to persons in greatest need. The following action recommendations are prioritized by the following categories: First priority: Voluntary Counseling and Testing; Second Priority: Prevention and Education; and Third Priority: Harm Reduction and Treatment. They are provided in this sequence based on what response can realistically be implemented first with limited additional resources and can make the greatest immediate impact. The persons at greatest risk, HIV positive persons and IDUs, should be attended to first.

Attempted suicide among injecting and noninjecting cocaine users in Sydney, Australia

A sample of 183 current cocaine users, 120 primary injecting cocaine users (ICUs), and 63 primary noninjecting cocaine users (NICUs) were administered a structured interview to ascertain attempted suicide histories, methods used, and factors associated with suicide attempts. All respondents were volunteers and current cocaine users recruited through a wide range of sources. The mean age of participants was 30.1 years, and 65% were male. The ICUs were older (32.3 vs. 26.7 years, respectively), more likely to be male (72% vs. 54%, respectively), to be unemployed (84% vs. 23%, respectively) and to have a prison history (53% vs. 1%, respectively) compared to NICUs. Of the sample, 31% had attempted suicide, 18% had done so on more than one occasion, and 8% had made an attempt in the preceding 12 months. Overall, 28% of the sample had been treated by a medical practitioner after an attempt. ICUs (38%) were significantly more likely than NICUs (10%) to have attempted suicide and to have done so on more than one occasion (23% vs. 3%, respectively). The most common method used among both groups was self-poisoning (ICUs 28%, NICUs 8%), primarily by drug overdose. Violent methods had been used by 22% of ICUs and 3% of NICUs. Multivariate analyses revealed that injecting, female gender, and more extensive polydrug use were independent predictors of a suicide attempt. The prevalence of suicide in this study indicates that it represents a major clinical issue among ICUs and to a lesser extent among noninjectors of the drug. Those treating cocaine users for drug dependence need to be aware of the salience of suicide as a problem, among injectors in particular.

A genetic locus for inducibility of C-type in BALB-c cells: the effect of a nonlinked regulatory gene on detection of virus after chemical activation

Previous studies have shown that chemicals can transiently activate endogenous C-type viruses from embryo cells of the BALB/c mouse strain, but not from cells of another mouse strain, NIH Swiss. The number of genetic loci for inducibility of endogenous virus in BALB/c cells was investigated with cell lines derived from appropriate, F(1), F(2)-hybrid, and backcross generation embryos of these strains. A single genetic locus responsible for inducibility of virus in BALB/c cells was detected, and tentatively designated Ind. A second locus, previously described in studies of mouse-cell susceptibility to exogenous virus infection, Fv-1, was found to be genetically nonlinked to Ind. This regulatory gene plays an important role in determining whether the induced viruses of BALB/c cells can persist after chemical activation.