Patterns and characteristics of hepatitis C transmission clusters among HIV-positive and HIV-negative individuals in the Australian trial in acute hepatitis C.

BACKGROUND: Injecting drug users remain the population at greatest risk of acquiring hepatitis C virus (HCV) infection, although a recent increase in cases of sexually transmitted HCV infection has been observed among human immunodeficiency virus (HIV)-infected individuals. The extent to which these separate epidemics overlap is unknown. METHODS: The Australian Trial in Acute Hepatitis C (ATAHC) enrolled 163 individuals (29% of whom were HIV infected) with recent HCV infection. E1/HVR1 sequences were used to construct phylogenetic trees demonstrating monophyletic clusters or pairs, and viral epidemic history and phylogeography were assessed using molecular clock analysis. Individual clusters were characterized by clinical and demographic characteristics. RESULTS: Transmission through injection drug use occurred for 73% of subjects, with sexual transmission occurring for 18% (92% of whom were HIV infected). Among 112 individuals with available E1/HVR1 sequences, 23 (20%) were infected with a strain of HCV identical to that of another subject, comprising 4 homologous clusters and 3 monophyletic pairs, the majority of which (78%) were HIV infected. Clusters contained individuals with both injection drug use-related and sex-related acquisition, and in all clusters (except for 1 female HIV-uninfected pair), individuals identified as men who have sex with men, irrespective of HIV status. CONCLUSIONS: This large unique study of HIV-infected and HIV-uninfected individuals with recently acquired HCV infection demonstrates that clustering is common in the HIV-infected population and that it occurred almost invariably among men who have sex with men, irrespective of the actual mode of acquisition. These findings suggest the coexistence of both injection drug use and sexual risk behaviors for individuals in the same social networks and have implications for the development of public health messages. Clinical trial registration. NCT00192569.

Sex work practices and condom use in female sex workers in Sydney.

The aim of this study was to determine sex work practices and predictors of condom use among female sex workers (SWs) in Sydney. SWs from two centres completed a self-administered questionnaire covering demographic and sexual characteristics and sex work practices. One hundred and forty-eight international (born in Asia) and 141 local SWs (born in Australia, New Zealand or the UK) were recruited. Local SWs saw more clients per shift than international SWs (P = 0.002), but international SWs worked more shifts per week than local SWs (P = 0.001). International SWs used condoms less consistently at work than local SWs (P = 0.001). About 37% of international SWs never used condoms with non-paying partners, compared with 14% of local SWs (P = 0.01). Speaking Thai (odds ratio [OR] 8.9, 95% confidence interval [CI]; 3.19-24.87) or Chinese (OR 17.4; 95% CI 4.98-60.89) (both P < 0.001) and previous sex work in Thailand (OR 10.0 95% CI 2.31-43.52; P = 0.02) were associated with inconsistent condom use. Strategies to improve condom use need to be evaluated.

Fertility and reproductive choice in women with HIV-1 infection.

OBJECTIVE: To measure fertility and birth rates and to describe the reproductive histories of women diagnosed with HIV-1 infection in Australia. METHODS: The medical records of 294 women with HIV-1 infection in four states of Australia were reviewed. Expected fertility and birth rates were calculated using national statistics. RESULTS: In the study population, 152 (52%) women had at least one pregnancy prior or subsequent to HIV-1 diagnosis. At maternal HIV-1 diagnosis, 71 (24%) women had a total of 106 children aged under 15 years. During the study period, 246 women were aged 15, 44 years and 58 (23%) of these became pregnant after HIV-1 diagnosis. Women whose exposure to HIV-1 was injecting drug use were twice as likely to become pregnant and more likely to have multiple pregnancies than women who did not report injecting drug use. The annual general fertility rate was 30 per 10,000 compared with 63 per 10,000 for the Australian female population aged 15-44 years, and the birth rate in women with HIV-1 infection was one-half that of the general female population. Of pregnancies confirmed after HIV-1 diagnosis, 47% were voluntarily terminated, a rate more than double that of the general population. All multiple terminations were among women whose exposure to HIV-1 was injecting drug use. CONCLUSIONS: Fertility and birth rates among women with HIV-1 infection are lower than the general population and the rate of termination higher. The results of this study provide a basis for the management of women with HIV-1 infection who are considering pregnancy.

PIP: Review of the medical records of 294 HIV-1-infected women in four states of Australia found the fertility and birth rates among those women to be lower and the rate of pregnancy termination higher than those of the general female Australian population. Expected fertility and birth rates were calculated using national statistics. 152 women had at least one pregnancy before or subsequent to HIV-1 diagnosis. At maternal HIV-1 diagnosis, 71 women had a total of 106 children under age 15 years. During the study period of 1987-92, 58 of the 246 women aged 15-44 years became pregnant after HIV-1 diagnosis. Women whose exposure to HIV-1 was IV drug use were twice as likely to become pregnant and more likely to have multiple pregnancies than women who did not report such drug use. The annual general fertility rate was 30/10,000 compared to 63/10,000 for the general Australian female population, while the birth rate among HIV-1-infected women was also half that of the general female population. Of pregnancies confirmed after HIV-1 diagnosis, 47% were voluntarily terminated, a rate more than double that of the general population. All multiple terminations were among women whose exposure to HIV-1 was through IV drug use.

Pilot randomized controlled study of dexamphetamine substitution for amphetamine dependence.

AIMS: To test the feasibility of conducting a definitive randomized controlled trial of dexamphetamine substitution for amphetamine dependent people and provide preliminary data. DESIGN: An open, two-group pre-post randomized controlled trial. PARTICIPANTS: Forty-one long-term, dependent amphetamine users seeking treatment. INTERVENTION: Twenty subjects were offered weekly counselling. Twenty-one subjects were, in addition, prescribed up to 60 mg dexamphetamine daily. MEASUREMENTS: Immunoassay and mass spectrometric urinalysis techniques were used to identify the presence of amphetamine and methylamphetamine in urine. The Opiate Treatment Index and Severity of Dependence Scale were used to collect pre- and post-self-report data. Subjects were screened using the Composite International Diagnostic Interview. FINDINGS: Reduced street amphetamine use and amphetamine dependence was observed both in subjects prescribed dexamphetamine and subjects receiving counselling only. Treatment subjects appeared more likely to attend counselling. CONCLUSIONS: A definitive randomized controlled trial of dexamphetamine substitution using the techniques and instruments piloted in this study is feasible. Users appeared to be attracted and retained in substitution treatment. The intervention also appeared to be acceptable to clinicians.

Epidemiology of hepatitis C virus infection among injecting drug users in Australia.

STUDY OBJECTIVE: To review the epidemiology of hepatitis C virus (HCV) infection among injecting drug users (IDUs) in Australia, and consider needs for further research and prevention policies and programmes. DESIGN: (1) Review of the results of surveillance for HCV; (2) review of published literature on prevalence, incidence, and risk factors for HCV among IDUs; and (3) reconstruction of incidence rates from prevalence studies of HCV in IDUs. SETTING AND PARTICIPANTS: Field and clinic based studies of IDUs in Australia. MAIN RESULTS: HCV has been present at high prevalences (of the order of 60-70%) in populations of Australian IDUs since at least 1971. Duration of injecting and main drug injected were the main predictors of seropositivity, the latter possibly a surrogate for frequency of injecting and both together as surrogate for cumulative numbers of times injected. Risk of infection begins with first injection and continues as long as injecting does. Current incidence is approximately 15 per 100 person years, and up to 40 per 100 person years in some subpopulations. Incidence may have decreased through the 1980s as a result of behaviour change in relation to HIV, as it has for hepatitis B, but not significantly so. CONCLUSIONS: Control of HCV infection in Australia will depend on effectiveness of measures to control HCV spread among IDUs. This will be a greater challenge than the control of HIV in this population has been. Needs identified include improved surveillance, especially for recently acquired infection, better understanding of exact transmission modes, and urgent improvement in prevention strategies.

Cervical human papillomavirus infections in commercial sex workers-risk factors and behaviours.

We have investigated the prevalence of, and risk factors for, cervical human papillomavirus (HPV) infection in commercial sex workers (CSWs) and controls attending the same sexual health clinics in Sydney. A self-administered 'risk factor' questionnaire was completed and a Pap smear and a specimen for HPV detection and typing were taken. Results from the 288 CSWs and 266 controls were assessed by univariate and multivariate analyses. No significant difference in the rates of cervical HPV infection in CSWs (31.6%) and controls (24.4%) was found but HPV related cytological abnormalities were more common on the CSWs (P <0.05). In both groups, factors independently associated with HPV infection were the use of non-barrier contraception, cytological abnormalities, age under 36 and the number of non-paying sexual partners. A risk factor for CSWs only was sex-work in Japan. A detailed 'work' history from CSWs may be useful to identify unsafe practices or work in countries where safer sex may be less acceptable.

Preference to have used a medically supervised injecting centre among injecting drug users in Kings Cross, Sydney.

OBJECTIVE: To assess factors affecting preference to have last injected in a medically supervised injecting centre (MSIC) among injecting drug users (IDUs) attending a needle syringe program (NSP) in Kings Cross, Sydney. METHODS: All NSP attenders over a two-day period in August 1999 were asked where they last injected, whether they injected alone and if they would have preferred to use an MSIC. This was in addition to the routine data collected, which included age, gender and last drug injected. RESULTS: Among the 178 respondents, 52 (29%) last injected in a public place and 77 (44%) last injected alone. Seventy-one per cent of all respondents would have preferred to use an MSIC. Of those who injected in public, 83% would have preferred to use an MSIC compared to 66% of those who injected in private, which was significant (p = 0.03). Age, gender, last drug injected and having injected alone did not affect preference to use an MSIC. CONCLUSIONS: Respondents' high preference to use an MSIC suggests that it may well achieve its public order and public health objectives. IMPLICATIONS: An MSIC may significantly shift current patterns of illicit drug use in Kings Cross, the community impact of which should be monitored and managed.

The health and welfare needs of female and transgender street sex workers in New South Wales.

OBJECTIVES: To determine the health and welfare status of female and transgender street sex workers and their work-related experiences. Also to estimate population numbers, determine work locations, and identify the most appropriate education, health and welfare services for this group. METHODS: Forty-eight street sex workers completed a questionnaire, mainly at their place of work. Demographic and sexual health profiles of sex workers attending the Sydney Sexual Health Centre and the Kirketon Road Centre in 1997 were compared with the street sample. RESULTS: Up to 120 female and transgender sex workers worked on the streets in Sydney, Newcastle, Wollongong and surrounding areas in any one night: more than 80% of these were female. Of those sampled, fewer street workers than brothel sex workers (6% vs. 41%; p<0.001) were from non-English speaking backgrounds, and more (77% vs. 7%; p<0.0001) were currently injecting drugs. The street workers reported lower rates of condom use at work than local brothel workers (91.7% vs. 98.8%; p<0.016) and high rates of hepatitis B and C infection. Seventy-five per cent had experienced violence at work. Child care, lack of supportive relationships, community intolerance and low self-esteem were important problems for the street workers. While the police were frequently required by the community to move the street workers on, there were no reports of corrupt behaviour by police. CONCLUSIONS: Health services need to specifically target this group with particular attention to the prevention of blood-borne virus infections, contraception, drug dependency and transgender issues. Consideration should be given to developing a network of safe houses to reduce community pressure and violence.

Drug consumption facilities: an update since 2000.

The topic of drug consumption facilities or rooms (DCRs) was reviewed by Dolan, Kimber and others in Harm Reduction Digest 10, published in the September 2000 issue of DAR. As one of the first English language papers on the topic this paper has been cited extensively. Now, 3 years on, these authors and have brought together an international team of experts to revisit the topic. In this update they: (i) highlight where DCRs are operating or under consideration, (ii) review briefly new literature and (iii) discuss future directions. This Digest is a 'must read' for policy makers, advocates and practitioners in the drug field.

Infection with HIV and hepatitis C virus among injecting drug users in a prevention setting: retrospective cohort study.

OBJECTIVES: To estimate the incidence of HIV and hepatitis C virus and risk factors for seroconversion among a cohort of injecting drug users. DESIGN: Retrospective cohort study. SETTING: Primary healthcare facility in central Sydney. SUBJECTS: Injecting drug users tested for HIV-1 antibody (n=1179) and antibodies to hepatitis C virus (n=1078) from February 1992 to October 1995. MAIN OUTCOME MEASURES: Incidence of HIV-1 and hepatitis C virus among seronegative subjects who injected drugs and underwent repeat testing. Demographic and behavioural risk factors for hepatitis seroconversion. RESULTS: Incidence of HIV-1 among 426 initially seronegative injecting drug users was 0.17/100 person years (two seroconversions) compared with an incidence of hepatitis C virus of 20.9/100 person years (31 seroconversions) among 152 injecting drug users initially negative for hepatitis C virus. Incidence of hepatitis C virus among injecting drug users aged less than 20 years was 75.6/100 person years. Independent risk factors for hepatitis C virus seroconversion were age less than 20 years and a history of imprisonment. CONCLUSIONS: In a setting where prevention measures have contributed to the maintenance of low prevalence and incidence of HIV-1, transmission of hepatitis C virus continues at extremely high levels, particularly among young injecting drug users.

Potential biases in estimates of hepatitis C RNA clearance in newly acquired hepatitis C infection among a cohort of injecting drug users.

Estimates of hepatitis C virus (HCV) clearance following acute infection range from 14 to 46%. This wide range is likely to be due to the characteristics of the populations studied and analysis methods. This paper examines how differing definitions of clearance parameters affect estimates of viral clearance in a cohort of 85 injecting drug users with newly acquired HCV infection. Kaplan-Meier estimates of time to HCV clearance were determined using varying definitions of eligible cohort, viral clearance, date of infection and date of clearance. Based on which combinations of definitions were used, the number of subjects eligible for analysis ranged from 27 to 75, clearance rate ranged from 14 to 68% and time to achieving 25% clearance ranged from approximately 5 months to 14 months. Standardized definitions and methodologies are required to enable valid comparisons of rates of clearance across newly acquired HCV infection natural history studies.

High incidence of hepatitis C virus reinfection within a cohort of injecting drug users.

A retrospective cohort study was established of injecting drug users (IDUs) to assess evidence for hepatitis C virus (HCV) protective immunity through a comparison of incidence of initial HCV infection and HCV reinfection. Incidence of initial HCV infection was determined among HCV seronegative IDUs, and HCV reinfection determined among IDUs with newly acquired HCV infection, HCV viraemia and subsequent HCV RNA clearance. Serum was available for HCV RNA analysis from stored samples taken at the time of prior blood-borne virus screening. Potential HCV reinfection was defined as a positive HCV RNA following at least one negative HCV RNA. Incidence of initial HCV infection was 17/100 person-years (95% CI, 14-20/100 person-years). The incidence of potential HCV reinfection was 42/100 person-years (95% CI, 25-61/100 person-years), and after excluding cases without a change in HCV genotype and less than three consecutive HCV RNA negative assessment, incidence of reinfection was 31/100 person-years (95% CI, 17-62/100 person-years). Following adjustment for HCV risk behaviour variables the incidence rate ratio of HCV reinfection to initial infection was 1.11 (P = 0.8). Several cases of HCV reinfection appear to have developed persistent infection.

Managing HIV. Part 6: People living with HIV. 6.5 HIV and injecting drug use.

Injecting drug use can not only lead to HIV infection via the sharing of injecting equipment, it can also complicate the course and management of infection.

Prevalence of tuberculosis infection among homeless young people in central and eastern Sydney.

OBJECTIVE: To determine the prevalence of tuberculosis (TB) infection among homeless young people (aged 12-25 years) in central and eastern Sydney. METHODOLOGY: A cross-sectional survey was conducted in 16 youth refuges and four drop-in centres in Central and Eastern Sydney Health Areas and at the Cellblock Youth Health Centre, Glebe and the Kirketon Road Centre, Darlinghurst, New South Wales (NSW). Participants completed a questionnaire and underwent Mantoux testing. RESULTS: One hundred and forty-one young people completed questionnaires and 139 received a Mantoux test; 112 (80. 6%) had their Mantoux read and 10 (8.9%) were Mantoux positive (95% confidence interval 3.6-14.2). None of the risk factors examined were found to be associated with increased risk for TB infection. CONCLUSIONS: In this sample of homeless young people in central and eastern Sydney, the Mantoux positivity rate appears to be higher than the general population in NSW, but they would not currently be considered a high-risk group for TB infection.

Risk factors for hepatitis C virus infection among injecting drug users in Sydney.

OBJECTIVE: To study risk factors for hepatitis C virus (HCV) infection in injecting drug users (IDUs) from central Sydney. SETTING AND SUBJECTS: All IDUs attending a primary health care facility in central Sydney between December 1991 and November 1992 who underwent HCV antibody testing. METHODS: Information was obtained retrospectively from client forms routinely completed at the time of medical consultation. Additional information on injecting history and practice was obtained from the registration forms of subjects who also attended the needle syringe exchange programme at the same health care facility. RESULTS: Of the 201 IDUs tested, 118 (59%) had HCV antibodies, which did not differ significantly between males and females. HCV prevalence increased significantly with age, being highest in IDUs who were aged 35 years or more (93%) and lowest in IDUs aged under 20 years (17%). HCV prevalence increased significantly with time since first injecting, from 26% for IDUs who had injected for less than 3 years to 94% for those who had injected for more than 10 years. HCV prevalence was also significantly higher in heterosexual IDUs as compared with homosexual male IDUs, and in opiate users as compared with stimulant users, even after adjustment for age and duration of injecting. HCV prevalence was strongly associated with exposure to hepatitis B virus, but was not associated with exposure to HIV. CONCLUSION: Recent HCV transmission indicates ongoing injecting risk behaviour despite HIV prevention efforts, and underlies the potential for increased transmission of HIV through the sharing of injecting equipment. Within the population of IDUs, those who are heterosexual or inject heroin appear to be at increased risk of HCV infection.

Nurse practitioners: an evaluation of the extended role of nurses at the Kirketon Road Centre in Sydney, Australia.

The aim of the present study was to formally evaluate the effectiveness, professional appropriateness and acceptability of the extended role of the nurse practitioner at the Kirketon Road Centre (KRC) in Sydney, Australia. Data collection consisted of client and staff surveys and case file review by two assessors (one medical and one nursing). This paper will report on one section of this research, namely the case file review section of the study. Total study subjects were 1046 'at risk' youth, sex workers and injecting drug users attending KRC for their primary health care needs between September 1994 and April 1995. Nurse practitioners (NP) saw 613 of the clients who presented over this period. The majority of these clients were women (77.3%). The majority of NP consults were related to STD (51%), gynaecological (17%) and hepatitis (16%) issues. The results demonstrated that nurse practitioners were professionally appropriate in all aspects of expected 'best practice' in over 95% of consultations.

Hepatitis C virus antibody prevalence among injecting drug users at selected needle and syringe programs in Australia, 1995-1997. Collaboration of Australian NSPs.

OBJECTIVES: To describe point prevalence of HCV antibody and relevant risk behaviour among people who inject drugs and who attended selected needle and syringe programs throughout Australia in 1995, 1996 and 1997. DESIGN AND SETTING: Repeated cross-sectional surveys of one week's duration were carried out in 21, 20 and 23 needle and syringe program sites throughout Australia in 1995, 1996 and 1997, respectively. PARTICIPANTS: All clients attending participating sites during the designated survey week were asked to complete a self-administered questionnaire and provide a finger-prick blood sample for HCV antibody testing. MAIN OUTCOME MEASURES: Prevalence of HCV antibody. RESULTS: Survey response was 41% (n = 979) in 1995, 51% (n = 1463) in 1996 and 48% (n = 1699) in 1997. HCV prevalence declined significantly from 63% in 1995 to 51% in 1996 and 50% in 1997 (P < 0.001). Among respondents who reported injecting for less than three years, prevalence declined from 22% in 1995 to 13% in 1996 and 1997 (P < 0.001). Reported use of needles and syringes after someone else in the previous month declined from 31% in 1995 and 28% in 1996 to 15% in 1997 (P < 0.001). CONCLUSIONS: Despite an apparent decline in HCV prevalence, carriage rates of HCV antibody remain high.

Hepatitis C prevalence among Australian injecting drug users in the 1970s and profiles of virus genotypes in the 1970s and 1990s.

OBJECTIVES: To examine the seroprevalence of hepatitis C virus (HCV) in the Australian injecting drug-using community in the 1970s, and to compare the profile of HCV genotypes with that seen in the 1990s. DESIGN: Investigation of stored sera that were collected from injecting drug users in the 1970s and comparison with sera collected in the 1990s. SETTING: Inner Sydney, 1974-1975 and 1994-1996. PATIENTS: The 1970s group comprised 141 consecutive injecting drug users who attended the Brisbane Street Methadone Clinic. The 1990s group comprised 88 consecutive, injecting drug users of European origin who were HCV antibody-positive and attended a primary healthcare facility (the Kirketon Road Centre). MAIN OUTCOME MEASURES: HCV antibody prevalence (1970s); profile of HCV serotypes (1970s and 1990s); and serological evidence of hepatitis A and B. RESULTS: 84% of the 1970s group were HCV antibody-positive, of whom 92% were infected with HCV serotype 1 and 1% with serotype 3. In contrast, in the 1990s group, 69% were infected with HCV serotype 1 and 25% with serotype 3. The HCV-positive subjects from the early group were more likely than those from the recent group to have serological evidence of previous HBV infection. CONCLUSIONS: The high prevalence of HCV among injecting drug users in the 1970s in Australia confirms an epidemic that has been present for at least 25 years. Over this period, the proportion of HCV genotype 1 infections has decreased and genotype 3 infections have emerged.

HIV prevalence and risk behaviour in needle exchange attenders: a national study. The Collaboration of Australian Needle Exchanges.

OBJECTIVE: To determine whether needle and syringe exchange programs represent feasible sites to describe the prevalence of HIV and related risk behaviour among injecting drug users. DESIGN: Cross-sectional survey. SETTING: 21 needle and syringe exchange programs in all Australian jurisdictions. PARTICIPANTS: All persons attending the needle and syringe exchange programs over one week in March 1995 were eligible to participate in the study once. INTERVENTION: Needle and syringe exchange attenders were asked to complete a brief, self-administered questionnaire and provide a finger-prick blood sample. MAIN OUTCOME MEASURES: Prevalence of HIV antibody, drug injecting and sexual behaviour, and survey cost. RESULTS: Completed questionnaires with blood samples suitable for testing were provided by 1005 (42%) of 2373 individuals who attended the needle and syringe exchange programs during the survey week. Women were more likely than men to participate in the survey but there was no difference in the response rate by age group. The HIV prevalence was 2.1% and was significantly higher in men who described themselves as homosexual, compared to men who described themselves as heterosexual (22.5% v. 0.7%; P < 0.001). Thirty-one per cent of respondents reported using a syringe after someone else in the preceding month. CONCLUSION: Cross-sectional surveys of needle exchange clients offer a practical method for monitoring risk behaviour and seroprevalence of bloodborne viral infections.