Patterns of smoking and injecting methamphetamine and their association with health and social outcomes.

INTRODUCTION: We examine how smoking and injecting methamphetamine change over time and correlate with specific health and social outcomes. METHODS: Panel data from a longitudinal cohort dependent on methamphetamine (N = 444; 891 months). Random effects regression models examined the relationship between smoking and/or injecting methamphetamine and past month outcomes (substance use, ≥daily injection, needle/syringe sharing, psychological distress, poor mental and physical health, sexual behaviour, psychotic symptoms, violent behaviour and crime). Effects were adjusted for between-group differences at baseline. RESULTS: At baseline, 56% of participants only injected methamphetamine in the past month, 18% only smoked and 26% both injected and smoked (concurrent injecting and smoking). Compared to injecting only, concurrent injecting and smoking was associated with more days of methamphetamine use (b = 1.3, P < 0.001; adjusted [A] b = 1.2, P < 0.001), more frequent injection [odds ratio (OR) 1.8, P = 0.013; adjusted OR (AOR) 1.6, P = 0.042], violent behaviour (OR 2.1, P = 0.001; AOR 1.8, P = 0.013] and crime (OR 3.1, P < 0.001; AOR 2.5, P < 0.001). Non-injecting related outcomes did not differ significantly for only smoking versus only injecting. There was no significant transition from injecting methamphetamine at baseline to non-injecting methamphetamine use at follow up, or from exclusively smoking methamphetamine at baseline to any methamphetamine injection at follow up. DISCUSSION AND CONCLUSION: Efforts are needed to address heavier methamphetamine use, more frequent drug injection and elevated violent behaviour and crime among people who concurrently smoke and inject methamphetamine.

Positividade ao hiv e fatores associados em um centro de testagem e aconselhamento / Positividad al vih y factores asociados en un centro de consejería y pruebas / Hiv positivity and associated factors in a counseling and testing center

RESUMO Objetivo: Analisar os fatores sociodemográficos e comportamentais associados à positividade ao Vírus da Imunodeficiência Humana (HIV) em usuários de um Centro de Testagem e Aconselhamento (CTA). Método: Estudo transversal com 5.229 usuários que realizaram o teste rápido para HIV, registrados no Sistema de Informação do CTA. As análises bivariadas e multivariadas foram realizadas utilizando-se a regressão logística binária, com apresentação do OddsRatio, intervalo de confiança de 95% e p-valor <0,05. Resultados: A prevalência de infecção pelo HIV foi de 5,0% (259), com maior acometimento da população mais jovem (p=0,010). Observou-se maior positividade entre as pessoas vivendo com HIV/Aids (91,3%; p<0,001) e homens que fazem sexo com homens (HSH) (20%; p<0,001). Nas análises multivariadas verificou-se maior associação à infecção pelo HIV no modelo 2 que inclui, as variáveis sociodemográficas e comportamentais, como: o recorte populacional de HSH, o compartilhamento de seringas, a orientação sexual HSH, ter infecções sexualmente transmissíveis (IST) nos últimos 12 meses, parceiro soropositivo para HIV e uso irregular ou não uso do preservativo nos últimos 12 meses com parceiro fixo. Conclusão: A vulnerabilidade ao HIV foi mais associada aos fatores relacionados ao compartilhamento de seringas e ao comportamento sexual, especialmente os HSH e as parcerias fixas.

resumen Objetivo: analizar los factores sociodemográficos y comportamentales asociados a la positividad al Virus de la Inmunodeficiencia Humana (VIH) en usuarios de un Centro de Consejería y Pruebas. Método: estudio transversal con 5.229 usuarios que realizaron la prueba rápida para VIH, registrados en el Sistema de Información del Centro. Los análisis bivariados y multivariados fueron realizados utilizando la regresión logística binaria, con presentación del OddsRatio, intervalo de confianza de 95% y p-valor <0,05. Resultados: la prevalencia de infección por el VIH fue de 5,0% (259), con mayor acometimiento de la población más joven (p=0,010). Se observó mayor positividad entre las personas viviendo con VIH/sida (91,3%; p<0,001) y hombres que hacen sexo con hombres (HSH) (20%; p<0,001). En los análisis multivariados se verificó mayor asociacióna la infección por el VIH en el modelo 2 que incluye las variables sociodemográficas y comportamentales como: el recorte poblacional de HSH, el compartir jeringas, la orientación sexual HSH, tener enfermedades de transmisión sexual (ETS) en los últimos 12 meses, compañero seropositivo para VIHy uso irregular o la falta del uso de preservativo en los últimos 12 meses con compañero fijo. Conclusión: la vulnerabilidad al VIH fue más asociada a los factores relacionados al compartir jeringas y al comportamiento sexual, especialmente los HSH y los compañeros fijos.

ABSTRACT Objective: To analyze the sociodemographic and behavioral factors associated with Human Immunodeficiency Virus (HIV) positivity in users of a Counseling and Testing Center (CTC). Method: Across-sectional study with 5,229 users who performed the rapid HIV test, registered in the CTC's Information System. Bivariate and multivariate analyzes were performed using binary logistic regression, presenting OddsRatio, 95% confidence interval and p-value <0.05. Results: The prevalence of HIV infection was 5.0% (259), with greater involvement of the younger population (p=0.010). Greater positivity was observed among people living with HIV/AIDS(91.3%; p <0.001) and men who have sex with men (MSM) (20%; p<0.001). In multivariate analyzes, there was a greater association with HIV infection in model 2, which includes sociodemographic and behavioral variables, such as: the populational cut of MSM, needle sharing, MSM sexual orientation, having sexually transmitted infections (STIs) in the last 12 months, HIV-positive partner and irregular or no condom use in the last 12 months with a steady partner. Results: Conclusion: Vulnerability to HIV was more associated with factors related to needle sharing and sexual behavior, especially MSM and steady partnerships.

Human Immunodeficiency Virus Testing, Diagnosis, Linkage to Care, and Prevention Services Among Persons Who Inject Drugs, United States, 2012-2017.

BACKGROUND: Human immunodeficiency virus (HIV) testing and early diagnosis is associated with effective disease management and reduction in HIV transmission among persons who inject drugs (PWID). We examined trends in HIV testing outcomes among PWID during 2012-2017. METHODS: Centers for Disease Control and Prevention (CDC)-funded HIV testing data submitted by 61 health departments and 150 directly-funded community-based organizations during 2012-2017 were analyzed. We calculated estimated annual percentage changes (EAPC) to assess trends for HIV testing and testing outcomes. RESULTS: A total of 19 739 857 CDC-funded HIV tests were conducted during 2012-2017. Of these, 529 349 (2.7%) were among PWID. The percentage of newly diagnosed HIV increased from .7% in 2012 to .8% in 2017 (EAPC, 4.15%). The percentage interviewed for partner services increased from 46.7% in 2012 to 66.3% in 2017 (EAPC, 1.81%). No significant change was identified in trends for linkage to HIV medical care ≤90 days after diagnosis (EAPC, 0.52%) or referral to HIV prevention services (EAPC, 0.98%). CONCLUSIONS: Human immunodeficiency virus testing data revealed an increasing trend in newly diagnosed HIV among PWID but not linkage to HIV medical care or referral to prevention services. Expanding efforts to increase HIV testing and enhance linkage to services can lead to reductions in HIV transmission and improved health outcomes.

Serious Mental Illness Among Young People Who Inject Drugs: An Assessment of Injection Risks and Healthcare Use.

BACKGROUND: Data on behavioral correlates of mental illness among young people who inject drugs (PWID) are limited. We examine injection risks and healthcare use among young PWID with probable serious mental illness (PSMI). METHODS: People who inject drugs were recruited and interviewed in 20 US cities for 2015 National HIV Behavioral Surveillance. Probable serious mental illness was assessed using the Kessler-6 screening scale. Bivariate analyses using log-linked Poisson regression with generalized estimating equations adjusted for design covariates were conducted to examine associations between PSMI and behaviors among PWID ages 18-29 years. RESULTS: Of 1769 young PWID, 45% had PSMI. Compared to those without PSMI, PWID with PSMI were more likely to report injecting more than once a day, receptive syringe sharing, sharing of other injection equipment, and unmet needs for medical care and substance use disorder (SUD) treatment. Those with PSMI were less likely to use syringe services programs than those without PSMI. CONCLUSIONS: Approximately half of young PWID had PSMI. People who inject drugs with PSMI engaged in high-risk injection behaviors and encountered barriers to healthcare. Human immunodeficiency virus prevention programs such as Syringe Services Programs (SSPs) could benefit from screening for mental illness among young PWID and strong linkage to healthcare, including mental health and SUD treatment.

Epidemiology of HIV in Iran.

Iran has been one of the active countries fighting against HIV/AIDS in the Middle East during the last decades. Moreover, there is a strong push to strengthen the national health management system concerning HIV prevention and control. In Iran, HIV disease has its unique features, from changes in modes of transmission to improvement in treatment and care programs, which can make it a good case for closer scrutiny. The present review describes the HIV epidemic in Iran from the first case diagnosed until prevention among different groups at risk and co-infections. Not only we addressed the key populations and community-based attempts to overcome HIV-related issues in clinics, but we also elaborated on the efforts and trends in society and the actual behaviors related to HIV/AIDS. Being located in the Middle East and North Africa (MENA) region, given the countryspecific characteristics, and despite all the national efforts along with other countries in this region, Iran still needs to take extra measures to reduce HIV transmission, especially in health education. Although Iran is one of the pioneers in implementing applicable and appropriate policies in the MENA region, including harm reduction services to reduce HIV incidence, people with substance use disorder continue to be the majority of those living with HIV in the country. Similar to other countries in this region, the HIV prevention and control programs aim at 90-90-90 targets to eliminate HIV infection and reduce the transmission, especially the mother-to-child transmission and among other key populations.

Prevalence and risk factors associated with HIV/hepatitis B and HIV/hepatitis C co-infections among people who inject drugs in Mozambique.

BACKGROUND: There is scare information about HIV co-infections with hepatitis B virus (HBV) and/or hepatitis C virus (HCV) among People Who Inject Drugs (PWID) in Mozambique. This information is critical to ensure the treatment necessary to decrease the progression of liver disease and the transmission of both HIV and hepatitis. We assess the prevalence of HIV, HBV and HCV co-infections as well as associated risk factors among PWID. METHODS: The first Bio-Behavioral Surveillance Survey was conducted in 2013-2014 among persons who self-reported to have ever injected drugs. Using respondent-driven sampling, PWID aged 18 years and older were recruited in two cross-sectional samples in Maputo and Nampula/Nacala, two large urban centers of Mozambique. Rapid screening of HIV, HBV (HBsAg) and HCV was performed on site. Data from participants in both cities were pooled to conduct RDS-weighted bivariate analyses with HIV/HBV and HIV/HCV co-infections as separate outcomes. Unweighted bivariate and multivariate logistic regression analyses were conducted to assess correlates of co-infection. RESULTS: Among 492 eligible PWID, 93.3% were male and median age was 32 years [IQR: 27-36]. HIV, HBV and HCV prevalence were respectively 44.9% (95% CI:37.6-52.3), 32.8% (95% CI:26.3-39.5) and 38.3 (95% CI:30.6-45.9). Co-infections of HIV/HBV, HIV/HCV and HIV/HBV/HCV were identified in 13.1% (95% CI:7.2-18.9), 29.5% (95% CI:22.2-36.8) and 9.2% (95% CI:3.7-14.7) of PWID, respectively. Older age, history of needle/syringe sharing and history of injection with used needle/syringe was associated with HIV/HBV co-infection. Living in Maputo city, have older age, history of needle/syringe sharing and history of injection with used needle/syringe was associated with HIV/HCV co-infection. CONCLUSION: There is a high burden of HBV and HCV among HIV-infected PWID in Mozambique. Our results highlight the need for targeted harm reduction interventions that include needle exchange programs and integrated services for the diagnosis and treatment of HIV, HBV and HCV to address these epidemics among PWID. Efforts should be made to strengthen ART coverage in the population as an important treatment strategy for both viruses.

HIV infection prevalence and associated risk factors in people who inject drugs in Medellin / Prevalencia de infección por VIH y factores de riesgo asociados, en personas que se inyectan drogas en la ciudad de Medellín

Introduction: the availability of high purity and low-cost drugs has increased the use of intravenous substances, which makes it a public health problem due to its association with HIV infection. Objective: to identify the factors associated with HIV infection in people who inject drugs. Materials and methods: a cross-sectional descriptive study was carried out between December 2017 and January 2018 in Medellin, Colombia. We use the sampling conducted by the respondent (RDS). Results: They have recruited 224 subjects, 86.2% were men, 82.0% were single and 67.0% belonged to the subsidized or linked health system. The prevalence of HIV infection was 3.6%. This study found that 38.8% of consumers have shared needles and syringes with up to three people, representing a risk of infection of 5.07 times, compared to those who do not share (RPc = 5.07 95% CI: 1.19-21.55), and if this practice is carried out with a close friend, the probability increases to almost double (10.69) (RPc = 10.69 IC 95%: 2.26-50.61) (p <0.05). Conclusion: Given the low prevalence of HIV, it is vital to develop and implement public policies whose objective is to create prevention programs that ultimately lead to the reduction of infection in this population.

Introducción: La disponibilidad de drogas con una alta pureza y un bajo costo, ha aumentado el consumo de sustancias por vía intravenosa; llevándolo a ser considerado como un problema de salud pública, por su asociación con la presencia de infección por VIH. Se estima que existen aproximadamente 16 millones de consumidores de drogas intravenosas en el mundo y en Colombia, 15.000. Objetivo: identificar los factores asociados con la infección por VIH en personas que se inyectan drogas. Materiales y métodos: estudio descriptivo transversal, realizado (diciembre 2017/ enero 2018) Medellín - Colombia, se utilizó la metodología Respondent Driven Sampling (RDS). Resultados: Fueron reclutados 224 participantes, un 86,2% fueron hombres, el 82,0% eran solteros, el (67,0%) pertenecía al régimen de salud subsidiado o vinculado. Con relación a la prevalencia de infección por VIH esta fue del 3,6%. Este estudio encontró que el 38,8% de los consumidores había compartido agujas y jeringas con hasta tres personas, lo cual representa una probabilidad de 5,07 veces de contraer la infección comparado con aquellos que no comparten (RPc=5,07 CI95% 1,19-21,55), si esta práctica se hace con un amigo cercano dicha probabilidad aumenta a casi el doble 10,69 (RPc= 10,69 CI95% 2,26-50,61), (p<0,05). Conclusión: Ante la baja prevalencia de VIH, es necesario, el desarrollo e implementación de políticas públicas que tengan como objetivo la creación de programas de prevención que finalmente, lleven a la reducción de la infección en esta población.

Prevalence of hepatitis B and anti-hepatitis C virus antibody among people who inject drugs in the Lebanese population.

BACKGROUND: People who inject drugs (PWIDs) are prone to a number of blood-borne viral infections. Hepatitis B virus (HBV) and hepatitis C virus (HCV) constitute an important public health concern in this high risk group. AIMS: We aimed to determine the prevalence of HBV and HCV antibody among PWIDs in Lebanon. METHODS: We conducted a prospective cross-sectional study between June 2015 and June 2016 on PWIDs recruited through Lebanese nongovernmental organizations in collaboration with the Lebanese Ministry of Public Health. The participants were tested for HBs antigen and HCV antibody using rapid test kits. The prevalence of each virus was then calculated. The correlation between both infections and other possible risk factors was also analysed. RESULTS: A total of 250 people were included in our study, of whom 98% were males. Mean age was 31.9 (standard deviation 8.7) years. The prevalence of HBsAg and anti-HCV among PWIDs was 1.2% and 15.6%, respectively. Older age, longer duration of drug use and lack of awareness were significantly correlated with a higher rate of HCV infection (P < 0.01). The high rate of needle sharing among our PWIDs significantly affected the prevalence of anti-HCVAb. CONCLUSION: PWIDs remain the subpopulation most affected with chronic HCV in Lebanon.

Heroin type, injecting behavior, and HIV transmission. A simulation model of HIV incidence and prevalence.

BACKGROUND AND AIMS: Using mathematical modeling to illustrate and predict how different heroin source-forms: "black tar" (BTH) and powder heroin (PH) can affect HIV transmission in the context of contrasting injecting practices. By quantifying HIV risk by these two heroin source-types we show how each affects the incidence and prevalence of HIV over time. From 1997 to 2010 PH reaching the United States was manufactured overwhelmingly by Colombian suppliers and distributed in the eastern states of the United States. Recently Mexican cartels that supply the western U.S. states have started to produce PH too, replacing Colombian distribution to the east. This raises the possibility that BTH in the western U.S. may be replaced by PH in the future. DESIGN: We used an agent-based model to evaluate the impact of use of different heroin formulations in high- and low-risk populations of persons who inject drugs (PWID) who use different types of syringes (high vs. low dead space) and injecting practices. We obtained model parameters from peer-reviewed publications and ethnographic research. RESULTS: Heating of BTH, additional syringe rinsing, and subcutaneous injection can substantially decrease the risk of HIV transmission. Simulation analysis shows that HIV transmission risk may be strongly affected by the type of heroin used. We reproduced historic differences in HIV prevalence and incidence. The protective effect of BTH is much stronger in high-risk compared with low-risk populations. Simulation of future outbreaks show that when PH replaces BTH we expect a long-term overall increase in HIV prevalence. In a population of PWID with mixed low- and high-risk clusters we find that local HIV outbreaks can occur even when the overall prevalence and incidence are low. The results are dependent on evidence-supported assumptions. CONCLUSIONS: The results support harm-reduction measures focused on a reduction in syringe sharing and promoting protective measures of syringe rinsing and drug solution heating.

Distributive Syringe Sharing and Use of Syringe Services Programs (SSPs) Among Persons Who Inject Drugs.

Monitoring distributive syringe sharing (DSS) and syringe services program (SSP) use among persons who inject drugs (PWID) is important for HIV prevention. PWID aged ≥ 18 in 20 US cities were recruited for National HIV Behavioral Surveillance in 2015 using respondent-driven sampling, interviewed and offered HIV testing. Bivariate and multivariable analyses via log-linked Poisson regression with generalized estimating equations were conducted to examine associations between demographic and behavioral variables and DSS. Effect of SSP use on DSS by HIV sero-status was assessed by including an interaction between SSP and sero-status. Analyses were adjusted for sampling design. Among 10,402 PWID, 42% reported DSS. DSS was less likely to be reported among HIV-positive compared to HIV-negative PWID (aPR = 0.51, CI 0.45-0.60), and among those who primarily obtained syringes from SSPs versus those who did not (aPR = 0.82, 95% CI 0.77-0.88). After adjustment, those who primarily used SSPs were less likely to report DSS than those who did not among both HIV-negative PWID (aPR = 0.84, 95% CI 0.78-0.90) and HIV-positive PWID (aPR = 0.54, 95% CI 0.39-0.75). Findings support expansion of SSPs, and referrals to SSPs by providers working with PWID.

Retrospective case series describing the efficacy, safety and cost-effectiveness of a vial-sharing programme for canakinumab treatment for paediatric patients with cryopyrin-associated periodic syndrome.

BACKGROUND: Cryopyrin-associated periodic syndrome (CAPS) is a rare autoinflammatory disease, caused by gain of function mutation in NLRP3 resulting in excess production of interleukin-1 (IL-1). Canakinumab is a human monoclonal antibody against Interleukin-1 beta (IL-1ß), licensed for the treatment of CAPS. The objective of the study was to describe the feasibility and cost-effectiveness of a canakinumab vial-sharing programme for paediatric patients with CAPS. METHOD: Retrospective case series and clinical service description of a national specially commissioned CAPS clinic at Great Ormond Street Hospital (GOSH). Effectiveness was assessed using a CAPS disease activity score (DAS) and serum amyloid A protein (SAA). Adverse events were collected to determine safety. The number of canakinumab vials saved was considered when investigating the cost-effectiveness of vial-sharing. RESULTS: Nineteen/20 (95%) of our paediatric patients achieved minimally active clinical disease activity with canakinumab monotherapy; and 75% achieved both minimally active clinical disease and serological remission using a pre-specified definition based on the CAPS DAS and SAA level. Canakinumab was well tolerated, with only one child developing an infection requiring hospitalisation during the study. Canakinumab vial sharing resulted in 117 vials of canakinumab saved over a 24-month period, equating to a direct drug-related cost saving of £1,385,821, and a conservative estimated 5-year cost-saving of £3,464,552.50. CONCLUSION: We provide further evidence for the effectiveness and safety of canakinumab in children with CAPS, and highlight the cost-effectiveness of a vial-sharing programme for this high cost medicine. We suggest that this could have important implications for the delivery of other high cost medicines used in paediatric practice.

Injecting-related trust, cooperation, intimacy, and power as key factors influencing risk perception among drug injecting partnerships.

Sharing of injection drug use paraphernalia is a dyadic process linked to the transmission of HIV and hepatitis C virus (HCV). Despite this, limited research exists identifying specific dyadic interpersonal factors driving injecting partners' engagement in needle/syringe and ancillary injecting equipment sharing among young adults. Using semi-structured in-depth interview data collected between 2014 and 2015 from twenty-seven people who inject drugs (PWID), we applied an inductive approach to identify key injection drug-related interpersonal factors and developed a conceptual model integrating the findings based on interdependence theory. Interactions between injecting partners resulted in varying levels of injecting-related trust, cooperation, intimacy, and power. These factors interacted to collectively influence the type and level of risk perceived and enacted by injecting partners. The relationship between these injecting-related interpersonal factors, on the one hand, and risk perception on the other was dynamic and fluctuated between actions that protect the self (person-centered) and those that protect the partnership (partnership-centered). These findings indicate that the interpersonal context exerts substantial influence that shapes risk perception in all types of injecting partnerships. Partnership-focused prevention strategies should consider the dynamics of trust, cooperation, intimacy, and power, in characterizing dyadic risk perceptions and in understanding risky injecting practices among PWID.

Cluster of hepatitis C in a family: a twenty-year follow-up.

OBJECTIVE: We described an impressive cluster of hepatitis C in a single family. Of nine members of the family, six - the mother and five daughters - were affected by chronic hepatitis, hepatitis C virus (HCV) genotype 1b, of which two were co-infected with hepatitis B virus (HBV). Sharing a non-disposable injection equipment for intramuscular medical care was the most likely route of contagion. Twenty years after the first observation, we performed a follow up of this family. METHODS: The clinical history was updated, and the members of the family underwent a clinical evaluation, extensive liver laboratory tests, and whole serology for hepatitis C and B. Protein chain reaction for HCV RNA was performed when indicated. The eight spouses of the offspring and their eight children underwent the same evaluation. RESULTS: The main findings of this study are the favourable outcome of the two members of the family mono-infected by HCV, treated with peginterferon and ribavirin (sustained response and free of liver disease), in contrast with the ominous outcome of the two members co-infected with HCV and HBV, who evolved to decompensated cirrhosis, with hepatocellular carcinoma in one case, ultimately leading to death. A further feature is the absence of transmission of HCV to the spouses and to the third generation of children of this family, consistent with the assumption that sexual and vertical transmission is unlikely. CONCLUSIONS: A thorough epidemiological investigation of the two first generations of this family, the study of their spouses and children, and the twenty years of follow up provided a strong presumption that the infection with HCV had occurred within this family through the promiscuous use of the same inadequately sterilized glass syringe for intramuscular therapies, as was a common practice during the fifties and sixties worldwide and still is in some part of the world.

Understanding the public health consequences of suspending a rural syringe services program: a qualitative study of the experiences of people who inject drugs.

BACKGROUND: Syringe services programs (SSPs) are evidence-based interventions that are associated with decreases in prevalence and incidence rates of HIV and viral hepatitis among people who inject drugs (PWID). SSPs are also effective conduits to deliver overdose prevention resources among PWID. In December 2015, the Kanawha-Charleston Health Department (KCHD) in West Virginia implemented a SSP; however, the program was indefinitely suspended in early 2018 following policy changes that would have forced the program to operate in ways that conflicted with established best practices. The purpose of this research is to explore the public health implications of the suspension of the KCHD SSP among rural PWID. METHODS: We conducted semi-structured interviews with 27 PWID (59.3% male, 88.9% White) to explore access to sterile injection equipment and overdose prevention resources, high-risk injection practices, and HIV risk perceptions following the KCHD SSP suspension. Participants were recruited from street locations frequented by PWID. Interviews were audio-recorded and transcribed verbatim. We employed an iterative, modified constant comparison approach to systematically code and synthesize textual interview data. RESULTS: Participants described the KCHD SSP as providing a variety of harm reduction services to PWID and being able to speak honestly with SSP staff about their drug use without fear of stigmatization. The suspension of the KCHD SSP fundamentally changed the public health landscape for PWID, ushering in a new era of increased risks for acquiring bloodborne infections and overdose. PWID described more frequently injecting with used syringes and engaging in a range of high-risk injection practices after the SSP was suspended. PWID also discussed having decreased access to naloxone and being less likely to get routinely tested for HIV following the KCHD SSP suspension. CONCLUSIONS: This research demonstrates that the suspension of a SSP in rural West Virginia increased risks for HIV/HCV acquisition and overdose among PWID. The suspension of the SSP led to community-wide decreases in access to sterile injection equipment and naloxone among PWID. The suspension of the KCHD SSP should be viewed as a call to action for sustaining evidence-based interventions in the face of sociopolitical forces that attempt to subvert public health.

Facing the Growing Heroin Problem in Colombia: The New Methadone-assisted Treatment Programs. / Enfrentando el problema emergente de consumo de heroína en Colombia: los nuevos programas de tratamiento asistido con metadona.

OBJECTIVE: Colombia is facing a rising epidemic of intravenous heroin use. Knowledge of the methadone-assisted treatment programs in the country is crucial in order to propose improvement strategies. METHODS: 13 programmes from priority regions were surveyed. The demographic and clinical characteristics of the patients attending the programs, a description of the services offered, their methadone treatment protocols, the various barriers to treatment and the causes of treatment abandonment were reviewed. RESULTS: 12/13 questionnaires were analysed with a total of 538 active patients. Most of the patients attending these programs were men (85.5%) between 18 and 34 years-old (70%). Forty percent (40%) were intravenous drug users and 25% admitted sharing needles. The comorbidities associated with heroin use were mental illness (48%), hepatitis C (8.7%) and HIV (2%). Psychiatric comorbidity was more likely in patients attending the private sector (69.8% vs 29.7%; p<0.03). The initial average dose of methadone administered was 25.3±8.9mg/day, with a maintenance dose ranging from 41 to 80mg/day. Lack of alignment with primary care was perceived to be the most serious barrier to access, ahead of problems with insurance and prejudice towards treatment with methadone (p<0.05). Health Administration and insurance problems (p<0.003), together with the lack of availability of methadone (p<0.018) and relapse (p<0.014) were the most important reasons for abandonment of treatment. CONCLUSIONS: The treatment protocols of these programmes offer different levels of development and implementation. Some of the barriers to access and reasons for abandonment of treatment with methadone can be mitigated with better health administration.

Understanding hepatitis B, hepatitis C and HIV among people who inject drugs in South Africa: findings from a three-city cross-sectional survey.

BACKGROUND: People who inject drugs (PWID) are at high risk for hepatitis C (HCV), hepatitis B (HBV) and HIV without accessible harm reduction programmes. Coverage of needle and syringe and opioid substitution therapy (OST) services in South Africa is below global recommendations and no hepatitis services exist for PWID. We assessed HCV, HBV and HIV prevalence and risk factors among PWID accessing harm reduction services in Cape Town, Durban and Pretoria to inform policy and programming. METHODS: We conducted a cross-sectional survey among PWID in these cities between August 2016 and October 2017. Participants were opportunistically sampled while accessing services. Study team members administered a questionnaire that assessed sociodemographic characteristics, drug use and sexual risk practices. We tested for HCV (antibody, viral load and genotype), HBV surface antigen (HBsAg) and HIV. Bivariate and multivariate analyses assessed associations with HCV serostatus. RESULTS: Nine hundred and forty-three PWID were included in the per protocol analysis. The majority (87%, 819/943) were male, the overall median age was 29 and most lived on the street (66%, 626/943). At last injection, 77% (722/943) reported using a new needle and syringe and 17% (163/943) shared equipment. HIV prevalence was 21% (196/926), HBsAg positivity 5% (47/936), HCV seroprevalence 55% (513/937), HCV viraemic prevalence (proportion tested with detectable HCV) 43% (404/937) and HCV viraemic rate (proportion HCV antibody positive with detectable HCV) 79% (404/513). HCV genotype 1a (73%, 270/368) was the most prevalent. In multivariate analysis, HCV infection was positively associated with residing in Pretoria (adjusted odds ratio (aOR) 1.27, 95% CI 1.21-1.34), living on the street (aOR 1.90, 95% CI 1.38-2.60), frequent injecting (aOR 1.58, 95% CI 1.15-2.16) and HIV infection (aOR 1.69, 95% CI 1.15-2.47), and negatively associated with black race (aOR 0.52, 95% CI 0.36-0.74) and sexual activity in the previous month (aOR 0.61, 95% CI 0.42-0.88). CONCLUSIONS: HCV and HIV are major health threats affecting PWID in these cities. Access to OST and needle and syringe services needs to be increased and integrated with HCV services. Social and structural factors affecting PWID who live on the street need to be addressed.

Interpersonal and structural factors associated with receptive syringe-sharing among a prospective cohort of female sex workers who inject drugs.

AIMS: To determine the interpersonal and structural factors associated with receptive syringe sharing (RSS) among female sex workers who inject drugs (FSW-IDU), a group at high risk of HIV/hepatitis C virus (HCV) acquisition. DESIGN: Sex workers And Police Promoting Health In Risky Environments (SAPPHIRE) study, a prospective cohort study. SETTING: Baltimore, MD, USA PARTICIPANTS: One hundred and eighty FSW-IDU; mean age = 33 years, 77.1% white and 62.9% in a relationship/married. MEASUREMENTS: Surveys were conducted between April 2016 and February 2018. The main outcome was recent RSS (past 3 months). In addition to socio-demographic characteristics and drug use behaviors, we assessed factors at the interpersonal level, including injection practices, intimate partner and client drug use and exposure to violence. Structural-level factors included methods of syringe access. FINDINGS: Nearly all FSW-IDU used heroin (97.1%) or crack cocaine (89.7%). Recent RSS was reported by 18.3%. Syringes were accessed from needle exchange programs (64.6%), pharmacies (29.7%), street sellers (30.3%) or personal networks (29.1%). Some FSW-IDU had clients or intimate partners who injected drugs (26.3 and 26.9%, respectively). Longitudinal factors independently associated with RSS in the multi-level mixed-effects model were recent client violence [adjusted odds ratio (aOR) = 2.17, 95% confidence interval (CI) = 1.09-4.33], having an intimate partner who injected drugs (aOR = 2.18, 95% CI = 0.98-4.85), being injected by others (aOR = 4.95, 95% CI = 2.42-10.10) and obtaining syringes from a street seller (aOR = 1.88, 95% CI = 0.94-3.78) or from a member of their personal network (aOR = 4.43, 95% CI = 2.21-8.90). CONCLUSIONS: Client violence, intimate partner injection drug use, being injected by others and obtaining syringes from personal connections appear to increase parenteral HIV/HCV risk among female sex workers who inject drugs.

Comparing Injecting Risk Behaviors of Long-Term Injectors with New Injectors in Tehran, Iran.

BACKGROUND: Global estimates suggest there are 15.6 million people who inject drugs (PWID) of whom 17.8% are living with HIV.Few studies have characterized newly-onset injectors with long-term injectors and its association with injecting risk behaviors. OBJECTIVES: We examined the relationship between length of injection and risk behaviors among people who inject drugs (PWID) in Tehran, Iran. METHODS: A cross-sectional study was conducted among PWID, from March to August 2016 in Tehran, Iran. PWID were recruited by convenience and snowball sampling from five Drop-in Centers (DIC) located in the south of Tehran. Our primary independent variable was length of injecting career, defined as the number of months since injecting initiation. Those defined as new injectors (were injecting for less than 18 months), and long-term injectors (as injecting drugs for more than 18 months). We reported the adjusted odds ratio (aOR) point estimate and 95% confidence interval (CI95%) as the effect measure. The level of significance used in multiple logistic regression model was 0.05. We used STATA v. 11 for all analyzes. RESULTS: The analytical sample comprised of 500 participants (100% male). Mean (±SD) age of PWID with a length of injection history was 31.2 ± 7.2 years. Overall, 270 (54%) (CI95%: 49.6%, 58.4%) of participants were long-term injectors. The average age of drug use initiation among long-term injectors group was lower as compared to new injectors group (31.2 vs. 29.4, p < 0.001). The odds of distributive syringe sharing among new injectors were two times higher than long-term injectors (AOR = 2.1, 95% CI 1.4-4.7). The odds of receptive syringe sharing were lower among new injectors group (AOR = 0.7, CI95% 0.2-0.87), compared to long-term injectors. New injectors had higher odds of reusing their own syringes (OR = 2.8, 95% CI: 1.4-5.7; p = 0.01). CONCLUSIONS: Improvements in harm reduction service provision can occur through taregted risk reduction education for new injectors focusing on reducing distributive syringe sharing among them.

Prevalence of HIV and other infections and injection behaviours among people who inject drugs in Addis Ababa, Ethiopia.

BACKGROUND: Ethiopia is one of the sub-Saharan African countries most affected by HIV/AIDS. However, the country lacks data describing the extent of the epidemic among people who inject drugs (PWID). Thus, a bio-behavioural study was conducted in 2015 to generate strategic information on the magnitude of HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), syphilis and related risk behaviours among PWID in Addis Ababa. METHODS: A cross-sectional study using respondent-driven sampling was conducted among people reported to have injected illicit drugs within 6 months before the study. Males and females aged 15 years or above and who were resident in Addis Ababa were included in the study between 26 March and 22 May 2015. Data was analysed using respondent-driven (RDS) Analyst software. RESULTS: A total of 237 participants, including 6 seeds, enrolled in the study; most of the PWID were males (96%) with a mean age of 26 years. Most (79%) of the PWID reported injecting heroin but also reported using non-injecting drugs, including marijuana or ganja (47%) and/or khat (31%). Forty per cent of PWID reported ever sharing needles and 56% reported sharing other injecting equipment. However, only 14% reported injecting daily, and 49% reported injecting only 1 to 3 times a month. HIV prevalence was 6%, HBV was 5.1%, HCV was 2.9% and syphilis 5.1% among PWID. Among HIV-positive PWID, 60% reported sharing a needle the last time they injected. CONCLUSION: Even though the prevalence of HIV among drug users is not much higher than in the general population in Addis Ababa, the needle sharing prevalence was high. Thus, this baseline study shows the need to establish harm reduction programmes and prevention strategies for the PWID in Addis Ababa.

A large healthcare-associated outbreak of hepatitis C virus genotype 1a in a clinic in Korea.

BACKGROUND: In November 2015, reuse of needles and syringes in conjunction with an increase in cases of HCV at a clinic in Korea was reported and investigated by public health authorities. Patients who received injections at the clinic from the first time this infection control breach may have occurred in 2008 through 2015 when the practice was stopped were offered screening for HCV and other blood-borne pathogens such as HIV, HTLV, HBV, syphilis, and malaria. OBJECTIVES: The aim of this study was to assess whether an outbreak of hepatitis C had occurred among the potentially exposed clinic patients due to this infection control breach. STUDY DESIGN: We performed hepatitis C viral RNA load tests and genotyping using plasma from hepatitis C antibody-positive individuals who had visited the clinic between May 2008 and November 2015. We analyzed the core-E2 and NS5B regions of the virus from RNA-positive samples by constructing a phylogenetic tree based on maximum likelihood analysis. To identify transmission risk factors and epidemiological relationships among the patients, we reviewed their medical records, assessed staff infection control practices and performed environmental inspection of the clinic. Environmental samples from medication room surfaces and medication vial contents were tested for HCV RNA. RESULTS AND CONCLUSIONS: Among the 1721 patients tested, 96 were IgG-positive and 70 were viral RNA-positive. Among the 61 patients whose viral loads were greater than the detection limit, 41 (67.2%) were classified as genotype 1a, 1 (1.6%) as genotype 1b, 18 (29.5%) as genotype 1, and one (1.6%) as genotype 2. After sequencing, 12 genotype 1 cases were further classified as genotype 1a (11) or 1b (1). The sequences of the core-E2 and NS5B regions of 45 patients formed a monophyletic cluster distinct from genotype 1a. The hepatitis C virus sequences from patients and environmental specimens were well-matched in the partial E1 gene region. We detected genotype 1a RNA in environmental specimens, indicating a healthcare-associated outbreak caused by reuse of syringes and contaminated multi-dose vials. Our molecular epidemiological investigation of hepatitis C genotype 1a, rare in Korea, will aid investigations of infection sources during future pathogen outbreaks.