Impact of COVID-19 & Response Measures on HIV-HCV Prevention Services and Social Determinants in People Who Inject Drugs in 13 Sites with Recent HIV Outbreaks in Europe, North America and Israel.

HIV/HCV prevention among people who inject drugs (PWID) is of key public health importance. We aimed to assess the impact of COVID-19 and associated response measures on HIV/HCV prevention services and socio-economic status of PWID in high-HIV-risk sites. Sites with recent (2011-2019) HIV outbreaks among PWID in Europe North America and Israel, that had been previously identified, were contacted early May 2020. Out of 17 sites invited to participate, 13 accepted. Semi-structured qualitative site reports were prepared covering data from March to May 2020, analyzed/coded and confirmed with a structured questionnaire, in which all sites explicitly responded to all 103 issues reported in the qualitative reports. Opioid maintenance treatment, needle/syringe programs and antiretroviral treatment /hepatitis C treatment continued, but with important reductions and operational changes. Increases in overdoses, widespread difficulties with food and hygiene needs, disruptions in drug supply, and increased homelessness were reported. Service programs rapidly reformed long established, and politically entrenched, restrictive service delivery policies. Future epidemic control measures should include mitigation of negative side-effects on service provision and socio-economic determinants in PWID.

RESUMEN: La prevención del VIH/VHC entre las personas que se inyectan drogas (PWID) es de vital importancia para la salud pública. Nuestro objetivo fue evaluar el impacto de COVID-19 y las medidas de respuesta asociadas en los servicios de prevención del VIH/VHC y el estado socioeconómico de las PWID en sitios de alto riesgo de VIH. Se contactó con sitios con brotes recientes (2011­2019) de VIH entre PWID en Europa, América del Norte e Israel, que habían sido previamente identificados, a principios de mayo de 2020. De los 17 sitios invitados a participar, 13 aceptaron. Se prepararon informes cualitativos semiestructurados del sitio que cubrían los datos de marzo a mayo de 2020, analizados/codificados y confirmados con un cuestionario estructurado, en el que todos los sitios respondieron explícitamente a los 103 asuntos reportados en los informes cualitativos. El tratamiento de mantenimiento con opiáceos, los programas de agujas/jeringas y el tratamiento antirretroviral/tratamiento de la hepatitis C continuaron, pero con importantes reducciones y cambios operativos. Se reportaron aumentos en las sobredosis, dificultades generalizadas con las necesidades alimentarias y de higiene, interrupciones en el suministro de medicamentos y aumento de personas sin hogar. Los programas de servicios reformaron rápidamente las políticas restrictivas de prestación de servicios, establecidas desde hace mucho tiempo y políticamente arraigadas. Las futuras medidas de control de epidemias deben incluir la mitigación de los efectos secundarios negativos en la prestación de servicios y los determinantes socioeconómicos en las PWID.

Geographic distribution of risk ("Hotspots") for HIV, HCV, and drug overdose among persons who use drugs in New York City: the importance of local history.

AIMS: To identify geographic "hotspots" for potential transmission of HIV and HCV and for drug overdose among persons who use heroin and cocaine in New York City and to examine historical continuities in problem drug use hotspots in the city. METHODS: A total of 2714 study participants were recruited among persons entering Beth Israel substance use treatment programs. A structured questionnaire was administered and blood samples for HIV and HCV testing were collected. Hotspots for potential virus transmission were defined as ZIP codes with 10+ participants, 2+ persons infected with the virus and engaging in transmission behavior, and 2+ persons not infected and engaging in acquisition behavior. ZIP codes with 3+ persons with previous overdoses were considered potential hotspots for future overdoses. RESULTS: Participants resided in 166/178 (93%) of the ZIP codes in New York City. Injecting drug use was reported in 150/178 (84%) of the ZIP codes. No zip codes were identified for injecting-related HIV transmission, 5 zip codes were identified for sexual HIV transmission, 3 for HCV transmission, and 8 for drug overdose. Many of the ZIP code potential hotspots were in neighborhoods long associated with drug use: Lower Eastside and Harlem in Manhattan, the South Bronx, and Central Brooklyn. DISCUSSION: Heroin and cocaine use requiring treatment were reported from almost all ZIP codes in New York City, indicating needs for widely dispersed harm reduction services. Identified hotspots should be targeted for reducing sexual transmission of HIV, transmission of HCV, and drug overdoses. Some of the hotspots have persisted as problem drug use areas for 40 to over 100 years. Monitoring of drug use patterns in historical hotspot neighborhoods may permit early identification of and response to emerging drug use-related health problems. Persistent historical hotspots for problem drug use present a complex problem for implementing harm reduction services that deserve additional research.

Being "hooked up" during a sharp increase in the availability of illicitly manufactured fentanyl: Adaptations of drug using practices among people who use drugs (PWUD) in New York City.

Illicitly manufactured fentanyl (IMF), a category of synthetic opioids 50-100 times more potent than morphine, is increasingly being added to heroin and other drugs in the United States (US). Persons who use drugs (PWUD) are frequently unaware of the presence of fentanyl in drugs. Use of heroin and other drugs containing fentanyl has been linked to sharp increases in opioid mortality. In New York City (NYC), opioid-related mortality increased from 8.2 per 100,000 residents in 2010 to 19.9 per 100,000 residents in 2016; and, in 2016, fentanyl accounted for 44% of NYC overdose deaths. Little is known about how PWUD are adapting to the increase in fentanyl and overdose mortality. This study explores PWUDs' adaptations to drug using practices due to fentanyl. In-depth qualitative interviews were conducted with 55 PWUD at three NYC syringe services programs (SSP) about perceptions of fentanyl, overdose experiences and adaptations of drug using practices. PWUD utilized test shots, a consistent drug dealer, fentanyl test strips, naloxone, getting high with or near others and reducing drug use to protect from overdose. Consistent application of these methods was often negated by structural level factors such as stigma, poverty and homelessness. To address these, multi-level overdose prevention approaches should be implemented in order to reduce the continuing increase in opioid mortality.

Potential geographic "hotspots" for drug-injection related transmission of HIV and HCV and for initiation into injecting drug use in New York City, 2011-2015, with implications for the current opioid epidemic in the US.

OBJECTIVE: We identified potential geographic "hotspots" for drug-injecting transmission of HIV and hepatitis C virus (HCV) among persons who inject drugs (PWID) in New York City. The HIV epidemic among PWID is currently in an "end of the epidemic" stage, while HCV is in a continuing, high prevalence (> 50%) stage. METHODS: We recruited 910 PWID entering Mount Sinai Beth Israel substance use treatment programs from 2011-2015. Structured interviews and HIV/ HCV testing were conducted. Residential ZIP codes were used as geographic units of analysis. Potential "hotspots" for HIV and HCV transmission were defined as 1) having relatively large numbers of PWID 2) having 2 or more HIV (or HCV) seropositive PWID reporting transmission risk-passing on used syringes to others, and 3) having 2 or more HIV (or HCV) seronegative PWID reporting acquisition risk-injecting with previously used needles/syringes. Hotspots for injecting drug use initiation were defined as ZIP codes with 5 or more persons who began injecting within the previous 6 years. RESULTS: Among PWID, 96% injected heroin, 81% male, 34% White, 15% African-American, 47% Latinx, mean age 40 (SD = 10), 7% HIV seropositive, 62% HCV seropositive. Participants resided in 234 ZIP codes. No ZIP codes were identified as potential hotspots due to small numbers of HIV seropositive PWID reporting transmission risk. Four ZIP codes were identified as potential hotspots for HCV transmission. 12 ZIP codes identified as hotspots for injecting drug use initiation. DISCUSSION: For HIV, the lack of potential hotspots is further validation of widespread effectiveness of efforts to reduce injecting-related HIV transmission. Injecting-related HIV transmission is likely to be a rare, random event. HCV prevention efforts should include focus on potential hotspots for transmission and on hotspots for initiation into injecting drug use. We consider application of methods for the current opioid epidemic in the US.

HIV research productivity and structural factors associated with HIV research output in European Union countries: a bibliometric analysis.

OBJECTIVES: To assess HIV/AIDS research productivity in the 27 countries of the European Union (EU), and the structural level factors associated with levels of HIV/AIDS research productivity. METHODS: A bibliometric analysis was conducted with systematic search methods used to locate HIV/AIDS research publications (period of 1 January 2002 to 31 December 2011; search databases: MEDLINE (Ovid, PubMed), EMBASE, ISI-Thomson Web of Science; no language restrictions). The publication rate (number of HIV/AIDS research publications per million population in 10 years) and the rate of articles published in HIV/AIDS journals and selected journals with moderate to very high (IF ≥3) 5-year impact factors were used as markers for HIV research productivity. A negative binomial regression model was fitted to assess the impact of structural level factors (sociodemographic, health, HIV prevalence and research/development indicators) associated with the variation in HIV research productivity. RESULTS: The total numbers of HIV/AIDS research publications in 2002-2011 by country ranged from 7 to 9128 (median 319). The median publication rate (per million population in 10 years) was 45 (range 5-150) for all publications. Across all countries, 16% of the HIV/AIDS research was published in HIV/AIDS journals and 7% in selected journals with IF ≥3. Indicators describing economic (gross domestic product), demographic (size of the population) and epidemiological (HIV prevalence) conditions as well as overall scientific activity (total research output) in a country were positively associated with HIV research productivity. CONCLUSIONS: HIV research productivity varies noticeably across EU countries, and this variation is associated with recognisable structural factors.

Combined HIV prevention, the New York City condom distribution program, and the evolution of safer sex behavior among persons who inject drugs in New York City.

Examine long term sexual risk behaviors among persons who inject drugs (PWID) in New York City following implementation of "combined" prevention programming, including condom social marketing. Quantitative interviews and human immunodeficiency virus (HIV) testing were conducted among PWID entering Beth Israel Medical Center drug treatment programs 1990-2012. Data were analyzed by four time periods corresponding to the cumulative implementation of HIV prevention interventions. 7,132 subjects were recruited from 1990 to 2012; little change in sexual behavior occurred among HIV seronegative subjects, while HIV seropositive subjects reported significant decreases in being sexually active and significant increases in consistent condom use. HIV transmission risk (being HIV positive and engaging in unprotected sex) declined from 14 % in 1990-1995 to 2 % in 2007-2012 for primary sexual partners and from 6 to 1 % for casual partners. Cumulative implementation of combined prevention programming for PWID was associated with substantial decreases in sexual risk behavior among HIV seropositives.

30 Years on Selected Issues in the Prevention of HIV among Persons Who Inject Drugs.

After 30 years of extensive research on human immunodeficiency virus (HIV) among persons who inject drugs (PWID), we now have a good understanding of the critical issues involved. Following the discovery of HIV in 1981, epidemics among PWID were noted in many countries, and consensus recommendations for interventions for reducing injection related HIV transmission have been developed. While high-income countries have continued to develop and implement new Harm Reduction programs, most low-/middle-income countries have implemented Harm Reduction at very low levels. Modeling of combined prevention programming including needle exchange (NSP) and antiretroviral therapy (ARV) suggests that NSP be given the highest priority. Future HIV prevention programming should continue to provide Harm Reduction programs for PWID coupled with interventions aimed at reducing sexual transmission. As HIV continues to spread in low- and middle-income countries, it is important to achieve and maintain high coverage of Harm Reduction programs in these locations. As PWID almost always experience multiple health problems, it will be important to address these multiple problems within a comprehensive approach grounded in a human rights perspective.

Risk for Heterosexual HIV Transmission Among Non-Injecting Female Partners of Injection Drug Users in Estonia.

The HIV epidemic in Estonia, as with other eastern European countries, is currently concentrated among injection drug users (IDUs). Non-IDUs who have IDU sex partners could serve as a potential bridge in an expanding epidemic. We applied HIV transmission modelling to data collected from non-IDU/IDU heterosexual couples in Kohtla-Järve, Estonia to estimate HIV risk from IDUs to their sex partners based on self-reported sexual behaviors shared by the couple. IDUs and their current main non-injecting sex partners were recruited for an interviewer-administered survey and HIV testing. Bernoulli modelling techniques were applied to estimate the risk of HIV transmission (incidence) among HIV negative non-injecting female partners of male IDUs. The estimated HIV incidence in this population of non-injecting women with only main sexual partners in the last 6 months ranged from 3.24 to 4.94 HIV seroconversions per 100 person years depending on the value used in the models for the per act transmission rate during acute stage infection. Non-IDUs who have IDU sex partners are at high risk for HIV and could serve as a potential bridge to a more generalized epidemic. Whether this might lead to an expansion of the HIV epidemic beyond core groups in Estonia or other Eastern European countries warrants closer study.

Hepatitis C virus-specific immune responses in noninjecting drug users.

Noninjection drug use, although recognized as an emerging risk factor for acquisition of other blood-born pathogens, is still unconfirmed as a route of hepatitis C virus (HCV) transmission. Our goal was to measure HCV exposure and prevalence in noninjection drug users (NIDUs). Fifty-seven NIDUs were screened by extensive questionnaire to exclude prior injection drug use and evaluated for HCV-specific serologic and cellular immune responses. HCV-specific T-cell responses were measured using interferon-gamma (IFN-γ) enzyme-linked immunospot (ELISpot) assay with overlapping HCV peptides covering the entire HCV genome. Fifteen individuals who never used illicit drugs served as negative controls. Eleven people with no history of injecting drug use (19.3%) were HCV seropositive: seven with chronic HCV infection and four with previously resolved infection. Of 51 NIDUs with ELISpot results, HCV-specific cellular immunity was detected in 5 (9.8%). These responses were relatively weak and narrow. We did not find significant associations between HCV-specific immune responses and noninjection drug use practices. Subjects with HCV-specific immunity, however, were significantly more likely to have bought sex in the past 6 months, to have had more casual partners of the opposite sex in the last 6 months, and those partners were more likely to have ever injected drugs compared to subjects without HCV-specific immunity. In summary, we found serologic or cellular HCV-specific immune responses in 27.5% of NIDUs. Our results suggest that sexual behaviour associated with noninjection drug use might be a risk factor for HCV acquisition. Additional studies are needed to precisely determine the practices that lead to HCV exposure among this population.

Emergent properties of HIV risk among injection drug users in Tallinn, Estonia: synthesis of individual and neighbourhood-level factors.

OBJECTIVES: HIV/AIDS risk is embodied within multiple levels including structural and social levels. The aim of this study was to assess the effects of neighbourhood characteristics on HIV prevalence among injection drug users (IDU) residing in the area of Tallinn, Estonia in 2007. METHODS: A cross-sectional, multilevel design collecting individual-level data--a behaviour survey including data on self-reported residency and HIV antibody testing among 350 IDU and neighbourhood-level data--aggregate measures on socio-demo-economic residential characteristics from the 2000 Estonian census. Geocoding and multilevel modelling analysis was employed. RESULTS: Among the 350 IDU recruited, earlier age at first injection, fentanyl as the main injection drug, receptive syringe sharing, main income source other than legal employment and ever attended a syringe exchange programme remained significantly associated with increased odds of anti-HIV positivity in the multivariable analysis involving individual effects with no predictors at the neighbourhood level. In the multilevel model, individual (earlier at IDU initiation AOR 1.86, 95% CI 1.01 to 3.44; injecting opioids AOR 4.43, 95% CI 2.74 to 7.18; receptive syringe sharing AOR 2.51, 95% CI 1.86 to 3.37; main income source other than work AOR 2.04, 95% CI 1.32 to 3.14; ever attended a syringe exchange programme AOR 2.58, 95% CI 1.83 to 3.61) and neighbourhood level (higher unemployment rate AOR 5.95, 95% CI 2.47 to 14.31; greater residential change AOR 1.89, 95% CI 1.09 to 3.26) emerged as significant predictors of individual HIV-positive status. CONCLUSIONS: Our results indicate that both individual-level and emergent neighbourhood-level factors contribute to HIV risk among IDU and are amenable for preventive interventions.

HIV prevention and psychoactive drug use: a research agenda.

Much has been learned about how to prevent HIV infection among psychoactive drug users in the last 25 years, but, worldwide, the problems of drug-use-related HIV transmission have increased during this time. We consider the need for additional research on four aspects of drug use-related HIV transmission: (1) why evidence-based effective prevention programmes have not been implemented, (2) HIV infection among ethnic minority drug users, (3) relationships--or lack of relationships--between individual risk behaviour and HIV infection and (4) reducing drug use-related sexual transmission of HIV and other sexually transmitted infections (STIs). These topics were selected because we see them as critical for reducing HIV transmission among drug users (topics 1 and 4), reducing health disparities among racial and ethnic groups of drug users (topic 2), and understanding HIV epidemiology and evaluating prevention programmes for drug users (topic 3).

Hepatitis C virus-specific T-cell immune responses in seronegative injection drug users.

T-cell responses to hepatitis C virus (HCV) antigens have been reported in high-risk HCV seronegative persons, suggesting that an effective cellular immune response might be able to clear infection without the development of antibodies. Such findings, however, could be explained by waning antibody or cross-reactivity to other antigens. To address these issues, we evaluated HCV-specific T-cell responses in 26 young (age 18-33 years) aviremic, seronegative injection drug users (IDUs) (median duration of injection, 6 years) by interferon-gamma enzyme-linked immunospot (ELISpot) assay using 429 overlapping HCV peptides pooled in 21 mixes. Seventeen aviremic, seropositive IDUs (spontaneous resolvers) and 15 healthy people were used as positive and negative controls, respectively. The percentage of patients with HCV-specific cellular immune responses was similar in seronegative and seropositive aviremic IDUs (46%vs 59%, P = 0.4), while these responses were not detected in any of the negative controls. Among the seronegative IDUs, six (23%) had intermediate to very strong responses to 10-20 peptide mixes and another six (23%) had moderately strong responses for two to six mixes. The 12 seronegative IDUs with HCV-specific T-cell responses had higher demographical and behavioural risk profiles than the 14 IDUs without T-cell responses (estimated risk of HCV infection, 0.47 vs 0.26, P < 0.01). In conclusion, HCV-specific T-cell responses are common among high-risk, seronegative IDUs. The responses are broad and are associated with risk factors for HCV exposure, suggesting that they reflect true exposure to HCV in seronegative persons.

HIV prevention for injection drug users in China and Vietnam: policy and research considerations.

A pattern of serious injection drug user (IDU) driven HIV epidemics in Asia, with emerging evidence of generalization through heterosexual transmission, indicates the need for interventions focusing on both drug- and sex-related risk reduction. In a cross-border HIV prevention project for IDUs in northern Vietnam and southern China, peer educators disseminated risk reduction information to IDUs in the community and provided 20,000-25,000 sterile needles/syringes and 4,000-6,000 condoms per month. Since implementation of these interventions, the frequency of both injecting and sexual risk behaviours fell significantly, HIV prevalence among IDUs declined or stabilized, and HIV incidence dropped. There is official support for harm reduction interventions in both countries but this appears precarious in view of persistently powerful political and financial support for a law enforcement approach. Moreover, the simultaneous pursuit of inconsistent policies can have negative effects on the implementation of interventions. A harmonized and consistent policy environment is needed. Most of the evidence for efficacy of community-based HIV prevention comes from the developed world, but well-designed evaluations of such interventions in Asia and elsewhere in the developing world would have a better chance to influence policy decisions there. A synergistic approach to research, policy development, and service delivery is best calculated to achieve positive results in the struggle against HIV/AIDS in developing countries.

Needle exchange use, sexual risk behaviour, and the prevalence of HIV, hepatitis B virus, and hepatitis C virus infections among Bulgarian injection drug users.

At a time when the rates of HIV, hepatitis C virus (HCV), and hepatitis B virus (HBV) infections have risen among injection drug users (IDUs) in other countries in the region, little is known about the prevalence of these infections among Bulgarian injectors and about their sexual risk behaviours. IDUs (n = 773) in a community-based needle exchange programme (NEP) and two major drug treatment facilities in Sofia completed a structured interview and were tested for HIV, HBV, and HCV antibodies. While HCV prevalence in the sample was 73.9%, HBV and HIV prevalence was low -6% and 0.5%, respectively. Having more than 10 sexual partners, having sex with someone with hepatitis C or another IDU, and never using a condom with another IDU were common among those who were recruited through NEP. As 40% of the IDUs reported using NEP, it appears that needle exchange provides an opportunity to reach high-risk populations and prevent sexual transmission of blood-borne pathogens.

Hepatitis C virus infection: prevalence, predictor variables and prevention opportunities among drug users in Italy.

The study assessed rates and predictor variables of hepatitis C virus (HCV) infection among drug users receiving pharmacological treatment for opiates addiction. There was a large cohort study in 16 public centres for drug users in north-eastern Italy, with data collected by standardized face-to-face interviews between February 2001 and August 2001. Of 1095 participants, 74.2% were HCV seropositive. Anti-HCV status was independently associated with duration of drug use of over 10 years, injecting as a route of drug administration, and hepatitis B virus (HBV) and human immunodeficiency virus (HIV) seropositivity. Further statistical analysis was conducted by dividing the subjects on the basis of the duration of heroin use: more or <10 years. In the multivariate analyses, route of drug administration and HBV status were associated with HCV seropositivity among both groups. Less education was associated with HCV among the shorter term drug users. HIV status and having a sexual partner with a history of drug use were associated with HCV seropositivity among the longer term drug users. Half of the short-term heroin users were still HCV seronegative when starting treatment, suggesting opportunities for reducing new HCV infections. Remarkable was the relationship between vaccination for hepatitis B and HCV serostatus. Being HBV seropositive was strongly associated with being HCV seropositive. But heroin users who had been vaccinated for HBV were not significantly more likely to be HCV seropositive than heroin users who were HBV seronegative. HBV vaccination does not provide biological protection against HCV; however, vaccinating heroin users against HBV may help to create a stronger pro-health attitude among heroin users, leading to a reduction in HCV risk behaviour.

Consistent condom use among drug-using youth in a high HIV-risk neighbourhood.

The objectives of this study were to determine predictors of consistent condom use in heterosexual relationships of young adults who use hard drugs in a neighbourhood with widespread drug-use-connected HIV. We interviewed 196 18-24 year olds who injected drugs or used heroin, cocaine or crack in the prior year and lived in the Bushwick neighbourhood of New York City. Interviews covered sociodemographics, substance use and sexual networks. The unit of analysis is the relationship; the dependent variable measures consistent condom use over the prior 30 days in a given relationship. Consistent condom use was reported in 26% of 377 non-commercial relationships and in all of 22 commercial relationships. Using multiple logistic regression, consistent condom use in non-commercial relationships was more likely in relationships that are not 'very close'; for men (but not women) with peers whose norms are more favourable to condom use; and for subjects who had concurrent sex partners in the last 12 months. In conclusion, we found that: (1) the lack of relationship between the peer norms of drug-using women and their condom use suggests they may have little control over condom use in their relationships-programmes should attempt to empower young women drug users and to develop ways for their peers to influence the men in their lives; (2) epidemiologically, the positive association of concurrency to consistent condom use suggests that condom use may be restricting HIV spread through the community-the presence of consistent condom use in all of the commercial sexual relationships also may restrict HIV spread; (3) prevention efforts should attempt to change peer cultures as a way to develop self-sustaining risk reduction. These changes should include changes in gender roles and power relations.

Stigmatized drug use, sexual partner concurrency, and other sex risk network and behavior characteristics of 18- to 24-year-old youth in a high-risk neighborhood.

BACKGROUND: Sex risks and drug use are related. This relation in youth is described. GOAL: To determine how stigmatized drug use is related to sexual risk behaviors and network characteristics among youth. STUDY DESIGN: In-person interviews were conducted with both a probability household sample (n = 363) and a targeted, street-recruited sample of cocaine, heroin, crack, or injected drug users (n - 165) comprising 18- to 24-year-olds in an inner city neighborhood. Drug use in the preceding 12 months was scaled hierarchically, lowest to highest social stigma, as none, marijuana, noninjected cocaine, noninjected heroin, crack, and injected drugs. RESULTS: Users of the more stigmatized drugs had more sex partners. They were more likely to report a history of concurrent sex partners, sex with someone who also had engaged in sex with a network member, commercial sex work, and unprotected sex. Findings showed crack use and drug injection to be associated more strongly with increased sex risk among women than among men. CONCLUSIONS: Young users of the more stigmatized drugs are at much greater network and behavior risk for sexually transmitted diseases. Drug use prevention, harm reduction interventions, or both may lower this risk.