Differential risks of syringe service program participants in Central Ohio: a latent class analysis.

BACKGROUND: Significant heterogeneity exists among people who use drugs (PWUD). We identify distinct profiles of syringe service program (SSP) clients to (a) evaluate differential risk factors across subgroups and (b) inform harm reduction programming. METHODS: Latent class analysis (LCA) was applied to identify subgroups of participants (N = 3418) in a SSP in Columbus, Ohio, from 2019 to 2021. Demographics (age, sex, race/ethnicity, sexual orientation, housing status) and drug use characteristics (substance[s] used, syringe gauge, needle length, using alone, mixing drugs, sharing supplies, reducing use, self-reported perceptions on the impact of use, and treatment/support resources) were used as indicators to define latent classes. A five-class LCA model was developed, and logistic regression was then employed to compare risk factors at program initiation and at follow-up visits between latent classes. RESULTS: Five latent classes were identified: (1) heterosexual males using opioids/stimulants with housing instability and limited resources for treatment/support (16.1%), (2) heterosexual individuals using opioids with stable housing and resources for treatment/support (33.1%), (3) individuals using methamphetamine (12.4%), (4) young white individuals using opioids/methamphetamine (20.5%), and (5) females using opioids/cocaine (17.9%). Class 2 served as the reference group for logistic regression models, and at the time of entry, class 1 was more likely to report history of substance use treatment, overdose, HCV, sharing supplies, and mixing drugs, with persistently higher odds of sharing supplies and mixing drugs at follow-up. Class 3 was more likely to report history of overdose, sharing supplies, and mixing drugs, but outcomes at follow-up were comparable. Class 4 was the least likely to report history of overdose, HCV, and mixing drugs, but the most likely to report HIV. Class 5 was more likely to report history of substance use treatment, overdose, HCV, sharing supplies, and mixing drugs at entry, and higher reports of accessing substance use treatment and testing positive for HCV persisted at follow-up. CONCLUSIONS: Considerable heterogeneity exists among PWUD, leading to differential risk factors that may persist throughout engagement in harm reduction services. LCA can identify distinct profiles of PWUD accessing services to tailor interventions that address risks, improve outcomes, and mitigate disparities.

The Changing Epidemiology of Hepatitis C Virus Infection in the United States During the Years 2010 to 2018.

Hepatitis C virus (HCV) infection remains an important cause of morbidity and mortality throughout the world, leading to serious health problems among those who are chronically infected. Since 1992, the Centers for Disease Control and Prevention has been collecting data on the incidence of HCV infection in the United States. In 2018, more than 50 000 individuals were estimated to have acute HCV infection.The most recently reported data on the prevalence of infection indicate that approximately 2.4 million people are living with hepatitis C in the United States. Transmission of HCV occurs predominantly through sharing contaminated equipment for injecting drugs.Two major events have had a significant impact on the incidence and prevalence of hepatitis C in the past few decades: the US opioid crisis and the discovery of curative treatments for HCV infection. To better understand the impact of these events, we examine reported trends in the incidence and prevalence of infection.

The opioid crisis and HIV in the USA: deadly synergies.

The opioid epidemic is one of the greatest public health problems that the USA faces. Opioid overdose death rates have increased steadily for more than a decade and doubled in 2013-17, as the highly potent synthetic opioid fentanyl entered the drug supply. Demographics of new HIV diagnoses among people who inject drugs are also changing, with more new HIV diagnoses occurring among White people, young people (aged 13-34 years), and people who reside outside large central metropolitan areas. Racial differences also exist in syringe sharing, which decreased among Black people and Hispanic people but remained unchanged among White people in 2005-15. Recent HIV outbreaks have occurred in rural areas of the USA, as well as among marginalised people in urban areas with robust HIV prevention and treatment services (eg, Seattle, WA). Multiple evidence-based interventions can effectively treat opioid use disorder and prevent HIV acquisition. However, considerable barriers exist precluding delivery of these solutions to many people who inject drugs. If the USA is serious about HIV prevention among this group, stigma must be eliminated, discriminatory policies must change, and comprehensive health care must be accessible to all. Finally, root causes of the opioid epidemic such as hopelessness need to be identified and addressed.

Cost-effectiveness of syringe service programs, medications for opioid use disorder, and combination programs in hepatitis C harm reduction among opioid injection drug users: a public payer perspective using a decision tree.

BACKGROUND: The hepatitis C virus (HCV) prevalence rate among injection drug users (IDUs) in North America is 55.2%, with 1.41 million individuals estimated to be HCV-antibody positive. Studies have shown the effectiveness of syringe service programs (SSPs) alone, medications for opioid use disorder (MOUD) alone, or SSP+MOUD combination in reducing HCV transmission among opioid IDUs. OBJECTIVE: To evaluate the cost-effectiveness of SSP alone, MOUD alone, and SSP + MOUD combination in preventing HCV cases among opioid IDUs in the United States. METHODS: We used a decision tree analysis model based on published literature and publicly available data. Effectiveness was presented as the number of HCV cases avoided per 100 opioid IDUs. A micro-costing approach was undertaken and included both direct medical and nonmedical costs. Cost-effectiveness was assessed from a public payer perspective over a 1-year time horizon. It was expressed as an incremental cost-effectiveness ratio (ICER) and an incremental cost savings per HCV case avoided per 100 opioid IDUs compared with cost savings with "no intervention." Costs were standardized to 2019 U.S. dollars. RESULTS: The incremental cost savings per HCV case avoided per 100 opioid IDUs compared with no intervention were as follows: SSP + MOUD combination = $347,573; SSP alone = $363,821; MOUD alone = $317,428. The ICER for the combined strategy was $4,699 compared with the ICER for the SSP group. Sensitivity analysis showed that the results of the base-case cost-effectiveness analysis were sensitive to variations in the probabilities of injection-risk behavior for the SSP and SSP + MOUD combination groups, probability of no HCV with no intervention, and costs of MOUD and HCV antiviral medications. CONCLUSIONS: The SSP + MOUD combination and SSP alone strategies dominate MOUD alone and no intervention strategies. SSP had the largest incremental cost savings per HCV case avoided per 100 opioid IDUs compared with the no intervention strategy. Public payers adopting the SSP + MOUD combination harm-reduction strategy instead of SSP alone would have to pay an additional $4,699 to avoid an additional HCV case among opioid IDUs. Although these harm-reduction programs will provide benefits in a 1-year time frame, the largest benefit may become evident in the years ahead. DISCLOSURES: This research had no external funding. The authors declare no financial interests in this article. Ijioma is a Health Economics and Outcomes Research (HEOR) postdoctoral Fellow with Virginia Commonwealth University and Indivior. Indivior is a pharmaceutical manufacturer of opioid addiction treatment drugs but was not involved in the design, analysis, or write-up of the manuscript.

Methamphetamine use and HIV risk behavior among men who inject drugs: causal inference using coarsened exact matching.

BACKGROUND: Understanding the association between methamphetamine (MA) use and HIV risk behavior among people who inject drugs (PWID) will assist policy-makers and program managers to sharpen the focus of HIV prevention interventions. This study examines the relationship between MA use and HIV risk behavior among men who inject drugs (MWID) in Tehran, Iran, using coarsened exact matching (CEM). METHODS: Data for these analyses were derived from a cross-sectional study conducted between June and July 2016. We assessed three outcomes of interest-all treated as binary variables, including distributive and receptive needle and syringe (NS) sharing and condomless sex during the month before interview. Our primary exposure of interest was whether study participants reported any MA use in the month prior to the interview. Firstly, we report the descriptive statistics for the pooled samples and matched sub-samples using CEM. The pooled and matched estimates of the associations and their 95% CI were estimated using a logistic regression model. RESULTS: Overall, 500 MWID aged between 18 and 63 years (mean = 28.44, SD = 7.22) were recruited. Imbalances in the measured demographic characteristics and risk behaviors between MA users and non-users were attenuated using matching. In the matched samples, the regression models showed participants who reported MA use were 1.82 times more likely to report condomless sex (OR = 1.82 95% CI 1.51, 4.10; P = 0.031), and 1.35 times more likely to report distributive NS sharing in the past 30 days, as compared to MA non-users (OR = 1.35 95% CI 1.15-1.81). Finally, there was a statistically significant relationship between MA use and receptive NS sharing in the past month. People who use MA in the last month had higher odds of receptive NS sharing when compared to MA non-users (OR = 4.2 95% CI 2.7, 7.5; P = 0.013). CONCLUSIONS: Our results show a significant relationship between MA use and HIV risk behavior among MWID in Tehran, Iran. MA use was related with increased NS sharing, which is associated with higher risk for HIV exposure and transmission.

Assessing routes of hepatitis C transmission in HIV-infected men who have sex with men using single genome sequencing.

The epidemic of hepatitis C virus (HCV) infection among HIV-infected men who have sex with men (MSM) is in its second decade, but the routes of transmission remain poorly understood. We hypothesized that by pairing single genome sequencing (SGS), to enumerate infecting HCV genomes (viruses), with detailed sexual and drug histories, we could gain insight into the routes of transmission among MSM. We used SGS to analyze blood specimens from eight HIV-infected MSM who had 10 episodes of acute (seronegative) or early HCV infections. Seven of eight men reported condomless receptive anal intercourse (CRAI), six with rectal exposure to semen, and all eight denied rectal trauma or bleeding. Of the 10 HCV infections, eight resulted from transmission of a single virus; one infection resulted from transmission of either one or a few (three or four) closely-related viruses; and one infection resulted from transmission of >10 distinct viruses. The participant infected by >10 viruses reported sharing injection equipment for methamphetamine during sex. Two other participants also injected methamphetamine during sex but they did not share injection equipment and were infected by a single virus. Conclusions: Most HCV infections of HIV-infected MSM without a history of either rectal trauma or bleeding or shared injection equipment were caused by a single virus. Intra-rectal exposure to semen during CRAI is therefore likely sufficient for HCV transmission among MSM. Conversely, rectal trauma or bleeding or shared injection equipment are not necessary for HCV transmission among MSM. These results help clarify routes of HCV transmission among MSM and can therefore help guide the design of much-needed behavioral and other interventions to prevent HCV transmission among MSM.

HCV incidence is associated with injecting partner age and HCV serostatus mixing in young adults who inject drugs in San Francisco.

BACKGROUND: HCV incidence is increasing in the US, notably among younger people who inject drugs (PWID). In a cohort of young adult (age<30 years) PWID in San Francisco we examined whether 'injecting partner mixing' factors, i.e. age of partner and knowledge of their HCV serostatus, were associated with HCV transmission. METHODS: In 448 susceptible PWID studied prospectively. All participants were asked to report characteristics and behaviors they engaged in with up to 3 injecting partners defined as "people whom you injected the most with" in the past month". These partnerships did not specify that drugs or injecting equipment was shared. HCV incidence was estimated by age of up to 3 injecting partners, categorized as: (i) all <30; (ii) mixed-age (<&≥30); and (iii) all ≥30 years and perceived knowledge of the HCV status of participants' injecting partners' HCV status. Interaction was evaluated between partnership age categories and perceived HCV status of partners. RESULTS: Between 2006-2018, overall HCV incidence (/100 person years observation [pyo]) was 19.4 (95% CI: 16.4, 22.9). Incidence was highest in those with mixed-age partnerships: 28.5 (95% CI: 21.8, 37.1) and those whose partners were all <30 (23.9; 95% CI: 18.8, 30.4), and lowest if partners were ≥30 (7.5; 95% CI: 4.8, 11.8). In a multivariable analyses adjusting for age, sex (of index), injection frequency, and injection partnership 'monogamy', we found evidence for an interaction: the highest HCV incidence was seen in PWID whose partners were all <30 and who knew at least one of their partners was HCV-positive (58.9, 95% CI: 43.3, 80.0; p<0.01). CONCLUSIONS: Younger injectors are more likely to acquire HCV from their similarly-aged peers, than older injecting partners. Protective seroadaptive behavior may contribute to reduce incidence. These findings can inform new HCV prevention approaches for young PWID needed to curb the HCV epidemic.

The effect of the needle exchange program on the spread of some sexually transmitted diseases.

In this paper we consider a model for the spread of a sexually transmitted disease considering sexual transmission and spread via infected needles among intravenous drug users. Besides the transmission among drug users, we also consider sexual contacts between intravenous drug users and non-drug users. Furthermore, the needles are considered as a vector population. For several European countries, a sharp increase of sexually transmitted diseases was reported and several others are rated as endangered based on the number of syringes given out per intravenous drug users per year. The main purpose of the paper is to investigate the dynamics of this model including the effect of needle exchange and study the risk of an increased transmission among non-drug users, induced by the reduction of the needle exchange program. Following the determination of the basic reproduction number R0 it is shown that all solutions tend to the unique disease-free equilibrium if R0 < 1. We also prove that the disease persists in the human population if R0 > 1. Our numerical simulations, based on real life and hypothetical data for HIV, suggest that a decrease in the rate of the distribution and discharge rate of new needles might imply that the considered disease is becoming endemic in the considered human population of drug users and non-drug users. A variant of our model with time- variable needle distribition parameter is fitted to recent HIV data from Hungary to give a forecast for the number of infected in the following years.

Optimising opioid substitution therapy in the prison environment.

PURPOSE: The purpose of this paper is to examine the current provision of opioid substitution therapy (OST) during and immediately following release from detention in prisons in England and Wales. DESIGN/METHODOLOGY/APPROACH: A group of experts was convened to comment on current practices and to make recommendations for improving OST management in prison. Current practices were previously assessed using an online survey and a focus group with experience of OST in prison (Webster, 2017). FINDINGS: Disruption to the management of addiction and reduced treatment choice for OST adversely influences adequate provision of OST in prison. A key concern was the routine diversion of opiate substitutes to other prisoners. The new controlled drug formulations were considered a positive development to ensure streamlined and efficient OST administration. The following patient populations were identified as having concerns beyond their opioid use, and therefore require additional considerations in prison: older people with comorbidities and complex treatment needs; women who have experienced trauma and have childcare issues; and those with existing mental health needs requiring effective understanding and treatment in prison. ORIGINALITY/VALUE: Integration of clinical and psychosocial services would enable a joint care plan to be tailored for each individual with opioid dependence and include options for detoxification or maintenance treatment. This would better enable those struggling with opioid use to make informed choices concerning their care during incarceration and for the period immediately following their release. Improvements in coordination of OST would facilitate inclusion of strategies to further streamline this process for the benefit of prisoners and prison staff.

Association of Injection Practices and Overdose With Drug Use Typologies: A Latent Class Analysis Among People Who Inject Drugs in Baltimore, 2017.

Increasing overdose mortality and new HIV outbreaks in the U.S. highlight the need to identify risk behavior profiles among people who inject drugs (PWID). We characterized latent classes of drug use among a community-based sample of 671 PWID in Baltimore during 2017 and evaluated associations of these classes with sharing syringes, obtaining syringes from pharmacies or syringe services programs (SSPs), and nonfatal overdose in the past 6 months. We identified three classes of current drug use: infrequent use (76% of participants), prescription drug use (12%), and heroin and/or cocaine injection (12%). PWID in the heroin and/or cocaine injection and prescription drug use classes had higher odds of both overdose and sharing syringes (relative to infrequent use). PWID in the prescription drug use class were 64% less likely to obtain syringes through SSPs/pharmacies relative to heroin and/or cocaine injection. Harm reduction programs need to engage people who obtain prescription drugs illicitly.

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.

Predictors of Drug Injection in High-Risk Populations of Prisoners with a History of Tattooing: A Cross-Sectional Study.

BACKGROUND: Transmitting blood-borne diseases is alarming in places with high prevalence of people who inject drugs. This study aimed to determine the prevalence of drug injection and its related predictors among prisoners with a history of tattooing in Iran. STUDY DESIGN: Cross-sectional study. METHODS: By using a census sampling, 5493 prisoners with a history of tattooing of 11988 prisoners participated for hepatitis B and C bio-behavioral surveillance surveys (BSS) in prisons of Iran, during 2015-2016 from 55 prisons in 19 provinces were assessed. The data for the BSS were collected using face-to-face checklist-based interviews. Weighted prevalence and the association between variables and history of drug injection were determined using Chi-square test and adjusted odds ratio (AOR) was estimated through multivariate logistic regression test using survey package. RESULTS: The mean age of participants was 33.9 ±8.3 yr. Most of them were male (96.4%) and had a history of drug use (85.4%). The prevalence of drug injection among drug users was 20.2%, of which 33.9% had a history of shared injection. The prevalence of drug injection among prisoners with a history of tattooing is associated with male gender (P=0.047), age ≥35 yr (P<0.001), being single (P=0.002), being divorced/widow (P=0.039), and a history of imprisonment (P<0.001). CONCLUSION: The prevalence of drug injection increases in the presence of other high-risk behaviors. It is necessary to initiate harm reduction programs and preventive interventions in groups with multiple high-risk behaviors.

Interactive Versus Video-Based Training of Police to Communicate Syringe Legality to People Who Inject Drugs: The SHIELD Study, Mexico, 2015-2016.

Objectives. To assess how instructional techniques affect officers' intent to communicate syringe legality during searches in Tijuana, Mexico, where pervasive syringe confiscation potentiates risk of HIV and HCV among people who inject drugs (PWID) and of occupational needle-stick injury among police. Methods. Using the SHIELD (Safety and Health Integration in the Enforcement of Laws on Drugs) model, Tijuana police underwent training to encourage communication of syringe possession legality to PWID. Trainees received either passive video or interactive role-play exercise on safer search techniques. We used logistic regression to assess the training's impact on self-reported intent to communicate syringe legality by training type and gender. Results. Officers (n = 1749) were mostly men (86%) assigned to patrol (84%). After the training, intent to communicate the law improved markedly: from 20% to 39% (video group) and 20% to 58% (interactive group). Gender and training type significantly predicted intent to communicate syringe legality. Male and female officers' adjusted odds ratios in the interactive group were 5.37 (95% confidence interval [CI] = 4.56, 6.33) and 9.16 (95% CI = 5.88, 14.28), respectively, after the training. Conclusions. To more effectively persuade police to endorse harm reduction and occupational safety practices, police trainings should include interactive elements.

Sharing of Injection Drug Preparation Equipment Is Associated With HIV Infection: A Cross-sectional Study.

BACKGROUND: Sharing needles/syringes and sexual transmission are widely appreciated as means of HIV transmission among persons who inject drugs (PWIDs). London, Canada, is experiencing an outbreak of HIV among PWIDs, despite a large needle/syringe distribution program and low rates of needle/syringe sharing. OBJECTIVE: To determine whether sharing of injection drug preparation equipment (IDPE) is associated with HIV infection. METHODS: Between August 2016 and June 2017, individuals with a history of injection drug use and residence in London were recruited to complete a comprehensive questionnaire and HIV testing. RESULTS: A total of 127 participants were recruited; 8 were excluded because of failure to complete HIV testing. The remaining 35 HIV-infected (cases) and 84 HIV-uninfected (controls) participants were assessed. Regression analysis found that sharing IDPE, without sharing needles/syringes, was strongly associated with HIV infection (adjusted odds ratio: 22.1, 95% confidence interval: 4.51 to 108.6, P < 0.001). CONCLUSIONS: Sharing of IDPE is a risk factor for HIV infection among PWIDs, even in the absence of needle/syringe sharing. Harm reduction interventions to reduce HIV transmission associated with this practice are urgently needed.

Outcome evaluation of a "common factors" approach to develop culturally tailored HIV prevention interventions for people who inject drugs.

BACKGROUND: Current models of HIV prevention intervention dissemination involve packaging interventions developed in one context and training providers to implement that specific intervention with fidelity. Providers rarely implement these programs with fidelity due to perceived incompatibility, resource constraints, and preference for locally-generated solutions. Moreover, such interventions may not reflect local drug markets and drug use practices that contribute to HIV risk. PURPOSE: This paper examines whether provider-developed interventions based on common factors of effective, evidence-based behavioral interventions led to reduction in drug-related HIV risk behaviors at four study sites in Ukraine. METHODS: We trained staff from eight nongovernmental organizations (NGOs) to develop HIV prevention interventions based on a common factors approach. We then selected four NGOs to participate in an outcome evaluation. Each NGO conducted its intervention for at least N = 130 participants, with baseline and 3-month follow-up assessments. RESULTS: At three sites, we observed reductions in the prevalence of both any risk in drug acquisition and any risk in drug injection. At the fourth site, prevalence of any risk in drug injection decreased substantially, but the prevalence of any risk in drug acquisition essentially stayed unchanged. CONCLUSIONS: The common factors approach has some evidence of efficacy in implementation, but further research is needed to assess its effectiveness in reducing HIV risk behaviors and transmission. Behavioral interventions to reduce HIV risk developed using the common factors approach could become an important part of the HIV response in low resource settings where capacity building remains a high priority.

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.