Correlates of sharing of needles and syringes among people who inject drugs in Dhaka city, Bangladesh.

INTRODUCTION: This paper examines the correlates of needle and syringe sharing among People Who Inject Drugs in Dhaka city, Bangladesh, which is currently experiencing a steep increase in HIV prevalence despite the ongoing presence of Needle Exchange Programs. METHODOLOGY: This was a retrospective chart review with cross-sectional design that extracted data from 783 male People Who Inject Drugs enrolled into five Opioid Substitution Treatment clinics in Dhaka city between April 2010 and January 2016. Data were retrieved from the program's electronic database. Needle and syringe sharing constituted the borrowing or lending of needles and syringes from others within the past month preceding data collection. RESULTS: Buprenorphine was the preferred injection drug and 44.6% shared needles and syringes within the past month. Multivariate analysis indicated that People Who Inject Drugs who were homeless (OR = 8.1, 95% CI = 1.4-44.9, p < 0.05), living with friends (OR = 6.8, 95% CI = 2.5-18.2, p < 0.001), injecting 2-3 times/day (OR = 4.8, 95% CI = 1.2-19.7, p < 0.05), injecting more than three times/day (OR = 4.8, 95% CI = 1.1-20.0, p < 0.05), not using condom with non-commercial female sex partners (OR = 3.3, 95% CI = 1.8-6.0, p < 0.05), bought sex from female sex workers (OR = 2.9, 95% CI = 1.0-8.3, p < 0.05), and did non-suicidal self-injury (OR = 1.8, 95% CI = 1.0-3.0, p < 0.05) were more likely to share needles and syringes. CONCLUSIONS: This study demonstrates that operating a standalone harm reduction approach that just provides sterile needles and syringes may not adequately curb needle and syringe sharing among People Who Inject Drugs.

Knowledge about sexually transmitted infections among young men presenting to the Brazilian Army, 2016: A STROBE-compliant national survey-based cross-sectional observational study.

ABSTRACT: Global burden of sexually transmitted infections (STIs) remains high and has a profound impact on health and lives of children, adolescents and adults worldwide. For over a decade, the Brazilian Department of Chronic Condition Diseases and Sexually Transmitted Infections and the Ministry of Defense have been conducting the Conscripts Survey aiming to assess the STI prevalence and obtain data on knowledge regarding STIs and risk factors among youth.A cross-sectional study was conducted among conscripts across Brazil aged 17 to 22 years from August to December 2016. It included a self-reported questionnaire containing 74 questions, 25 questions related to awareness and knowledge of STIs and their associated symptoms, routes of transmission, complications and risk factors.A total of 37,282 young men across Brazil were considered for the analysis. The majority resided in the Northeast and Southeast regions (38.9% and 30.0%, respectively), followed by the South (13.9%), North (9.7%), and Central-west (7.5%) regions. Of the conscripts, 97.2% have the knowledge they may be at risk if they do not use condoms during sex. Conscripts with a higher level of education have almost 2 times greater chance of having knowledge of having sex without a condom (OR 3.23 CI95% 2.82-3.70 P = .000) and sharing needles and syringes (OR 2.84 CI95% 2.62-3.07 P = .000) represents a risk. Those with higher education also have an almost 50% greater chance of having knowledge regarding STI transmission from mother to child (OR 1.54 CI95% 1.44-1.64 P = .000), and knowledge of no transmission by mosquito bite (OR 1.61 CI95%1.51-1.72 P = .000), by kissing (OR 1.45 CI95% 1.36-1.55 P = .000) or by using public toilets (OR 1.51 CI95% 1.41-1.61 P = .000). Television (71.8%) and internet (69.4%) are the preferred forms to obtain STIs information regardless of the level of education.Conscripts with higher level of education have greater knowledge regarding transmission of STIs. However, there are gaps regarding their knowledge about HIV pre-exposure prophylaxis and the fact that other STIs can increase the chances of acquiring HIV.

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.

Prevalence and correlates of receptive syringe-sharing among people who inject drugs in rural Appalachia.

BACKGROUND AND AIMS: Syringe-sharing significantly increases the risk of HIV and viral hepatitis acquisition among people who inject drugs (PWID). Clearer understanding of the correlates of receptive syringe-sharing (RSS) is a critical step in preventing bloodborne infectious disease transmission among PWID in rural communities throughout the United States. This study aimed to measure the prevalence and correlates of RSS among PWID in a rural county in Appalachia. DESIGN: Observational, cross-sectional sample from a capture-recapture parent study. SETTING: Cabell County, West Virginia (WV), USA, June-July 2018. PARTICIPANTS: The sample was restricted to people who reported injecting drugs in the past 6 months (n = 420). A total of 180 participants (43%) reported recent (past 6 months) RSS. Participants reported high levels of homelessness (56.0%), food insecurity (64.8%) and unemployment (66.0%). MEASUREMENTS: The main outcome was recent re-use of syringes that participants knew someone else had used before them. Key explanatory variables of interest, selected from the risk environment framework, included: unemployment, arrest and receipt of sterile syringes from a syringe services program (SSP). Logistic regression was used to determine correlates of recent RSS. FINDINGS: PWID reporting recent RSS also reported higher prevalence of homelessness, food insecurity and unemployment than their non-RSS-engaging counterparts. In adjusted analyses, correlates of RSS included: engagement in transactional sex work [adjusted odds ratio (aOR) = 2.27, 95% confidence interval (CI) = 1.26-4.09], unemployment (aOR = 1.67, 95% CI = 1.03-1.72), number of drug types injected (aOR = 1.33, 95% CI = 1.15-1.53) and injection in a public location (aOR = 2.59, 95% CI = 1.64-4.08). Having accessed sterile syringes at an SSP was protective against RSS (aOR = 0.57, 95% CI = 0.35-0.92). CONCLUSION: The prevalence of receptive syringe-sharing among people who inject drugs in a rural US county appears to be high and comparable to urban-based populations. Receptive syringe-sharing among people who inject drugs in a rural setting appears to be associated with several structural and substance use factors, including unemployment and engaging in public injection drug use. Having recently acquired sterile syringes at a syringe services program appears to be protective against receptive syringe sharing.

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.

The Impact of Syringe Services Program Policy on Risk Behaviors Among Persons Who Inject Drugs in 3 US Cities, 2005-2015.

OBJECTIVES: The impact of a syringe services program (SSP) policy on risk behaviors and its durability are not as well studied as the impact of the SSPs themselves. We examined whether trends in syringe sharing among persons who inject drugs (PWID) were associated with changes to syringe access policies in 3 US cities: Denver, New Orleans, and Philadelphia. METHODS: PWID were surveyed through National HIV Behavioral Surveillance System surveys in each city in 2005, 2009, 2012, and 2015. We assessed changes in syringe sharing from 2005 to 2015 by city. We used multivariable stepwise logistic regression analysis to measure the associations among syringe sharing and injection works sharing, time, and SSP access. RESULTS: From 2005 to 2015, syringe sharing decreased significantly from 49.1% to 33.1% in Denver (P < .001), increased significantly from 32.0% to 50.5% in New Orleans (P < .001), and remained unchanged in Philadelphia (30.4% to 31.5%; P = .87). Compared with persons who obtained syringes from any nonsterile source, the adjusted odds of syringe sharing among PWID were significantly lower in each city if syringes were obtained from sterile sources only: Denver adjusted odds ratio (aOR) = 0.23 (95% confidence interval [CI], 0.18-0.30; New Orleans aOR = 0.26 (95% CI, 0.19-0.35), and Philadelphia aOR = 0.43 (95% CI, 0.33-0.57). CONCLUSIONS: The lowest proportion of PWID reporting syringe sharing was in Philadelphia, which has a long-standing legal SSP. Implementation of a legal SSP in Denver in 2012 corresponded to a decrease in sharing, whereas the lack of a legal SSP in New Orleans corresponded to an increase in sharing. Universal long-term access to legal SSPs could further the progress made in HIV prevention among PWID.

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.

Personal historical perspective of HIV: part 11.

All animal life on earth is thought to have a common origin and have common genetic mechanisms. Evolution has enabled differentiation of species. Pathogens likewise have evolved within various species and mostly come to a settled dynamic equilibrium such that co-existence results (pathogens ideally should not kill their hosts). Problems arise when pathogens jump species because the new host had not developed any resistance. These infections from related species are known as zoonoses. COVID-19 is the latest example of a virus entering another species but HIV (and various strains of influenza) were previous examples. HIV entered the human population from monkeys in Africa. These two papers outline the underlying principle of HIV and the differing epidemiologies in Africa, the USA and in Edinburgh. The underlying immunosuppression of HIV in Africa was initially hidden behind common infections and HIV first came to world awareness in focal areas of the USA as a disease seemingly limited to gay males. The epidemic of intravenous drug abuse in Edinburgh was associated with overlapping epidemics of bloodborne viruses like hepatitis B, hepatitis C and HIV.

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.

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.

Injection and sexual risk among people who use or inject drugs in Kampala, Uganda: An exploratory qualitative study.

BACKGROUND: Countries in Sub-Saharan Africa (SSA) have seen rapid increases in injection drug use since 2008. In Uganda, the Global Sate of Harm report and studies conducted by Makerere University Crane Surveys have estimated HIV prevalence among people who inject drugs (PWID) at approximately 17%. The objective of the research was to document injection and other drug-related risks among people who use drugs in Uganda to develop comprehensive HIV/HCV prevention interventions. METHODS: Between August and September 2018, we conducted qualitative interviews among male and female people who use drugs. Interview topics included the availability and accessibility of clean syringes, injection risks, overdose, sexual-risk behaviors, and the availability and accessibility of harm reduction and drug treatment services. RESULTS: Participants reported several injection-related risks including sharing and reusing syringes, pooling and mixing drugs in the same container, measuring drugs using syringes, getting prefilled injections from dealers, being injected by other people who inject drugs, and using contaminated water or blood to dilute drugs. Participants reported a scarcity of harm reduction services, although a few appear to have participated in the syringe exchange pilot conducted by the Uganda Harm Reduction Network (UHRN). Even fewer reported knowing organizations that helped people who use drugs abstain from or reduce their use. Medication assisted therapy (MAT) and naloxone to reverse overdoses are not currently available. CONCLUSIONS: Comprehensive prevention and treatment services are needed in Uganda and should include expanded syringe exchange programs, social network HIV testing, HCV testing, provision of naloxone and MAT, and linkage to and retention in HIV care.

Negative affect, affect-related impulsivity, and receptive syringe sharing among people who inject drugs.

Receptive syringe sharing (RSS) among people who inject drugs (PWID) is a risk factor for hepatitis C virus and HIV infections. PWID with borderline personality disorder (BPD) have increased risk of RSS, but it remains unclear what drives this association. This study used ecological momentary assessment (EMA) to study characteristics associated with BPD, and RSS among PWID. We recruited PWID, ages 18-35, through two Community Outreach Intervention Projects syringe service program sites in Chicago, Illinois. After a baseline interview, participants used a mobile phone app to respond to momentary surveys on mood, substance use, and injection risk behavior for two weeks. For each momentary assessment, ratings on negative mood descriptors were combined to create measures of total negative affect (NA), and NA components of dejection, shame, anger, irritability, and worry. RSS was defined by participant responses indicating that they had used a syringe that someone else had used. We estimated mixed effects logistic models, regressing RSS on baseline affect-related impulsivity, lagged momentary NA, and the interaction term. Out of 163 participants who completed at least two EMA assessments, 152 (93%) reported at least one injection event and had valid pre-injection mood assessments required to be included in the analysis. We found that affect-related impulsivity, combined with worried mood in the hours preceding the injection episode, predicted increased risk of RSS. PWID having difficulties with emotion regulation may be at increased risk of RSS during periods of anxiety or tension. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

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.

Exposure to HIV risks among young people who use drugs (YPUD) in three cities in Vietnam: time to develop targeted interventions.

INTRODUCTION: The aim of this study is to identify the profiles of young people who use drugs (YPUD) and their exposure to HIV risks in the 3 main cities of Vietnam, Haiphong, Hanoi, and Ho Chi Minh City (HCMC), in order to design a community-based intervention to prevent HIV. METHODS: A survey using respondent-driven sampling (RDS) was conducted among YPUD aged 16-24. Participants were eligible if they reported drug use, confirmed by a urine test. After obtaining informed consent, they were screened for HIV/HCV and assessed using face-to-face questionnaires and self-report. A cluster analysis was conducted, taking into account risk behaviors and confirmed HIV-positive status. RESULTS: Seven hundred and three YPUD aged 16-24 were recruited between October 2016 and February 2017, 584 of whom were included in the final analysis. Median age was 21 (17.7, 23.0); 79% were male, 18% female, and 2% transgender. Methamphetamines use was reported by 77%, followed by cannabis (51%) and heroin (17%); polydrug use was common; 15% had "ever" injected drugs. HIV prevalence was 7%. Among all participants, 48% reported non-consistent condom use and 1% reported needle/syringe sharing during the previous month. Four distinct profiles of HIV risk behaviors were identified: The high multiple-risk group mixed unsafe drug use with unsafe sexual practices and had higher prevalence of HIV; the second group practiced high-risk sex with non-consistent condom combined with methamphetamine use; the third group was a moderate-risk group with limited unsafe sexual practices; and the fourth was considered at "low-risk" as reportedly, most never had sex and never injected. The highest risk group included more female YPUD, living in HCMC, who used heroin and had unsafe sex with their regular partners. The second high-risk group included most of the MSM and all transgender people and frequently reported mental health disorders. CONCLUSIONS: The profiles of YPUD who are at risk of HIV vary according to age, location, and population group. Injecting YPUD are the most exposed to risk and need immediate attention. Sexual exposure to HIV is very common. Mental health is a major concern. Interventions need to be integrated in a differentiated but holistic approach.

Longitudinal Factors Associated with Used Syringe Lending Among HIV-Positive Antiretroviral Therapy-Naïve People Who Inject Drugs in a Canadian Setting.

Sharing used syringes is an important route of HIV transmission, however, factors shaping used syringe-lending among antiretroviral therapy (ART)-naïve HIV-positive people who inject drugs (PWID) are not well-characterized. Multivariable logistic regression analyses using generalized estimating equations (GEE) were employed to investigate correlates of used syringe lending among ART-naïve PWID. Data was drawn from ACCESS, a prospective community-recruited cohort of HIV-positive illicit drug users in Vancouver, Canada, from 1996 to 2015. The analysis included 482 ART-naïve PWID, of which 116 (24.1%) reported ≥ 1 periods of used syringe lending. In longitudinal analyses, incarceration (Adjusted Odds Ratio [AOR] = 2.18, 95% Confidence Interval [CI] 1.48-3.20), daily cocaine injection (AOR= 1.97, 95% CI 1.33-2.90), and sex work (AOR = 1.61, 95% CI 1.02-2.55) during the 180-day observation period were positively associated with used syringe lending, while having a high school diploma (AOR = 0.63, 95% CI 0.43-0.93) and holding formal employment (AOR = 0.20, 95% CI 0.05-0.82) were negatively associated. We found a high prevalence of used syringe lending among ART-naïve HIV-positive PWID, particularly among those recently incarcerated, involved in sex work or who injected cocaine frequently. Conversely, markers of higher socio-economic status were negatively associated with used syringe lending. These findings highlight the critical need for policies and interventions to decrease socio-economic marginalization and criminalization among PWID living with HIV alongside the scale up of access to harm reduction services.

Correlates of Transactional Sex Among a Rural Population of People Who Inject Drugs.

In the United States, high rates of HIV infection among persons who engage in transactional sex are partially driven by substance use. Little is known about transactional sex among rural populations of people who inject drugs (PWID). Using data from a 2018 survey of 420 rural PWID in West Virginia, we used logistic regression to identify correlates of recent transactional sex (past 6 months). Most study participants were male (61.2%), white (83.6%), and reported having injected heroin (81.0%) in the past 6 months. Nearly one-fifth (18.3%) reported engaging in recent transactional sex. Independent correlates of transactional sex were: being female [adjusted odds ratio (aOR) 3.90; 95% CI 2.12-7.16]; being a sexual minority (aOR 3.07; 95% CI 1.60-5.87); being single (aOR 3.22; 95% CI 1.73-6.01); receptive syringe sharing (aOR 3.13; 95% CI 1.73-5.66); and number of injections per day (aOR 1.08; 95% CI 1.01-1.15). Rural PWID who engage in transactional sex are characterized by multiple vulnerabilities that increase their HIV risk.

Pregnancy Status, Risk Factors, and Opportunities for Referral to Care Among Reproductive-Aged Women With Newly Reported Chronic Hepatitis C Virus Infection in Tennessee.

OBJECTIVES: From 2006 through 2012, the number of acute hepatitis C virus (HCV) infections increased 364% among persons aged ≤30, including reproductive-aged women, in Central Appalachian states. Outreach to reproductive-aged women with newly diagnosed HCV infection affords a unique opportunity to provide counseling, further testing, and linkage to treatment. We modeled a centrally located statewide effort to reach this population and their health care providers to ascertain pregnancy status, HCV risk factors, and opportunities for linkage to additional services. METHODS: Using the Tennessee Department of Health's surveillance database, we identified women aged 18-45 residing in Tennessee with newly reported chronic HCV infection from May through October 2017. We contacted health care providers and patients to request information on pregnancy status and HCV risk factors as well as to provide linkage to treatment services. RESULTS: Of 1548 women included in this study, health care provider or patient contact information was available for 1316 (85.0%) women. Of the 1316 women, 806 (61.2%) women had a health care provider or patient response, of whom 242 (30.0%) were pregnant. Of 296 patients contacted, 194 (65.5%) reported intranasal drug use, 193 (65.2%) reported having been incarcerated for more than 24 hours, and 180 (60.8%) reported injection drug use. Ninety-eight (33.1%) patients were referred for confirmatory testing, and 174 (58.8%) were referred to treatment. CONCLUSION: A high proportion of reproductive-aged women with newly diagnosed HCV infection were pregnant. Surveillance-informed outreach to this population was feasible and provided opportunities for counseling and linkage to confirmatory testing and treatment. Future studies should evaluate whether a similar model would enhance testing and linkage to care of HCV-exposed infants.

Maintaining the healthy body: Blood management and hepatitis C prevention among men who inject performance and image-enhancing drugs.

Australia's ambitious aim to 'eliminate' hepatitis C as a public health concern by 2030 requires researchers, policy makers and health practitioners to engage with populations rarely identified as a priority. Men who inject performance and image-enhancing drugs (PIEDs) are one such population, yet research suggests they have low rates of knowledge about hepatitis C. Although rates of needle-sharing in this group are thought to be low, other risks of blood-to-blood contact exist due to the use of large-gauge needles, intramuscular injecting, hard-to-reach injection sites, repeated injecting and peer-to-peer injecting. How should health initiatives engage people who might not customarily consider themselves vulnerable to hepatitis C? Drawing on the work of body theorist Margrit Shildrick, this article considers how men who inject PIEDs understand their bodies, with a particular focus on injecting practices, blood awareness and infection control, in order to inform hepatitis C prevention efforts. In our analysis, we draw on qualitative interviews with 60 men who inject PIEDs, which we conducted for an Australian Research Council-funded project focused on better understanding PIED injecting to improve health and minimise hepatitis C transmission. The interviews suggest that men who inject PIEDs closely monitor potential external infection risks, such as dirt and bacteria that might intrude upon the 'purity and security' of the body. However, less attention appears to be paid to what might be transferred out of the body and potentially to others, such as blood. Notions of trust and cleanliness, and normative perceptions of intravenous drug use, also shaped injecting practices and cursory attention to blood management. While environmental transmission poses a smaller transmission risk than needle-sharing, educating PIED consumers about it is nevertheless warranted. Focusing targeted health promotion materials on environmental blood as a potential route of hepatitis C transmission may help engage this population in prevention, and encourage more frequent hepatitis C testing.

Associations between perceived illicit fentanyl use and infectious disease risks among people who inject drugs.

BACKGROUND: Over the last several years, fentanyl has been introduced into the illicit drug supply in the United States. While the impact of fentanyl on overdose fatalities is clear, the increase in fentanyl use may also be affecting drug use practices with implications for infectious disease transmission. We conducted a cross-sectional survey to explore associations of perceived illicit fentanyl use with opioid use frequency, injection frequency and syringe sharing among people who inject drugs in two California cities. METHODS: People who inject drugs (PWID) were recruited from community settings in Los Angeles and San Francisco, CA from June 2017 to September 2018. Multivariable logistic regression was used to explore adjusted associations between perceived illicit fentanyl use and high frequency opioid use, high frequency injection and syringe sharing. RESULTS: Among the 395 study participants, the median age of participants was 44 years; 74% of participants were cisgender male; 73% reported to be homeless; 61% lived in San Francisco and 39% in Los Angeles. The prevalence of perceived illicit fentanyl use in the past six months was 50.4% (95% confidence interval (CI): 45.4%-55.3%) among PWID. Findings from our adjusted logistic regression models suggested that people reporting perceived illicit fentanyl use had a greater odds of high frequency opioid use (adjusted odds ratio (aOR) = 2.36; 95% CI: 1.43-3.91; p = 0.001), high frequency injection (aOR = 1.84; 95% CI: 1.08-3.13; p = 0.03) and receptive syringe sharing (aOR = 2.16; 95% CI: 1.06-4.36; p = 0.03), as compared to people using heroin and other street drugs but not fentanyl. CONCLUSION: People reporting perceived illicit fentanyl use were at increased risk for injection-related infectious disease risks. Actions must be taken to reduce these risks, including improved access to syringe service programs and opioid treatment and consideration of innovative approaches, such as supervised consumption services.