Using standardized methods for research on HIV and injecting drug use in developing/transitional countries: case study from the WHO Drug Injection Study Phase II

BACKGROUND: Successful cross-national research requires methods that are both standardized across sites and adaptable to local conditions. We report on the development and implementation of the methodology underlying the survey component of the WHO Drug Injection Study Phase II – a multi-site study of risk behavior and HIV seroprevalence among Injecting Drug Users (IDUs). METHODS: Standardized operational guidelines were developed by the Survey Coordinating Center in collaboration with the WHO Project Officer and participating site Investigators. Throughout the duration of the study, survey implementation at the local level was monitored by the Coordinating Center. Surveys were conducted in 12 different cities. Prior rapid assessment conducted in 10 cities provided insight into local context and guided survey implementation. Where possible, subjects were recruited both from drug abuse treatment centers and via street outreach. While emphasis was on IDUs, non-injectors were also recruited in cities with substantial non-injecting use of injectable drugs. A structured interview and HIV counseling/testing were administered. RESULTS: Over 5,000 subjects were recruited. Subjects were recruited from both drug treatment and street outreach in 10 cities. Non-injectors were recruited in nine cities. Prior rapid assessment identified suitable recruitment areas, reduced drug users' distrust of survey staff, and revealed site-specific risk behaviors. Centralized survey coordination facilitated local questionnaire modification within a core structure, standardized data collection protocols, uniform database structure, and cross-site analyses. Major site-specific problems included: questionnaire translation difficulties; locating affordable HIV-testing facilities; recruitment from drug treatment due to limited/selective treatment infrastructure; access to specific sub-groups of drug users in the community, particularly females or higher income groups; security problems for users and interviewers, hostility from local drug dealers; and interference by local service providers. CONCLUSION: Rapid assessment proved invaluable in paving the way for the survey. Central coordination of data collection is crucial. While fully standardized methods may be a research ideal, local circumstances may require substantial adaptation of the methods to achieve meaningful local representation. Allowance for understanding of local context may increase rather than decrease the generalizability of the data

Past-year prevalence of prescription opioid misuse among those 11 to 30

AbstractBackgroundThere are high levels of prescription and consumption of prescription opioids in the US. Misuse of prescription opioids has been shown to be highly correlated with prescription opioid-related morbidity and mortality including fatal and non-fatal overdose. We characterized the past-year prevalence of prescription opioid misuse among those 11–30years of age in the US.MethodsA systematic review and meta-analysis were carried out following a published protocol and PRISMA guidelines. We searched electronic databases; reports were eligible if they were published between 1/1/1990–5/30/2014, and included data on individuals 11–30years of age from the US. Study quality was assessed using the Newcastle-Ottawa Scale.ResultsA total of 3211 abstracts were reviewed for inclusion; after discarding duplicates and identifying non-eligible reports, a total of 19 unique reports, providing 34 estimates, were included in the final systematic review and meta-analysis. The range of past-year prescription opioid misuse prevalence the reports was 0.7%–16.3%. An increase in prevalence of 0.4% was observed over the years of data collection.ConclusionsThis systematic review and meta-analysis found a high prevalence of past-year prescription opioid misuse among individuals 11–30years of age. Importantly, we identified an increase in past-year prevalence 1990–2014. Misuse of prescription opioids has played an important role in national increases of fatal and non-fatal drug overdose, heroin use and injection, and HIV and HCV infection among young people. The observed high and increasing prevalence of prescription opioid misuse is an urgent public health issue

Community acceptance and implementation of HIV prevention interventions for injection drug users

In 1997, the National Institutes of Health (NIH) reviewed evidence of the effectiveness of HIV prevention programs for injection drug users (IDUs) and recommended that three types ofinterventions be implemented to prevent transmission of HIV among IDUs: 1) community-based outreach, 2) expanded syringe access (including needle exchange programs [NEP] and pharmacy sales), and 3) drug treatment. Progress on increasing the acceptance and feasibility of implementing these programs has been made at the national level, but their implementation has been varied at the local level.Understanding the conditions under which communities accept and implement interventions can help guide effective strategies to foster the implementation of these interventions in areas where programs do not currently exist

Comparison of injecting drug users who obtain syringes from pharmacies and syringe exchange programs in Tallinn, Estonia

<p>Abstract</p> <p>Background</p> <p>Both syringe exchange programs (SEPs) and pharmacy sales of syringes are available in Estonia, though the current high incidence and high prevalence of HIV among injection drug users (IDUs) in Tallinn, Estonia requires large-scale implementation of additional harm reduction programs as a matter of great urgency. The aims of this report were to compare risk behavior and HIV infection and to assess the prevention needs among IDUs who primarily use pharmacies as their source of sterile syringes with IDUs who primarily use SEPs in Tallinn.</p> <p>Methods</p> <p>A cross-sectional study using respondent-driven sampling was used to recruit 350 IDUs for an interviewer-administered survey and HIV testing. IDUs were categorized into two groups based on their self-reported main source for syringes within the last six months. Odds ratios with 95% CI were used to compare characteristics and risk factors between the groups.</p> <p>Results</p> <p>The main sources of sterile needles for injection drug users were SEP/SEP outreach (59%) and pharmacies (41%). There were no differences in age, age at injection drug use initiation, the main drug used or experiencing overdoses. Those IDUs using pharmacies as a main source of sterile needles had lower odds for being infected with either HIV (AOR 0.54 95% CI 0.33–0.87) or HCV (AOR 0.10 95% CI 0.02–0.50), had close to twice the odds of reporting more than one sexual partner within the previous 12 months (AOR 1.88 95% CI 1.17–3.04) and engaging in casual sexual relationships (AOR 2.09 95% CI 1.24–3.53) in the last six months.</p> <p>Conclusion</p> <p>The data suggest that the pharmacy users were at a less "advanced" stage of their injection career and had lower HIV prevalence than SEP users. This suggests that pharmacies could be utilized as a site for providing additional HIV prevention messages, services for IDUs and in linking IDUs with existing harm reduction services.</p

Stigmatization of Newly Emerging Infectious Diseases: AIDS and SARS

Objectives. We assessed relationships between sociodemographic characteristics and mental health status and knowledge of, being worried about, and stigmatization of 2 emerging infectious diseases: AIDS and SARS. Methods. We conducted a random-digit-dialed survey of 928 residents of the New York City metropolitan area as part of a study of the effects of the September 11, 2001, terrorist attacks. Questions added for this study concerned respondents’ knowledge of, worry about, and support of stigmatizing actions to control AIDS and SARS. Results. In general, respondents with greater personal resources (income, education, social support) and better mental health status had more knowledge, were less worried, and were less likely to stigmatize. This pattern held for both AIDS and SARS. Conclusions. Personal resources and mental health factors are likely to influence the public’s ability to learn about, rationally appraise the threat of, and minimize stigmatization of emerging infectious diseases such as AIDS and SARS.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/40384/2/Des Jarlais_Stigmatization of Newly Emerging Infectious Diseases_2006.pd

Social Factors Associated with AIDS and SARS

We conducted a survey of 928 New York City area residents to assess knowledge and worry about AIDS and SARS. Specific sociodemographic groups of persons were more likely to be less informed and more worried about contracting the diseases.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/40253/2/Des Jarlais_Social Factors Associated with AIDS_2005.pd

Updating the Infection Risk Reduction Hierarchy: Preventing Transition into Injection

Current approaches to prevention of blood-borne infections in injection drug users include referral to drug abuse treatment, access to sterile syringes, bleach disinfection of injection equipment, and education about not sharing equipment. However, rates of some blood-borne infections (e.g., hepatitis C virus) remain elevated among injection drug users, especially early after initiation into injection drug use. With lower infection rates in noninjectors and transition into injection drug use occurring most commonly among these noninjectors, prevention of transition into injection drug use as an additional step to reduce risk for acquisition and transmission of blood-borne infections merits closer attention.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/40275/2/Vlahov_Updating the Infection Risk Reduction Hierarchy_2004.pd

Will "Combined Prevention" Eliminate Racial/Ethnic Disparities in HIV Infection among Persons Who Inject Drugs in New York City?

It has not been determined whether implementation of combined prevention programming for persons who inject drugs reduce racial/ethnic disparities in HIV infection. We examine racial/ethnic disparities in New York City among persons who inject drugs after implementation of the New York City Condom Social Marketing Program in 2007. Quantitative interviews and HIV testing were conducted among persons who inject drugs entering Mount Sinai Beth Israel drug treatment (2007–2014). 703 persons who inject drugs who began injecting after implementation of large-scale syringe exchange were included in the analyses. Factors independently associated with being HIV seropositive were identified and a published model was used to estimate HIV infections due to sexual transmission. Overall HIV prevalence was 4%; Whites 1%, African-Americans 17%, and Hispanics 4%. Adjusted odds ratios were 21.0 (95% CI 5.7, 77.5) for African-Americans to Whites and 4.5 (95% CI 1.3, 16.3) for Hispanics to Whites. There was an overall significant trend towards reduced HIV prevalence over time (adjusted odd ratio = 0.7 per year, 95% confidence interval (0.6–0.8). An estimated 75% or more of the HIV infections were due to sexual transmission. Racial/ethnic disparities among persons who inject drugs were not significantly different from previous disparities. Reducing these persistent disparities may require new interventions (treatment as prevention, pre-exposure prophylaxis) for all racial/ethnic groups

Expanded syringe exchange programs and reduced HIV infection among new injection drug users in Tallinn, Estonia

<p>Abstract</p> <p>Background</p> <p>Estonia has experienced an HIV epidemic among intravenous drug users (IDUs) with the highest per capita HIV prevalence in Eastern Europe. We assessed the effects of expanded syringe exchange programs (SEP) in the capital city, Tallinn, which has an estimated 10,000 IDUs.</p> <p>Methods</p> <p>SEP implementation was monitored with data from the Estonian National Institute for Health Development. Respondent driven sampling (RDS) interview surveys with HIV testing were conducted in Tallinn in 2005, 2007 and 2009 (involving 350, 350 and 327 IDUs respectively). HIV incidence among new injectors (those injecting for < = 3 years) was estimated by assuming (1) new injectors were HIV seronegative when they began injecting, and (2) HIV infection occurred at the midpoint between first injection and time of interview.</p> <p>Results</p> <p>SEP increased from 230,000 syringes exchanged in 2005 to 440,000 in 2007 and 770,000 in 2009. In all three surveys, IDUs were predominantly male (80%), ethnic Russians (>80%), and young adults (mean ages 24 to 27 years). The proportion of new injectors decreased significantly over the years (from 21% in 2005 to 12% in 2009, p = 0.005). HIV prevalence among all respondents stabilized at slightly over 50% (54% in 2005, 55% in 2007, 51% in 2009), and decreased among new injectors (34% in 2005, 16% in 2009, p = 0.046). Estimated HIV incidence among new injectors decreased significantly from 18/100 person-years in 2005 and 21/100 person-years in 2007 to 9/100 person-years in 2009 (p = 0.026).</p> <p>Conclusions</p> <p>In Estonia, a transitional country, a decrease in the HIV prevalence among new injectors and in the numbers of people initiating injection drug use coincided with implementation of large-scale SEPs. Further reductions in HIV transmission among IDUs are still required. Provision of 70 or more syringes per IDU per year may be needed before significant reductions in HIV incidence occur.</p