HIV This Week

Retention in Opioid Substitution Treatment: A Major Predictor of Long-Term Virological Success for HIV-Infected Injection Drug Users Receiving Antiretroviral Treatment.

Roux P, Carrieri MP, Cohen J, Ravaux I, Poizot-Martin I, Dellamonica P, Spire B. Clin Infect Dis. 2009; 49:1433-40.

The positive impact of opioid substitution treatment on opioid-dependent individuals with human immunodeficiency virus (HIV) infection is well documented, especially with regard to adherence to antiretroviral therapy. Roux et al used the data from a 5-year longitudinal study of the MANIF 2000 cohort of individuals infected with HIV (as a result of injection drug use) and receiving ART to investigate the predictors of long-term virological success. Data were collected every 6 months from outpatient hospital services delivering HIV care in France. The authors selected all patients who were receiving antiretroviral therapy for at least 6 months (baseline visit) and who had indications for opioid substitution treatment (ie, still dependent on opioids). They selected a total of 113 patients, accounting for a total of 562 visits for all the analyses. Long-term virological success was defined as an undetectable viral load after at least 6 months on antiretroviral therapy. Retention in opioid substitution treatment was defined as the time interval between the last initiation or reinitiation of opioid substitution treatment during antiretroviral therapy follow-up and any given visit on opioid substitution treatment. A mixed logistic model was used to identify predictors of long-term virological success. At baseline, 53 patients were receiving buprenorphine, 28 patients were receiving methadone, and 32 patients were not on opioid substitution treatment. The median duration of opioid substitution treatment was 25 months (range, 3-42 months). In the multivariate analysis, after adjustment for significant predictors of long-term virological success such as adherence to antiretroviral therapy and early virological response, retention in opioid substitution treatment was associated with long-term virological success (odds ratio, 1.20 per 6-month increase; 95% confidence interval, 1.09-1.32). The study presents important evidence of the positive impact of retention in opioid substitution treatment on HIV outcomes. Increasing access to opioid substitution treatment based on a comprehensive model of care for HIV-infected patients who have indications for opioid substitution treatment may foster adherence and ensure long-term response to antiretroviral therapy.

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Editors’ note: Although people who inject drugs and who adhere to antiretroviral treatment have similar HIV outcomes to people who do not inject drugs, physicians may deny or delay initiation of antiretroviral treatment to active drug users. This is the first study to show that retention in opioid substitution treatment contributes to long-term virological suppression in injecting drug users on antiretroviral treatment. Expanded access to opioid substitutes, in the context of comprehensive care, is known to reduce the use of nonsterile injecting equipment and to increase consistent condom use. Given that opioid substitutes are included in the WHO list of essential medicines, the virological outcomes reported here give added impetus to initiatives to increase access to opioid substitution treatment for people living with HIV who inject drugs.

 

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 Expanding the reach of harm reduction in Thailand: Experiences with a drug user-run drop-in centre.

Kerr T, Hayashi K, Fairbairn N, Kaplan K, Suwannawong P, Zhang R, Wood E . Int J Drug Policy. 2009 Sep. [Epub ahead of print]

Despite an ongoing epidemic of HIV among Thai people who inject drugs, Thailand has failed to implement essential harm reduction programmes. In response, a drug user-led harm reduction centre opened in 2004 in an effort to expand reduction programming in Thailand. The authors examined experiences with the Mitsampan Harm Reduction Centre (MSHRC) among injecting drug users participating in the Mitsampan Community Research Project ( Bangkok). Multivariate logistic regression was used to identify factors associated with Mitsampan Harm Reduction Centre use. Kerr et al also examined services used at and barriers to the Mitsampan Harm Reduction Centre. 252 injecting drug users participated in this study, including 66 (26.2%) females. In total, 74 (29.3%) participants had accessed the Mitsampan Harm Reduction Centre. In multivariate analyses, Mitsampan Harm Reduction Centre use was positively associated with difficulty accessing syringes (Adjusted Odds Ratio [AOR]=4.05; 95% Confidence Interval [CI]: 1.67-9.80), midazolam injection (AOR=3.25; 95%CI: 1.58-6.71), having greater than primary school education (AOR=1.88; 95%CI: 1.01-3.52), and was negatively associated with female gender (AOR=0.20; 95%CI: 0.08-0.50). Forms of support most commonly accessed included: syringe distribution (100%), food and a place to rest (83.8%), HIV education (75.7%), and safer injecting education (66.2%). The primary reason given for not having accessed the Mitsampan Harm Reduction Centre was “didn’t know it existed.” The Mitsampan Harm Reduction Centre is expanding the scope of harm reduction in Thailand by reaching injecting drug users, including those who report difficulty accessing sterile syringes, and by providing various forms of support. In order to maximise its benefits, efforts should be made to increase awareness of the Mitsampan Harm Reduction Centre, in particular among women.

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Editors’ note: Although drug user-led initiatives to provide harm reduction services have been described in North America, Europe, and Australia, the group of drug users who opened this drug-user-run drop-in centre in Bangkok in 2004 with funding from the Global Fund to fight AIDS, Tuberculosis and Malaria were sailing in un-charted waters for Thailand. The Thai Drug Users Network and the Thai AIDS Treatment Action Group (TTAG) collaborated to start the centre which is open six days a week from 10 am to 7 pm and has 500 to 600 visits per month. At the end of the Global Fund grant in 2008, TTAG assumed oversight of the centre, with drug users continuing to run the centre. It is perhaps not surprising that many drug users interviewed were not aware of the centre given obvious difficulties in advertising its services in a context of documented extreme stigma and discrimination. Expanding the scope of this service and increasing the availability of harm reduction services in general in Thailand will require enlightened leadership in order to reduce the risk of HIV acquisition and transmission among Thais who inject drugs.

A situation update on HIV epidemics among people who inject drugs and national responses in South-East Asia Region.

Sharma M, Oppenheimer E, Saidel T, Loo V, Garg R. AIDS. 2009;23:1405-13.

The authors explore the magnitude of and current trends in HIV infection among people who inject drugs and estimate the reach of harm reduction interventions among them in seven high-burden countries of the South-East Asia Region. Their data are drawn from the published and unpublished literature, routine national HIV serological and behavioural surveillance surveys and information from key informants. Six countries ( Thailand, Myanmar, Nepal, Indonesia, India, and Bangladesh) had significant epidemics of HIV among people who inject drugs. In Thailand, Indonesia, Bangladesh, Myanmar and India, there is no significant decline in the prevalence of HIV epidemics in this population. In Nepal, north-east India, and some cities in Myanmar, there is some evidence of decline in risk behaviours and a concomitant decline in HIV prevalence. This is countered by the rapid emergence of epidemics in new geographical pockets. Available programme data suggest that less than 12 000 of the estimated 800 000 (1.5%) people who inject drugs have access to opioid substitution therapy, and 20-25% were reached by needle-syringe programmes at least once during the past 12 months. A mapping of harm reduction interventions suggests a lack of congruence between the location of established and emerging epidemics and the availability of scaled-up prevention services. Harm reduction interventions in closed settings are almost nonexistent. To achieve significant impact on the HIV epidemics among this population, governments, specifically national AIDS programmes, urgently need to scale up needle-syringe programmes and opioid substitution therapy and make these widely available both in community and closed settings.

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Editors’ note: This broad mapping, across 7 high drug use burden South East Asian countries with significant, longstanding HIV epidemics among people who inject drugs, draws from a variety of data sources to paint a picture of national prevention responses. In addition to the strikingly inadequate reach of harm reduction programmes, current surveillance systems are not designed to pick up new epidemics. Indonesia is the only country with a national strategy (2005-2009) to guide HIV prevention, treatment, and care in prison settings – the very settings that are known to be high-risk environments worldwide for HIV transmission. Methadone and buprenorphine are unavailable and too expensive in most countries. Tensions between supply/demand reduction and harm reduction approaches call out now for enlightened leadership at all levels to implement effective HIV prevention programmes to cover at least 50-60% of people who inject drugs.  

A Literature Review of International Implementation of Opioid Substitution Treatment in Prisons: Equivalence of Care? Larney S, Dolan K. Eur Addict Res. 2009; 15: 107-12.

Opioid substitution treatment is an effective treatment for heroin dependence. The World Health Organization has recommended that opioid substitution treatment be implemented in prisons because of its role in reducing drug injection and associated problems such as HIV transmission. The aim of this paper was to examine the extent to which opioid substitution treatment has been implemented in prisons internationally. As of January 2008, opioid substitution treatment had been implemented in prisons in at least 29 countries or territories. For 20 of those countries, the proportion of all prisoners in opioid substitution treatment could be calculated, with results ranging from less than 1% to over 14%. At least 37 countries offer opioid substitution treatment in community settings, but not prisons. This study has identified an increase in the international implementation of opioid substitution treatment in prisons. However, there remain large numbers of prisoners who are unable to access opioid substitution treatment, even in countries that provide such programs. This raises issues of equivalence of care for prisoners and HIV prevention in prisons.

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Editors’ note: Opioid substitution therapy, the most cost-effective treatment available for heroin dependence, is available in 66 countries and territories, including low- and middle-income countries such as China, Indonesia, and Iran. The largest prison programmes are in Ireland, Scotland, and Spain with 12 to 14% of inmates in these countries receiving opioid substitution treatment. Some countries unnecessarily restrict access to inmates serving sentences of a particular length, to those who were in treatment before incarceration, or to those who can confirm that they have a post-release treatment place. Furthermore, the 37 countries which offer opioid substitution therapy in the community but not in prisons are contravening the multiple international covenants and legal instruments that entitle incarcerated people access to health services equivalent to those available in the general community in their countries. Thus, despite prison access to opioid substitution treatment having increased from 5 countries in 1996 to 29 in 2008, much remains to be done to improve coverage worldwide both in prisons and in the community.

Des Jarlais DC, McKnight C, Goldblatt C, Purchase D. Doing harm reduction better: syringe exchange in the United States. Addiction. 2009 Feb 10. [Epub ahead of print]

To trace the growth of syringe exchange programs in the United States since 1994-95 and assess the current state of syringe exchange programs, annual surveys of US syringe exchange programs known to the North American Syringe Exchange Network (NASEN) were mailed to executive directors with follow-up interviews by telephone and/or e-mail. Response rates have varied between 70% and 88% since surveys were initiated in 1996. The numbers of programs known to NASEN have increased from 68 in 1994-95 to 186 in 2007. Among programs participating in the survey, numbers of syringes exchanged have increased from 8.0 million per year to 29.5 million per year, total annual budgets have increased from $6.3 to $19.6 million and public funding (from state and local governments) has increased from $3.9 to $14.4 million. In 2007, 89% of programs permitted secondary exchange and 76% encouraged it. Condoms, referrals to substance abuse treatment; human immunodeficiency virus (HIV), hepatitis C virus (HCV), hepatitis B virus (HBV) counselling and testing and naloxone for overdose were among the most commonly provided services in addition to basic syringe exchange. Each of these services was provided by 40% or more of syringe exchange programs in 2007. While syringe exchange has remained controversial in the United States, there has been very substantial growth in numbers of programs, syringes exchange and program budgets. Utilizing secondary exchange to reach large numbers of injecting drug users and utilizing syringe exchange programs as a new platform for providing health and social services beyond basic syringe exchange have been the two major organizational strategies in the growth of syringe exchange programs in the United States.

Editors’ note: Two-thirds of these US programmes do not adhere to a restrictive ‘one-for-one’ needle exchange policy and 89% permit secondary exchange, allowing an individual participant to exchange for peers who do not necessarily attend the exchange. These policies have served to increase the numbers of sterile syringes available to injecting drug users with the result that HIV incidence in the USA has declined to under 1 per 100 person years and the majority of new infections among injecting drug users appear to be sexually transmitted. The recent Congress bill lifting the 20-year ban on federal funding for needle exchange http://www.speaker.gov/blog/?p=1885 may encourage more equitable service coverage across the US, reduce stigmatisation of drug users, and facilitate a move toward integration of services for drug users into the regular health system.

Altaf A, Saleem N, Abbas S, Muzaffar R. High prevalence of HIV infection among injection drug users (IDUs) in Hyderabad and Sukkur, Pakistan. J Pak Med Assoc. 2009;59(3):136-40.

Altaf and colleagues aimed to estimate size of the injecting drug user population, determine the behaviours that put injecting drugs users at high-risk of HIV exposure, and assess the prevalence of HIV. As part of second generation surveillance, they investigated specific demographic and behavioural characteristics of people who inject drugs in Hyderabad and Sukkur in 2005. It was a cross sectional study. The survey was preceded by geographic mapping to determine size estimation and to define sampling procedures prior to conduct an integrated behavioural and biological survey. A sample size of at least 400 was calculated for each city. Besides calculating frequencies, chi square was used for comparing variables among HIV positive and negative injecting drug users like time elapsed as an injector, number of injections, using unsterile needles, and self perception of risk of acquiring HIV infection. A total of 800 ( Hyderabad 398; Sukkur 402) questionnaires and dried blood samples were collected. The estimated number of injecting drug users in both cities was 3,225 ( Hyderabad 975 and Sukkur 2250 respectively). Average age of the injectors in Hyderabad was 36.5 years and 34.6 years in Sukkur. Using unsterile injecting equipment for last injection was reported by 34 (8.5%) in Hyderabad and 135 (33.6%) in Sukkur. In both cities behaviours such as injecting drugs for more than 10 years (p = 0.00) and injecting four or more times in a day (p = 0.11) were significantly associated with HIV seropositivity. In Hyderabad the HIV seroprevalence was 25.4% (101/398) and in Sukkur it was 19.2% (77/402). In conclusion, the burden of HIV among people who inject drugs in Hyderabad and Sukkur is extremely high and can play a significant role in transmitting the infection to other vulnerable groups.

Editors’ note: Fluctuations in heroin availability, purity, and price have led many of the estimated 484, 000 heroin users in Pakistan to change over to injecting rather than less cost-efficient snorting or smoking. This first reported serosurvey from Hyderabad and Sukkur in Sindh province north of Karachi reveals that over one in five injectors (defined as having injected drugs for non-therapeutic purposes in the past 6 months) in these cities already has HIV infection. There is an urgent need for an organised programme of harm reduction services in both cities to reduce the negative health, social, and economic consequences of drug use for individual injectors and the wider community.

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Todadze K, Lezhava G. Implementation of drug substitution therapy in Georgia. Cent Eur J Public Health. 2008;16(3):121-3.

The geopolitical uniqueness of the regional socioeconomic situation and the existence of territories outside the control of the national government have facilitated the spread of drug use in Georgia. A special problem is injection of opiates, in particular heroin and Subutex (buprenorphine). It has been established that among registered HIV infected individuals the main route of transmission is injecting drug use. Although the prevalence of HIV among people who inject drugs is only 1-3%, the high number of injecting drug users and the high prevalence of hepatitis C in this population creates high risk of dramatic spread of HIV in Georgia. Beginning at the end of 2005, the Global Fund to fight HIV/AIDS, Tuberculosis and Malaria supported methadone substitution programmes in Georgia. At present, three programmes are functioning. At the same time, they involve 230 patients altogether. The studies carried out by the Research Institute on Addiction, with the aim to control the efficacy of pilot programmes have revealed a dramatic improvement of psychophysical state of patients, with very high rate of re-socialization and decriminalization, and significant diminishment of drug-related risky behaviour. Obtained results indicate high efficiency of methadone substitution programmes in Georgia, as an important tool both for treatment of opioid dependence and harm reduction. In order to obtain a more significant impact on public health, substitution therapy programmes have to be further expanded.

Editors’ note: Drug use in Georgia, an important drug transit route from Asia to Europe, escalated in the early 1990s following the breakdown of the Soviet Union, and ensuing unemployment and social pessimism. Despite economic development and crime reduction, drug use has not decreased. The Georgian parliament passed a law in 2002 permitting substitution therapy. This report of improved health and psychosocial patient outcomes from Georgia’s first methadone substitution programme should spur expansion of the programme there and set an example for other Eastern European countries.

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Jürgens R, Ball A, Verster A. Interventions to reduce HIV transmission related to injecting drug use in prison. Lancet Infect Dis. 2009;9(1):57-66. The high prevalence of HIV infection and drug dependence among prisoners, combined with the reuse of non-sterile injecting drug equipment, make prisons a high-risk environment for the transmission of HIV. Ultimately, this contributes to HIV epidemics in the communities to which prisoners return on their release. Jürgens and colleagues reviewed the effectiveness of interventions to reduce injecting drug use risk behaviours and, consequently, HIV transmission in prisons. Many studies reported high levels of injecting drug use in prisons and HIV transmission has been documented. There is increasing evidence of what prison systems can do to prevent HIV transmission related to injecting drug use. In particular, needle and syringe programmes and opioid substitution therapies have proven effective at reducing HIV risk behaviours in a wide range of prison environments, without resulting in negative consequences for the health of prison staff or prisoners. The introduction of these programmes in countries with an existing or emergent epidemic of HIV infection among injecting drug users is therefore warranted, as part of comprehensive programmes to address HIV in prisons.

Editors’ note: Although most prisoners living with HIV contract their infections before imprisonment, the risk of acquiring HIV in prison through use of contaminated injecting equipment is high. Prisoners have the right to receive health care, including preventive measures, equivalent to that available in the community. Furthermore, national commitments to universal access to prevention, treatment, care, and support cannot be achieved without introducing and rapidly expanding comprehensive HIV programmes in prisons. Thus, implementation of evidence-informed HIV programming in prisons is an essential component of any national AIDS programme.

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Bayoumi AM Md Msc, Zaric GS Phd. The cost-effectiveness of Vancouver’s supervised injection facility. CMAJ. 2008;179(11):1143-1151.

The cost-effectiveness of Canada’s only supervised injection facility has not been rigorously evaluated. Bayoumi and colleagues estimated the impact of the facility on survival, rates of HIV and hepatitis C virus infection, referral to methadone maintenance treatment, and associated costs. They simulated the population of Vancouver, British Columbia, including injection drug users and persons infected with HIV and hepatitis C virus. The model used a time horizon of 10 years and the perspective of the health care system. They compared the situation of the supervised injection facility with one that had no facility but that had other interventions, such as needle-exchange programmes. The effects considered were decreased needle reuse, increased use of safe injection practices and increased referral to methadone maintenance treatment. Outcomes included life-years gained, costs, and incremental cost-effectiveness ratios discounted at 5% per year. Focusing on the base assumption of decreased needle reuse as the only effect of the supervised injection facility, they found that the facility was associated with an incremental net savings of almost $14 million and 920 life-years gained over 10 years. When the authors also considered the health effect of increased use of safe injection practices, the incremental net savings increased to more than $20 million and the number of life-years gained to 1070. Further increases were estimated when they considered all 3 health benefits: the incremental net savings was more than $18 million and the number of life-years gained 1175. Results were sensitive to assumptions related to injection frequency, the risk of HIV transmission through needle sharing, the frequency of safe injection practices among users of the facility, the costs of HIV-related care and of operating the facility, and the proportion of users who inject in the facility. Vancouver’s supervised injection site is associated with improved health and cost savings, even with conservative estimates of efficacy.

Editors’ note: Supervised injecting facilities or SIFs provide a hygienic, safe environment for people to inject their previously obtained illicit drugs under supervision. SIFs reduce overdose mortality, decrease public injecting and discarding of syringes, and increase referrals to social and health services. This computer simulation estimates considerable cost savings and improved health outcomes comparing a supervised injecting facility to standard needle exchange and methadone maintenance treatment. Findings such as these, combined with results from acceptability, feasibility, and anticipated impact studies, support evidence-informed decision-making about the introduction and continued functioning of such programmes.

Malta M, Strathdee SA, Magnanini MM, Bastos FI. Adherence to antiretroviral therapy for human immunodeficiency virus/acquired immune deficiency syndrome among drug users: a systematic review. Addiction 2008;103(8):1242-57.

Adherence to highly active antiretroviral therapy (HAART) is a key predictor of survival for human immunodeficiency virus (HIV)-infected people. Suboptimal adherence among marginalized populations such as HIV-positive drug users could be associated with clinical failure and the emergence of viral resistance. Malta and colleagues aimed to conduct a systematic review of studies assessing adherence to HAART among HIV-positive drug users and identify factors associated with non-adherence to HIV treatment. Seven electronic databases were searched for peer-reviewed papers published in English, French, Spanish or Portuguese, from 1996 to 2007. Studies were excluded if they presented only qualitative data, were reviews themselves or assessed other populations without disaggregating data on people who use drugs. Findings on adherence were extracted and summarized. Forty-one studies were considered, which studied a total of 15 194 patients, the majority of whom were HIV-positive drug users (n = 11 628, 76.5%). Twenty-two studies assessed adherence using patient self-reports, eight used pharmacy records, three used electronic monitoring [i.e. Medication Event Monitoring Systems caps], six studies used a combination of patient self-report, clinical data, and Medication Event Monitoring Systems caps, and two analyzed secondary data. Overall, active substance use was associated with poor adherence, as well as depression and low social support. Higher adherence was found in patients receiving care in structured settings (e.g. directly observed therapy) and/or drug addiction treatment (especially substitution therapy). While lower than other populations-especially among users of stimulants, incarcerated drug users and patients with psychiatric comorbidities-adherence to HAART among HIV-positive people who use drugs can be achieved. Better adherence was identified among those engaged in comprehensive services providing HIV and addiction treatment with psychosocial support.

Editors’ note: This is the first systematic review summarising the growing body of research on adherence to antiretroviral treatment among drug users. As with other populations, self-reported adherence tended to be higher than other adherence measurements. The structured daily routines of substitution therapy or directly observed treatment, higher self-esteem and self-efficacy, and positive patient-provider relationships made adherence more likely. Non-coercive, comprehensive HIV management and care assists traditionally marginalized patients to access, accept, and adhere to complex therapeutic regimens. All 41 studies considered in this review were from high-income countries. Similar studies are urgently needed in the developing and transitional countries that have experienced the largest HIV epidemics among drug users in recent years.

Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA, Wodak A, Panda S, Tyndall M, Toufik A, Mattick RP; for the 2007 Reference Group to the UN on HIV and Injecting Drug Use. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet. 2008;372(9651):1733-45.

Injecting drug use is an increasingly important cause of HIV transmission in most countries worldwide. Mathers and colleagues set out to determine the prevalence of injecting drug use among individuals aged 15-64 years, and of HIV among people who inject drugs. They did a systematic search of peer-reviewed (Medline, EmBase, and PubMed/BioMed Central), internet, and grey literature databases; and data requests were made to UN agencies and international experts. 11 022 documents were reviewed, graded, and catalogued by the Reference Group to the UN on HIV and Injecting Drug Use. Injecting drug use was identified in 148 countries; data for the extent of injecting drug use was absent for many countries in Africa, the Middle East, and Latin America. The presence of HIV infection among injectors had been reported in 120 of these countries. Prevalence estimates of injecting drug use could be ascertained for 61 countries, containing 77% of the world’s total population aged 15-64 years. Extrapolated estimates suggest that 15.9 million (range 11.0-21.2 million) people might inject drugs worldwide; the largest numbers of injectors were found in China, the USA, and Russia, where mid-estimates of HIV prevalence among injectors were 12%, 16%, and 37%, respectively. HIV prevalence among injecting drug users was 20-40% in five countries and over 40% in nine. Worldwide, an estimated 3.0 million (range 0.8-6.6 million) people who inject drugs might be HIV positive. The number of countries in which the injection of drugs has been reported has increased over the last decade. The high prevalence of HIV among many populations of injecting drug users represents a substantial global health challenge. However, existing data are far from adequate, in both quality and quantity, particularly in view of the increasing importance of injecting drug use as a mode of HIV transmission in many regions.

Editors’ note: This systematic assessment of peer-reviewed and grey (non-peer-reviewed) literature by the 2007 Reference Group to the UN on HIV and Injecting Drug Use found that injecting drug use is occurring in 148 countries of the world of which 128 have reported HIV infection in this population, an apparent rise since the last such study published in 2004. Inadequate investment in research to document HIV prevalence and to evaluate HIV prevention programmes with a view to improving performance is hampering evidence-informed decision-making to minimise harms. Enough is known already about HIV prevention, as well as treatment and care of HIV-positive injecting drug users, for effective action. It is important to study local impact so that strategies can be adjusted for optimum results.

Ba O, O’Regan C, Nachega J, Cooper C, Anema A, Rachlis B, Mills EJ. HIV/AIDS in African militaries: an ecological analysis. Med Confl Surviv. 2008;24(2):88-100.

The HIV pandemic is considered a security threat. Policy-makers have warned of destabilization of militaries due to massive troop deaths. Estimates of the rate of HIV within African militaries have been as high as 90 per cent. Ba and colleagues aimed to determine if HIV prevalence within African militaries is higher than their host nation prevalence rates. Using systematic searching and access to United States Department of Defense data, the authors abstracted data on prevalence within militaries and their host communities. They conducted a random effects pooled analysis to determine differences in HIV prevalence rates in the military versus the host population, obtaining data on 21 African militaries. In general, HIV prevalence within the military was elevated compared to the general population. The differences were significant (odds ratio 1.97, 95% confidence interval: 1.58-2.45, P < 0.001). Further, inflated rates of HIV in militaries compared to non-military males of similar age were also significant (6.09, 4.47-8.30, P < or = 0.0001). States with recent conflicts and wars had elevated military rates, but these were also not significant (P = 0.4). Population levels predicted military prevalence rates (P < or = 0.001). HIV prevalence rates in most African militaries are significantly elevated compared to their host communities.

Editors’ note: The high HIV prevalence documented in the militaries of some countries in Africa is not surprising given that they are comprised predominantly of young, sexually active males. It does raise concerns about the potential for shortages in the numbers of qualified and experienced military personnel available for deployment, particularly when the armed forces play a key role in maintaining and promoting peace in the region. Intensified HIV prevention and antiretroviral treatment are key to maintaining a healthy military.

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Strathdee SA, Lozada R, Ojeda VD, Pollini RA, Brouwer KC, Vera A, Cornelius W, Nguyen L, Magis-Rodriguez C, Patterson TL; Proyecto El Cuete. Differential effects of migration and deportation on HIV infection among male and female injection drug users in Tijuana, Mexico. PLoS ONE. 2008;3(7):e2690.

HIV prevalence is rising, especially among high risk females in Tijuana, Baja California, a Mexico-US border city situated on major migration and drug trafficking routes. Strathdee and colleagues compared factors associated with HIV infection among male and female injection drug users in Tijuana in an effort to inform HIV prevention and treatment programmes. Injection drug users aged > or = 18 years were recruited using respondent-driven sampling and underwent testing for HIV, syphilis and structured interviews. Logistic regression identified correlates of HIV infection, stratified by gender. Among 1056 injection drug users, most were Mexican-born but 67% were born outside Tijuana. Reasons for moving to Tijuana included deportation from the US (56% for males, 29% for females), and looking for work/better life (34% for females, 15% for males). HIV prevalence was higher in females versus males (10.2% vs. 3.5%, p = 0.001). Among females (N=158), factors independently associated with higher HIV prevalence included younger age, lifetime syphilis infection and living in Tijuana for longer durations. Among males (N=898), factors independently associated with higher HIV prevalence were syphilis titres consistent with active infection, being arrested for having ‘track-marks’, having larger numbers of recent injection partners and living in Tijuana for shorter durations. An interaction between gender and number of years lived in Tijuana regressed on HIV infection was significant (p = 0.03). Upon further analysis, deportation from the U.S. explained the association between shorter duration lived in Tijuana and HIV infection among males; odds of HIV infection were four-fold higher among male injectors deported from the US, compared to other males, adjusting for all other significant correlates (p = 0.002). Geographic mobility has a profound influence on Tijuana’s evolving HIV epidemic, and its impact is significantly modified by gender. Future studies are needed to elucidate the context of mobility and HIV acquisition in this region, and whether US immigration policies adversely affect HIV risk.

Editors’ note: These findings suggest that geographic mobility may have had a differential effect on the risk of HIV infection among male and female injecting drug users in Tijuana, with a three-fold higher HIV prevalence documented among the women. However, its cross-sectional design means that a causal relationship cannot be confirmed. Nonetheless, supportive programmes for migrants, deportees, and other displaced persons on both sides of the U.S.-Mexico border could help mitigate the effects of social disruption and displacement.

Wodak A, McLeod L. The role of harm reduction in controlling HIV among injecting drug users. AIDS. 2008;Suppl 2:S81-92.

Injecting drug users now account for one in 10 new HIV infections world wide. Yet it has been known since the early 1990s that HIV among injecting drug users can be effectively, safely and cost-effectively controlled by the early and vigorous implementation of a comprehensive package of strategies known as ‘harm reduction’. This concept means that decreasing drug-related harms is accorded an even higher priority than reduction of drug consumption. Strategies required involve: explicit and peer-based education about the risk of HIV from sharing injecting equipment; needle syringe programmes; drug treatment (including especially opiate substitution treatment), and community development. Many countries experiencing or threatened by an HIV epidemic among injecting drug users have now adopted harm reduction but often implementation has been too little and too late. Although coverage is slowly improving in many countries, HIV is still spreading faster among injecting drug users than harm reduction programmes while coverage in correctional centres lags far behind community settings. The scientific debate about harm reduction is now over. National and international support for harm reduction is growing while almost all the major UN organizations responsible for drug policy now support harm reduction. Only a small number of countries, led by the USA, are still vehemently opposed to harm reduction. Excessive reliance on drug law enforcement remains the major barrier to increased adoption of harm reduction. Sometimes zealous drug law enforcement undermines harm reduction. A more balanced approach to drug law enforcement is required with illicit drug use recognized primarily as a health and social problem.

Editor’s Note: With injecting drug use reported from 144 countries, of which 128 have detected HIV among injecting drug users, the pragmatic approach of harm reduction must be scalled-up deliberately and rapidly around the world. It is no longer conscionable to deny access to sterile needles and syringes and to substitution treatment for injecting drug uses in the face of the evidence of their effectiveness in reducing HIV infection. Promotion and protecting the human rights of injecting drug users underpin effective public health responses to stem the HIV epidemic among them. There is no time to lose.

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Gowing L, Farrell M, Bornemann R, Sullivan L, Ali R. Substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Syst Rev. 2008;(2):CD004145.

Injecting drug users are vulnerable to infection with HIV and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour. Gowing and co-authors aimed to assess the effect of oral substitution treatment for opioid-dependent injecting drug users on rates of HIV infections,and high risk behaviours. They searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and PsycINFO to March 2007. They also searched reference lists of articles, reviews, and conference abstracts. Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered. Two reviewers independently assessed studies for inclusion. One reviewer extracted data from included studies, assessed quality, and confirmed decisions by consulting with all other reviewers. The authors included thirty-three studies, involving 10,400 participants. The majority were not randomised controlled studies and there were problems of confounding and bias. The studies varied in several aspects limiting the extent of quantitative analysis. Studies consistently showed that oral substitution treatment for opioid-dependent injecting drug users was associated with statistically significant reductions in illicit opioid use, injecting use, and sharing of injecting equipment. It was also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but had little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection. The authors conclude that oral substitution treatment for injecting opioid users reduces drug-related behaviours with a high risk of HIV transmission, but has less effect on sex-related risk behaviours. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review.

Editor’s Note: This review assessing the effectiveness of oral substitution treatment in reducing injecting and sexual risk behaviours included studies of methadone, buprenorphine, LAAM (levo alpha acetyl methadol), codeine, and slow release morphine but not of the injectable preparations used in Switzerland, the Netherlands, the United Kingdom and Germany. Substitution treatment, a key pillar of harm reduction, reduces risk behaviours and HIV acquisition. It is high time to remove legal, policy, and other barriers to offering it to opioid dependent injecting drug users around the world.

Sylla L, Bruce RD, Kamarulzaman A, Altice FL. Integration and co-location of HIV/AIDS, tuberculosis and drug treatment services. Int J Drug Policy 2007; 18:306-12.

Injection drug use plays a critical role in the HIV epidemic in several countries throughout the world. In these countries, injection drug users are at significant risk for both HIV and tuberculosis, and active injection drug use negatively impacts treatment access, adherence, and retention. Comprehensive strategies are therefore needed to effectively deliver preventive, diagnostic, and curative services to these complex patient populations. Sylla and colleagues propose that developing co-located integrated care delivery systems should become the focus of national programmes as they continue to scale-up access to antiretroviral medications for drug users. Existing data suggest that such a programme will expand services for each of these diseases; increase detection of tuberculosis and HIV; improve medication adherence; increase entry into substance use treatment; decrease the likelihood of adverse drug events; and improve the effectiveness of prevention interventions. Key aspects of integration programmes include: co-location of services convenient to the patient; provision of effective substance use treatment, including pharmacotherapies; cross-training of generalist and specialist care providers; and provision of enhanced monitoring of drug-drug interactions and adverse side effects. Central to implementing this agenda will be fostering the political will to fund infrastructure and service delivery, expanding street-level outreach to injection drug users, and training community health workers capable of cost effectively delivering these services.

Editors’ note: The case for co-location of HIV, TB, and drug treatment services is strong. The “two diseases-one life” nomenclature for TB/HIV puts the focus on the patient, adding drug treatment services and reproductive health services recognises the need for integrated care for this complex and vulnerable patient population.

Yang L, Li J, Zhang Y, Li H, Zhang W, Dai F, Ren Z, Qi G, Cheng W. Societal perception and support for methadone maintenance treatment in a Chinese province with high HIV prevalence. Am J Drug Alcohol Abuse. 2008;34(1):5-16.

Methadone maintenance treatment was first piloted in April 2004 in Yunnan, China, to reduce HIV transmission. This study aimed to examine public support for methadone maintenance treatment and was based on cross-sectional data collected in March-April 2006 on a random sample of 411 police staff, medical/health professionals, community members, and drug users. Multivariate logistic regressions were used to analyze the data. The support was the strongest amongst the police and medical professionals but the lowest in drug users. A considerable proportion of the respondents viewed methadone maintenance treatment as contradictory to China’s drug control policies and this factor was negatively associated with support for methadone maintenance treatment. Dissemination of more accurate knowledge and the resolution of these conflicts are urgently needed to increase the public support for methadone maintenance treatment.

Editors’ note: This study in Yunnan province underscores the need to discover the reasons that drug users themselves are the people least supportive of methadone maintenance, particularly as China proceeds to scale-up dramatically such programmes. The reason could be as basic as inadequate knowledge about the effectiveness and safety of methadone substitution.

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 Walsh N, Gibbie TM, Higgs P. The development of peer educator-based harm reduction programmes in northern Vietnam. Drug Alcohol Rev. 2008;27(2):200-3.

Injecting drug use remains an important risk factor for transmission in Vietnam, with an estimated 50% of the 290 000 people living with HIV reporting injecting drug use as a risk factor. Despite this, effective harm reduction interventions are generally lacking. Walsh and colleagues describe the implementation of peer-based harm reduction programmes in two rural provinces of Vietnam. Peer educators were trained in basic HIV prevention, including harm reduction. After significant preparation work with the Provincial AIDS Committees of Bac Giang and Thanh Hoa and other relevant national, provincial and local authorities, the interventions were commenced. Harm reduction interventions were delivered through outreach as well as on site. These included needle and syringe distribution and collection. Community advocacy occurred throughout the life of the project. Local authorities and peers believed that while there was a general reduction in stigma and discrimination, legal barriers associated particularly with the carrying of injecting equipment remained. This affected the ability of peer educators to work with their clients. Nonetheless, peer-based delivery of harm reduction interventions, including needle and syringe programmes, is feasible and acceptable in these two rural Vietnamese provinces. Community acceptance and uptake of these interventions are key to successful expansion across the region. Active participation by families of drug users seems crucial. This initiative demonstrates that despite a difficult policy environment, peer-delivered needle and syringe programmes are feasible within a rural Asian environment as long as there is adequate local political and community support.

Editors’ note: This local harm reduction programme delivered through peer educators mobilised communities to change attitudes, engaged families, was acceptable to police and other local government officials, and resulted in a large reduction in discarded needles and syringes. Shifts in drug policy with the release of thousands of detainees from drug rehabilitation suggest the potential for scaling–up community-based harm reduction programmes more widely in Vietnam.

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Kerr T, Tyndall MW, Zhang R, Lai C, Montaner JS, Wood E. Circumstances of first injection among illicit drug users accessing a medically supervised safer injection facility. Am J Public Health. 2007;97:1228-30.

There have been concerns that safer injecting facilities may promote initiation into injection drug use. Kerr and colleagues examined length of injecting career and circumstances surrounding initiation into injection drug use among 1065 users of North America’s first safer injecting facility and found that the median years of injection drug use were 15.9 years, and that only 1 individual reported performing a first injection at the safer injecting facility. These findings indicate that the safer injecting facility’s benefits have not been offset by a rise in initiation into injection drug use.

Editors’ note: This supervised injecting facility requires all new visitors to sign a waiver indicating that they have injected previously, a fact that is well known in the community. Deterring people who are insistent on injecting for the first time could be a problem since such individuals tend to use another person’s injecting equipment and are at high risk of overdose. One solution would be for them to be assessed first by an on site addictions counsellor, encouraging consideration of the option of referral for treatment.

Des Jarlais DC, Kling R, Hammett TM, Ngu D, Liu W, Chen Y, Binh KT, Friedmann P. Reducing HIV infection among new injecting drug users in the China-Vietnam Cross Border Project. AIDS. 2007;21 Suppl 8:S109-14.

Des Jarlais and colleagues aimed to assess an HIV prevention programme for injecting drug users (IDU) in the crossborder area between China and Vietnam. The project included peer educator outreach and the large-scale distribution of sterile injection equipment. Serial cross-sectional surveys with HIV testing of community recruited IDU were conducted at baseline (before implementation) and 6, 12, 18, 24 and 36 months post-baseline. HIV prevalence and estimated HIV incidence among new injectors (individuals injecting drugs for < 3 years) in each survey wave were the primary outcome measures. The percentages of new injectors among all subjects declined across each survey waves in both Ning Ming (China) and Lang Son (Vietnam). HIV prevalence and estimated incidence fell by approximately half at the 24-month survey and by approximately three quarters at the 36-month survey in both areas (all P < 0.01). The authors conclude that implementation of large-scale outreach and syringe access programmes was followed by substantial reductions in HIV infection among new injectors, with no evidence of any increase in individuals beginning to inject drugs. This project may serve as a model for large-scale HIV prevention programming for IDU in China, Vietnam, and other developing/transitional countries.

Editors’ note: Large-scale implementation of harm reduction programmes to reduce the risk of HIV exposure and transmission among injecting drug users (which include community outreach, needle and syringe access, and substitution treatment) have brought HIV epidemics under control in a number of high-income countries. This cross-border programme aimed to achieve public health scale implementation, considered as 7 to 10 syringes per injecting drug user per month, through direct syringe provision and no-cost vouchers to exchange for sterile injecting equipment and condoms in participating local pharmacies. Although the observed dramatic reduction in HIV incidence may be due in part to behaviour change motivated by the large number of AIDS deaths, increased access to sterile injecting equipment helped translate increased motivation into effective risk reduction. This study demonstrates that when harm reduction programmes are implemented at a scale commensurate to the size of the problem, they can turn around an HIV epidemic among injecting drug users in a developing or transitional country.

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Booth RE, Lehman WE, Kwiatkowski CF, Brewster JT, Sinitsyna L, Dvoryak S. Stimulant Injectors in Ukraine: The Next Wave of the Epidemic? AIDS Behav. 2008 Feb 9 [Epub ahead of print].

This study was designed to assess differences in drug and sex-related risk behaviours between injectors of opiates only, opiate/sedative mix only and stimulants only. Participants were current out-of-treatment injection drug users (IDUs), unaware of their HIV status, recruited through street outreach in Kiev, Odessa and Makeevka/Donetsk, Ukraine. Overall, 22% tested positive for HIV, including 39% among opiate/sedative injectors, 19% among opiate injectors and 17% among stimulant injectors. Despite these differences, stimulant injectors were at higher risk than other IDUs in sharing a used needle/syringe, always injecting with others, injecting a drug solution drawn from a common container, having an IDU sex partner, not using condoms during vaginal or anal sex and on composite measures of injection and sex risks. After controlling for age differences, stimulant injectors remained at higher risk in their needle and sex risk behaviours. Without intervention, it is likely that HIV will increase among stimulant injectors.

Editors’ note: Stimulant injectors in North America generally have higher HIV prevalence, second only to polydrug users, a population excluded from this study. Rather than cocaine, in the Ukraine context the stimulant is pseudo-ephedrine obtained through pharmacies and prepared for injection in a shared mixing container. Although they are younger and have lower HIV prevalence than other drug users, Ukrainian stimulant injectors have the sexual and injecting behaviours to set aflame the next wave of HIV in their country.

Razani N, Mohraz M, Kheirandish P, Malekinejad M, Malekafzali H, Mokri A, McFarland W, Rutherford G. HIV risk behavior among injection drug users in Tehran, Iran. Addiction. 2007 Sep;102(9):1472-82.

Iran faces parallel human immunodeficiency virus (HIV) and injection drug use epidemics; more than 62% of known HIV cases occur among injection drug users (IDU). Razani and colleagues conducted a formative study of IDU in Tehran to explore risk behaviour in the wake of the recent harm reduction efforts. Key informant interviews (n = 40), focus group discussions (nine groups of IDU, n = 66) and a review of existing published and unpublished literature were conducted. Participants included IDU, physicians, policy makers, police, IDU advocates and their families. IDU were diverse in gender, education, income and neighborhood of residence. Interviews were transcribed and analyzed using grounded theory. A typology of IDUs in Tehran, categorized according to self-defined networks as well as HIV risks, is presented. This categorization is based on the groups identified by IDUs, compared to those identified by other key informants, and on a secondary data review. Homeless, female, young IDU and users of a more potent form of heroin were identified as having increased risks for HIV. Participants described shortening transitions from smoked opium to injected opiates. Whereas a majority of participants considered needle sharing less common than previously, sharing continues in locations of group injection, and in states of withdrawal or severe addiction. System-wise barriers to harm reduction were discussed, and include the cost or stigma of purchasing needles from pharmacies, over-burdened clinics, irregular enforcement of laws protecting IDU and lack of efforts to address the sexual risks of IDU. This research is one of the first to describe a diversity of IDU, including women and higher socio-economic class individuals, in Tehran. While efforts in harm reduction in Iran to date have been notable, ongoing risks point to an urgent need for targeted, culturally acceptable interventions.

Editors’ note: Qualitative studies such as these, in a country that has a long-standing history of opiate use, can help paint a contextual picture far beyond the numbers. Such information can provide constructive ideas for programmes that can help reduce the likelihood of transition to injecting and minimise the harm associated with opium use.

McKnight I, Maas B, Wood E, Tyndall MW, Small W, Lai C, Montaner JS, Kerr T. Factors associated with public injecting among users of Vancouver’s supervised injection facility. Am J Drug Alcohol Abuse 2007;33:319-25.

McKnight and colleagues evaluated factors associated with public drug injection among a cohort of injection drug users (SEOSI Scientific Evaluation of Supervised Injecting cohort study) originally recruited from within Vancouver’s supervised injecting facility. The authors used univariate statistics and logistic regression to examine factors associated with public drug injection among SEOSI participants. Between June 2004 and July 2005, 714 IDU were followed up as part of SEOSI. In multivariate analyses, factors associated with public drug injection included homelessness (adjusted odds ratio (aOR) = 3.10; p < .001), syringe lending (aOR = 5.39; p < .001), requiring help injecting (aOR = 1.60; p = .05), and reporting that wait times affected frequency of supervised injecting facility use (aOR = 3.26; p < .001). Persistent public injection was independently associated with elevated HIV risk behaviours, as well as programmatic factors that limit supervised injecting facility use. Supervised injecting facility programme expansion may further help to reduce persistent risk behaviours and the community concerns related to public injection drug use.

Editors’ note: Public injecting carries a much higher risk of HIV exposure because it is generally furtive, rushed, and undertaken under conditions of poor lighting with whatever equipment is available. As well, discarded injecting equipment may pose risks of accidental needle stick injuries to the community. This study determined several variables independently linked to public injecting, including one that is under the control of programme planners – waiting times at the supervised injecting facility.