Risk behaviours for HIV infection among drug users in prison.

OBJECTIVE--To study a group of injecting drug users to establish the degree of illicit drug use in prisons, the prevalence of risk behaviours for HIV infection, and the uptake of treatment for drug dependency with drugs within the prison system. DESIGN--Anonymous, self administered, questionnaire. SETTING--Two drug agencies in central London; one operating a scheme for exchanging needles, and the other offering drug advice and information. SUBJECTS--50 (42 Men, eight women) self selected injecting drug users (mean age 31.2 (range 21-42)), all of whom had been held in custody at some time since 1982. MAIN OUTCOME MEASURES--Details about periods served in custody since 1982; the number of respondents who took drugs (orally or by injection), either illicitly or prescribed, while in prison and the types of substances taken; the respondents'' sexual activity in prison and between periods in custody. RESULTS--The average time spent in custody before the study was 20.6 months (range 1-72). Most prosecutions were directly or indirectly related to drug taking. 47 Of the 50 respondents reported taking at least one illicit drug while in custody; 33 by injection, 26 of whom had shared injecting equipment. 30 Had been treated for drug dependency by the prescribing of drugs while in prison. While in custody, one woman and four men (with a mean of seven (range 2-16) male partners) had had sex. Between periods spent in custody, men reported having a mean of eight (range 0-90) female partners and women a mean of one (range 0-3) male partner. Three men had had sex with other men, with a mean of six (range 2-11) partners. Since their last period in custody, men had had a mean of two (range 0-18) female partners and women had had a mean of two (range 1-3) male partners. Five men had also had male partners. CONCLUSIONS--A high prevalence of injecting and sexual risk behaviours among injecting drug users within and between periods in custody has been shown. Most of these offenders continued to take drugs while in custody, and just over half not only injected drugs but shared equipment. Some of the male prisoners compounded their risk of HIV infection by engaging in sexual activity with multiple partners. Prisoners who then have multiple sexual partners after release place their partners in the community at particular risk of HIV infection. Although many of the drug users were prescribed drugs for their dependency, limited access to appropriate treatment, counselling, and health education may compound the situation.     

Characteristics of clients tested for human immunodeficiency virus infection at the Voluntary Counselling and Testing Center in Zagreb, Croatia

The objective of this study was to present some epidemiological characteristics of persons tested for HIV/AIDS at the Voluntary Counselling and Testing Centre (VCT) Zagreb that was founded in November 2004. The majority of clients tested were between 25 and 29 years old and had a secondary level education. 78% of the clients tested reported one risky behaviour in the past, the majority of which was attributed to risky heterosexual behaviour (having unprotected sexual intercourse). 35% of the clients reported having never or only occasionally used condom with a non-regular partner. 30% of the clients with a history of injecting drug use reported that they never "shared" injecting equipment. The results presented in this paper could be a useful tool for public health officers when targeting interventions for HIV prevention.     

Drug injection and HIV prevalence in inmates of Glenochil prison.

OBJECTIVE--To determine prevalence of HIV infection and drug injecting behaviour among inmates of Glenochil Prison on a specified date a year after an outbreak of hepatitis B and HIV infection. DESIGN--Cross sectional: voluntary, anonymous HIV salivary antibody surveillance and linked self completion questionnaire on risk factors. SETTING--Glenochil prison, Scotland, a year after an outbreak of hepatitis B and HIV transmission related to drug injection. SUBJECTS--352 prisoners, of whom 295 (84%) took part; 284 questionnaires (96%) passed logical checks. MAIN OUTCOME MEASURES--HIV prevalence; proportion of all inmates who had ever injected drugs, had ever injected inside prison, had started injecting drugs while inside prison. RESULTS--More than half (150/284) the current inmates were also in Glenochil Prison during the critical period of January to June 1993, when hepatitis B and HIV were transmitted. Similar proportions of current inmates and men who were also in Glenochil during the critical period were drug users (27% (75/278) v 30% (44/149)). A quarter of injecting drug users (18/72) had first injected inside prison, irrespective of whether they were in Glenochil in January to June 1993 and regardless of the calendar period when they first injected. Significantly more inmates from Glasgow (41%; 56/138) than from Edinburgh (21%; 7/34) or elsewhere (11%; 12/106) were injecting drug users. On testing for HIV, seven saliva samples out of 293 gave positive results--four were presumed to be from inmates known to be infected with HIV, and the others from injecting drug users from Glasgow, all of whom had been in Glenochil during January to June 1993, when two of the three had injected drugs and had been tested for HIV, with negative results. The ratio of overall (2.4%) to disclosed (1.4%) HIV prevalence was 1.7. For men who had injected drugs in Glenochil during January to June 1993, HIV prevalence was estimated at 29%. CONCLUSION--Between a quarter and a third of prisoners who injected drugs in Glenochil in January to June 1993 were infected with HIV. There is widespread ongoing risk of bloodborne virus infection within prisons, which is probably long standing but demands urgent attention.     

Characteristics of hepatitis C infection in injecting drug users in Zadar County, Croatia

The aim of the study was to determine additional risk factors that could increase the prevalence of hepatitis C (HCV) infection among injecting drug users (IDU). The study included 327 heroin addicts registered in Zadar County, Croatia. The participants were divided into two groups according to their HCV status. HCV-positive and HCV-negative study participants were compared. HCV-positive group started injecting heroin at earlier age (median 18.5 years) than HCV-negative group (median 20.0 years) (p = 0.032) and had been injecting heroin for a significantly longer period (median 5 years vs. median 4 years, respectively; p < 0.001). IDUs in HCV-positive group shared their injecting equipment significantly more often than IDUs in HCV-negative group (p < 0.001; chi2 = 32.7). The main reasons for starting drugs were curiosity, psychological reasons (depression and/or neurosis), and peer or partner pressure in HCV-positive group, and fun, curiosity, and peer pressure in HCV-negative group (p = 0.051; chi2 = 23.6). Earlier onset of heroin use, longer heroin use, sharing injection equipment, curiosity, and psychological problems as reasons for starting drugs were associated with higher prevalence of HCV infection among injecting heroin users in Zadar County.     

Prostitution and risk of HIV: female prostitutes in London.

OBJECTIVE--To measure the prevalence of HIV and to describe established risk factors in female prostitutes. DESIGN--A cross sectional survey. SETTING--A genitourinary medicine clinic, streets, and magistrates'' courts in London. SUBJECTS--280 female prostitutes recruited between April 1989 and August 1991. MAIN OUTCOME MEASURES--Infection with HIV-1, reported risk behaviours, and prevalence of sexually transmitted infections. RESULTS--228 of the women had HIV tests, and two (0.9% (95% confidence interval 0% to 2.1%)) were infected with HIV-1. Reported use of condoms was high for commercial clients and low for non-paying partners: 98% (251/255) of women used condoms with all clients and 12% (25/207) with non-paying partners for vaginal intercourse. Twenty two women were current or past injecting drug users. Of the 193 women examined for sexually transmitted infections, 27 had an acute infection (gonorrhoea, chlamydia, trichomonas, or primary genital herpes) at the time of interview. Infection was associated with younger age and increasing numbers of non-paying sexual partners, but not with duration of prostitution, numbers of clients, or reports of condom failures. When age and numbers of non-paying partners were analysed by logistic regression they remained significantly associated with sexually transmitted infections. CONCLUSIONS--A large and diverse sample of prostitutes had a low prevalence of infection with HIV and high levels of use of condoms in commercial sex. There was a significant risk of other sexually transmitted infections associated with prostitutes'' non-commercial sexual relationships, in which unprotected sex is common. Interventions to reduce the risk of sexually transmitted infections in prostitutes should address both commercial and non-commercial sexual partnerships.     

Infection with HIV and hepatitis C virus among injecting drug users in a prevention setting: retrospective cohort study

Objectives: To estimate the incidence of HIV and hepatitis C virus and risk factors for seroconversion among a cohort of injecting drug users. Design: Retrospective cohort study. Setting: Primary healthcare facility in central Sydney. Subjects: Injecting drug users tested for HIV-1 antibody (n=1179) and antibodies to hepatitis C virus (n=1078) from February 1992 to October 1995. Main outcome measures: Incidence of HIV-1 and hepatitis C virus among seronegative subjects who injected drugs and underwent repeat testing. Demographic and behavioural risk factors for hepatitis seroconversion. Results: Incidence of HIV-1 among 426 initially seronegative injecting drug users was 0.17/100 person years (two seroconversions) compared with an incidence of hepatitis C virus of 20.9/100 person years (31 seroconversions) among 152 injecting drug users initially negative for hepatitis C virus. Incidence of hepatitis C virus among injecting drug users aged less than 20 years was 75.6/100 person years. Independent risk factors for hepatitis C virus seroconversion were age less than 20 years and a history of imprisonment. Conclusions: In a setting where prevention measures have contributed to the maintenance of low prevalence and incidence of HIV-1, transmission of hepatitis C virus continues at extremely high levels, particularly among young injecting drug users.

Key messages

• The prevalence and incidence of hepatitis C virus is high, while the prevalence and incidence of HIV remains low among injecting drug users
• Young age and history of imprisonment are risk factors for acquisition of hepatitis C virus infection
• HIV prevention strategies have been relatively ineffective in preventing hepatitis C virus infection in this population
• The role of imprisonment in the acquisition of hepatitis C infection should be further investigated

     

Creating a new drug service in Edinburgh.

After one year Edinburgh''s Community Drug Problem Service has shown that if psychiatric services offer consultation and regular support for drug users many general practitioners will share the care of such patients and prescribe for them, under contract conditions, whether the key worker is a community psychiatric nurse or a drug worker from a voluntary agency. This seems to apply whether the prescribing is part of a "harm reduction" strategy over a long period or whether it is a short period of methadone substitution treatment. Given the 50% prevalence of HIV infection among drug users in the Edinburgh area and the fact that only half of them have been tested for seropositivity, the health and care of this demanding group of young people with a chaotic lifestyle are better shared among primary care, community based drug workers, and specialist community drugs team than treated exclusively by a centralised hospital drug dependency unit. As the progression to AIDS is predictable in a larger proportion of drug users who are positive for HIV, there is an even greater need for coordinated care between specialists and community agencies in the near future.     

Epidemic human immunodeficiency virus (HIV) infection among intravenous drug users (IVDU)

Human immunodeficiency virus (HIV) infection is epidemic among intravenous drug users (IVDU), particularly in the northeastern United States. IVDU are playing a critical role in the spread of HIV by infecting their heterosexual partners and children, as well as their needle-sharing partners. The epidemiology of HIV infection among IVDU is reviewed here, including a compilation of seroprevalence data. Relevant determinants of the future spread of HIV among IVDU are discussed, including the major risk factors for HIV seropositivity, the modes of HIV transmission, and aspects of the natural history of HIV infection in IVDU. The public health policy implications of these issues include the need for education of adolescents and the general public about the risks of drug injection and heterosexual intercourse with IVDU, as well as motivation of IVDU to stop injecting, never share injection paraphernalia, or, at least, clean needles effectively.     

Effects of drug relief hospital-based AIDS educational methods on drug users

The objective of this study is to explore a potentially effective training method for the hospital professionals to educate drug users and to enhance their knowledge of HIV infection. One hundred and sixty one subjects, who came from 13 different provinces and were admitted in a drug relief hospital in Beijing, were recruited for this study. The average age of these subjects was 35.21 +/- 6.24 year old. The average numbers of years for drug addiction were 7 years, and the average numbers of drug relief treatment received in the past was 5.5 times. The level of AIDS knowledge of these subjects, including pathogenic factors, source of infection, route of transmission and preventive measures, were evaluated before and after receiving the AIDS educational training to these drug users. Our results showed that there was a statistically significant increase (P<0.01) in the knowledge of HIV infection and prevention among these subjects. Positive attitude and behavioral tendencies toward HIV prevention were also improved. Therefore, it is imperative for the medical professionals to incorporate AIDS education into drug relief treatment to achieve the maximum effect on the knowledge of AIDS and improvement of positive attitudes and behaviors toward HIV prevention among drug users.     

Prevalence of HIV antibody in high and low risk groups in England. Public Health Laboratory Service Working Group.

Most studies of the spread of HIV infection have centred on homosexuals and intravenous drug users. To estimate the extent of infection in different groups, including heterosexuals, the prevalence of HIV antibody was studied in 34,222 subjects tested with consent between October 1986 and December 1987 in England. These included subjects in high risk groups for HIV infection, heterosexuals with partners in the high risk groups and heterosexuals with multiple partners or with no identifiable risk factors. The prevalence was highest in homosexual or bisexual men in London (15.1%; 213/1412), being 4.0% (146/3607) outside London. The yearly incidence of infection in 632 homosexual or bisexual men without HIV antibody when retested during the study period was 3%. Among intravenous drug users the prevalence of HIV antibody was 5.7% (36/633) in London and 1.5% (39/2562) outside. Of 3272 heterosexual subjects tested, whose partner was in a risk group, eight of 515 (1.6%) in London and six of 2757 (0.2%) outside were positive for the antibody. Among 20,455 heterosexuals with a history of multiple partners or with no declared risk, only six subjects with HIV antibody were identified, two of whom had been infected abroad. Heterosexual spread of infection in England is evidently still largely confined to subjects whose partner has an identifiable risk.     

Risk for AIDS in multiethnic neighborhoods in San Francisco,California. The population-based AMEN Study.

To examine the actual and potential spread of human immunodeficiency virus (HIV) from an acquired immunodeficiency syndrome (AIDS) epicenter to surrounding neighborhoods, we studied the prevalence of the viral infection and AIDS risk behaviors from 1988 to 1989 in a representative sample of unmarried whites, African Americans, and Hispanics living in San Francisco. We surveyed 1,770 single men and women aged 20 to 44 years (a 64% response rate) in a random household sample drawn from 3 neighborhoods of varying geographic and cultural proximity to the Castro District where the San Francisco epidemic began. Of 1,369 with blood tests, 69 (5%) had HIV antibodies; all but 5 of these reported either homosexual activity (32% HIV-positive; 95% confidence interval [CI] = 23%, 41%), injection drug use (5% HIV-positive; CI = 1%, 14%), or both (59% HIV-positive; CI 42%, 74%). Homosexual activity was more common among white men than among African-American or Hispanic men, but the proportion of those infected was similar in the 3 races. Both the prevalence of homosexually active men and the proportion infected were much lower in the 2 more outlying neighborhoods. Risk behaviors in the past year for acquiring HIV heterosexually--sex with an HIV-infected person or homosexually active man or injection drug user, unprotected sexual intercourse with more than 4 partners, and (as a proxy) having a sexually transmitted disease--were assessed in 1,573 neighborhood residents who were themselves neither homosexually active men nor injection drug users. The prevalence of reporting at least 1 of these risk behaviors was 12% overall, and race-gender estimates ranged from 5% among Hispanic women to 21% among white women. We conclude that in San Francisco, infection with HIV is rare among people who are neither homosexually active nor injection drug users, but the potential for the use spread of infection is substantial, as 12% of this group reported important risk behaviors for acquiring the virus heterosexually.     

Strategic problems in counteracting the spread of HIV infection in the Altai Territory

The Altai Territory belongs at present to regions with the insignificant level of the spread of HIV infection. By December 1, 1999, the Altai Territory had 31 registered cases of HIV infection, which constituted 1.33 per 10,000 of the population (the corresponding figure for the whole of Russia being 14.92). But the situation with HIV/AIDS showed the general tendency to the development of the epidemic of HIV infection due to steady growth and the wide involvement of injecting drug users in the epidemic process. Before 1999 all cases of HIV infection registered in the Altai Territory were imported. Out of 31 HIV infected persons detected in the territory, 18 were injecting drug users. In 1999 local foci of HIV infection were formed among drug users in two big cities of the Altai Territory, which was indicative of the gradual transition of HIV infection from the phase of the registration of individual cases to the phase of the formation of local foci among some groups of the population.     

Building a city wide service for exchanging needles and syringes.

How best can injecting drug misusers obtain clean injecting equipment in a city where drug injecting is widespread? An exchange service for needles and syringes throughout Glasgow has been established in health centres and clinics in the evening. Over the past four years seven new exchanges have been opened and over 2700 injecting drug misusers have attended. Attendances rose from under 1000 in 1988 to 28,000 in 1992. The exchanges also provide a wide range of other health and social services. Public hostility to the exchanges has abated. During the same period equipment sharing in the city diminished and the observed prevalence of HIV among injecting drug misusers stabilised at around 1%.     

The results of sentinel epidemiological surveillance on the level of HIV prevalence among injection narcotic abusers in the city of Poltava

The sentinel epidemiological surveillance on the level of spread of HIV infection among injecting drug users in Poltava, taking part in the program of harm reduction, was carried out. The results of the surveillance revealed that the level of HIV infection among drug users was 37.8%, the level of HIV infection among females being higher than that among males. These data indicate that the level of HIV infection rises with the increase of age and the time of drug consumption. Still in the age group of 30 years and older and among drug addicts using drugs for 7 years and longer the lowest level of HIV infection was noted.     

Prevalence of human immunodeficiency virus infection in alcoholics

To verify the prevalence of infection by human immunodeficiency virus (HIV) in alcoholics we studied 131 alcoholic patients (119 males and 12 females) with a mean age of 44.3 +/- 10.8 years. Serum samples were collected from this group and analysed, by ELISA, for antibodies against HIV as well as for serological markers for hepatitis B virus (HBV) and hepatitis C virus (HCV). As we have previously described, we found a high prevalence of HBV (26.4%) and HCV (4.2%) markers as compared to the prevalence of these markers in samples of normal blood donors from Uberlandia's Hemocentro Regional, which are 4% and 0.4%, respectively. Of the 131 patients, four (3%) had antibodies against HIV, three (75%) of which were injecting drug users (IDU). In the HIV-negative group, only one patient was an IDU. The prevalence of HIV in our population, according to data from the city's Health Secretary, varies from 3.1% to 6.2%. We conclude that, at least for the moment, alcoholism per se, did not constitute an important risk factor for HIV infection. However, acquired immunodeficiency syndrome is a rather recent disease as compared to hepatitis B and C and, as the transmission routes are similar for HIV and hepatitis viruses, an increase in the incidence of HIV infection in alcoholics may be just a question of time.     

After the epidemic: follow up study of HIV seroprevalence and changing patterns of drug use.

OBJECTIVE--To follow up known intravenous drug users to determine current health state and drug use, compare characteristics with those of recent drug users, and examine HIV exposure and serostate. DESIGN--Subjects were identified from conventional general practice records and recruited from 1980 to the end of 1985; they were followed up during 1987 and 1988 and compared with drug users identified in the same way but recruited after 1985. SETTING--General practice and community in north west Edinburgh. Follow up conducted throughout the United Kingdom. SUBJECTS--Subjects known to have injected illegal drugs before 1986 (n = 203) and since that time. MAIN OUTCOME MEASURES--Mortality from and prevalence of HIV seropositivity and various parameters indicative of abstinence. RESULTS--Of the 203 subjects in the follow up group, 189 (93%) were traced; 16 (8%) had died and the remaining 173 (85%) were interviewed. In all, 146 (72% of the follow up cohort) had been tested for HIV antibodies, 94 (64%) having positive and 52 (36%) negative results; 57 (28%) had not been tested. Of the 65 subjects in the recently recruited group, 51 (79%) had been tested for HIV, 15 (29%) having positive results. A further 21 (43%) were currently negative for HIV antibody but still at risk. Thirty three (19%) of those followed up were confirmed abstinent, although more (about half) showed evidence of diminished drug injecting. Age correlated strongly with abstinence (p less than 0.001). One third of the group currently used cannabis, buprenorphine, dihydrocodeine, or diazepam. When the two groups were analysed together there was a strong association between the date of starting injecting and HIV seropositivity (chi 3 = 23.81, df = 2, p less than 0.001), with a peak around 1980-3. CONCLUSIONS--Although only a fifth of the followed up group were convincingly abstinent, a much larger group showed evidence of prolonged periods of remission. Overall, much use of oral drugs was confirmed and worrying trends towards taking buprenorphine and benzodiazepines were evident. The peak incidence of starting drug use and the comparatively low seroprevalence of HIV in the newer drug users probably explain the anomalous high seroprevalence in Edinburgh drug users during 1980-5. The epidemic of HIV during the first half of the 1980s in the group suggests that the virus was probably being transmitted because of a pattern of behaviour. Changing patterns of HIV transmission suggest a need to concentrate on heterosexual transmission as the main problem in the future.     

Risk factors for human T cell lymphotropic virus type I among injecting drug users in northeast Brazil: possibly greater efficiency of male to female transmission

It was observed in the city of Salvador, State of Bahia, the highest seroprevalence of human T cell lymphotropic virus type 1 (HTLV-I) infection in Brazil as demonstrated by national wide blood bank surveys. In this paper, we report results of an investigation of drug use and sexual behavior associated with HTLV-I infection among male and female injecting drug users (IDUs) in Salvador. A cross sectional study was conducted in the Historical District of Salvador from 1994-1996 (Projeto Brasil-Salvador) and 216 asymptomatic IDUs were selected using the snowball contact technique. Blood samples were collected for serological assays. Sera were screened for human immunodeficiency virus (HIV-1/2) and HTLV-I/II antibodies by ELISA and confirmed by Western blot. The overall prevalence of HTLV-I/II was 35.2% (76/216). The seroprevalence of HTLV-I, HTLV-II and HIV-I was for males 22%, 11.3% and 44.1% and for females 46.2%, 10.3% and 74.4% respectively. HTLV-I was identified in 72.4% of HTLV positive IDUs. Variables which were significantly associated with HTLV-I infection among males included needle sharing practices, duration of injecting drug use, HIV-I seropositivity and syphilis. Among women, duration of injecting drug use and syphilis were strongly associated with HTLV-I infection. Multivariate analysis did not change the direction of these associations. Sexual intercourse might play a more important role in HTLV-I infection among women than in men.     

Risk of hepatitis B infection among young injection drug users in San Francisco: opportunities for intervention

Objective To compare the demographic characteristics and risk behaviors for hepatitis B infection among injection drug users younger than 30 years with those aged 30 or older and to evaluate participants'' knowledge, attitudes, and experiences of infection, screening, and vaccination against hepatitis B virus. Design A systematic sample of injection drug users not currently in a treatment program were recruited and interviewed at needle exchange programs and community sites. Participants 135 injection drug users younger than 30 years and 96 injection drug users aged 30 or older. Results Injection drug users younger than 30 were twice as likely as drug users aged 30 or older to report having shared needles in the past 30 days (36/135 [27%] vs 12/96 [13%]). Injection drug users younger than 30 were also twice as likely to report having had more than two sexual partners in the past 6 months (80/135 [59%] vs 29/96 [30%]). Although 88 of 135 (68%) young injection drug users reported having had contact with medical providers within the past 6 months only 13 of 135 (10%) had completed the hepatitis B vaccine series and only 16 of (13%) perceived themselves as being at high risk of becoming infected with the virus. Conclusion Few young injection drug users have been immunized even though they have more frequent contact with medical providers and are at a higher risk for new hepatitis B infection than older drug users. Clinicians caring for young injection drug users and others at high risk of infection should provide education, screening, and vaccination to reduce an important source of hepatitis B infection.     

Club Drugs and HIV/STD Infection: An Exploratory Analysis among Men Who Have Sex with Men in Changsha,China

ObjectiveTo evaluate current club drug use and its potential association with the transmission of HIV/STD among Changsha men who have sex with men (MSM).MethodA cross-sectional survey was conducted by using self-administered questionnaires including information regarding socio-demographics, club drug use, high-risk behaviors, and HIV/STD infections. Multiple methods including venue-based, peer referral using “snowball” techniques, and internet advertisements were used to recruit study participants.ResultsOf the 826 participants, 177 (21.4%) reported that they had used club drugs at some time before or during sex in the past six months. MSM with young age, low education level, and seeking partners through the internet or bars were the main population who used drugs. Poppers were the most common drug used among Changsha MSM. The prevalence of HIV, syphilis, and herpes simplex virus-2 were higher among drug users. There were no significant differences in unprotected sexual intercourse and condom use between drug users and non-users. Compared with non-users, risk behaviors such as group sex, multiple sex partners, and sex with foreigners were more frequent among drug users.ConclusionClub drug use is common among Changsha MSM, and is related to unsafe sex activities and HIV/STD infection. It is necessary to build novel targeted HIV prevention strategies to monitor and reduce club drug use among MSM.