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EMCDDA DOCUMENTATION CENTRE INFORMATION BULLETIN

INFECTIOUS DISEASES

1 April 2016 ______

JOURNAL ARTICLES – Hepatitis

Hepatitis C virus treatment as prevention in people who inject drugs: testing the evidence Hickman, M; De Angelis, D; Vickerman, P; Hutchinson, S; Martin, N Current Opinion in Infectious Diseases 28 (6) p.576-582, 2015

Purpose of Review: The majority of hepatitis C virus (HCV) infections in the United Kingdom and many developing countries were acquired through injecting. New clinical guidance suggests that HCV treatment should be offered to people with a transmission risk - such as people who inject drugs (PWID) - irrespective of severity of liver disease. We consider the strength of the evidence base and potential problems in evaluating HCV treatment as prevention among PWID. Recent Findings: There is good theoretical evidence from dynamic models that HCV treatment for PWID could reduce HCV chronic prevalence and incidence among PWID. Economic evaluations from high-income settings have suggested HCV treatment for PWID is cost-effective, and that in many settings HCV treatment of PWID could be more cost- effective than treating those at an equivalent stage with no ongoing transmission risk. Epidemiological studies of older interferon treatments have suggested that PWID can achieve similar treatment outcomes to other patient groups treated for chronic HCV. Impact and cost-effectiveness of HCV treatment is driven by the potential 'prevention benefit' of treating PWID. Model projections suggest that more future infections, end stage liver disease, and HCV-related deaths will be averted than lost through reinfection of PWID treated successfully for HCV. However, there is to date no empirical evidence from trials or observational studies that test the model projections and 'prevention benefit' hypothesis. In part this is because of uncertainty in the evidence base but also there is unlikely to have been a change in HCV prevalence due to HCV treatment because PWID HCV treatment rates historically in most sites have been low, and any scale-up and switch to the new direct acting antiviral has not yet occurred. There are a number of key uncertainties in the data available on PWID that need to be improved and addressed to evaluate treatment as prevention. These include estimates of the prevalence of PWID, measurements of HCV chronic prevalence and incidence among PWID, and how to interpret reinfection rates as potential outcome measures. Summary: Eliminating HCV through scaling up treatment is a theoretical possibility. But empirical data are required to demonstrate that HCV treatment can reduce HCV transmission, which will require an improved evidence base and analytic framework for measuring PWID and HCV prevalence. [FULL TEXT AVAILABLE]

Defining populations and injecting parameters among people who inject drugs: Implications for the assessment of hepatitis C treatment programs Larney, S; Grabely, J; Hickman, M; De Angelis, D; Dore, G J; Degenhardt, L International Journal of Drug Policy 25, p.950-957, 2015

There is considerable interest in determining the impact that increased uptake of treatment for hepatitis C virus (HCV) infection will have on the burden of HCV among people who inject drugs (PWID). An understanding of the size of the population of PWID, rates of injecting cessation and HCV prevalence and incidence within the PWID population is essential for such exercises. However, these parameters are often uncertain. In this paper we review methods for estimating the size of the population of PWID and related parameters, taking into account the uncertainty that exists around data on the natural history of injecting drug use; consider issues in the estimation of HCV prevalence among PWID; and consider the importance of opioid substitution therapy and prisons as settings for the prevention and treatment of HCV infection among PWID. These latter two points are illustrated through examples of ongoing work in England, Scotland and Australia. We conclude that an improved understanding of the size of PWID populations, including current and former PWID and parameters related to injecting drug use and settings where PWID may be reached, is necessary to inform HCV prevention and treatment strategies.

JOURNAL ARTICLES – HIV/AIDS

Risk environments, race/ethnicity, and HIV status in a large sample of people who inject drugs in the United States Cooper, H L, Linton, S, Kelley, M E, Ross, Z, Wolfe, M E, Chen, Y T, Zlotorzynska, M, Hunter-Jones, J, Friedman, S R, Des Jarlais, D C, Tempalski, B, DiNenno, E, Broz, D, Wejnert, C, Paz-Bailey, G PLoS ONE 11, 3, e0150410, 2016

Introduction: We analyzed relationships between place characteristics and being HIV-negative among black, Latino, and white people who inject drugs (PWID) in the US. Methods: Data on PWID (N = 9077) were from the Centers for Disease Control and Prevention's 2009 National HIV Behavioral Surveillance. Administrative data were analyzed to describe the 968 ZIP codes, 51 counties, and 19 metropolitan statistical areas (MSAs) where they lived. Multilevel multivariable models examined relationships between place characteristics and HIV status. Exploratory population attributable risk percents (e-PAR%s) were estimated. Results: Black and Latino PWID were more likely to be HIV-negative if they lived in less economically disadvantaged counties, or in MSAs with less criminal-justice activity (i.e., lower drug-related arrest rates, lower policing/corrections expenditures). Latino PWID were more likely to be HIV-negative in MSAs with more Latino isolation, less black isolation, and less violent crime. E-PAR%s attributed 8-19% of HIV cases among black PWID and 1-15% of cases among Latino PWID to place characteristics. Discussion: Evaluations of structural interventions to improve economic conditions and reduce drug-related criminal justice activity may show evidence that they protect black and Latino PWID from HIV infection. [FULL TEXT AVAILABLE]

Krokodile injectors in Ukraine: fuelling the HIV epidemic? Booth, R E; Davis, J M; Brewster, J T; Lisovska, O; Dvoryak, S AIDS and Behavior 20, 2, p.369-373, 2016

This study was designed to assess the characteristics of krokodile injectors, a recent phenomenon in Ukraine, and HIV-related risk factors among people who inject drugs (PWID). In three Ukraine cities, Odessa, Donetsk and Nikolayev, 550 PWID were recruited between December 2012 and October 2013 using modified targeted sampling methods. The sample averaged 31 爕 ears of age and they had been injecting for over 12 爕 ears. Overall, 39 % tested positive for HIV, including 45 % of krokodile injectors. In the past 30 燿 ays, 25 % reported injecting krokodile. Those who injected krokodile injected more frequently (p < 0.001) and they injected more often with others (p = 0.005). Despite knowing their HIV status to be positive, krokodile users did not reduce their injection frequency, indeed, they injected as much as 85 % (p = 0.016) more frequently than those who did not know their HIV status or thought they were negative. This behavior was not seen in non-krokodile using PWID. Although only a small sample of knowledgeable HIV positive krokodile users was available (N = 12), this suggests that krokodile users may disregard their HIV status more so than nonkrokodile users. In spite of widespread knowledge of its harmful physical consequences, a growing number of PWID are turning to injecting krokodile in Ukraine. Given the recency of krokodile use the country, the associated higher frequency of injecting, a propensity to inject more often with others, and what could be a unique level of disregard of HIV among krokodile users, HIV incidence could increase in future years.

A comparison of men who have sex with men, people who inject drugs and high- risk heterosexuals' risk for HIV infection, San Francisco Raymond, H F; Ick, T O, Chen, Y H AIDS and Behavior 20, 2, p.417-422, 2016

HIV in the United States is concentrated in populations such as men who have sex with men (MSM), people who inject drugs (PWID), women of color and people living in poverty. These populations are labeled high-risk for HIV infection because of the higher levels of HIV or HIV risk taking behaviors seen in these groups compared to other sub-populations. It is also possible that a group may engage in behaviors that are "high-risk" for HIV infection but never become infected since HIV is not present or not present to a great extent in their social or sexual networks. We analyzed samples of MSM, PWID and high-risk heterosexuals (HRH) collected through the National HIV Behavioral Surveillance (NHBS) system in San Francisco to examine HIV risk taking and HIV burden to determine if the label "high-risk" is appropriately applied. NHBS samples MSM using time location sampling and PWID and HRH using Respondent Driven Sampling. We sampled 508 MSM in 2011, 570 PWID in 2012 and 267 HRH in 2013. There were, as expected, differences in demographic characteristics across the three groups. HRH had a greater number of high-risk behaviors compared to MSM and PWID but had the lowest HIV prevalence. Focusing on risk behavior alone to label populations without considering the background HIV prevalence in communities, the types of risks engaged in and actual HIV infections may obscure which populations truly merit the label "high-risk" for HIV infection.

Providing ART to HIV seropositive persons who use drugs: progress in New York City, prospects for "ending the epidemic" Jarlais, D C; Arasteh, K; McKnight, C; Feelemeyer, J; Hagan, H; Cooper, H L; Campbell, A N; Tross, S; Perlman, D C AIDS and Behavior 20, 2, p.353-362, 2016

New York City has experienced the largest HIV epidemic among persons who use psychoactive drugs. We examined progress in placing HIV seropositive persons who inject drugs (PWID) and HIV seropositive non-injecting drug users (NIDU) onto antiretroviral treatment (ART) in New York City over the last 15 爕 ears. We recruited 3511 PWID and 3543 NIDU from persons voluntarily entering drug detoxification and methadone maintenance treatment programs in New York City from 2001 to 2014. HIV prevalence declined significantly among both PWID and NIDU. The percentage who reported receiving ART increased significantly, from approximately 50 % (2001-2005) to approximately 75 % (2012-2014). There were no racial/ethnic disparities in the percentages of HIV seropositive persons who were on ART. Continued improvement in ART uptake and TasP and maintenance of other prevention and care services should lead to an "End of the AIDS Epidemic" for persons who use heroin and cocaine in New York City.

High prevalence of assisted injection among street-involved youth in a Canadian setting Cheng T, Kerr T, Small W, Dong H, Montaner J, Wood E, DeBeck K AIDS and Behavior 20 (2) p.377-384, 2016

Many people who inject illicit drugs receive manual assistance when injecting, and this practice has been linked to increased risk of HIV infection and other harms. Little is known, however, about this practice among youth. This study uses a multivariate generalized estimating equation to identify factors associated with receiving assistance with injecting among a cohort of street-involved youth aged 14-26 in Vancouver, Canada. A total of 253 participants reported injecting drugs during the study period, and 49 % (n = 125) of these youth reported receiving assistance with injecting in the past 6 months. In multivariate analysis, younger age, female gender, binge drug use, heroin injecting, cocaine injecting, crystal methamphetamine injecting, and syringe sharing were positively and independently associated with assisted injection (all p < 0.05). These findings underscore the need for expanding substance abuse treatment alongside HIV prevention and health promotion interventions to empower youth to enact safer injection practices.

Impact of length of injecting career on HIV incidence among people who inject drugs Montain, J; Ti, L; Hayashi, K; Nguyen, P; Wood, E; Kerr, T Addictive Behaviors 58, p.90-94, 2016

We examined the relationship between duration of injecting career and HIV seroconversion among people who inject drugs (PWID) in Vancouver, Canada. Data were derived from HIV-negative PWID enrolled in a prospective cohort study. We employed Kaplan-Meier methods and Cox regression to investigate the effect of length of time since injection drug use initiation on time to HIV seroconversion. In multivariable Cox analysis, duration of injecting career was negatively associated with time to HIV seroconversion (adjusted hazard ratio=0.82; 95% confidence interval [CI]: 0.69-0.97). Our findings highlight the need for interventions that target individuals who participate in high-risk drug use behaviors.

Psychosocial factors in adherence to antiretroviral therapy among HIV-positive people who use drugs Lee, W K; Milloy, M J; Walsh, J; Nguyen, P; Wood, E; Kerr, T Health Psychology 35, 3, p.290-297, 2016

Objective: Suboptimal adherence to antiretroviral therapy (ART) among HIV-infected people who use illicit drugs (PWUD) remains a significant concern, and there is a lack of effective adherence interventions for this population. Therefore, we sought to identify psychosocial determinants of optimal adherence, including adherence self-efficacy and outcome expectancies, with the aim of informing interventions designed to improve adherence among PWUD. Method: From December 2005 to November 2013, we collected data from the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS), a prospective cohort of PWUD in Vancouver, Canada. We used multivariable generalized estimating equations (GEE) analysis to identify longitudinal factors independently associated with 95% or greater adherence to ART. Results: Among 667 participants, including 220 (33%) women, 391 (59%) had 95% or greater ART adherence at baseline. In multivariable GEE analysis, adherence self-efficacy, adjusted odds ratio (AOR) = 1.16, 95% confidence interval (CI) [1.11, 1.21] per 10- point increase, was independently and positively associated with adherence, while negative outcome expectancy, AOR = 0.95, 95% CI [0.93, 0.98], was negatively associated. Conclusion: In light of the ongoing challenges associated with ART adherence among HIV-positive PWUD, and our findings of associations between adherence, self-efficacy, and outcomes expectancies, tailored intervention strategies based on constructs of social learning theory should be implemented and evaluated to improve adherence among HIV-infected PWUD.

Benzodiazepine use as an independent risk factor for HIV infection in a Canadian setting Ickowicz, S; Hayahsi, K; Dong, H; Milloy, M J; Kerr, T; Montaner, J S; Wood, E Drug and Alcohol Dependence 155, p.190-194, 2015

Background: Although the harms of prescription drug diversion are of growing international concern, the potential impact of prescription drug use on HIV infection has not been well assessed. We evaluated whether benzodiazepine use was associated with HIV seroconversion among a cohort of persons who inject drugs (PWID) in a Canadian setting. Methods: Between May, 1996 and November, 2013, data were derived through a prospective cohort study of PWID in Vancouver, Canada. A total of 1682 baseline HIV negative participants were followed for a median of 79.5 months (interquartile range: 32.1- 119.1), among whom 501 (29.8%) reported benzodiazepine use at baseline, and 176 seroconverted during follow-up, equal to an incidence density of 1.5 (95% Confidence Interval [CI]: 1.3-1.7) cases per 100 person-years. Poisson regression with time- dependent variables was used to assess whether benzodiazepine use was associated with the time to HIV seroconversion. Results: After adjustment for potential confounders, benzodiazepine use (Adjusted Rate Ratio: 1.50; 95% CI: 1.01-2.24) was independently associated with a higher rate of HIV seroconversion. Conclusions: Benzodiazepine use was an independent risk factor for HIV seroconversion among PWID in this setting. Greater recognition of the safety concerns related to benzodiazepine medications including diversion are needed.

JOURNAL ARTICLES – Other Conditions / Issues

Technical Note: Simple, scalable, and sensitive protocol for retrieving Bacillus anthracis (and other live bacteria) from heroin Grass, G; Ahrens, B; Schleenbecker, U; Dobrzykowski, L; Wagner, M; Kr 黦 er, C; W 鰈 fel, R Forensic Science International 259, p.32-35, 2016 We describe a culture-based method suitable for isolating Bacillus anthracis and other live bacteria from heroin. This protocol was developed as a consequence of the bioforensic need to retrieve bacteria from batches of the drug associated with cases of injectional anthrax among heroin-consumers in Europe. This uncommon manifestation of infection with the notorious pathogen B. anthracis has resulted in 26 deaths between the years 2000 to 2013. Thus far, no life disease agent has been isolated from heroin during forensic investigations surrounding these incidences. Because of the conjectured very small number of disease-causing endospores in the contaminated drug it is likely that too few target sequences are available for molecular genetic analysis. Therefore, a direct culture-based approach was chosen here. Endospores of attenuated B. anthracis artificially spiked into heroin were successfully retrieved at 84- 98% recovery rates using a wash solution consisting of 0.5% Tween 20 in water. Using this approach, 82 samples of un-cut heroin originating from the German Federal Criminal Police Office's heroin analysis program seized during the period between 2000 and 2014 were tested and found to be surprisingly poor in retrievable bacteria. Notably, while no B. anthracis was isolated from the drug batches, other bacteria were successfully cultured. The resulting methodical protocol is therefore suitable for analyzing un-cut heroin which can be anticipated to comprise the original microbiota from the drug's original source without interference from contaminations introduced by cutting.

Racialized risk environments in a large sample of people who inject drugs in the United States Cooper, H L; Linton, S; Kelley, M E International Journal of Drug Policy 27, p.43-55, 2016

Background: Substantial racial/ethnic disparities exist in HIV infection among people who inject drugs (PWID) in many countries. To strengthen efforts to understand the causes of disparities in HIV-related outcomes and eliminate them, we expand the "Risk Environment Model" to encompass the construct "racialized risk environments," and investigate whether PWID risk environments in the United States are racialized. Specifically, we investigate whether black and Latino PWID are more likely than white PWID to live in places that create vulnerability to adverse HIV-related outcomes. Methods: As part of the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance, 9170 PWID were sampled from 19 metropolitan statistical areas (MSAs) in 2009. Self-reported data were used to ascertain PWID race/ethnicity. Using Census data and other administrative sources, we characterized features of PWID risk environments at four geographic scales (i.e., ZIP codes, counties, MSAs, and states). Means for each feature of the risk environment were computed for each racial/ethnic group of PWID, and were compared across racial/ethnic groups. Results: Almost universally across measures, black PWID were more likely than white PWID to live in environments associated with vulnerability to adverse HIV-related outcomes. Compared to white PWID, black PWID lived in ZIP codes with higher poverty rates and worse spatial access to substance abuse treatment and in counties with higher violent crime rates. Black PWID were less likely to live in states with laws facilitating sterile syringe access (e.g., laws permitting over-the-counter syringe sales). Latino/white differences in risk environments emerged at the MSA level (e.g., Latino PWID lived in MSAs with higher drug-related arrest rates). Conclusion: PWID risk environments in the US are racialized. Future research should explore the implications of this racialization for racial/ethnic disparities in HIV-related outcomes, using appropriate methods.

Infectious disease, injection practices, and risky sexual behavior among anabolic steroid users Ip, E J; Yadao, M A; Shah, B M; Lau, B AIDS Care 28, 3, p.294-299, 2016

Anabolic-androgenic steroids (AAS) and other performance-enhancing drugs (PEDs) are commonly misused to increase muscle size and strength, as well as improve physical appearance. Many AAS and certain PEDs are administered via injection and therefore pose a risk for transmission of infectious diseases such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and skin and soft tissue infections (SSTIs). Further, AAS users may be more likely to take part in high-risk sexual behaviors than non-AAS users. This review explores the prevalence of infectious diseases as well as risky injection practices and sexual behaviors of AAS users in the current literature. A comprehensive MEDLINE search (1984-17 April 2015) for English language reports was performed on AAS users. Ten studies analyzed the prevalence of HIV infection, 6 studies analyzed HBV infection, and 6 studies analyzed HCV infection; 20 studies analyzed injection practices and 7 studies analyzed high-risk sexual behaviors of AAS users. HIV, HBV, HCV, and SSTIs have been associated with AAS users. In particular, HIV infection seems much higher among homosexual male AAS users. AAS users also take part in high-risk injection practices but to a much lower extent than intravenous drug users. AAS users are also more likely to engage in high-risk sexual behaviors than the general population. Clinicians and health-policy leaders may utilize these findings to implement strategies to decrease the spread of infectious diseases.

Glasgow HIV cases reach highest in decade as numbers quadruple NHS GREATER Glasgow have seen a surge in the number of new HIV cases in the area rising from an average of 10 per year to 47 in 2015 | Daily Record, UK http://www.dailyrecord.co.uk/news/scottish-news/glasgow-hiv-cases-reach-highest- 7636942#4zPr5DCO7XCeo8jj.99