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EMCDDA DOCUMENTATION CENTRE INFORMATION BULLETIN

INFECTIOUS DISEASES

8 January 2016 ______

JOURNAL ARTICLES – Hepatitis

A longitudinal study of hepatitis C virus testing and infection status notification on behaviour change in people who inject drugs Spelman T., Morris M.D., Zang G. et al. Journal of Epidemiology and Community Health: 2015, 69, p. 745–752

Background Hepatitis C virus (HCV) testing and counselling have the potential to impact individual behaviour and transmission dynamics at the population level. Evidence of the impact of an HCV-positive status notification on injection risk reduction is limited. The objective of our study was to (1) assess drug and alcohol use and injection risk behaviours following notification; (2) to compare behaviour change in people who inject drugs (PWID) who received a positive test result and those who remained negative; and (3) to assess the effect of age on risk behaviour. Methods Data from the International Collaboration of Incident HIV and HCV Infection in Injecting Cohorts (InC3 Study) were analysed. Participants who were initially HCV seronegative were followed prospectively with periodic HCV blood testing and post-test disclosure and interview-administered questionnaires assessing drug use and injection behaviours. Multivariable generalised estimating equations were used to assess behavioural changes over time. Results Notification of an HCV-positive test was independently associated with a small increase in alcohol use relative to notification of a negative test. No significant differences in postnotification injection drug use, receptive sharing of ancillary injecting equipment and syringe borrowing postnotification were observed between diagnosis groups. Younger PWID receiving a positive HCV test notification demonstrated a significant increase in subsequent alcohol use compared with younger HCV negative. Conclusions The proportion of PWID reporting alcohol use increased among those receiving an HCV-positive notification, increased the frequency of alcohol use postnotification, while no reduction in injection drug use behaviours was observed between notification groups. These findings underscore the need to develop novel communication strategies during post-test notification to improve their impact on subsequent alcohol use and risk behaviours.

Human rights and access to hepatitis C treatment for people who inject drugs Wolfe D, Luhmann N, Harris M, Momenghalibaf A, Albers E, Byrne J, Swan T International Journal of Drug Policy 26(11):1072-80, 2015

Background: People who inject drugs (PWID) achieve adherence to and outcomes from hepatitis C virus (HCV) treatment comparable to other patients. Nonetheless, this population has been excluded from treatment by regulation or practice. Approval of safer and more effective oral HCV medicines should offer greater treatment options for PWID, although high medicine prices have led to continued treatment rationing and exclusion in developed countries. In middle-income countries (MICS), treatment is largely unavailable and unaffordable for most PWID. Methods: Human rights analysis, with its emphasis on the universal and interconnected nature of the economic, social and political spheres, offers a useful framework for HCV treatment reform. Using peer-reviewed and grey literature, as well as community case reports, we discuss barriers to treatment, correlate these barriers to rights violations, and highlight examples of community advocacy to increase treatment for PWID. Results: Structural drivers of lack of treatment access for PWID include stigma in health settings; drug use status as a criterion for treatment exclusion; requirements for fees or registration by name as a drug user prior to treatment initiation; and incarceration/detention in prisons and rehabilitation centers where treatment is unavailable. High medicine prices force further exclusion of PWID, with cost containment masked as concern about treatment adherence. These barriers correlate to multiple rights violations, including of the rights to privacy; non-discrimination; health; freedom of information; fair trial; and freedom from cruel, inhuman and degrading treatment. Conclusions: Needed reforms include decriminalization of drug use, possession of drugs and drug injecting equipment; removal of exclusionary or discriminatory treatment protocols; approaches to strengthen links between health providers and increase participation of PWID in treatment design and implementation; and measures to increase transparency in government/pharmaceutical company negotiations and reduce treatment price. [FULL TEXT AVAILABLE]

Opioid use trajectories, injection drug use, and hepatitis C virus risk among young adult immigrants from the former Soviet Union living in New York City Guarino H, Marsch LA, Deren S, Straussner SL, Teper A Journal of Addictive Diseases 34 (2-3) p.162-77, 2015

Available evidence suggests that young former Soviet Union immigrants in New York City have high rates of non-medical prescription opioid and heroin use, drug injection and injection-related risk behavior, making them vulnerable to hepatitis C virus (HCV)/human immunodeficiency virus (HIV) infection, overdose and associated harms. This group has been the focus of little research, however. This paper presents quantitative and qualitative data from 80 former Soviet immigrants (ages 18-29) to characterize their opioid use trajectories, injection risk behavior, HCV/HIV testing histories and self-reported HCV/HIV serostatus, and provides clinically meaningful data to inform tailored education, prevention and harm reduction interventions. [FULL TEXT AVAILABLE]

Can HIV and hepatitis C virus infection be eliminated among persons who inject drugs? Perlman DC, Des Jarlais DC, Feelemyer J Journal of Addictive Diseases 34 (2-3) p.198-205, 2015

HIV and hepatitis C virus (HCV) infection are readily transmitted among persons who inject drugs. The HIV and HCV epidemics have expanded rapidly, becoming global health issues. Combined prevention has been implemented to reduce injection and sexual transmission of HIV and HCV among persons who inject drugs. Reductions in risky injection and sexual behavior have led to dramatic reductions in HIV in many countries. Whether comparable reductions in HCV transmission can be achieved has yet to be determined. Eliminating HIV and HCV among persons who inject drugs will require considerable resources and commitment, particularly in low and middle income countries.

JOURNAL ARTICLES – HIV/AIDS

Psychiatric severity and HIV-risk sexual behaviors among persons with substance use disorders Majer JM, Komer AC, Jason LA Journal of Dual Diagnosis, 2015, 11, 1, p.3-11

Objective: The relationship between mental illness and human-immunodeficiency virus (HIV)-risk sexual behavior among persons with substance use disorders is not well-established because of differences in assessing psychiatric factors (types, symptoms, severity), substance use (diagnosis, survey responses, past substance use), and HIV-risk sexual behaviors (individual measures, combination of sex/drug use risk behaviors) across studies. This study utilized a more global and dimensional aspect of psychiatric issues (problem severity) to examine the relationship with HIV-risk sexual behaviors and substance use among persons with substance use disorders. Methods: Participants included 224 men and 46 women, with a mean age of 40.4 years (SD = 9.5). The most common substances were heroin/opiates, with 41.4% reporting use of these substances (n = 110), while 27.8% reported using cocaine (n = 74) and 12.8% reported using alcohol (n = 34). Of all participants, 39 (14.4%) were identified as having high psychiatric severity (defined using the psychiatric severity score from the Addiction Severity Index), which was used as an indication of probable comorbid psychiatric and substance use disorders. Among these participants likely to have comorbid disorders, hierarchical linear regression was conducted to examine HIV-risk sexual behaviors (number of partners and unprotected sexual behaviors in the past 30 days) in relation to psychiatric severity, substance use, and gender. Results: Gender (women) and psychiatric severity (higher) were significantly related to greater HIV-risk sexual behaviors. After entering gender and substance use into the regression model, psychiatric severity accounted for another 21.9% of the variance in number of partners and 14.1% of the variance in unprotected sexual behaviors. Overall, the models accounted for 55.5% and 15.6% of the variance, respectively. A significant interaction was found for number of partners (but not frequency of unprotected behavior), such that those higher in psychiatric severity and higher in substance use had a greater number of sexual partners. The model including this interaction term accounted for 63.4% of the variance in number of partners. Conclusions: Findings suggest psychiatric severity is an underlying risk factor for HIV-risk sexual behavior among persons with substance use disorders who have various psychiatric comorbidities. [FULL TEXT AVAILABLE]

Design and structure of the Estonian HIV Cohort Study (E-HIV) Soodla P, Rajasaar H, Avi R, Zilmer K, Kink K, Novikova L, Huik K, Maimets M, Lutsar I. Infectious Diseases 47(11):768-75, 2015

Background: Estonia is experiencing the new Eastern Europe human immunodeficiency virus (HIV) epidemic, with the highest incidence of new infections in the EU. We describe demographic changes, HIV-related laboratory parameters and co-infections during the concentrated HIV epidemic using the Estonian HIV Cohort Study (E-HIV) database, founded in 2009. Methods: All 3750 subjects in the E-HIV database on December 31, 2013 were included. Subjects were divided into risk groups: people who inject drugs (PWIDs), sexual transmission (heterosexual/homosexual), and other (perinatal) or unknown risk group. Subjects diagnosed before 2009 (first period) and after (second period) were analyzed separately. Results: The mean age at diagnosis has increased from 22.8 years (interquartile range (IQR) = 19.5-27.2) to 29.7 years (IQR = 25.3-36.2) (p < 0.001) between the first and second periods. PWIDs were younger than other transmission groups (23.2 vs 27.1; p < 0.001). There is a statistical difference in the route of transmission among genders, with overall increasing sexual transmission. The most common AIDS-defining illness was tuberculosis (0.5%). HIV/hepatitis C (HCV) co-infection was diagnosed in 42% of cases. The population median CD4 + cell count at diagnosis has declined over the years; in total 53% have been late presenters. Half of the patients are receiving antiretroviral treatment (cART). The most common combinations are nucleoside reverse transcriptase inhibitor (NRTI) backbone plus protease inhibitors (PIs) (57%) or NRTI backbone + non-NRTIs (42%). Conclusion: The E-HIV enables us to fill the gap in the lack of data on the course of the new Eastern European HIV epidemic. These data demonstrate that the HIV epidemic in Estonia is moving from PWIDs to the general population, suggesting that prevention measures and testing guidelines should be revised.

HIV care continuum among men who have sex with men and persons who inject drugs in India: barriers to successful engagement Mehta SH1, Lucas GM2, Solomon S3, Srikrishnan AK3, McFall AM1, Dhingra N4, Nandagopal P3, Kumar MS3, Celentano DD1, Solomon SS5. Clinical Infectious Diseases 61(11):1732-41, 2015

Background: We characterize the human immunodeficiency virus (HIV) care continuum for men who have sex with men (MSM) and persons who inject drugs (PWID) across India. Methods: We recruited 12 022 MSM and 14 481 PWID across 26 Indian cities, using respondent-driven sampling (September 2012 to December 2013). Participants were aged ?18 years and either self-identified as male and reported sex with a man in the prior year (MSM) or reported injection drug use in the prior 2 years (PWID). Correlates of awareness of HIV-positive status were characterized using multilevel logistic regression. Results: A total of 1146 MSM were HIV infected, of whom a median of 30% were aware of their HIV-positive status, 23% were linked to care, 22% were retained before antiretroviral therapy (ART), 16% had started ART, 16% were currently receiving ART, and 10% had suppressed viral loads. There was site variability (awareness range, 0%-90%; suppressed viral load range, 0%-58%). A total of 2906 PWID were HIV infected, of whom a median of 41% were aware, 36% were linked to care, 31% were retained before ART, 20% had started ART, 18% were currently receiving ART, and 15% had suppressed viral loads. Similar site variability was observed (awareness range: 2%- 93%; suppressed viral load range: 0%-47%). Factors significantly associated with awareness were region, older age, being married (MSM) or female (PWID), use of other services (PWID), more lifetime sexual partners (MSM), and needle sharing (PWID). Ongoing injection drug use (PWID) and alcohol use (MSM) were associated with lower awareness. Conclusions: In this large sample, the major barrier to HIV care engagement was awareness of HIV- positive status. Efforts should focus on linking HIV testing to other essential services.

The complex interaction between methamphetamine abuse and hiv-1 pathogenesis Passaro RC, Pandhare J, Qian HZ, Dash C Journal of Neuroimmune Pharmacology 10 (3) p.477-86, 2015

The global HIV/AIDS pandemic has claimed the lives of an estimated 35 million people. A significant barrier for combating this global pandemic is substance use since it is associated with HIV transmission, delayed diagnosis/initiation of therapy, and poor adherence to therapy. Clinical studies also suggest a link between substance use and HIV-disease progression/AIDS-associated mortality. Methamphetamine (METH) use is one of the fastest-growing substance use problems in the world. METH use enhances high-risk sexual behaviors, therefore increases the likelihood of HIV-1 acquisition. METH use is also associated with higher viral loads, immune dysfunction, and antiretroviral resistance. Moreover, METH use has also been correlated with rapid progression to AIDS. However, direct effects of METH on HIV-1 disease progression remains poorly understood because use of METH and other illicit drugs is often associated with reduced/non adherence to ART. Nevertheless, in vitro studies demonstrate that METH increases HIV-1 replication in cell cultures and animal models. Thus, it has been proposed that METH's potentiating effects on HIV-1 replication may in part contribute to the worsening of HIV-1 pathogenesis. However, our recent data demonstrate that METH at physiologically relevant concentrations has no effect and at higher concentrations inhibits HIV-1 replication in CD4+ T cells. Thus, the goal of this review is to systematically examine the published literature to better understand the complex interaction between METH abuse and HIV-1 disease progression.

Prevalence and characteristics of HIV/HBV and HIV/HCV coinfections in Tuscany Monia Puglia, Cristina Stasi, Monica Da Frè, Fabio Voller Brazilian Journal of Infectious Diseases doi:10.1016/j.bjid.2015.11.007 Available online 31 December 2015

Introduction Worldwide about 30% of HIV-infected patients are coinfected with HCV or HBV. The HIV/HCV coinfection is more common in individuals who have a history of drug addiction. The aims of this study were to assess the HCV and HBV prevalence in HIV- infected patients and analyze their characteristics. Methods We considered the new HIV diagnoses notified by the regional surveillance system of Tuscany from 2009 to 2013. Descriptive analyses were conducted on the socio- demographic characteristics, routes of transmission, and reason to perform the test. In coinfected patients we assessed the risk for being late presenter (LP) or the risk of having AIDS. Results In 5 years of surveillance a total of 1354 new HIV diagnoses were notified: 1188 (87.7%) were HIV alone, 106 (7.8%) HIV/HCV, 56 (4.1%) HIV/HBV, and 4 (0.33%) HIV/HCV/HBV. The main risk factor was injection drug use in 52.8% of HCV/HIV cases, while in HIV/HBV patients the main risk factor was sexual exposure. HIV/HBV coinfected patients showed worse clinical and immunological features than HIV and HIV/HCV patients: 78.6% had CD4 count less than 350 mm?3 (vs. 54.6% and 62.1%, respectively) and 39.4% had AIDS (vs 20.7% and 7.6%). The risk for being LP triples for HIV/HBV (OR 2.98; 95% IC: 1.56–5.70) than patients with HIV alone. Conclusions We have observed less advanced disease in HIV and HCV-HIV patients compared with HBV–HIV coinfected patients. Moreover, our results show a higher prevalence of HIV/HCV among drug addicts and in the age-group 35–59, corresponding to those born in years considered most at risk for addiction. This study also confirms the finding of a less advanced HIV disease in HIV/HCV coinfected patients. Nonprescription syringe sales: A missed opportunity for HIV prevention in California Robin A. Pollini, Abby E. Rudolph, Patricia Case Journal of the American Pharmacists Association Volume 55, Issue 1, Pages 31-40, 2015

Objective To assess implementation of California Senate Bill SB41 in two inland California counties where prevalence of injection drug use is among the highest in the nation. Design Syringe purchase trial. Setting Fresno and Kern counties, California. Participants All 248 community pharmacies in the counties. Main outcome measure Successful or unsuccessful syringe purchase attempt. Results Only 52 (21.0%) syringe purchase attempts were successful. The proportion of successful attempts did not vary by county or by data collector ethnicity. The most common reasons for unsuccessful syringe purchase attempts were prescription requirements (45.7%), the requested syringe size was not available (10.7%), and the pharmacy did not sell syringes (9.7%). In addition, some syringe purchase attempts (4.1%) were unsuccessful because the data collector was asked to purchase more syringes than allowed by law. Although 80% and 78% of Fresno and Kern residents, respectively, live within a 5-minute drive of a community pharmacy, less than one-half live within a 5-minute drive of a community pharmacy that sold syringes. Conclusion SB41 has not resulted in broad pharmacy-based syringe access in California's inland counties, where a disproportionate number of cases of human immunodeficiency virus (HIV) infections are associated with injection drug use. Additional steps by legislative bodies, regulatory agencies, and professional organizations are needed to actively engage pharmacies in expanding nonprescription syringe sales to reduce HIV transmission among injection drug users.

JOURNAL ARTICLES – Other Conditions / Issues

Exploring the public health impacts of private security guards on people who use drugs: a qualitative study Nicole Markwick, Ryan McNeil, Will Small, Thomas Kerr Journal of Urban Health Volume 92, Issue 6, pp 1117-1130, 2015

Private security guards occupy an increasingly prominent role in the policing of private and public spaces. There are growing concerns regarding security guards’ potential to shape violence, discrimination, and adverse health outcomes among vulnerable populations, including people who use drugs (PWUD). This is relevant in Vancouver, Canada, where private security guards have increasingly been employed by private organizations to manage public and private spaces, including those within urban drug scenes. This qualitative study sought to understand interactions between PWUD and private security guards and explore their impacts on health care access, risks, and harms among PWUD. Semi-structured interviews were conducted with 30 PWUD recruited from two ongoing prospective cohort studies. Interviews were transcribed and analyzed using a coding framework comprised of a priori and emergent categories. Study data indicate that participants experience pervasive, discriminatory profiling and surveillance by security guards, which exacerbates existing social marginalization and structural vulnerability, particularly among PWUD of Aboriginal ancestry. Participants reported that security guards restrict PWUD’s access to public and private spaces, including pharmacies and hospitals. PWUD also reported that their interactions with security guards often involved interpersonal violence and aggression, experiences that served to increase their vulnerability to subsequent risks and harms. Our findings highlight that private security forces contribute significantly to the everyday violence experienced by PWUD within drug scenes and elsewhere and do so in a manner very similar to that of traditional police forces. These findings point to the urgent need for greater oversight and training of private security guards in order to protect the health and safety of PWUD.

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; Krüger, C; Wölfel, R Forensic Science International, December 2015, doi:10.1016/j.forsciint.2015.11.017

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. [FULL TEXT AVAILABLE] Whole genome analysis of injectional anthrax identifies two disease clusters spanning more than 13 years Paul Keim, Roland Grunow, Richard Vipond, Gregor Grass, Alex Hoffmaster, Dawn N. Birdsell, Silke R. Klee, Steven Pullan, Markus Antwerpen, Brittany N. Bayer, Jennie Latham, Kristin Wiggins, Crystal Hepp, Talima Pearson, Tim Brooks, Jason Sahl, David M. Wagner EBioMedicine Volume 2, Issue 11, Pages 1613–1618, 2015

Background Anthrax is a rare disease in humans but elicits great public fear because of its past use as an agent of bioterrorism. Injectional anthrax has been occurring sporadically for more than ten years in heroin consumers across multiple European countries and this outbreak has been difficult to trace back to a source. Methods We took a molecular epidemiological approach in understanding this disease outbreak, including whole genome sequencing of Bacillus anthracis isolates from the anthrax victims. We also screened two large strain repositories for closely related strains to provide context to the outbreak. Findings Analyzing 60 Bacillus anthracis isolates associated with injectional anthrax cases and closely related reference strains, we identified 1071 Single Nucleotide Polymorphisms (SNPs). The synapomorphic SNPs (350) were used to reconstruct phylogenetic relationships, infer likely epidemiological sources and explore the dynamics of evolving pathogen populations. Injectional anthrax genomes separated into two tight clusters: one group was exclusively associated with the 2009–10 outbreak and located primarily in Scotland, whereas the second comprised more recent (2012–13) cases but also a single Norwegian case from 2000. Interpretation Genome-based differentiation of injectional anthrax isolates argues for at least two separate disease events spanning >12 ?years. The genomic similarity of the two clusters makes it likely that they are caused by separate contamination events originating from the same geographic region and perhaps the same site of drug manufacturing or processing. Pathogen diversity within single patients challenges assumptions concerning population dynamics of infecting B. anthracis and host defensive barriers for injectional anthrax. [FULL TEXT AVAILABLE]

Curing hepatitis C, in an experiment the size of Egypt A new approach tested in Egypt could become the blueprint for providing cutting-edge medicines to the poor | NY Times, USA http://www.nytimes.com/2015/12/16/health/hepatitis-c-treatment-egypt.html?_r=1

NAU Scientists Track Anthrax-Tainted Heroin In Europe http://science.kjzz.org/content/241509/nau-scientists-track-anthrax-tainted-heroin- europe 'Half' of injecting drug users in Wales at Hepatitis C risk Half of known injecting drug users are at risk of contracting Hepatitis C, Public Health Wales has warned | BBC, UK http://www.bbc.co.uk/news/uk-wales-34984444

World Hepatitis Alliance highlights need to recognise impact of coinfection between HIV and viral hepatitis http://www.news-medical.net/news/20151207/World-Hepatitis-Alliance-highlights-need- to-recognise-impact-of-coinfection-between-HIV-and-viral-hepatitis.aspx