Apinun Aramrattana

Not Just the Needle: The State of HIV-Prevention Science Among Substance Users and Future Directions

Abstract:Efforts to prevent HIV transmission among substance-using populations have focused primarily among injection drug users, which have produced measurable reductions in HIV incidence and prevalence. By contrast, the majority of substances used worldwide are administered by noninjectable means, and there is a dearth of HIV prevention interventions that target noninjecting substance users. Increased surveillance of trends in substance use, especially cocaine (including crack) and methamphetamine, in addition to new and emerging substances (eg, synthetic cannabinoids, cathinones, and other amphetamine analogs) are needed to develop and scale up effective and robust interventions for populations at risk for HIV transmission via sexual behaviors related to noninjection substance use. Strategies are needed that address unique challenges to HIV prevention for substance users who are HIV infected and those who are HIV uninfected and are at high risk. We propose a research agenda that prioritizes (1) combination HIV-prevention strategies in substance users; (2) behavioral HIV prevention programs that reduce sexual transmission behaviors in nontreatment seeking individuals; (3) medical and/or behavioral treatments for substance abuse that reduce/eliminate substance-related sexual transmission behaviors; and (4) structural interventions to reduce HIV incidence.

Towards Combination HIV Prevention for Injection Drug Users: Addressing Addictophobia, Apathy and Inattention

Purpose of reviewRecent breakthroughs in HIV-prevention science led us to evaluate the current state of combination HIV prevention for injection drug users (IDUs). We review the recent literature focusing on possible reasons why coverage of prevention interventions for HIV, hepatitis C virus (HCV) and tuberculosis among IDUs remains dismal. We make recommendations for future HIV research and policy. Recent findingsIDUs disproportionately under-utilize voluntary HIV counseling and testing (VCT), primary care and antiretroviral therapy (ART), especially in countries that have the largest burden of HIV among IDUs. IDUs present later in the course of HIV infection and experience greater morbidity and mortality. Why are IDUs under-represented in HIV-prevention research, access to treatment for both HIV and addiction, and access to HIV combination prevention? Possible explanations include addictophobia, apathy, and inattention, which we describe in the context of recent literature and events. SummaryThis commentary discusses the current state of HIV-prevention interventions for IDUs including VCT, needle and syringe program (NSP), opioid substitution therapy (OST), ART and pre-exposure chemoprophylaxis (PrEP), and discusses ways to work towards true combination HIV prevention for IDU populations. Communities need to overcome tacit assumptions that IDUs can navigate through systems that are maintained as separate silos, and begin to take a rights-based approach to HIV prevention to ensure that IDUs have equitable access to life-saving prevention and treatments.

Sexually transmitted infections and sexual and substance use correlates among young adults in Chiang Mai, Thailand.

Background: Data on the prevalence of and associated behavioral risk factors for sexually transmitted infections (STI) in young adults in Asia have not been widely studied. Study Design: We conducted a cross-sectional study in Chiang Mai, Thailand in 2005–2006 among 658 sexually active participants aged 18 to 25 years, the majority having a history of recent methamphetamine (MA) use. Data were collected by interview and STI were detected using standard laboratory assays. Results: Overall, 38% of participants had at least one laboratory confirmed STI. Herpes simplex virus and Chlamydia were significantly more common among women, whereas hepatitis B virus was significantly more common among men. Men reported a greater number of sexual partners than women, and condom use at last sex was infrequent. Most participants reported using MA at least weekly, with men more frequent users than women, and more often giving reports of frequent drunkenness and lifetime arrests. Behavioral correlates of prevalent STI were similar to the published literature. In multivariate analysis, women ≥20 years of age, with ≥2 heterosexual partners in the past year and a younger age at sexual debut were significantly more likely to have a prevalent STI. Men ≥20 years of age, with ≥2 heterosexual partners in the past year and who enrolled both sex and drug network members were significantly more likely to have a prevalent STI, whereas men who used a condom at last sex were significantly less likely to have a prevalent STI. Substance abuse was associated with behavioral risks but not with prevalent STI. Conclusions: Sexual risks and substance abuse are substantially elevated among young Thai MA users, but only sexual risks are associated with prevalent STI.

Building community partnerships: case studies of Community Advisory Boards at research sites in Peru, Zimbabwe, and Thailand

Background Differences in resources, knowledge, and infrastructure between countries initiating and countries hosting HIV prevention research trials frequently yield ethical dilemmas. Community Advisory Boards (CABs) have emerged as one strategy for establishing partnerships between researchers and host communities to promote community consultation in socially sensitive research. Purpose To understand the evolution of CABs and community partnerships at international research sites conducting HIV prevention trials. Methods Three research sites of the HIV Prevention Trials Network (HPTN) were selected to include geographical representation and diverse populations at risk for HIV/AIDS — in Lima, Peru; Chitungwiza, Zimbabwe; and Chiang Mai, Thailand. Data collection included review of secondary data, including academic publications and site-specific progress reports; observations at the research sites; face-to-face interviews with CAB members, research staff, and other key informants; and focus groups with study participants. Rapid assessment techniques were used for data analysis. Results Two of the three CABs developed new strategies for community representation in response to new studies. All three CABs expanded their original function and became advocates for broader community interests beyond HIV prevention. The participation and input of community representatives, in response to critical incidents that occurred at the sites over the past five years, helped to solidify partnerships between researchers and communities. Limitations Rapid Assessment is an exploratory methodology designed to provide an understanding of a situation based on the integration of multiple data sources, collected within a short period of time, without a formal examination of transcribed and coded data. Case studies, as a method, are meant to draw out what can be learned from a single case but are not, in the scientific sense, generalizable. Conclusions In developing countries, CABs can be dynamic entities that enhance the HIV research process, assist in responding to issues involving research ethics, and prepare communities for HIV research. Clinical Trials 2008; 5: 147—156. http://ctj.sagepub.com

Incidence of HIV and Sexually Transmitted Infections and Risk Factors for Acquisition Among Young Methamphetamine Users in Northern Thailand

Background: Southeast Asia is experiencing an epidemic of methamphetamine use, a drug associated with risky sexual behaviors, putting a large segment of the population at increased risk for sexually transmitted infections (STIs) and HIV and in need of prevention efforts. Incidence estimates of STIs are rare in Southeast Asia, especially among newer risk groups. Study Design: We enrolled methamphetamine users aged 18 to 25 years in a 12-month randomized behavioral intervention trial in Chiang Mai, Thailand in 2005. Behavioral questionnaires were administered at visits every 3 months, and biologic specimens were collected at baseline and 12 months to test for common STIs (chlamydia, gonorrhea, HSV-2, and HIV). Poisson regression with robust variance was used to determine risk factors for incident STIs. Results: Overall, 12.7% of 519 participants acquired at least 1 STI. Chlamydia was the most common (10.6%), followed by HSV-2 (4.0%), gonorrhea (2.9%), and HIV (0.6%). Risk factors for both men and women included self-reported incarceration and having a casual sex partner during follow-up, and having a prevalent STI at baseline. Additionally, among women, having 2 or more heterosexual partners, and among men, having a greater frequency of drunkenness were risk factors for STI acquisition. Conclusions: Although HIV incidence is low in this population, incidence of other STIs is high compared with previous studies of young Thai adults. Risk factors for acquisition emphasize the need for new prevention strategies targeted toward current populations at risk.

Entomological evaluation of community-wide use of lambdacyhalothrinimpregnated bed nets against malaria in a border area of north-west Thailand

This paper reports 2 studies. (i) After a year of baseline data collection, lambdacyhalothrin-treated bed nets were introduced into 3 of 5 villages in north-west Thailand, the remaining 2 being treated with placebo. Human bait collections were carried out in each village on 2 nights per month, for 8 months of each year, and the biting densities were compared between the first year and the second year. The treated bed nets did not have any significant impact on the density or parous rates of Anopheles sawadwongporni and A. maculatus s.s. populations. The results for A. dirus s.l. were not conclusive because of the low number caught. Significant reductions in biting and parous rates of A. minimus species A were observed in only one of the 3 treated villages, and there was no overall difference between treated and control groups. However, the trial suffered from the washing of nets by villagers and the low rate of reimpregnation. (ii) A short-term study involved 4 villages in a cross-over design, and lasted 48 d. For the first 24 d, residents of 2 villages were given new treated nets while the other 2 villages retained their own untreated nets. For the second 24 d, this situation was reversed. Daily light-trapping revealed no significant difference in the indoor densities or parous rates of A. minimus species A between the periods with treated or untreated nets.(ABSTRACT TRUNCATED AT 250 WORDS)

A qualitative study of sexual behaviours among methamphetamine users in Chiang Mai, Thailand: a typology of risk

INTRODUCTION AND AIMS Methamphetamine (MA) has become the leading drug of abuse in northern Thailand over the past several years, particularly among youth. The current qualitative study explores the relationship between sexual behaviours and MA. DESIGN AND METHODS Between March 2002 and January 2003, 48 in-depth interviews with young MA users aged 15-2 years in Chiang Mai. Interviews were transcribed verbatim in Thai and translated into English. Data were analysed inductively using the constant comparative method common to grounded theory methods. Atlas-ti was used for data management. The current analysis was stratified by gender. RESULTS Participants were 44% male and the median age was 20 years. At the time of the interviews, 70% were not using MA. A typology of experiences with and feelings about MAs relationship to sexual activity emerged: (1) enhanced libido--individuals who found that MA enhances their sexual experiences (n = 13); (2) decreased libido or no effect--individuals who found that MA detracted from sexual desire (n = 22); and (3) virgins (n = 13). DISCUSSION AND CONCLUSIONS Participants reported several distinct patterns of relationship between MA and sex. Tailored interventions are needed that address specific patterns of sexual behaviors among youth in order to promote sustainable safer sex behaviours in this population.

Drug and alcohol services in middle-income countries

Purpose of review The present review summarizes current research in middle-income countries on drug and alcohol services for prevention, screening, treatment, care and rehabilitation between June 2006 and December 2007. Recent findings There is a dearth of scientific literature on prevention, treatment and rehabilitation in middle-income countries and no novel effective approaches reported during the review period. The Lancet Series on Global Mental Health showed only 0.7% of all papers reviewed were on low-income and middle-income countries. Several studies in these countries confirmed the effectiveness of brief interventions in treating alcohol use disorders at a primary care level. One study on alcohol screening in Brazil produced a promising screening tool. Other studies reported the availability of pharmacological and nonpharmacological treatments for alcohol and drug use disorders. Overall, poor accessibility to services and delayed onset of treatment persist. Political and cultural environments play a crucial role in providing services to fulfill treatment needs. Summary During the review period, reports from middle-income countries on alcohol and drug services were very limited. A few studies in some countries confirm the effectiveness of brief interventions in primary care settings. There is an obvious need for more research on alcohol and drug treatment services in middle-income countries.

Young Thai women who use methamphetamine: Intersection of sexual partnerships, drug use, and social networks

BACKGROUND Given high rates of methamphetamine (MA) use among young people in Thailand and evidence of an association between MA and increased sexual risk behaviour, we examined the association between womens recent sexual partnerships, social network characteristics and drug and alcohol use. METHODS Female participants (n=320) in an HIV behavioural trial among young (18-25 years) MA users in Chiang Mai completed a drug and sexual behaviour survey and social network inventory. Multinomial regression analyses accounting for clustered data examined individual and network characteristics associated with recent sexual partnership category. We compared women with only one male partner in the past year (39%) to those with multiple male partners (37%) and those with only female partners (24%). RESULTS Differences in levels of drug and alcohol use and social and sexual network characteristics were dependent on recent sexual partnership profiles. The multiple partner group reported an average of five male partners in the past year; 12% reported consistent condom use in the past 30 days. Compared to both groups, women with multiple male partners used MA more frequently, had larger non-sex networks with more MA users, were more likely to have an MA-using sex partner, and received less emotional support from their partners. Women with multiple male partners and only female partners reported more frequent alcohol use. CONCLUSIONS Policy and intervention efforts targeting drug use and sexual behaviour among young Thai women are drastically needed and may benefit from consideration of the diversity within the population. These data point to the need for targeted prevention approaches that take into account the varying characteristics and social influences of these different groups of women.

Are there adverse consequences of quizzing during informed consent for HIV research

Introduction While quizzing during informed consent for research to ensure understanding has become commonplace, it is unclear whether the quizzing itself is problematic for potential participants. In this study, we address this issue in a multinational HIV prevention research trial enrolling injection drug users in China and Thailand. Methods Enrolment procedures included an informed consent comprehension quiz. An informed consent survey followed. Results 525 participants completed the informed consent survey (Heng County, China=255, Xinjiang, China=229, Chiang Mai, Thailand=41). Mean age was 33 and mean educational level was 8 yrs. While quizzing was felt to be a good way to determine if a person understands the nature of clinical trial participation (97%) and participants did not generally find the quiz to be problematic, minorities of respondents felt pressured (6%); anxious (5%); bored (5%); minded (5%); and did not find the questions easy (13%). In multivariate analysis, lower educational level was associated with not minding the quizzing (6–10 yrs vs 0–5 yrs: OR=0.27, p=0.03; more than 11 yrs vs 0–5 yrs: OR=0.18, p=0.03). There were also site differences (Heng County vs Xinjiang) in feeling anxious (OR=0.07; p=<0.01), not minding (OR=0.26; p=0.03), being bored (OR=0.25; p=0.01) and not finding the questions easy (OR=0.10; p=<0.01). Conclusions Quizzing during the informed consent process can be problematic for a minority of participants. These problems may be associated with the setting in which research takes place and educational level. Further research is needed to develop, test and implement alternative methods of ensuring comprehension of informed consent. Trial Registration clinicaltrials.gov number NCT00270257.