Danielle Horyniak

Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews

BACKGROUND Injecting drug use is an important risk factor for transmission of viral hepatitis, but detailed, transparent estimates of the scale of the issue do not exist. We estimated national, regional, and global prevalence and population size for hepatitis C virus (HCV) and hepatitis B virus (HBV) in injecting drug users (IDUs). METHODS We systematically searched for data for HBV and HCV in IDUs in peer-reviewed databases (Medline, Embase, and PsycINFO), grey literature, conference abstracts, and online resources, and made a widely distributed call for additional data. From 4386 peer-reviewed and 1019 grey literature sources, we reviewed 1125 sources in full. We extracted studies into a customised database and graded them according to their methods. We included serological reports of HCV antibodies (anti-HCV), HBV antibodies (anti-HBc), or HBV surface antigen (HBsAg) in studies of IDUs with more than 40 participants (<100% HIV-positive) and sampling frames that did not exclude participants on the basis of age or sex. With endorsed decision rules, we calculated prevalence estimates with anti-HCV and anti-HBc as proxies for exposure and HBsAg as proxy for current infection. We combined these estimates with IDU population sizes to calculate the number of IDUs with positive HBV or HCV statuses. FINDINGS We located eligible reports with data for prevalence of anti-HCV in IDUs for 77 countries; midpoint prevalence estimates suggested 60-80% of IDUs had anti-HCV in 25 countries and more than 80% of IDUs did so in 12 countries. About 10.0 million (range 6.0-15.2) IDUs worldwide might be anti-HCV positive. China (1.6 million), USA (1.5 million), and Russia (1.3 million) had the largest such populations. We identified eligible HBsAg reports for 59 countries, with midpoint prevalence estimates of 5-10% in 21 countries and more than 10% in ten countries. Worldwide, we estimate 6.4 million IDUs are anti-HBc positive (2.3-9.7 million), and 1.2 million (0.3-2.7 million) are HBsAg positive. INTERPRETATION More IDUs have anti-HCV than HIV infection, and viral hepatitis poses a key challenge to public health. Variation in the coverage and quality of existing research creates uncertainty around estimates. Improved and more complete data and reporting are needed to estimate the scale of the issue, which will inform efforts to prevent and treat HCV and HBV in IDUs. FUNDING WHO and US National Institutes of Health (NIDA R01 DA018609).

Let's get Wasted! and Other Apps: Characteristics, Acceptability, and Use of Alcohol-Related Smartphone Applications

Background Smartphone applications (“apps”) offer a number of possibilities for health promotion activities. However, young people may also be exposed to apps with incorrect or poor quality information, since, like the Internet, apps are mostly unregulated. Little is known about the quality of alcohol-related apps or what influence they may have on young people’s behavior. Objective To critically review popular alcohol-related smartphone apps and to explore young people’s opinions of these apps, their acceptability, and use for alcohol-related health promotion. Methods First, a content analysis of 500 smartphone apps available via Apple iTunes and Android Google Play stores was conducted. Second, all available blood alcohol concentration (BAC) apps were tested against four individual case profiles of known BAC from a previous study. Third, two focus group discussions explored how young people use alcohol-related apps, particularly BAC apps. Results 384 apps were included; 50% (192) were entertainment apps, 39% (148) were BAC apps, and 11% (44) were health promotion and/or stop drinking–related apps. When testing the BAC apps, there was wide variation in results, with apps tending to overestimate BAC scores compared with recorded scores. Participants were skeptical of the accuracy of BAC apps, and there was an overall concern that these apps would be used as a form of entertainment, further encouraging young people to drink, rather than reduce their drinking and risk taking. Conclusions The majority of popular alcohol-related apps encouraged alcohol consumption. Apps estimating blood alcohol concentration were widely available but were highly unreliable. Health departments and prominent health organizations need to endorse alcohol smartphone apps that are accurate and evidence-based to give specific apps credibility in the ever-expanding market of unregulated apps.

Establishing the Melbourne injecting drug user cohort study (MIX): rationale, methods, and baseline and twelve-month follow-up results

BackgroundCohort studies provide an excellent opportunity to monitor changes in behaviour and disease transmission over time. In Australia, cohort studies of people who inject drugs (PWID) have generally focused on older, in-treatment injectors, with only limited outcome measure data collected. In this study we specifically sought to recruit a sample of younger, largely out-of-treatment PWID, in order to study the trajectories of their drug use over time.MethodsRespondent driven sampling, traditional snowball sampling and street outreach methods were used to recruit heroin and amphetamine injectors from one outer-urban and two inner-urban regions of Melbourne, Australia. Information was collected on participants’ demographic and social characteristics, drug use characteristics, drug market access patterns, health and social functioning, and health service utilisation. Participants are followed-up on an annual basis.Results688 PWID were recruited into the study. At baseline, the median age of participants was 27.6 years (IQR: 24.4 years – 29.6 years) and two-thirds (67%) were male. Participants reported injecting for a median of 10.2 years (range: 1.5 months – 21.2 years), with 11% having injected for three years or less. Limited education, unemployment and previous incarceration were common. The majority of participants (82%) reported recent heroin injection, and one third reported being enrolled in Opioid Substitution Therapy (OST) at recruitment. At 12 months follow-up 458 participants (71% of eligible participants) were retained in the study. There were few differences in demographic and drug-use characteristics of those lost to follow-up compared with those retained in the study, with attrition significantly associated with recruitment at an inner-urban location, male gender, and providing incomplete contact information at baseline.ConclusionsOur efforts to recruit a sample of largely out-of-treatment PWID were limited by drug market characteristics at the time, where fluctuating heroin availability has led to large numbers of PWID accessing low-threshold OST. Nevertheless, this study of Australian injectors will provide valuable data on the natural history of drug use, along with risk and protective factors for adverse health outcomes associated with injecting drug use. Comprehensive follow-up procedures have led to good participant retention and limited attrition bias.

Post-marketing surveillance of buprenorphine-naloxone in Australia: Diversion, injection and adherence with supervised dosing

BACKGROUND These studies compared the diversion and injection of buprenorphine-naloxone (BNX), buprenorphine (BPN) and methadone (MET) in Australia. METHODS Surveys were conducted with regular injecting drug users (IDUs) (2004-2009, N=881-943), opioid substitution treatment (OST) clients (2008, N=440) and authorised OST prescribers (2007, N=291). Key outcome measures include the unsanctioned removal of supervised doses, diversion, injection, motivations, drug liking and street price. Levels of injection among IDUs were adjusted for background availability of medications. Doses not taken as directed by OST clients were adjusted by total number of daily doses dispensed. RESULTS Among regular IDUs, levels of injection were lower for BNX relative to BPN, but comparable to those for MET, adjusting for background availability. Among OST clients, fewer BNX clients (13%) reported recently injecting their medication, than BPN (28%) and MET clients (23%). Fewer MET clients (10%) reported removal of supervised doses, than BPN (35%) and BNX clients (22%). There were no differences in prevalence of recent diversion (28% of all OST clients). Adjusting for the total doses dispensed, more BPN was injected (10%), removed (12%) and diverted (5%), than MET (5%, <1% and 2% respectively) and BNX (5%, 9% and <1% respectively). In 2009, the median street price of BNX was equivalent to that for BPN. CONCLUSIONS BNX was less commonly and less frequently injected than BPN, but both sublingual medications were diverted more than liquid MET.

Behavioural interventions for preventing hepatitis C infection in people who inject drugs: A global systematic review

BACKGROUND A systematic review was conducted to determine whether behavioural interventions are effective in preventing transmission of hepatitis C virus (HCV) amongst people who inject drugs. METHODS Medline, EMBASE, the Cochrane Clinical Trial Database, PSYCHINFO and hand-searching of bibliographies were used to identify controlled trials of behavioural interventions for reducing HCV transmission amongst people who inject drugs. Behavioural interventions were defined as non-pharmacological interventions that aimed to change individual behaviours without explicitly attempting to change population norms. RESULTS Six trials evaluating peer-education training and counselling interventions were included in the review. There was considerable variation between trials with respect to intervention duration, control and study population. Trials evaluated the impact of interventions on HCV incidence (three studies, 1041 participants) and frequency of injecting risk behaviours (six studies, 2472 participants). Amongst the three studies which measured the impact of the intervention on HCV incidence, none found a statistically significant difference between intervention and control groups. Measures of frequency of injecting risk behaviours varied greatly and could not be pooled. Only two studies (n=418, 854) showed significantly greater reductions in injecting risk behaviours in the intervention group compared with the control group. CONCLUSIONS There was considerable variation in study design, outcome measures and magnitude, direction and statistical significance of findings between studies. Nonetheless, it is unlikely that behavioural interventions can have a considerable effect on HCV transmission. It is likely that multi-component interventions are required.

The relationship between age and risky injecting behaviours among a sample of Australian people who inject drugs.

BACKGROUND Limited evidence suggests that younger people who inject drugs (PWID) engage in high-risk injecting behaviours. This study aims to better understand the relationships between age and risky injecting behaviours. METHODS Data were taken from 11 years of a repeat cross-sectional study of sentinel samples of regular PWID (The Australian Illicit Drug Reporting System, 2001-2011). Multivariable Poisson regression was used to explore the relationship between age and four outcomes of interest: last drug injection occurred in public, receptive needle sharing (past month), experiencing injecting-related problems (e.g. abscess, dirty hit; past month), and non-fatal heroin overdose (past six months). RESULTS Data from 6795 first-time study participants were analysed (median age: 33 years, interquartile range [IQR]: 27-40; median duration of injecting: 13 years [IQR: 7-20]). After adjusting for factors including duration of injecting, each five year increase in age was associated with significant reductions in public injecting (adjusted incidence rate ratio [AIRR]: 0.90, 95% confidence interval [CI]: 0.88-0.92), needle sharing (AIRR: 0.84, 95% CI: 0.79-0.89) and injecting-related problems (AIRR: 0.96, 95% CI: 0.95-0.97). Among those who had injected heroin in the six months preceding interview, each five year increase in age was associated with an average 10% reduction in the risk of heroin overdose (AIRR: 0.90, 95% CI: 0.85-0.96). CONCLUSIONS Older PWID report significantly lower levels of high-risk injecting practices than younger PWID. Although they make up a small proportion of the current PWID population, younger PWID remain an important group for prevention and harm reduction.

The prevalence and correlates of buprenorphine inhalation amongst opioid substitution treatment (OST) clients in Australia.

BACKGROUND Diversion and injection of buprenorphine (Subutex(®)) and buprenorphine-naloxone (Suboxone(®)) have been well documented. Recent international research and local anecdotal evidence suggest that these medications are also used by other routes of administration, including smoking and snorting. METHODS A cross-sectional sample of 440 opioid substitution treatment (OST) clients was recruited through pharmacies and clinics in three Australian jurisdictions, and interviewed face-to-face using a structured questionnaire. Eligible participants were those aged 18 or over, who had resided in their home state for at least six months, and had been in their current treatment episode for at least 4 weeks. We compared differences in characteristics between clients who had ever inhaled (smoked or snorted) buprenorphine (including buprenorphine-naloxone) and other OST clients. Logistic regression was used to identify correlates of buprenorphine inhalation. Sixty-eight clients who had never used buprenorphine were excluded from analysis. RESULTS Sixty-five clients (18%) reported having ever inhaled buprenorphine, with Subutex(®) smoking being most common, reported by 50 clients (77%). In multivariable logistic regression, those who reported ever inhaling buprenorphine were significantly more likely to: be aged 35 or younger, have ever been in prison and have ever injected buprenorphine. Clients from New South Wales and Victoria were significantly less likely to have ever inhaled buprenorphine than those from South Australia. CONCLUSIONS Our data indicates that the inhalation of buprenorphine has occurred in a significant minority of Australian OST clients. The motivations, contexts and potential health consequences of buprenorphine use by these atypical routes of administration, particularly in a correctional setting, warrant further exploration.

Epidemiology of substance use among forced migrants: a global systematic review

Introduction Forced migration is occurring at unprecedented levels. Forced migrants may be at risk for substance use for reasons including coping with traumatic experiences, co-morbid mental health disorders, acculturation challenges and social and economic inequality. This paper aimed to systematically review the literature examining substance use among forced migrants, and identify priority areas for intervention and future research. Methods Seven medical, allied health and social science databases were searched from inception to September 2015 in accordance with PRISMA guidelines to identify original peer-reviewed articles describing any findings relating to alcohol and/or illicit drug use among refugees, internally displaced people (IDPs), asylum seekers, people displaced by disasters and deportees. A descriptive synthesis of evidence from quantitative studies was conducted, focusing primarily on studies which used validated measures of substance use. Synthesis of evidence from qualitative studies focused on identifying prominent themes relating to the contexts and consequences of substance use. Critical Appraisal Skills Programme (CASP) checklists were used to assess methodological quality of included studies. Results Forty-four quantitative (82% cross-sectional), 16 qualitative and three mixed-methods studies were included. Ten studies were rated as high methodological quality (16%), 39 as moderate quality (62%) and 14 as low quality (22%). The majority of research was conducted among refugees, IDPs and asylum seekers (n = 55, 87%), predominantly in high-income settings. The highest-quality prevalence estimates of hazardous/harmful alcohol use ranged from 17%-36% in camp settings and 4%-7% in community settings. Few studies collected validated measures of illicit drug use. Seven studies compared substance use among forced migrants to other migrant or native-born samples. Among eight studies which conducted multivariable analysis, male sex, trauma exposure and symptoms of mental illness were commonly identified correlates of substance use. Conclusion Our understanding of substance use among forced migrants remains limited, particularly regarding persons displaced due to disasters, development and deportation. Despite a growing body of work among refugee-background populations, few studies include refugees in low and middle-income countries, where over 80% of the global refugee population resides. Findings suggest a need to integrate substance use prevention and treatment into services offered to forced migrants, particularly in camp settings. Efforts to develop and evaluate interventions to reduce substance use and related harms are needed.

Pattern and characteristics of ecstasy and related drug (ERD) presentations at two hospital emergency departments, Melbourne, Australia, 2008–2010

Objective To describe patterns and characteristics of emergency department (ED) presentations related to the use of ecstasy and related drugs (ERDs) in Melbourne, Australia. Methods Retrospective audit of ERD-related presentations from 1 January 2008 to 31 December 2010 at two tertiary hospital EDs. Variation in presentations across years was tested using a two-tailed test for proportions. Univariate and multivariate logistic regressions were used to compare sociodemographic and clinical characteristics across groups. Results Most of the 1347 presentations occurred on weekends, 24:00–06:00. Most patients arrived by ambulance (69%) from public places (42%), private residences (26%) and licensed venues (21%). Ecstasy-related presentations decreased from 26% of presentations in 2008 to 14% in 2009 (p<0.05); γ-hydroxybutyrate (GHB) presentations were most common overall. GHB presentations were commonly related to altered conscious state (89%); other presentations were due to psychological concerns or nausea/vomiting. Compared with GHB presentations, patients in ecstasy-related presentations were significantly less likely to require intubation (OR 0.04, 95% CI 0.01 to 0.18), but more likely to result in hospital admission (OR 1.77, 95% CI 1.08 to 2.91). Patients in amphetamine-related cases were older than those in GHB-related cases (median 28.4 years vs 23.9 years; p<0.05), and more likely to have a history of substance use (OR 4.85, 95% CI 3.50 to 6.74) or psychiatric illness (OR 6.64, 95% CI 4.47 to 9.87). Overall, the median length of stay was 3.0 h (IQR 1.8–4.8), with most (81%) patients discharged directly home. Conclusions Although the majority of ERD-related presentations were effectively treated, with discharge within a short time frame, the number and timing of presentations places a significant burden on EDs. ERD harm reduction and improved management of minor harms at licensed venues could reduce this burden.

Heavy alcohol consumption among marginalised African refugee young people in Melbourne, Australia: motivations for drinking, experiences of alcohol-related problems and strategies for managing drinking

ABSTRACT Objective. Little is known about substance use among resettled refugee populations. This study aimed to describe motivations for drinking, experiences of alcohol-related problems and strategies for managing drinking among marginalised African refugee young people in Melbourne, Australia. Design. Face-to-face interviews were conducted with 16 self-identified African refugees recruited from street-based settings in 2012–2013. Interview transcripts were analysed inductively to identify key themes. Results. Participants gathered in public spaces to consume alcohol on a daily or near-daily basis. Three key motivations for heavy alcohol consumption were identified: drinking to cope with trauma, drinking to cope with boredom and frustration and drinking as a social experience. Participants reported experiencing a range of health and social consequences of their alcohol consumption, including breakdown of family relationships, homelessness, interpersonal violence, contact with the justice system and poor health. Strategies for managing drinking included attending counselling or residential detoxification programmes, self-imposed physical isolation and intentionally committing crime in order to be incarcerated. Conclusion. These findings highlight the urgent need for targeted harm reduction education for African young people who consume alcohol. Given the importance of social relationships within this community, use of peer-based strategies are likely to be particularly effective. Development and implementation of programmes that address the underlying health and psychosocial causes and consequences of heavy alcohol use are also needed.