Dita Broz

HIV Infection Linked to Injection Use of Oxymorphone in Indiana, 2014-2015.

BACKGROUND In January 2015, a total of 11 new diagnoses of human immunodeficiency virus (HIV) infection were reported in a small community in Indiana. We investigated the extent and cause of the outbreak and implemented control measures. METHODS We identified an outbreak-related case as laboratory-confirmed HIV infection newly diagnosed after October 1, 2014, in a person who either resided in Scott County, Indiana, or was named by another case patient as a syringe-sharing or sexual partner. HIV polymerase (pol) sequences from case patients were phylogenetically analyzed, and potential risk factors associated with HIV infection were ascertained. RESULTS From November 18, 2014, to November 1, 2015, HIV infection was diagnosed in 181 case patients. Most of these patients (87.8%) reported having injected the extended-release formulation of the prescription opioid oxymorphone, and 92.3% were coinfected with hepatitis C virus. Among 159 case patients who had an HIV type 1 pol gene sequence, 157 (98.7%) had sequences that were highly related, as determined by phylogenetic analyses. Contact tracing investigations led to the identification of 536 persons who were named as contacts of case patients; 468 of these contacts (87.3%) were located, assessed for risk, tested for HIV, and, if infected, linked to care. The number of times a contact was named as a syringe-sharing partner by a case patient was significantly associated with the risk of HIV infection (adjusted risk ratio for each time named, 1.9; P<0.001). In response to this outbreak, a public health emergency was declared on March 26, 2015, and a syringe-service program in Indiana was established for the first time. CONCLUSIONS Injection-drug use of extended-release oxymorphone within a network of persons who inject drugs in Indiana led to the introduction and rapid transmission of HIV. (Funded by the state government of Indiana and others.).

HIV Infection and HIV-Associated Behaviors Among Persons Who Inject Drugs — 20 Cities, United States, 2015

In the United States, 9% of human immunodeficiency virus (HIV) infections diagnosed in 2015 were attributed to injection drug use (1). In 2015, 79% of diagnoses of HIV infection among persons who inject drugs occurred in urban areas (2). To monitor the prevalence of HIV infection and associated behaviors among persons who inject drugs, CDCs National HIV Behavioral Surveillance (NHBS) conducts interviews and HIV testing in selected metropolitan statistical areas (MSAs) (3). The prevalence of HIV infection among persons who inject drugs in 20 MSAs in 2015 was 7%. In a behavioral analysis of HIV-negative persons who inject drugs, an estimated 27% receptively shared syringes and 67% had condomless vaginal sex in the previous 12 months. During the same period, 58% had tested for HIV infection and 52% received syringes from a syringe services program. Given the increased number of persons newly injecting drugs who are at risk for HIV infection because of the recent opioid epidemic (2,4), these findings underscore the importance of continuing and expanding health services, HIV prevention programs, and community-based strategies, such as those provided by syringe services programs, for this population.

Estimates of the size of key populations at risk for HIV infection: men who have sex with men, female sex workers and injecting drug users in Nairobi, Kenya.

Objectives Size estimates of populations at higher risk for HIV infection are needed to help policy makers understand the scope of the epidemic and allocate appropriate resources. Population size estimates of men who have sex with men (MSM), female sex workers (FSW) and intravenous drug users (IDU) are few or non-existent in Nairobi, Kenya. Methods We integrated three population size estimation methods into a behavioural surveillance survey among MSM, FSW and IDU in Nairobi during 2010–2011. These methods included the multiplier method, ‘Wisdom of the Crowds’ and an approach that drew on published literature. The median of the three estimates was hypothesised to be the most plausible size estimate with the other results forming the upper and lower plausible bounds. Data were shared with community representatives and stakeholders to finalise ‘best’ point estimates and plausible bounds based on the data collected in Nairobi, a priori expectations from the global literature and stakeholder input. Results We estimate there are approximately 11 042 MSM with a plausible range of 10 000–22 222, 29 494 FSW with a plausible range of 10 000–54 467 FSW and approximately 6107 IDU and plausibly 5031–10 937 IDU living in Nairobi. Conclusions We employed multiple methods and used a wide range of data sources to estimate the size of three hidden populations in Nairobi, Kenya. These estimates may be useful to advocate for and to plan, implement and evaluate HIV prevention and care programmes for MSM, FSW and IDU. Surveillance activities should consider integrating population size estimation in their protocols.

HIV and STI prevalence and risk factors among male sex workers and other men who have sex with men in Nairobi, Kenya.

Abstract:Previous surveys of men who have sex with men (MSM) in Africa have not adequately profiled HIV status and risk factors by sex work status. MSM in Nairobi, Kenya, were recruited using respondent-driven sampling, completed a behavioral interview, and were tested for HIV and sexually transmitted infections. Overlapping recruitment among 273 male sex workers and 290 other MSM was common. Sex workers were more likely to report receptive anal sex with multiple partners (65.7% versus 18.0%, P < 0.001) and unprotected receptive anal intercourse (40.0% versus 22.8%, P = 0.005). Male sex workers were also more likely to be HIV infected (26.3% versus 12.2%, P = 0.007).

Prevalence of HIV, sexually transmitted infections, and viral hepatitis by Urbanicity, among men who have sex with men, injection drug users, and heterosexuals in the United States.

Background Men who have sex with men (MSM), injection drug users (IDUs), and certain subgroups of heterosexuals are disproportionately affected by the syndemics of HIV, other sexually transmitted infections, and viral hepatitis. Although understanding the burden of these infections in these populations by urbanicity (the degree to which a geographic area is urban) is critical to targeting prevention programs, few studies have done so. Methods We analyzed nationally representative 1999 to 2010 data from the National Health and Nutrition Examination Survey on persons aged 18 to 59 years. We estimated the weighted prevalence of HIV, herpes simplex virus type 2 (HSV-2), human papillomavirus, chlamydia, hepatitis B, and hepatitis C, stratified by urbanicity level, for the overall sample, MSM, IDUs, and heterosexuals. Geographic areas with population at least million are classified into large central and large fringe metropolitan counties. Results Overall, large central metropolitan areas had a higher prevalence of HIV, HSV-2, and hepatitis B. HIV prevalence among MSM was elevated in large central and large fringe metro areas (14.5% and 16.9%, respectively). Among heterosexuals, large central metropolitan areas had elevated prevalence of HSV-2, chlamydia, and hepatitis B. Human papillomavirus and hepatitis C prevalence did not vary significantly by urbanicity for any population, including IDUs. Conclusions Infections with higher prevalence in urban areas merit a geographically focused approach to screening and prevention programs, whereas those with uniform prevalence across levels of urbanicity would benefit from a generalized prevention approach. These nationally representative, population-based data allow for more effective planning for prevention programs.

Risk Environments, Race/Ethnicity, and HIV Status in a Large Sample of People Who Inject Drugs in the United States.

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.

Low HIV testing among persons who inject drugs—National HIV Behavioral Surveillance, 20 U.S. cities, 2012

INTRODUCTION Persons who inject drugs (PWID) continue to be disproportionately affected by HIV. HIV testing is key to reducing HIV transmission by increasing awareness of HIV status and linking HIV-positive persons to care. Using data from PWID participating in CDCs National HIV Behavioral Surveillance (NHBS) system, we examined prevalence of recent HIV testing among PWID by certain characteristics to guide interventions to increase HIV testing. METHODS We analyzed NHBS data from PWID 18 years or older recruited via respondent-driven sampling in 20 US cities in 2012. We examined demographic and behavioral factors associated with recent HIV testing (within 12 months before interview) using a Poisson model to calculate adjusted prevalence ratios (aPRs). RESULTS Of 9555 PWID, 53% had recently tested for HIV. In multivariable analysis, HIV testing was more frequent among participants who visited a healthcare provider (aPR 1.50, P<0.001), participated in alcohol or drug treatment (aPR 1.21, P<0.001), or received an HIV prevention intervention (aPR 1.26, P<0.001). HIV testing was also more frequent among participants who received free sterile syringes (aPR 1.12, P<0.001). DISCUSSION Only half of PWID participating in NHBS in 2012 reported recent HIV testing. HIV testing was more frequent among participants who accessed health and HIV prevention services. To increase HIV testing among PWID, it is important for providers in healthcare and HIV prevention settings to proactively assess risk factors for HIV, including injection drug use, and offer a wide range of appropriate interventions, such as HIV testing.

Antiretroviral Therapy Use Among HIV-Infected People Who Inject Drugs—20 Cities, United States, 2009–2015

Background: Approximately 16% of infections among those living with diagnosed HIV infection in the United States are attributable to injection drug use. Antiretrovirals (ARVs) are recommended for all infected persons to improve health and prevent transmission. Using data from National HIV Behavioral Surveillance, we evaluated changes in ARV use from 2009 to 2015 among HIV-positive people who inject drugs (PWID). Methods: PWID were recruited by respondent-driven sampling in 20 cities. ARV use was defined as self-reported use at the time of interview. Prevalence ratios measuring change in ARV use per 3-year increase in year were estimated using log-linked Poisson regression models with generalized estimating equations. Results: ARV use was 58% (319/548) in 2009, 67% (410/608) in 2012, and 71% (386/545) in 2015. In all 3 cycle years, a higher percentage of ARV treatment was observed among males, PWID of older age (≥50), and PWID with current health insurance. ARV use increased overall, with an adjusted relative increase of 8% per every 3-year increase in year (adjusted prevalence ratio 1.08, 95% confidence interval: 1.03 to 1.12). ARV use also increased among most subgroups. Conclusions: These findings show progress in ARV treatment, although ARV coverage remains low compared with other populations at risk for HIV. Efforts to improve ARV coverage among PWIDs are needed.

Exchange Sex and HIV Infection Among Women Who Inject Drugs—20 US Cities, 2009

Background: Women who inject drugs and who also exchange sex are at increased risk for HIV infection, but data on this population in the United States remain sparse. Methods: This study assessed the prevalence of exchanging sex for money or drugs among women who inject drugs using data from the 2009 US National HIV Behavioral Surveillance (NHBS) system. Prevalence of being HIV-positive (testing positive in NHBS), HIV-positive–unaware (reporting being HIV-negative or unknown status but testing positive in NHBS), and risk behaviors and use of services were compared between women who did and did not exchange sex. The association between exchange sex and being HIV-positive–unaware of the infection was examined using multivariate Poisson models with robust standard errors. Results: Among 2305 women who inject drugs, 39% reported receiving things like money or drugs from ≥1 male partners in exchange for oral, vaginal, or anal sex in the previous 12 months. Women who exchanged sex were more likely to be unemployed, homeless, lack health insurance, have multiple condomless vaginal or anal sex partners, and receptively share syringes. In multivariate analysis, exchange sex was associated with being HIV-positive–unaware (adjusted prevalence ratio 1.97, 95% confidence intervals: 1.31 to 2.97). Conclusions: Prevalence of exchange sex was high in this population. Women who exchange sex were more likely to be socially disadvantaged, report sexual and injection risk, and be HIV-positive–unaware. They represent an important group to reach with HIV prevention, testing, and care services.

Injection-related Risk Behavior and Engagement in Outreach, Intervention and Prevention Services Across 20 Us Cities

Background: Monitoring the effects of HIV prevention efforts on risk behaviors among persons who inject drugs is a key to inform prevention programs and policy. Methods: Using data from the 2012 National HIV Behavioral Surveillance interviews with persons who inject drugs across 20 US cities (n = 10,171), we conducted latent class analysis to identify injection risk classes and assess the relationship between engagement in prevention services and injection-related risk behavior. We conducted stratified analyses to examine the consistency of these associations across different geographical regions. Results: The latent class analysis identified 6 distinct classes of injection-related risk behavior. The class structure was consistent across regions of the United States, but the distribution of risk classes varied significantly across regions. With covariate adjustment, the South had the most high-risk behavior (21%) and the Midwest had the least (6%). Participation in syringe access services and other prevention services was the lowest in the South. Syringe access was associated with a significantly lower likelihood of membership in the highest risk class in all regions except the Midwest. Participation in individual or group intervention with a practical skills component was associated with less risky injection behavior in all regions except the Northeast. Interventions that featured only safer injection information and discussion had no relationship with risk class. Conclusions: Our findings support evidence of the effectiveness of syringe service programs and safer injection skills training in reducing high-risk injection behavior and underscore the need to improve access to these prevention interventions in the South of the United States.