Ernest Drucker

Epidemiology of chronic hepatitis C virus infection in sub-Saharan Africa

Hepatitis C virus (HCV) is a major cause of chronic liver disease in the world. The WHO estimates that 3% (170 million) of the worlds population are chronically infected with HCV. Sub-Saharan Africa is of great interest because it is reported to have the highest HCV prevalence rate (5.3%), and a concurrent HIV epidemic. In our review of the published literature we found consistent evidence of high HCV prevalence in many countries of Africa. We estimate the overall prevalence of HCV in Sub-Saharan Africa is 3.0%. The central African region has the highest estimated prevalence of 6%, west Africa has an estimated prevalence of 2.4%, and southern and east Africa with the lowest estimated prevalence of 1.6%. Given low sexual transmission of HCV and infrequency of intravenous drug use in Sub-Saharan Africa, iatrogenic causes of HCV transmission need to be further evaluated.

An opportunity lost: HIV infections associated with lack of a national needle-exchange programme in the USA

BACKGROUND Our aim was to estimate the number of HIV infections that could have been prevented had needle-exchange programmes been implemented during the early stages of the AIDS epidemic in the USA. We also estimated the cost to the US health-care system to treat these preventable HIV infections. METHODS The formula we used to calculate the annual number of preventable HIV infections accounted for the effectiveness and level of use of needle-exchange programmes, as well as sexual transmission to injection drug users (IDUs) and secondary transmission to their sexual partners and children. Data for the model were obtained from epidemiological and mathematical studies in peer-reviewed published research, government reports, and consultations with experts. Using data from Australia as a model, we calculated the number of HIV infections that could have been prevented by a national needle-exchange programme in the USA between 1987 and 1995. Cost calculations were based on the current US government estimate of the discounted lifetime cost of treating an HIV infection (US

The injection century: massive unsterile injections and the emergence of human pathogens

55640). FINDINGS Our conservative calculation of the number of HIV infections that could have been prevented ranged from 4394 (15% incidence reduction due to needle exchanges) to 9666 (33% incidence reduction). The cost to the US health-care system of treating these preventable HIV infections is between US

HIV infections in sub-Saharan Africa not explained by sexual or vertical transmission

244 million and US

Impact of the AIDS epidemic on morbidity and mortality among intravenous drug users in a New York City methadone maintenance program.

538 million, respectively. If current US policies are not changed, we estimate that an additional 5150-11329 preventable HIV infections could occur by the year 2000. INTERPRETATION The failure of the federal government in the USA to implement a national needle-exchange programme, despite six government-funded reports in support of needle exchanges, may have led to HIV infection among thousands of IDUs, their sexual partners, and their children. Revoking the US government ban on funding for needle-exchange programmes and accelerating the growth of such programmes in the USA are urgent public-health priorities.

Childhood tuberculosis in the Bronx, New York.

1that every year unsafe injections result in 80 000–160 000 new HIV-1 infections, 8–16 million hepatitis B infections, and 2·3–4·7 million hepatitis C infections worldwide (this figure does not include transfusions). Together, these illnesses account for 1·3 million deaths and 23 million years of lost life. 1 Even under the auspices of WHO regional immunisation programmes, which constitute 10% of all mass vaccination campaigns, an estimated 30% of injections are done with unclean syringes that are commonly reused. And, for other medicinal injections, over 50% are deemed unsafe, with rates as high as 90% in some campaigns. 1

AIDS and Addiction in New York City

An expanding body of evidence challenges the conventional hypothesis that sexual transmission is responsible for more than 90% of adult HIV infections in Africa. Differences in epidemic trajectories across Africa do not correspond to differences in sexual behaviour. Studies among African couples find low rates of heterosexual transmission, as in developed countries. Many studies report HIV infections in African adults with no sexual exposure to HIV and in children with HIV-negative mothers. Unexplained high rates of HIV incidence have been observed in African women during antenatal and postpartum periods. Many studies show 20%–40% of HIV infections in African adults associated with injections (though direction of causation is unknown). These and other findings that challenge the conventional hypothesis point to the possibility that HIV transmission through unsafe medical care may be an important factor in Africas HIV epidemic. More research is warranted to clarify risks for HIV transmission through health care.

Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved paradigm

To examine the impact of the AIDS epidemic on morbidity and mortality in a defined population of intravenous drug users, we analyzed overall and cause-specific death rates, AIDS incidence, and acute medical hospitalizations among patients in a long-term methadone maintenance program in New York City for the years 1984 through 1987 (midyear population for each year 828 to 891; demographic characteristics did not differ). The number of deaths while in treatment increased from 11 (13.3/1000) in 1984 to 39 (44.2/1000) in 1987. Deaths from AIDS increased from 3.6/1000 to 14.7/1000, deaths due to bacterial pneumonia/sepsis from 3.6/1000 to 13.6/1000; deaths from cirrhosis, drug overdose, trauma, and other causes remained relatively stable. AIDS incidence rose from six cases/1000 in 1984 to 20.4.1000 in 1987. Hospitalizations for AIDS, pneumonia, tuberculosis, and endocarditis/sepsis increased from 84.9/1000 in 1986 to 144.8/1000 in 1987. These data suggest that the AIDS epidemic has had a profound effect on patterns of morbidity and mortality among intravenous drug users in this methadone program population. Drug treatment programs may be important sites for targeting clinical services for drug users with AIDS, although the increasing burden of AIDS-related disease will require expansion of existing funding and treatment resources.

Beliefs About Methadone in an Inner-City Methadone Clinic

The resurgence of tuberculosis (TB) in New York City in the period 1978-92 has been closely linked to the AIDS epidemic but the increase of active TB in areas of urban poverty also implies increased community exposure. We have examined the ecological relation between community rates of AIDS and residential crowding and cases of active TB in Bronx children under age 5. Residential crowding was defined as the percent of households with more than 1 person per room. All childhood TB cases reported between 1986 and 1992 for the Bronx (n = 75) were included. Cumulative AIDS mortality rates for adult females through 1990 represented community HIV burden. All data were coded by the 64 health areas of the borough. We examined trends in these data and used Poisson regression to model the effect of HIV burden and residential crowding on TB risk. For the Bronx as a whole the two variables of TB and residential crowding showed a clear temporal correspondence for the period 1970-90. Residential crowding was associated with poverty and greater dependence on public assistance, large household size, Hispanic ethnicity, and a higher proportion of young children. The overall TB case rate increased with the proportion of crowded households, with a rise from 1.47 to over 8 cases per 10,000 children as the proportion of crowded households increased. At both the lowest and highest levels of AIDS mortality in these areas, the childhood TB risk increased as crowding increased. Children living in areas of the Bronx in which over 12 percent of homes are severely overcrowded were 5.6-fold more likely to develop active TB, even after holding constant the presumed HIV burden in each local community. While HIV infection, the newest risk factor for TB, appears to play a critical role in the resurgent epidemic, our findings show that the earliest known TB risk factors, poverty and household crowding, are still potent forces.

A prospective longitudinal study of neuropsychological and psychosocial factors in asymptomatic individuals at risk for HTLV-III/LAV infection in a methadone program: preliminary findings.

The association between AIDS and intravenous drug abuse is emerging as a critical component of the AIDS epidemic due to several factors: the high rate of infection of this group with the HTLV-III virus-approximately 50%; the risk of infection to others through shared needles, sexual contact, and intrauterine transmission to the fetus; and the impact of large numbers of new cases of AIDS among addicts on the health care services of a few urban areas. This paper outlines the projected dimensions of the AIDS epidemic among intravenous drug abusers in New York City and its implications for hospital utilization and local health care expenditures. These considerations indicate the urgent need for a rapid expansion of addiction treatment services and modification of treatment objectives to deal with this new problem.