Ingrid van Beek

Infection with HIV and hepatitis C virus among injecting drug users in a prevention setting: retrospective cohort study.

Abstract Objectives: To estimate the incidence of HIV and hepatitis C virus and risk factors for seroconversion among a cohort of injecting drug users. Design: Retrospective cohort study. Setting: Primary healthcare facility in central Sydney. Subjects: Injecting drug users tested for HIV-1 antibody (n=1179) and antibodies to hepatitis C virus (n=1078) from February 1992 to October 1995. Main outcome measures: Incidence of HIV-1 and hepatitis C virus among seronegative subjects who injected drugs and underwent repeat testing. Demographic and behavioural risk factors for hepatitis seroconversion. Results: Incidence of HIV-1 among 426 initially seronegative injecting drug users was 0.17/100 person years (two seroconversions) compared with an incidence of hepatitis C virus of 20.9/100 person years (31 seroconversions) among 152 injecting drug users initially negative for hepatitis C virus. Incidence of hepatitis C virus among injecting drug users aged less than 20 years was 75.6/100 person years. Independent risk factors for hepatitis C virus seroconversion were age less than 20 years and a history of imprisonment. Conclusions: In a setting where prevention measures have contributed to the maintenance of low prevalence and incidence of HIV-1, transmission of hepatitis C virus continues at extremely high levels, particularly among young injecting drug users. Key messages The prevalence and incidence of hepatitis C virus is high, while the prevalence and incidence of HIV remains low among injecting drug users Young age and history of imprisonment are risk factors for acquisition of hepatitis C virus infection HIV prevention strategies have been relatively ineffective in preventing hepatitis C virus infection in this population The role of imprisonment in the acquisition of hepatitis C infection should be further investigated

Effective Treatment of Injecting Drug Users With Recently Acquired Hepatitis C Virus Infection

BACKGROUND & AIMS Patients with acute hepatitis C virus (HCV) infection who receive treatment achieve high rates of sustained virologic response (SVR), but few studies have examined outcomes among injecting drug users (IDUs). We evaluated the efficacy of treatment of recent HCV infection in IDUs with acute and early chronic HCV. METHODS We analyzed data from the Australian Trial in Acute Hepatitis C-a prospective study of the natural history and treatment outcomes of patients with recent HCV infection. Participants eligible for the study had their first anti-HCV antibody-positive test result within the past 6 months and either acute clinical HCV within the past 12 months or documented anti-HCV seroconversion within 24 months. Participants with HCV received pegylated interferon-alfa-2a (180 microg/wk, n = 74); those with HCV/human immunodeficiency virus (HIV) co-infection received pegylated interferon-alfa-2a (180 microg/wk) with ribavirin (n = 35) for 24 weeks. RESULTS From June 2004 to February 2008, 167 participants were enrolled in the Australian Trial in Acute Hepatitis C; 79% had injected drugs in the previous 6 months. Among 74 with only HCV, the SVRs were 55% and 72% by intention-to-treat and per-protocol analysis, respectively. In multivariate analyses, baseline factors independently associated with lower SVR included decreased social functioning and current opiate pharmacotherapy. Adherent participants had higher SVR rates (63% vs 29%; P = .025). Of the 35 participants with HCV/HIV co-infection, the SVRs were 74% and 75% by intention-to-treat and per-protocol analysis, respectively. CONCLUSIONS Treatment of recent HCV infection among IDUs, including those with HIV co-infection, is effective. Strategies to engage socially marginalized individuals and increase adherence should improve treatment outcomes in this population.

A double-blind, placebo-controlled trial of modafinil (200 mg/day) for methamphetamine dependence

AIM To examine the safety and efficacy of modafinil (200 mg/day) compared to placebo in the treatment of methamphetamine dependence and to examine predictors of post-treatment outcome. PARTICIPANTS AND DESIGN Eighty methamphetamine-dependent subjects in Sydney, Australia were allocated randomly to modafinil (200 mg/day) (n = 38) or placebo (n = 42) under double-blind conditions for 10 weeks with a further 12 weeks post-treatment follow-up. MEASURES Comprehensive drug use data (urine specimens and self-report) and other health and psychosocial data were collected weekly during treatment and research interviews at baseline, week 10 and week 22. RESULTS Treatment retention and medication adherence were equivalent between groups. There were no differences in methamphetamine abstinence, craving or severity of dependence. Medication-compliant subjects tended to provide more methamphetamine-negative urine samples over the 10-week treatment period (P = 0.07). Outcomes were better for methamphetamine-dependent subjects with no other substance dependence and those who accessed counselling. There were statistically significant reductions in systolic blood pressure (P = 0.03) and weight gain (P = 0.05) in modafinil-compliant subjects compared to placebo. There were no medication-related serious adverse events. Adverse events were generally mild and consistent with known pharmacological effects. CONCLUSIONS Modafinil demonstrated promise in reducing methamphetamine use in selected methamphetamine-dependent patients. The study findings support definitive trials of modafinil in larger multi-site trials.

The health and welfare needs of female and transgender street sex workers in New South Wales

Objectives : To determine the health and welfare status of female and transgender street sex workers and their work‐related experiences. Also to estimate population numbers, determine work locations, and identify the most appropriate education, health and welfare services for this group.

Clearance of hepatitis C virus after newly acquired infection in injection drug users.

A retrospective cohort of injection drug users with newly acquired hepatitis C virus (HCV) infection was established to examine viral clearance. Newly acquired HCV infection was defined by anti-HCV antibody seroconversion within a 2-year interval. Stored serum samples were tested for HCV RNA, with viral clearance defined as >/=2 consecutive negative HCV RNA test results after infection. Ninety-nine cases of HCV infection were identified; 57 had >/=2 HCV RNA test results after infection. Viral clearance occurred in 24 (42%) cases, with Kaplan-Meier estimated probabilities of 23%, 38%, and 40% at 6, 12, and 24 months, respectively.

Adherence to treatment for recently acquired hepatitis C virus (HCV) infection among injecting drug users

BACKGROUND & AIMS Adherence to HCV therapy impacts sustained virological response (SVR) but there are limited data on adherence, particularly among injecting drug users (IDUs). We assessed 80/80 adherence (≥80% of PEG-IFN doses, ≥80% treatment), on-treatment adherence, and treatment completion in a study of treatment of recent HCV infection (ATAHC). METHODS Participants with HCV received pegylated interferon (PEG-IFN) alfa-2a (180μg/week, n=74) and those with HCV/HIV received PEG-IFN alfa-2a with ribavirin (n=35), for a planned 24 weeks. Logistic regression analyses were used to identify predictors of PEG-IFN 80/80 adherence. RESULTS A total of 109 out of 163 patients received treatment (HCV, n=74; HCV/HIV, n=35), with 75% ever reporting IDU. The proportion with 80/80 PEG-IFN adherence was 82% (n=89). During treatment, 14% missed ≥1 dose (on-treatment adherence=99%). Completion of 0-4, 5-19, 20-23, and all 24 weeks of PEG-IFN therapy occurred in 10% (n=11), 14% (n=15), 6% (n=7) and 70% (n=76) of cases, respectively. Participants with no tertiary education were less likely to have 80/80 PEG-IFN adherence (AOR 0.29, p=0.045). IDU prior to or during treatment did not impact 80/80 PEG-IFN adherence. SVR was higher among those patients with ≥80/80 PEG-IFN adherence (67% vs. 35%, p=0.007), but similar among those with and without missed doses during therapy (73% vs. 60%, p=0.309). SVR in those patients discontinuing therapy between 0-4, 5-19, 20-23, and 24 weeks was 9%, 33%, 43%, and 76%, respectively (p<0.001). CONCLUSIONS High adherence to treatment for recent HCV was observed, irrespective of IDU prior to, or during, therapy. Sub-optimal PEG-IFN exposure was mainly driven by early treatment discontinuation rather than missed doses during therapy.

Injecting-related injury and disease among clients of a supervised injecting facility.

BACKGROUND The process of drug injection may give rise to vascular and soft tissue injuries and infections. The social and physical environments in which drugs are injected play a significant role in these and other morbidities. Supervised injecting facilities (SIFs) seek to address such issues associated with public injecting drug use. AIMS Estimate lifetime prevalence of injecting-related problems, injury and disease and explore the socio-demographic and behavioral characteristics associated with the more serious complications. DESIGN, SETTING, PARTICIPANTS Self-report data from 9552 injecting drug users (IDUs) registering to use the Sydney Medically Supervised Injecting Centre (MSIC). FINDINGS Lifetime history of either injecting-related problems (IRP) or injecting-related injury and disease (IRID) was reported by 29% of the 9552 IDUs; 26% (n=2469) reported ever experiencing IRP and 10% (n=972) reported IRID. Prevalence of IRP included difficulties finding a vein (18%), prominent scarring or bruising (14%) and swelling of hands or feet (7%). Prevalence of IRID included abscesses or skin infection (6%), thrombosis (4%), septicaemia (2%) and endocarditis (1%). Females, those who mainly injected drugs other than heroin, and those who reported a history of drug treatment, drug overdose, and/or sex work, were more likely to report lifetime IRID. Frequency and duration of injecting, recent public injecting, and sharing of needles and/or syringes were also independently associated with IRID. CONCLUSIONS IRPs and IRIDs were common. Findings support the imperative for education and prevention activities to reduce the severity and burden of these preventable injecting outcomes. Through provision of hygienic environments and advice on venous access, safer injecting techniques and wound care, SIFs have the potential to address a number of risk factors for IRID.

The reliability of sensitive information provided by injecting drug users in a clinical setting: Clinician-administered versus audio computer-assisted self-interviewing (ACASI)

Abstract Research with injecting drug users (IDUs) suggests greater willingness to report sensitive and stigmatised behaviour via audio computer-assisted self-interviewing (ACASI) methods than during face-to-face interviews (FFIs); however, previous studies were limited in verifying this within the same individuals at the same time point. This study examines the relative willingness of IDUs to report sensitive information via ACASI and during a face-to-face clinical assessment administered in health services for IDUs. During recruitment for a randomised controlled trial undertaken at two IDU-targeted health services, assessments were undertaken as per clinical protocols, followed by referral of eligible clients to the trial, in which baseline self-report data were collected via ACASI. Five questions about sensitive injecting and sexual risk behaviours were administered to participants during both clinical interviews and baseline research data collection. “Percentage agreement” determined the magnitude of concordance/discordance in responses across interview methods, while tests appropriate to data format assessed the statistical significance of this variation. Results for all five variables suggest that, relative to ACASI, FFI elicited responses that may be perceived as more socially desirable. Discordance was statistically significant for four of the five variables examined. Participants who reported a history of sex work were more likely to provide discordant responses to at least one socially sensitive item. In health services for IDUs, information collection via ACASI may elicit more reliable and valid responses than FFI. Adoption of a universal precautionary approach to complement individually tailored assessment of and advice regarding health risk behaviours for IDUs may address this issue.

Prevalence of Production of Virus-Specific Interferon-γ among Seronegative Hepatitis C-Resistant Subjects Reporting Injection Drug Use

This report describes subjects who were highly likely to have been repeatedly exposed to hepatitis C virus (HCV) through injection drug use and who remained negative for anti-HCV antibody. Production of virus-specific interferon- gamma by peripheral blood mononuclear cells was seen in the majority of subjects (72%) and was associated with higher-risk behavior. For 92% of the subjects, results of recombinant immunoblot assays demonstrated faint bands against nonstructural proteins. The immune responses described are likely to have been primed and maintained by episodes of subclinical infection without classic seroconversion and may indicate a hepatitis C-resistant phenotype. Vaccine strategies to mimic this response may provide protection against persistent HCV infection.

The Sydney Medically Supervised Injecting Centre: reducing harm associated with heroin overdose

The Sydney Medically Supervised Injecting Centre (MSIC) commenced operation on a trial basis in May 2001. Operating within a clinical model, the Centres primary objective is to reduce the morbidity and mortality associated with drug overdose. Staff include nurses authorized to administer naloxone to reverse the central nervous system depressant effects of heroin, according to clinical protocols developed and modified for the Centres setting. Data were collected on clients’ drug overdose history, demographics, and recent drug and alcohol use at each subsequent visit. The MSIC registered 3747 injecting drug users and supervised 56 861 injecting episodes (61% to inject heroin, 30% to inject cocaine and 9% other drugs) in the first 18 months of operation. A total of 409 drug overdoses occurred (80% heroin, 15% cocaine and 5% other drugs) during this time. Among the heroin overdoses treated, 25% also required naloxone. Risk factors identified included history of heroin overdose, heroin as the main drug injected, engagement in sex work, frequent attendance at the MSIC, and otherwise injecting in a public place. Being in methadone maintenance treatment and a daily injector at registration were protective. Overall, It is likely that the early intervention provided by the supervised setting of the MSIC reduced the morbidity and mortality that would have otherwise been associated with these drug overdoses had they occurred elsewhere. Better understanding of risk factors for heroin overdose has the potential to also prevent heroin overdose in this and other settings.