Jacob M. Izenberg

Integration of health services improves multiple healthcare outcomes among HIV-infected people who inject drugs in Ukraine.

BACKGROUND People who inject drugs (PWID) experience poor outcomes and fuel HIV epidemics in middle-income countries in Eastern Europe and Central Asia. We assess integrated/co-located (ICL) healthcare for HIV-infected PWID, which despite international recommendations, is neither widely available nor empirically examined. METHODS A 2010 cross-sectional study randomly sampled 296 HIV-infected opioid-dependent PWID from two representative HIV-endemic regions in Ukraine where ICL, non-co-located (NCL) and harm reduction/outreach (HRO) settings are available. ICL settings provide onsite HIV, addiction, and tuberculosis services, NCLs only treat addiction, and HROs provide counseling, needles/syringes, and referrals, but no opioid substitution therapy (OST). The primary outcome was receipt of quality healthcare, measured using a quality healthcare indicator (QHI) composite score representing percentage of eight guidelines-based recommended indicators met for HIV, addiction and tuberculosis treatment. The secondary outcomes were individual QHIs and health-related quality-of-life (HRQoL). RESULTS On average, ICL-participants had significantly higher QHI composite scores compared to NCL- and HRO-participants (71.9% versus 54.8% versus 37.0%, p<0.001) even after controlling for potential confounders. Compared to NCL-participants, ICL-participants were significantly more likely to receive antiretroviral therapy (49.5% versus 19.2%, p<0.001), especially if CD4 ≤ 200 (93.8% versus 62.5% p<0.05); guideline-recommended OST dosage (57.3% versus 41.4%, p<0.05); and isoniazid preventive therapy (42.3% versus 11.2%, p<0.001). Subjects receiving OST had significantly higher HRQoL than those not receiving it (p<0.001); however, HRQoL did not differ significantly between ICL- and NCL-participants. CONCLUSIONS These findings suggest that OST alone improves quality-of-life, while receiving care in integrated settings collectively and individually improves healthcare quality indicators for PWID.

Risk behaviour and HIV prevalence among men who have sex with men in a multiethnic society: a venue-based study in Kuala Lumpur, Malaysia.

This research aimed to determine HIV prevalence, risk behaviour and knowledge of transmission methods among men who have sex with men (MSM) in Kuala Lumpur, Malaysia. Venue–day–time sampling (VDTS) was applied to identify venues where men congregate to solicit sex from other men. Participants recruited from clubs, massage parlours, saunas and one park self-completed a computerized behavioural questionnaire, were administered an oral rapid HIV test and given the opportunity to return later to receive full counselling and learn their HIV status. A total of 517 men were enrolled into the study. The majority were Malays (47.0%) and Chinese (43.7%). Twenty tested HIV positive (3.9%). Significant predictors of HIV infection included having unprotected anal sex with a casual partner (44.9% of participants, odds ratio [OR] = 2.99; 95% confidence interval [CI] 1.13–7.90; P = 0.027), having unprotected receptive anal sex (27.9%, OR = 2.71; 95% CI 1.10–6.54; P = 0.030) and having group sex (33.3%, OR = 3.95; 95% CI 1.55–10.09; P = 0.004). One in five participants (20.1% and 19.5%) did not believe that HIV could be transmitted through insertive or receptive anal sex, respectively. Risk behaviour is high and knowledge of HIV transmission methods was low among MSM in Kuala Lumpur. Future prevention efforts should focus on providing risk reduction education to this community.

High rates of police detention among recently released HIV-infected prisoners in Ukraine: Implications for health outcomes

BACKGROUND Ukraines HIV epidemic, primarily affecting people who inject drugs (PWID), is expanding and transitioning despite free opioid substitution therapy (OST) and antiretroviral therapy (ART), two effective ways to reduce HIV transmission. Police detention of PWID not resulting in a formal charge or imprisonment is common, but its prevalence and impact on health are not known. METHOD HIV-infected individuals (N=97) released from prison within one year were recruited and surveyed in two HIV-endemic Ukrainian cities about post-release police detention experiences. Data on the frequency of police detention, related adverse events, and impact on OST and ART continuity were collected, and correlates of detention were examined using logistic regression. RESULTS Detention responses were available for 94 (96.9%) participants, of which 55 (58.5%) reported police detentions (mean=9.4 per person-year). For those detained while prescribed OST (N=28) and ART (N=27), medication interruption was common (67.9% and 70.4%, respectively); 23 of 27 participants prescribed OST (85.2%) were detained en route to/from OST treatment. Significant independent correlates of detention without charges included post-release ART prescription (AOR 4.98, p=0.021), current high-risk injection practices (AOR 5.03, p=0.011), male gender (AOR 10.88, p=0.010), and lower lifetime months of imprisonment (AOR 0.99, p=0.031). CONCLUSIONS HIV-infected individuals recently released from prison in Ukraine experience frequent police detentions, resulting in withdrawal symptoms, confiscation of syringes, and interruptions of essential medications, including ART and OST. Structural changes are urgently needed to reduce police detentions in order to control HIV transmission and improve both individual and public health.

NEXT STEPS FOR UKRAINE ABOLITION OF HIV REGISTRIES, IMPLEMENTATION OF ROUTINE HUMAN IMMUNODEFICIENCY VIRUS TESTING AND EXPANSION OF SERVICES

Booth et al. should be congratulated on a rigorously conducted study with a challenging population. Their work demonstrated that compared to an indigenous leader outreach model, a less-expensive, briefer counseling intervention was equally effective at reducing sexual and injection risk-taking [1]. The data also confirm that learning ones own HIV+ status significantly reduces sexual HIV risk-taking, independently from each intervention. These data are consistent with findings elsewhere where an HIV+ diagnosis alone reduces sexual risk [2]. Knowing ones HIV+ status is essential for accessing life-saving antiretroviral treatment, itself an intervention associated with decreased HIV transmission [3]. On a population level, widespread treatment with antiretroviral medications is a powerful tool in controlling the HIV epidemic among all affected groups [4]. Why then has Ukraine not embarked upon incredibly cost-effective strategies [5] to increase HIV identification through deployment of routine testing? Routine testing would be most effective if multiple barriers were removed, including name-based registration programs (e.g. HIV and drug dependence) and pre-test counseling. HIV registries and voluntary testing programs stigmatize patients and discourage testing of high-risk individuals, particularly when risk-behaviors are assessed. Moreover, HIV registries and pre-test counseling add significant costs that detract from treatment and prevention, especially in the current global economic climate. In particular, implementation of routine testing could effectively be conducted at existing settings, including where patients are treated for substance abuse, tuberculosis, inpatient services and in newly-created integrated care settings [6]. The criminal justice system would also greatly benefit from routine HIV testing [7] in ways that Booth et al elegantly demonstrated for community outreach and harm reduction programs. These latter sites may serve as sentinel sites for initiating care for HIV and opioid substitution therapy (OST) and greatly contribute to controlling the HIV epidemic. Though stimulants exist in Ukraine, opioids remain the mainstay of drug dependence. Therefore, wider implementation of OST is urgently needed. While identifying HIV+ status reduces sexual risk-behaviors, OST dramatically reduces injection risk-behaviors [8]. Indeed, since Booths study, both buprenorphine and methadone have been introduced, but not at a sufficient magnitude to curb the HIV epidemic [9]. Though progress has been made since 2005, considerable legal, political, economic and social barriers continue to impede HIV prevention and treatment efforts. Laws regulating the transportation, storage, and dispensing of opioid treatment therapies currently hamper widespread access. Hospitals rarely offer OST, forcing hospitalized IDUs into agonizing forced-abstinence. Regulations requiring observed, daily OST dosing create a disincentive for patients wanting to return to the workforce. Requirements that physicians dispense OST create unneeded expense and distract them from attending to more complex cases. Laws that ban drivers licenses for OST patients are similarly ill-advised, limiting uptake of OST and further endangering society by encouraging active drug users to remain out of treatment and to drive under the influence of illicit drugs. In the political and economic arena, ideology and stigma regarding HIV prevention and treatment must be set aside to counter the explosive spread of HIV in Ukraine. Though seemingly daunting, effective HIV containment strategies now exist that will facilitate better health for all Ukrainians. The time to implement them is now.

Within-prison drug injection among HIV-infected Ukrainian prisoners: Prevalence and correlates of an extremely high-risk behaviour

BACKGROUND In Ukraine, HIV-infection, injection drug use, and incarceration are syndemic; however, few services are available to incarcerated people who inject drugs (PWIDs). While data are limited internationally, within-prison drug injection (WP-DI) appears widespread and may pose significant challenges in countries like Ukraine, where PWIDs contribute heavily to HIV incidence. To date, WP-DI has not been specifically examined among HIV-infected prisoners, the only persons that can transmit HIV. METHODS A convenience sample of 97 HIV-infected adults recently released from prison within 1-12 months was recruited in two major Ukrainian cities. Post-release surveys inquired about WP-DI and injection equipment sharing, as well as current and prior drug use and injection, mental health, and access to within-prison treatment for HIV and other comorbidities. Logistic regression identified independent correlates of WP-DI. RESULTS Complete data for WP-DI were available for 95 (97.9%) respondents. Overall, 54 (56.8%) reported WP-DI, among whom 40 (74.1%) shared injecting equipment with a mean of 4.4 (range 0-30) other injectors per needle/syringe. Independent correlates of WP-DI were recruitment in Kyiv (AOR 7.46, p=0.003), male gender (AOR 22.07, p=0.006), and active pre-incarceration opioid use (AOR 8.66, p=0.005). CONCLUSIONS Among these recently released HIV-infected prisoners, WP-DI and injection equipment sharing were frequent and involved many injecting partners per needle/syringe. The overwhelming majority of respondents reporting WP-DI used opioids both before and after incarceration, suggesting that implementation of evidence-based harm reduction practices, such as opioid substitution therapy and/or needle/syringe exchange programmes within prison, is crucial to addressing continuing HIV transmission among PWIDs within prison settings. The positive correlation between Kyiv site and WP-DI suggests that additional structural interventions may be useful.

Pre-incarceration police harassment, drug addiction and HIV risk behaviours among prisoners in Kyrgyzstan and Azerbaijan: results from a nationally representative cross-sectional study

The expanding HIV epidemic in Azerbaijan and Kyrgyzstan is concentrated among people who inject drugs (PWID), who comprise a third of prisoners there. Detention of PWID is common but its impact on health has not been previously studied in the region. We aimed to understand the relationship between official and unofficial (police harassment) detention of PWID and HIV risk behaviours.

Hospitality Invites Sociability, Which Builds Cohesion: a Model for the Role of Main Streets in Population Mental Health

The aim of this study was to investigate the contribution of main streets to community social cohesion, a factor important to health. Prior work suggests that casual contact in public space, which we call “sociability,” facilitates more sustained social bonds in the community. We appropriate the term “hospitality” to describe a main street’s propensity to support a density of such social interactions. Hospitality is a result of the integrity and complex contents of the main street and surrounding area. We examine this using a typology we term “box-circle-line” to represent the streetscape (the box), the local neighborhood (the circle), and the relationship to the regional network of streets (the line). Through field visits to 50 main streets in New Jersey and elsewhere, and a systematic qualitative investigation of main streets in a densely interconnected urban region (Essex County, New Jersey), we observed significant variation in main street hospitality, which generally correlated closely with sociability. Physical elements such as street wall, neighborhood elements such as connectivity, inter-community elements such as access and perceived welcome, and socio-political elements such as investment and racial discrimination were identified as relevant to main street hospitality. We describe the box-circle-line as a theoretical model for main street hospitality that links these various factors and provides a viable framework for further research into main street hospitality, particularly with regard to geographic health disparities.

Perceptions of Health-Related Community Reentry Challenges among Incarcerated Drug Users in Azerbaijan, Kyrgyzstan, and Ukraine

Facing competing demands with limited resources following release from prison, people who inject drugs (PWID) may neglect health needs, with grave implications including relapse, overdose, and non-continuous care. We examined the relative importance of health-related tasks after release compared to tasks of everyday life among a total sample of 577 drug users incarcerated in Ukraine, Azerbaijan, and Kyrgyzstan. A proxy measure of whether participants identified a task as applicable (easy or hard) versus not applicable was used to determine the importance of each task. Correlates of the importance of health-related reentry tasks were analyzed using logistic regression, with a parsimonious model being derived using Bayesian lasso method. Despite all participants having substance use disorders and high prevalence of comorbidities, participants in all three countries prioritized finding a source of income, reconnecting with family, and staying out of prison over receiving treatment for substance use disorders, general health conditions, and initiating methadone treatment. Participants with poorer general health were more likely to prioritize treatment for substance use disorders. While prior drug injection and opioid agonist treatment (OAT) correlated with any interest in methadone in all countries, only in Ukraine did a small number of participants prioritize getting methadone as the most important post-release task. While community-based OAT is available in all three countries and prison-based OAT only in Kyrgyzstan, Kyrgyz prisoners were less likely to choose help staying off drugs and getting methadone. Overall, prisoners consider methadone treatment inapplicable to their pre-release planning. Future studies that involve patient decision-making and scale-up of OAT within prison settings are needed to better improve individual and public health.

Health in changing neighborhoods: A study of the relationship between gentrification and self-rated health in the state of California

HighlightsOverall, gentrification was not associated with self‐rated health in California.However, among blacks, gentrification increased odds of fair/poor self‐rated health.No association was seen for other major racial/ethnic groups.Gentrification may play a role in perpetuating racial/ethnic health disparities.

Gentrification and binge drinking in California neighborhoods: It matters how long you’ve lived there

Background Neighborhood context plays a role in binge drinking, a behavior with major health and economic costs. Gentrification, the influx of capital and residents of higher socioeconomic status into historically-disinvested neighborhoods, is a growing trend with the potential to place urban communities under social and financial pressure. Hypothesizing that these pressures and other community changes resulting from gentrification could be tied to excessive alcohol consumption, we examined the relationship between gentrification and binge drinking in California neighborhoods. Methods California census tracts were categorized as non-gentrifiable, stable (gentrifiable), or gentrifying from 2006–2015. Outcomes and covariates were obtained from the California Health Interview Survey using combined 2013–2015 data (n = 60,196). Survey-weighted logistic regression tested for associations between gentrification and any binge drinking in the prior 12 months. Additional models tested interactions between gentrification and other variables of interest, including housing tenure, federal poverty level, race/ethnicity, sex, and duration of neighborhood residence. Results A third of respondents reported past-year binge drinking. Controlling for demographic covariates, gentrification was not associated with binge drinking in the population overall (AOR = 1.13, 95% CI = 0.95–1.34), but was associated with binge drinking among those living in the neighborhood <5 years (AOR = 1.49, 95% CI 1.15–1.93). No association was seen among those living in their neighborhood ≥5 years. Conclusions For those newer to their neighborhood, gentrification is associated with binge drinking. Further understanding the relationship between gentrification and high-risk alcohol use is important for policy and public health interventions mitigating the impact of this process.