Javier A. Cepeda

Public health and international drug policy.

The Johns Hopkins–Lancet Commission on Drug Policy and Health has sought to examine the emerging scientific evidence on public health issues arising from drug-control policy and to inform and encourage a central focus on public health evidence and outcomes in drug-policy debates, such as the important deliberations of the 2016 UNGASS on drugs. The Commission is concerned that drug policies are often coloured by ideas about drug use and dependence that are not scientifically grounded. The 1998 UNGASS declaration, for example, like the UN drug conventions and many national drug laws, does not distinguish between drug use and drug misuse. A 2015 report by the UN High Commissioner for Human Rights, by contrast, emphasised that drug use “is neither a medical condition, nor does it necessarily lead to drug dependence”. The idea that all drug use is dangerous and evil has led to enforcement-heavy policies and has made it difficult to see potentially dangerous drugs in the same light as potentially dangerous foods, tobacco, and alcohol, for which the goal of social policy is to reduce potential harms.

HIV in people reincarcerated in Connecticut prisons and jails: an observational cohort study

BACKGROUND Reincarceration in prison or jail correlates with non-sustained HIV viral suppression, but HIV treatment outcomes in released prisoners who are reincarcerated have not recently been systematically assessed despite advances in antiretroviral treatment (ART) potency, simplicity, and tolerability. METHODS In a retrospective cohort of reincarcerated inmates with HIV in Connecticut (2005-12), we used longitudinally linked demographic, pharmacy, and laboratory databases to examine correlates of viral suppression. The primary outcome was viral suppression on reincarceration, defined as viral load lower than 400 RNA copies per mL. FINDINGS Of 497 prisoners and jail detainees with HIV, with 934 reincarcerations, individuals were mostly unmarried, uninsured, and black men prescribed a protease-inhibitor-based ART regimen. During the median 329 days (IQR 179-621) between prison release and reincarceration, the proportion of incarceration periods with viral suppression decreased significantly from 52% to 31% (mean HIV-RNA increased by 0·4 log10; p<0·0001), lower than Connecticuts HIV-infected prison population and those prescribed ART nationally. 158 (51%) of 307 individuals with viral suppression on release had viral suppression on reincarceration. Viral suppression on reincarceration was associated with increasing age (adjusted odds ratio [aOR] 1·04, 95% CI 1·01-1·07), being prescribed non-nucleoside reverse transcriptase inhibitor-based regimens (1·63, 1·14-2·34), and having higher levels of medical or psychiatric comorbidity (1·16, 1·03-1·30). INTERPRETATION Identification of individuals most at risk for recidivism and loss of viral suppression might mitigate the risk that repeated reincarceration poses to systems of public health and safety. FUNDING Bristol-Myers Squibb Virology, Patterson Trust, and National Institute on Drug Abuse.

Racial/ethnic disparities in HIV infection among people who inject drugs: an international systematic review and meta-analysis

AIMS The Ethnic Minority Meta-Analysis (EMMA) aims to assess racial/ethnic disparities in HIV infection among people who inject drugs (PWID) across various countries. This is the first report of the data. METHODS Standard systematic review/meta-analysis methods were utilized, including searching for, screening and coding published and unpublished reports and meta-analytical statistics. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement and Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines for reporting methods. Disparities were measured with the odds ratio (OR) for HIV prevalence among ethnic minority PWID compared to ethnic majority PWID; an OR >1.0 indicated higher prevalence among ethnic minorities. RESULTS Racial/ethnic disparities in HIV prevalence among PWID were examined in 131 prevalence reports, with 214 racial/ethnic minority to majority comparisons, comprising 106 715 PWID. Overall, the pooled OR indicates an increased likelihood of higher HIV prevalence among racial/ethnic minority compared to racial/ethnic majority PWID [OR = 2.09, 95% confidence interval (CI): 1.92-2.28]. Among 214 comparisons, 106 produced a statistically significant higher OR for minorities; in 102 comparisons the OR was not significantly different from 1.0; six comparisons produced a statistically significant higher OR for majority group members. Disparities were particularly large in the United States, pooled OR = 2.22 (95% CI: 2.03-2.44). There was substantial variation in ORs-I(2)  = 75.3%: interquartile range = 1.38-3.56-and an approximate Gaussian distribution of the log ORs. CONCLUSIONS Among people who inject drugs, ethnic minorities are approximately twice as likely to be HIV seropositive than ethnic majorities. The great heterogeneity and Gaussian distribution suggest multiple causal factors and a need to tailor interventions to local conditions.

Drug Network Characteristics and HIV Risk Among Injection Drug Users in Russia: The roles of Trust, Size, and Stability

We investigated the influence of drug network characteristics including trust, size, and stability on HIV risk behaviors and HIV testing among injection drug users (IDUs) in St. Petersburg, Russia. Overall, male and female IDUs who reported having high levels of trust in their drug networks were significantly more likely to share syringes than those with lower levels of trust (OR [95% CI]) 2.87 [1.06, 7.81] and 4.89 [1.05, 21.94], respectively). Male and female IDUs in larger drug networks were more likely to share syringes than those in smaller networks (4.21 [1.54, 11.51] and 4.80 [1.20, 19.94], respectively). Characteristics that were significantly associated with not having been HIV tested included drug network instability among men and larger network size among women. High trust, large size, and instability were positively and significantly associated with syringe sharing and not having been HIV tested. Effectiveness of interventions in Russia to reduce the risk of HIV infection may be enhanced if network characteristics are addressed.

High-risk behaviors after release from incarceration among people who inject drugs in St. Petersburg, Russia.

BACKGROUND Injection drug use, infectious disease, and incarceration are inextricably linked in Russia. We aimed to identify factors associated with time to relapse (first opioid injection after release from prison) and using a non-sterile, previously used syringe at relapse in a sample of people who inject drugs in St. Petersburg. METHODS We collected data on time from release to relapse among individuals with a history of incarceration, a subsample of a larger study among people who inject drugs. Proportional hazards and logistic regression were used to identify factors associated with time to relapse and injection with a non-sterile previously used syringe at relapse, respectively. RESULTS The median time to relapse after release was 30 days. Factors that were independently associated with relapsing sooner were being a native of St. Petersburg compared to not being native (AHR: 1.64; 95% CI 1.15-2.33), unemployed at relapse compared to employed (AHR: 4.49; 95% CI 2.96-6.82) and receiving a previous diagnosis of HBV and HCV compared to no previous diagnosis (AHR: 1.49; 95% CI 1.03-2.14). Unemployment at relapse was also significant in modeling injection with a non-sterile, previously used syringe at relapse compared to those who were employed (AOR: 6.80; 95% CI 1.96-23.59). CONCLUSIONS Unemployment was an important correlate for both resuming opioid injection after release and using a non-sterile previously used syringe at relapse. Linkage to medical, harm reduction, and employment services should be developed for incarcerated Russian people who inject drugs prior to release.

Sex-Related Disparities in Criminal Justice and HIV Treatment Outcomes: A Retrospective Cohort Study of HIV-Infected Inmates

OBJECTIVES We evaluated sex-related differences in HIV and criminal justice (CJ) outcomes. METHODS We quantified sex-related differences in criminal offenses, incarcerations, and HIV outcomes among all HIV-infected inmates on antiretroviral therapy (ART) in Connecticut (2005-2012). Computed criminogenic risk scores estimated future CJ involvement. Stacked logistic regression models with random effects identified significant correlates of HIV viral suppression on CJ entry, reflecting preceding community-based treatment. RESULTS Compared with 866 HIV-infected men on ART (1619 incarcerations), 223 women (461 incarcerations) were more likely to be younger, White, and medically insured, with shorter incarceration periods (mean = 196.8 vs 368.1 days), mostly for public disorder offenses. One third of both women and men had viral suppression on CJ entry, correlating positively with older age and having treated comorbidities. Entry viral suppression inversely correlated with incarceration duration for women and with criminogenic risk score for men. CONCLUSIONS In the largest contemporary cohort of HIV-infected inmates on ART, womens higher prevalence of nonviolent offenses and treatable comorbidities supports alternatives to incarceration strategies. Sex-specific interventions for CJ populations with HIV effectively align public health and safety goals.

Advancing global health and strengthening the HIV response in the era of the Sustainable Development Goals: the International AIDS Society—Lancet Commission

Author(s): Bekker, Linda-Gail; Alleyne, George; Baral, Stefan; Cepeda, Javier; Daskalakis, Demetre; Dowdy, David; Dybul, Mark; Eholie, Serge; Esom, Kene; Garnett, Geoff; Grimsrud, Anna; Hakim, James; Havlir, Diane; Isbell, Michael T; Johnson, Leigh; Kamarulzaman, Adeeba; Kasaie, Parastu; Kazatchkine, Michel; Kilonzo, Nduku; Klag, Michael; Klein, Marina; Lewin, Sharon R; Luo, Chewe; Makofane, Keletso; Martin, Natasha K; Mayer, Kenneth; Millett, Gregorio; Ntusi, Ntobeko; Pace, Loyce; Pike, Carey; Piot, Peter; Pozniak, Anton; Quinn, Thomas C; Rockstroh, Jurgen; Ratevosian, Jirair; Ryan, Owen; Sippel, Serra; Spire, Bruno; Soucat, Agnes; Starrs, Ann; Strathdee, Steffanie A; Thomson, Nicholas; Vella, Stefano; Schechter, Mauro; Vickerman, Peter; Weir, Brian; Beyrer, Chris

Morbidity and Mortality Among Community-Based People Who Inject Drugs With a High Hepatitis C and Human Immunodeficiency Virus Burden in Chennai, India

We observed high mortality and liver disease progression associated primarily driven by untreated HIV and chronic hepatitis C as well as alcohol use in a cohort of PWID in India. Interventions to reduce HIV and HCV burden are needed.

Increased Mortality among Persons with Chronic Hepatitis C with Moderate or Severe Liver Disease: A Cohort Study

Background Despite the availability of curative treatment for hepatitis C virus (HCV) infection, because of cost, treatment is often denied until liver fibrosis has progressed to at least moderate fibrosis and, in some cases, cirrhosis. That practice is justified on assumptions that there are no medical consequences to having moderate disease and that disease stage transitions can be anticipated. Methods We performed transient elastography on 964 people chronically infected with HCV with a history of injection drug use living in Baltimore, Maryland. Liver stiffness was evaluated semiannually from 2006 to 2014 using validated cutoffs for moderate fibrosis (8.0-12.3 kPa) and severe fibrosis/cirrhosis (>12.3 kPa). Results Among 964 persons, 62%, 23% and 15% had baseline measurements suggestive of no/mild fibrosis, moderate fibrosis, and severe fibrosis/cirrhosis, respectively. All-cause and nonaccidental mortality were elevated in persons with moderate fibrosis (adjusted hazard ratio [aHR], 1.42 [95% confidence interval {CI}, .96-2.11]; aHR, 1.66 [95% CI, 1.06-2.59], respectively) after adjustment for sociodemographics, substance use, and human immunodeficiency virus status. Despite the increased risk of mortality among those with moderate fibrosis, no combination of demographic, behavioral, and clinical factors, nor changes in stiffness measurements themselves could predict the transition from mild to moderate fibrosis with sufficiently high diagnostic accuracy (C-statistic = 0.72 for best-performing model). Conclusions Delaying treatment for anyone chronically infected with HCV regardless of fibrosis stage may be detrimental given the increased risk of mortality even for those with moderate disease and the inability to predict the transition from mild to moderate disease.

Injection drug network characteristics are important markers of HIV risk behavior and lack of viral suppression

Background: People who inject drugs (PWID) who are highly connected within their injection drug networks may be important HIV transmission nodes if they frequently share syringes with other PWID and are not engaged in HIV care. In India, HIV transmission fueled by injection drug use is increasing; however, little is known about the associations between injection network size and syringe sharing and viral suppression. Methods: We recruited 14,481 PWID between October 2012 and December 2013 by respondent-driven sampling across 15 sites in India. Interviewer-administered questionnaires assessed network characteristics, substance use, HIV testing experience, and access to health services. We used multilevel logistic regression modeling to evaluate the relationship between injection drug network size and (1) syringe sharing at last injection and (2) viral suppression among HIV-positive participants (<150 copies/mL). Findings: The median injection network size was 3 (interquartile range: 1–5), and 7% of participants injected with >10 members in the past 30 days. PWID who had >10 members in their network were 1.65 times (95% confidence interval: 1.12 to 2.42, P = 0.0111) more likely to have shared a syringe at last injection compared with those in the 0–1 members in their drug networks. In addition, individuals with the largest injection drug networks were 31% (95% confidence interval: 0.53 to 0.90, P = 0.006) less likely to be virally suppressed compared with those in the smallest injection drug networks. Discussion: Individuals with larger networks may be important in HIV transmission within injection drug networks because they were the most likely to engage in recent syringe sharing and least likely to be virally suppressed.