José Pulido

Are Participants in a Street-Based HIV Testing Program Able to Perform Their Own Rapid Test and Interpret the Results?

Objective Availability of over-the-counter rapid HIV tests could improve access to testing those reluctant or unable to use current services. We aimed to evaluate the feasibility of HIV self-testing using a finger-stick whole-blood rapid test (Determine™ HIV Combo) to detect both antigen and antibody. Methods Before being tested, 313 participants in a street-based testing program were given adapted instructions and a test kit, and performed the self-test without supervision. These participants, together with another 207 who performed supervised self-testing, received additional instructions on how to interpret the test results shown in six colour photos and filled out a questionnaire. Logistic regression and generalized estimating equations (GEE) were used in the statistical analysis. Results About 8.0% (95%CI:4.8%–11.2%) obtained an invalid self-test. An invalid result was inversely associated with male participants who had sex with men (OR = 0.3;95%CI:0.1–1.0). Of the 3111 photos interpreted,4.9% (95%CI:4.1–5.7) were incorrect. Only 1.1% (95%CI:0.3–1.8) of the positive results were interpreted as negative. Age 30 or older (OR = 2.1; 95%CI:1.2–3.7), having been born in Latin America (OR = 1.6; 95%CI:1.1–2.2),and not having university education (OR = 2.1;95%CI:1.2–3.7) were associated with misinterpreting test results in the GEE. Participants perceptions of both their proficiency when conducting the test and interpretation were related with actual outcomes. Most participants (83.9%) were more motivated than before to use the self-test in the future, and 51.7% would pay >10 Euros for the test if it was sold in pharmacies. Conclusions This is the first study showing that blood-based self-testing with current technology is feasible in HIV-negative participants demanding the test and without prior training or supervision. Bearing in mind that it was conducted under difficult weather conditions and using a complex kit, over-the-counter tests could be a feasible option to complement current diagnostic strategies. More studies are needed to accommodate technology, minimise interpretation mistakes and provide on-line support.

Impact of the demerit point system on road traffic accident mortality in Spain

Background To assess the effect of the Demerit Point System (DPS), introduced in Spain on 1 July 2006, on the number of fatalities due to road traffic accidents, using a methodology that controls for the seasonal variation and trend in the data series. Methods Time-series analysis by ARIMA models of 29 113 fatalities in road traffic accidents (at the accident scene or within 24 h thereafter), between January 2000 and December 2007. The model permitted estimation of an intervention parameter, together with its 95% CI, to calculate the number of fatalities that would have occurred if the DPS had not been implemented, after controlling for the effect of other measures introduced in 2004. Results It was estimated that 618 persons (95% CI 259 to 977) would have died in traffic accidents in the 18 months after implementation of the DPS had it not been in effect, which represents a reduction of 14.5% (95% CI 6.1% to 23.0%) from a total of 4252 deaths. Conclusion Implementation of the DPS in Spain has led to a significant reduction in the number of traffic accident deaths in the context of a downward trend after the implementation of the 2004 measures.

HCV seroconversion among never-injecting heroin users at baseline: no predictors identified other than starting injection

BACKGROUND Heroin users who do not inject constitute a large pool of drug users with a potentially important impact on public health. We aimed to estimate the incidence of hepatitis C virus (HCV) among heroin users who had never injected (NIDUS) at baseline, and the effect of starting injecting during follow-up, other percutaneous exposures, sharing snorting paraphernalia, cocaine/crack use, and risky sexual behaviour on HCV-seroconversion. METHODS Prospective cohort of 305 HCV-negative NIDUs at baseline, aged 18-30 and street-recruited in three Spanish cities in 2001-2003. Computer-assisted personal interviews were conducted and dried blood-spot samples were collected. Bivariate and multivariable Poisson models were used. RESULTS Among the 305 never-injectors who were HCV-negative at baseline, 197 (64.6%) were followed-up and 21 seroconverted [HCV-incidence rate=5.8/100 person-years at risk (pyar) (95% CI: 3.6-8.9)]. HCV incidence in new-injectors was 28.4/100 pyar [(95% CI, 14.7-49.7) vs. 2.8/100 pyar (95% CI, 1.3-5.4)] among NIDUs. Of the risk exposures considered, starting injecting was the only predictor of HCV-seroconversion [adjusted relative risk=10.1, 95% CI: 3.8-26.7]. CONCLUSION The HCV-seroconversion rate was 10 times higher among new-injectors than never-injectors. No predictors other than starting injecting were found for HCV-seroconversion. Harm reduction interventions to prevent HCV infection should include prevention of drug injection.

Trends of heroin use and heroin injection epidemics in Europe: findings from the EMCDDA treatment demand indicator (TDI).

We estimate trends and geographical differences in the heroin epidemic in the European Union plus Croatia and Turkey by analyzing aggregated data on first heroin treatment admissions (cases) during 2000-2009. In 2005-2009 the proportion of drug injectors was higher in Central and Eastern European countries (CEECs) than in Western European countries (WECs), whereas the opposite occurred with mean age at first heroin use and first treatment. During this period, the number of cases, cases per center, and proportion of injectors in WECs declined, whereas mean age at first treatment and first heroin use increased. The opposite occurred in Turkey, except for proportion of injectors, while trends were less clear in the other CEECs. In the 7 WECs with data, trends in 2000-2005 and 2005-2009 were similar. This suggests that the number of recent-onset heroin users and heroin injectors may have declined some years before the study period, especially in WECs.

Association between cannabis use and non-traffic injuries

BACKGROUND This study aimed to assess the association between cannabis use and unintended non-fatal injuries other than those caused by road crashes. METHODS Cross-sectional data were collected from a nationwide sample of 27,934 subjects surveyed in 2005 in Spain: 14,699 persons aged 15-34 years and 13,235 aged 35-64 years. Logistic regression was used to obtain odds ratios (OR) between patterns of cannabis use and frequency of non-traffic injuries, adjusted for sociodemographic factors and for the use of alcohol, tobacco and other drugs. RESULTS Cannabis use in the last 12 months was associated with a higher frequency of injuries (OR=1.4; 95% CI: 1.2-1.7). The OR in older adults (35-64 year age group) was 1.8 and 1.3 in younger people (15-34 year age group). The strongest associations found were between weekly use of cannabis and injuries from knocks and bumps (OR=5.1; 95% CI 2.9-8.9) and those occurring outside work (OR=3.0; 95% CI 1.8-4.9) in the older adult population. CONCLUSION Although our analysis did not control for behavioural factors, cannabis use is independently associated with an increased frequency of non-traffic injuries, especially in the older adult population. These associations emphasise the need to carry out longitudinal studies addressing the causal links between cannabis use and unintended injuries.

Infrequent opioid overdose risk reduction behaviours among young adult heroin users in cities with wide coverage of HIV prevention programmes

BACKGROUND Opioid overdose risk reduction behaviours include some preventive behaviours to avoid overdoses (PB) and others to avoid death after overdose, such as never using heroin while alone (NUA). Few studies have examined the prevalence and predictors of these behaviours. AIM To establish the prevalence and predictors of PBs and NUA among heroin users, both injectors and non-injectors, in three Spanish cities. METHODS 516 injecting and 475 non-injecting heroin users aged 18-30 were street-recruited in 2001-2003 and interviewed by face-to-face computer-assisted interview. PBs and NUA in the last 12 months were explored using open-ended and precoded questions, respectively. Specific predictors for three PB categories were investigated: control of route of drug administration, control of quantity or type of heroin used, and control of co-use of other drugs. Bivariate and logistic regression methods were used. RESULTS Overall, the most prevalent PBs were: using a stable and not excessive amount of heroin (12.7%), injecting or using the whole heroin dose slowly or dividing it into smaller doses (12.4%), reducing or stopping heroin injection (8.3%), and not mixing heroin with tranquillisers (5.1%). Most PBs were significantly more prevalent among injectors than non-injectors. No one mentioned reducing the amount of heroin after an abstinence period. Some 36.2% had NUA. In multiple regression analysis, knowledge of risk factors for opioid overdose was a predictor of specific PBs, although this was not always the case. Use of syringe exchange programmes was a predictor of PB among injectors. However, attending methadone maintenance treatment (MMT) or other drug-dependence treatment was not a predictor of any opioid overdose reduction behaviour. Only ever having witnessed or experienced an overdose predicted PB in both injectors and non-injectors. CONCLUSIONS The proportion of heroin users with opioid overdose risk reduction behaviours is very low. Additional specific measures to prevent overdose are needed, as well as increased emphasis on reducing the risk of overdose in programmes to prevent HIV and other blood-borne infections in heroin injectors.

Injecting, Sexual Risk Behaviors and HIV Infection in Young Cocaine and Heroin Users in Spain

Aim: To evaluate differences between young cocaine users and heroin users (HUs) regarding the prevalence of sexual and injection risk behavior, and HIV, HCV and HBV infection. Methods: Two community cohorts were recruited in Madrid, Barcelona and Seville; 720 cocaine users, of whom 586 had never used heroin (CUs), and 991 HUs were interviewed. Dried blood spot samples were tested. Results: CUs were less marginalized socially than HUs. Only 0.9% had ever injected versus 64.3%; none had ever injected with borrowed syringes versus 25%; 2.2% had an injecting steady partner in the last 12 months versus 24.9%; 4.8% had ever traded sex versus 16.0%. However, 31.0 versus 12.7% had unprotected sex with more than two occasional partners in the last 12 months; 45.0 versus 21.9% had sniffed through tubes used by more than 10 persons. Only 32.3% knew their HIV status versus 80.3%; 0.4 versus 18.1% were HIV positive; 0.9 versus 51.9% were HCV positive, and 1.5 versus 17.0% were HBV positive. Conclusions: The intense cocaine epidemic has hitherto had little impact on either HIV, HBV or HCV in Spain. However, surveillance should be intensified given the high percentage of CUs having unprotected sex with occasional partners.

Estudios poblacionales en España sobre daños relacionados con el consumo de alcohol

A partir de la revision de los principales articulos cientificos e informes asi como del analisis de algunos datos secundarios, se evaluaron los problemas relacionados con el consumo de alcohol en Espana entre 1990 y 2011. En 2011 pudo ser atribuibles al alcohol el 10% de la mortalidad total y aproximadamente el 30% de la mortalidad por accidente de trafico en la poblacion de 15-64 anos. En esta misma poblacion al menos el 0,8% padecia trastornos por consumo de alcohol, el 5% adicional podia tener problemas que necesitaban evaluacion y aproximadamente el 20% habia tenido alguna intoxicacion etilica aguda (IEA) en el ultimo ano. Las IEA supusieron aproximadamente el 0,5-1,1% de las urgencias hospitalarias. Los costes sociales totales del consumo de alcohol podrian representar el 1% del producto interior bruto. La probabilidad de danos relacionados con el consumo de alcohol es bastante mayor en hombres que en mujeres, con una razon hombre/mujer de mortalidad o danos graves relacionados con alcohol de 3/4, situacion que apenas ha cambiado en los ultimos 20 anos. Los danos relacionados con alcohol han seguido una tendencia descendente, excepto la IEA. En el periodo 1990-2011 la tasa estandarizada de mortalidad relacionada con consumo de alcohol alcohol disminuyo a la mitad. Las grandes lagunas de conocimiento y las incertidumbres sobre los danos poblacionales relacionados con el alcohol en Espana justifican el apoyo institucional a su investigacion y la puesta en marcha de un sistema integral de monitorizacion.

Association between cannabis and cocaine use, traffic injuries and use of protective devices

The effect of cannabis and cocaine use on non-fatal traffic injuries and use of motorcycle helmets or car seatbelts was assessed in a nationwide sample of 17,484 car or motorcycle drivers surveyed in 2005 in Spain. Logistic regression was used to adjust for distance driven and potential confounders. Cocaine use ≥ 1 day/week and cannabis use >4 days/week were associated with more traffic injuries. A positive dose-response relationship was found between frequency of cocaine use and lack of consistent use of protective devices. Interventions to avoid driving under the influence of drugs and to increase use of protective devices among drug users are needed.

High hepatitis C virus prevalence and incidence in a community cohort of young heroin injectors in a context of extensive harm reduction programmes

Background Cohort studies on hepatitis C virus (HCV) among drug injectors are scarcer than studies on HIV. Combined harm reduction interventions (HRIs) can prevent HCV infection. Spain has a medium–high coverage of HRIs. Methods 513 young heroin users who injected drugs in the past 12 months (recent injectors) were street-recruited in 2001–2003 and followed until 2006 in three Spanish cities; 137 were anti-HCV seronegative, 77 of whom had ≥1 follow-up visit. Dried blood spots were tested for anti-HCV. HCV incidence and predictors of infection were estimated using Poisson models. Results At baseline, 73% were anti-HCV positive. Overall incidence (n=77) of HCV seroconversion was 39.8/100 person-years (py) (95% CI 28.7 to 53.8). Excluding non-injectors during follow-up from the analysis (n=57), HCV incidence was 52.9/100 py (95% CI 37.4 to 72.5). Injecting at least weekly (incidence rate ratio (IRR)=5.2 (95% CI 2.5 to 11.1)) and having ≥2 sexual partners (IRR=2.2 (95% CI 1.1 to 4.7)) were independent predictors of HCV seroconversion; drug-injection history <2 years was marginally associated (IRR=2.4 (95% CI 0.9 to 4.7)). HCV incidence may have been underestimated due to differential attrition. Conclusions Despite fairly high HRI coverage among Spanish drug injectors, a distressingly high incidence of HCV in a context of high HCV prevalence was found among young heroin injectors.