Kamyar Arasteh

HIV Incidence Among Injection Drug Users in New York City, 1990 to 2002: Use of Serologic Test Algorithm to Assess Expansion of HIV Prevention Services

OBJECTIVES We sought to estimate HIV incidence among injection drug users (IDUs) in New York City from 1990 to 2002 to assess the impact of an expansion of syringe exchange services. Syringe exchange increased greatly during this period, from 250,000 to 3,000,000 syringes exchanged annually. METHODS Serum samples were obtained from serial cross-sectional surveys of 3,651 IDUs. HIV-positive samples were tested with the Serologic Test Algorithm for Recent HIV Seroconversion (STARHS) assay to identify recent HIV infections and to estimate HIV incidence. Consistency with other incidence studies was used to assess strengths and limitations of STARHS. RESULTS HIV incidence declined from 3.55/100 person-years at risk (PYAR) from 1990-1992, to 2.63/100 PYAR from 1993-1995, to 1.05/100 PYAR from 1996-1998, and to 0.77/100 PYAR from 1999-2002 (P<.001). There was a very strong negative linear relationship (r= -.99, P<.005) between the annual numbers of syringes exchanged and estimated HIV incidence. These results were highly consistent with a large number of shorter incidence studies among IDUs conducted during the time period. CONCLUSIONS STARHS testing of samples from large serial cross-sectional surveys can provide important data for the assessment of community-level HIV prevention.

Alcohol and HIV sexual risk behaviors among injection drug users

We analyzed data from 6341 injection drug users (IDUs) entering detoxification or methadone maintenance treatment in New York City between 1990 and 2004 to test the hypothesis that alcohol use and intoxication is associated with increased HIV sexual risk behaviors. Two types of associations were assessed: (1) a global association (i.e., the relationship between HIV sexual risk behaviors during the 6 months prior to the interview and at-risk drinking in that period, defined as more than 14 drinks per week for males or 7 drinks per week for females), and (2) an event-specific association (i.e., the relationship between HIV sexual risk behaviors during the most recent sex episode and alcohol intoxication during that episode). Sexual risk behaviors included multiple sex partners and engaging in unprotected sex. After adjusting for the effects of other variables, at-risk-drinkers were more likely to report multiple sex partners and engaging in unprotected sex with casual sex partners (both global associations). IDUs who reported both they and their casual partners were intoxicated during the most recent sex episode were more likely to engage in unprotected sex (an event-specific association). We also observed two significant interactions. Among IDUs who did not inject cocaine, moderate-drinkers were more likely to report multiple partners. Among self-reported HIV seropositive IDUs, when both primary partners were intoxicated during the most recent sex episode they were more likely to engage in unprotected sex. These observations indicate both global and event-specific associations of alcohol and HIV sexual-risk behaviors.

Are females who inject drugs at higher risk for HIV infection than males who inject drugs: An international systematic review of high seroprevalence areas

OBJECTIVE There are multiple reasons why females who inject drugs may be more likely to become infected with HIV than males who inject drugs. Where this is the case, special HIV prevention programs for females would be needed. DESIGN International systematic review and meta-analysis of studies across 14 countries. METHODS Countries with high seroprevalence (>20%) HIV epidemics among persons who inject drugs (PWID) were identified from the Reference Group to the UN on HIV and Injecting Drug Use. Systematic literature reviews collected data on HIV prevalence by gender for these countries. Non-parametric and parametric tests along with meta-analytic techniques examined heterogeneity and differences in odds ratios (OR) across studies. RESULTS Data were abstracted from 117 studies in 14 countries; total sample size N = 128,745. The mean weighted OR for HIV prevalence among females to males was 1.18 [95% CI 1.10-1.26], with high heterogeneity among studies (I(2)= 70.7%). There was a Gaussian distribution of the log ORs across studies in the sample. CONCLUSION There was a significantly higher HIV prevalence among females compared to males who inject drugs in high seroprevalence settings, but the effect size is extremely modest. The high level of heterogeneity and the Gaussian distribution suggest multiple causes of differences in HIV prevalence between females and males, with a specific difference determined by local factors. Greater understanding of factors that may protect females from HIV infection may provide insights into more effective HIV prevention for both females and males who inject drugs.

Using hepatitis C virus and herpes simplex virus-2 to track HIV among injecting drug users in New York City

OBJECTIVE To explore the potential utility of hepatitis C virus (HCV) seroprevalence as a biomarker for injection risk, and herpes simplex virus-2 (HSV-2) as a biomarker for sexual risk among injecting drug users (IDUs). We examined the relationships between HCV and HIV and between HSV-2 and HIV among injecting drug users in New York City relative to the large-scale implementation of syringe exchange in the mid-1990s. METHODS 397 injecting drug users were recruited from a drug detoxification program in New York from 2005 to 2007. Informed consent was obtained, a questionnaire covering demographics, drug use and HIV risk was administered. Blood samples were tested for antibody to HIV, HCV and HSV-2. RESULTS Among all subjects, HIV prevalence was 17%, HCV prevalence 72% and HSV-2 prevalence 48%. Among IDUs who began injecting before 1995, HIV was 28%, HCV serostatus was strongly associated with HIV serostatus (AOR=8.96, 95% CI 1.16-69.04) and HSV-2 serostatus was not associated with HIV serostatus (AOR=1.31, 95% CI 0.64-2.67). Among subjects who began injecting in 1995 or later, HIV was 6%, HCV was not associated with HIV (AOR=1.04, 95% CI 0.27-4.08) and HSV-2 serostatus was strongly related to HIV serostatus (AOR=10.71, 95% CI 1.18-97.57). CONCLUSIONS HCV and HSV-2 HCV and HSV-2 may provide important new tools for monitoring evolving HIV epidemics among IDUs. Reconsideration of the current CDC hierarchical transmission risk classification system may also be warranted.

HIV among drug users at Beth Israel Medical Center, New York City, the first 25 years.

New York City experienced the first and largest HIV epidemic among injecting drug users (IDUs). Using data collected from IDUs entering the Beth Israel drug detoxification program, we trace the history of this epidemic from the mid-1970s through the early 2000s. The epidemic can best be described in terms of successive stages: (1) introduction and rapid transmission of HIV in the IDU population; (2) stabilization of HIV prevalence at a high level (over 50%); (3) a decline in incidence and prevalence, following large-scale implementation of syringe exchange programs; and (4) a sexual transmission phase, in which HIV prevalence is approximately equal among injecting and noninjecting heroin and cocaine users, and sexual transmission is more important than injecting-related transmission among IDUs. Given the current spread of HIV among IDUs in many places in the world, New York City provides a very strong example for implementation of large-scale comprehensive syringe exchange programs as early as possible in HIV epidemics among IDUs.

HIV among injecting drug users: current epidemiology, biologic markers, respondent-driven sampling, and supervised-injection facilities.

Purpose of reviewTo describe recent research done primarily during the past 12 months (i.e., primarily in 2008) on the epidemiology of HIV infection among injecting drug users (IDUs). Recent findingsMajor research developments include a global assessment of HIV infection among IDUs and evidence of a transition from epidemics concentrated among IDUs to generalized, heterosexual epidemics in eastern Europe and Asia. Intervention research also includes several studies of supervised-injecting facilities. Methodological research includes respondent-driven sampling and the use of hepatitis C virus and herpes simplex virus-2 as biomarkers for injecting and sexual risk. SummaryThere have been important advances in research during the past year, but HIV infection continues to spread rapidly across many areas of the world among IDUs and their nondrug-using sex partners.

Transitions from Injection-Drug-Use-Concentrated to Self-Sustaining Heterosexual HIV Epidemics: Patterns in the International Data

Background Injecting drug use continues to be a primary driver of HIV epidemics in many parts of the world. Many people who inject drugs (PWID) are sexually active, so it is possible that high-seroprevalence HIV epidemics among PWID may initiate self-sustaining heterosexual transmission epidemics. Methods Fourteen countries that had experienced high seroprevalence (<20%) HIV epidemics among PWID and had reliable data for injection drug use (IDU) and heterosexual cases of HIV or AIDS were identified. Graphs of newly reported HIV or AIDS cases among PWID and heterosexuals were constructed to identify temporal relationships between the two types of epidemics. The year in which newly reported cases among heterosexuals surpassed newly reported cases among PWID, aspects of the epidemic curves, and epidemic case histories were analyzed to assess whether it was “plausible” or “highly unlikely” that the HIV epidemic among PWID might have initiated the heterosexual epidemic in each country. Results Transitions have occurred in 11 of the 14 countries. Two types of temporal relationships between IDU and heterosexual HIV epidemics were identified, rapid high incidence transitions vs. delayed, low incidence transitions. In six countries it appears “plausible” that the IDU epidemic initiated a heterosexual epidemic, and in five countries it appears “highly unlikely” that the IDU epidemic initiated a heterosexual epidemic. A rapid decline in incidence among PWID after the peak year of new cases and national income were the best predictors of the “highly unlikely” initiation of a heterosexual epidemic. Discussion Transitions from IDU concentrated epidemics to heterosexual epidemics are common in countries with high seroprevalence among PWID though there are distinct types of transitions. Interventions to immediately reduce HIV incidence among PWID may reduce the likelihood that an IDU epidemic may initiate a heterosexual epidemic.

Changes in quality of life (WHOQOL-BREF) and addiction severity index (ASI) among participants in opioid substitution treatment (OST) in low and middle income countries: An international systematic review

BACKGROUND Opioid substitution treatment (OST) can increase quality of life (WHOQOL-BREF) and reduce addiction severity index (ASI) scores among participants over time. OST program participants have noted that improvement in quality of life is one of the most important variables to their reduction in drug use. However, there is little systematic understanding of WHOQOL-BREF and ASI domain changes among OST participants in low and middle-income countries (LMIC). METHODS Utilizing PRISMA guidelines we conducted a systematic literature search to identify OST program studies documenting changes in WHOQOL-BREF or ASI domains for participants in buprenorphine or methadone programs in LMIC. Standardized mean differences for baseline and follow-up domain scores were compared along with relationships between domain scores, OST dosage, and length of follow-up. RESULTS There were 13 OST program studies with 1801 participants from five countries eligible for inclusion in the review. Overall, statistically significant changes were noted in all four WHOQOL-BREF domain and four of the seven ASI domain scores (drug, psychological, legal, and family) documented in studies. Dosage of pharmacologic medication and length of follow-up did not affect changes in domain scores. CONCLUSION WHOQOL-BREF and ASI domain scoring is a useful tool in measuring overall quality of life and levels of addiction among OST participants. Coupled with measurements of blood-borne infection, drug use, relapse, and overdose, WHOQOL-BREF and ASI represent equally important tools for evaluating the effects of OST over time and should be further developed as integrated tools in the evaluation of participants in LMIC.

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.

Incidence and prevalence of hepatitis c virus infection among persons who inject drugs in New York City: 2006-2013

BACKGROUND Hepatitis C virus infection is a source of significant preventable morbidity and mortality among persons who inject drugs (PWID). We sought to assess trends in hepatitis C virus (HCV) infection among PWID from 2006 to 2013 in New York City (NYC). METHODS Annual cross-sectional surveys of PWID entering a large drug abuse treatment program were performed. Risk behavior questionnaires were administered, and HIV and HCV testing were conducted. Comparisons were made with prior prevalence and incidence estimates in 1990-1991 and 2000-2001 reflecting different periods of combined prevention and treatment efforts. RESULTS HCV prevalence among PWID (N: 1535) was 67% (95% CI: 66-70%) during the study period, and was not significantly different from that observed in 2000-2001. The estimated HCV incidence among new injectors (persons injecting for ≤6 years) during 2006-2013 was 19.5/100 PYO (95% CI: 17-23) and did not differ from that observed in 2000-2001 (18/100 PYO, 95% CI: 14-23/100). CONCLUSIONS Despite the expansion of combined prevention programming between 2000-2001 and 2006-2013, HCV prevalence remained high. Estimated HCV incidence among new injectors also remained high, and not significantly lower than in 2000-2001, indicating that expanded combined prevention efforts are needed to control the HCV epidemic among PWID in NYC.