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1.  Expanded syringe exchange programs and reduced HIV infection among new injection drug users in Tallinn, Estonia 
BMC Public Health  2011;11:517.
Background
Estonia has experienced an HIV epidemic among intravenous drug users (IDUs) with the highest per capita HIV prevalence in Eastern Europe. We assessed the effects of expanded syringe exchange programs (SEP) in the capital city, Tallinn, which has an estimated 10,000 IDUs.
Methods
SEP implementation was monitored with data from the Estonian National Institute for Health Development. Respondent driven sampling (RDS) interview surveys with HIV testing were conducted in Tallinn in 2005, 2007 and 2009 (involving 350, 350 and 327 IDUs respectively). HIV incidence among new injectors (those injecting for < = 3 years) was estimated by assuming (1) new injectors were HIV seronegative when they began injecting, and (2) HIV infection occurred at the midpoint between first injection and time of interview.
Results
SEP increased from 230,000 syringes exchanged in 2005 to 440,000 in 2007 and 770,000 in 2009. In all three surveys, IDUs were predominantly male (80%), ethnic Russians (>80%), and young adults (mean ages 24 to 27 years). The proportion of new injectors decreased significantly over the years (from 21% in 2005 to 12% in 2009, p = 0.005). HIV prevalence among all respondents stabilized at slightly over 50% (54% in 2005, 55% in 2007, 51% in 2009), and decreased among new injectors (34% in 2005, 16% in 2009, p = 0.046). Estimated HIV incidence among new injectors decreased significantly from 18/100 person-years in 2005 and 21/100 person-years in 2007 to 9/100 person-years in 2009 (p = 0.026).
Conclusions
In Estonia, a transitional country, a decrease in the HIV prevalence among new injectors and in the numbers of people initiating injection drug use coincided with implementation of large-scale SEPs. Further reductions in HIV transmission among IDUs are still required. Provision of 70 or more syringes per IDU per year may be needed before significant reductions in HIV incidence occur.
doi:10.1186/1471-2458-11-517
PMCID: PMC3146432  PMID: 21718469
2.  Comparison of injecting drug users who obtain syringes from pharmacies and syringe exchange programs in Tallinn, Estonia 
Background
Both syringe exchange programs (SEPs) and pharmacy sales of syringes are available in Estonia, though the current high incidence and high prevalence of HIV among injection drug users (IDUs) in Tallinn, Estonia requires large-scale implementation of additional harm reduction programs as a matter of great urgency. The aims of this report were to compare risk behavior and HIV infection and to assess the prevention needs among IDUs who primarily use pharmacies as their source of sterile syringes with IDUs who primarily use SEPs in Tallinn.
Methods
A cross-sectional study using respondent-driven sampling was used to recruit 350 IDUs for an interviewer-administered survey and HIV testing. IDUs were categorized into two groups based on their self-reported main source for syringes within the last six months. Odds ratios with 95% CI were used to compare characteristics and risk factors between the groups.
Results
The main sources of sterile needles for injection drug users were SEP/SEP outreach (59%) and pharmacies (41%). There were no differences in age, age at injection drug use initiation, the main drug used or experiencing overdoses. Those IDUs using pharmacies as a main source of sterile needles had lower odds for being infected with either HIV (AOR 0.54 95% CI 0.33–0.87) or HCV (AOR 0.10 95% CI 0.02–0.50), had close to twice the odds of reporting more than one sexual partner within the previous 12 months (AOR 1.88 95% CI 1.17–3.04) and engaging in casual sexual relationships (AOR 2.09 95% CI 1.24–3.53) in the last six months.
Conclusion
The data suggest that the pharmacy users were at a less "advanced" stage of their injection career and had lower HIV prevalence than SEP users. This suggests that pharmacies could be utilized as a site for providing additional HIV prevention messages, services for IDUs and in linking IDUs with existing harm reduction services.
doi:10.1186/1477-7517-6-3
PMCID: PMC2653475  PMID: 19232088
3.  Multiple routes of drug administration and HIV risk among injecting drug users 
This study assesses relationships between drug administration routes and HIV serostatus, drug-use and sexual behaviors among current injecting drug users (IDUs) in Tallinn, Estonia. We recruited 350 IDUs for a cross-sectional risk behavior survey. Adjusted odds ratios (AORs) were calculated to explore injection risk behavior, sexual behavior and HIV serostatus associated with multiple route use. Focus groups explored reasons why injectors might use non-injecting routes of administration. Those reporting multiple drug administration routes were less likely to be HIV seropositive (AOR 0.49; 95%CI 0.25-0.97), had almost twice the odds of having more than one sexual partner (AOR 1.90; 95%CI 1.01-3.60) and of reporting having sexually transmitted diseases (AOR 2.38; 95%CI 1.02-5.59).
IDUs who engage in non-injecting drug use may be reducing their risk of acquiring HIV though sharing injection equipment, but if infected may be a critical group for sexual transmission of HIV to people who do not inject drugs.
doi:10.1016/j.jsat.2011.09.014
PMCID: PMC3289756  PMID: 22116012
Injecting drug use; HIV; Risk behavior; Illicit drug use; Sexual risk behaviors
4.  Controlling HIV Epidemics among Injection Drug Users: Eight Years of Cross-Border HIV Prevention Interventions in Vietnam and China 
PLoS ONE  2012;7(8):e43141.
Introduction
HIV in Vietnam and Southern China is driven by injection drug use. We have implemented HIV prevention interventions for IDUs since 2002–2003 in Lang Son and Ha Giang Provinces, Vietnam and Ning Ming County (Guangxi), China.
Methods
Interventions provide peer education and needle/syringe distribution. Evaluation employed serial cross-sectional surveys of IDUs 26 waves from 2002 to 2011, including interviews and HIV testing. Outcomes were HIV risk behaviors, HIV prevalence and incidence. HIV incidence estimation used two methods: 1) among new injectors from prevalence data; and 2) a capture enzyme immunoassay (BED testing) on all HIV+ samples.
Results
We found significant declines in drug-related risk behaviors and sharp reductions in HIV prevalence among IDUs (Lang Son from 46% to 23% [p<0.001], Ning Ming: from 17% to 11% [p = 0.003], and Ha Giang: from 51% to 18% [p<0.001]), reductions not experienced in other provinces without such interventions. There were significant declines in HIV incidence to low levels among new injectors through 36–48 months, then some rebound, particularly in Ning Ming, but BED-based estimates revealed significant reductions in incidence through 96 months.
Discussion
This is one of the longest studies of HIV prevention among IDUs in Asia. The rebound in incidence among new injectors may reflect sexual transmission. BED-based estimates may overstate incidence (because of false-recent results in patients with long-term infection or on ARV treatment) but adjustment for false-recent results and survey responses on duration of infection generally confirm BED-based incidence trends. Combined trends from the two estimation methods show sharp declines in incidence to low levels. The significant downward trends in all primary outcome measures indicate that the Cross-Border interventions played an important role in bringing HIV epidemics among IDUs under control. The Cross-Border project offers a model of HIV prevention for IDUs that should be considered for large-scale replication.
doi:10.1371/journal.pone.0043141
PMCID: PMC3428343  PMID: 22952640
5.  HIV prevalence and risk behaviours among injecting drug users in six indonesian cities implications for future HIV prevention programs 
Background
The HIV prevalence among injecting drug users (IDUs) in Indonesia reached 50% in 2005. While drug use remains illegal in Indonesia, a needle and syringe program (NSP) was implemented in 2006.
Methods
In 2007, an integrated behavioural and biological surveillance survey was conducted among IDUs in six cities. IDUs were selected via time-location sampling and respondent-driven sampling. A questionnaire was administered face-to-face. IDUs from four cities were tested for HIV, syphilis, gonorrhoea and chlamydia. Factors associated with HIV were assessed using generalized estimating equations. Risk for sexual transmission of HIV was assessed among HIV-positive IDUs.
Results
Among 1,404 IDUs, 70% were daily injectors and 31% reported sharing needles in the past week. Most (76%) IDUs received injecting equipment from NSP in the prior week; 26% always carried a needle and those who didn’t, feared police arrest. STI prevalence was low (8%). HIV prevalence was 52%; 27% among IDUs injecting less than 1 year, 35% among those injecting for 1–3 years compared to 61% in long term injectors (p < 0.001). IDUs injecting for less than 3 years were more likely to have used clean needles in the past week compared to long term injectors (p < 0.001). HIV-positive status was associated with duration of injecting, ever been imprisoned and injecting in public parks. Among HIV-infected IDUs, consistent condom use last week with steady, casual and commercial sex partners was reported by 13%, 24% and 32%, respectively.
Conclusions
Although NSP uptake has possibly reduced HIV transmission among injectors with shorter injection history, the prevalence of HIV among IDUs in Indonesia remains unacceptably high. Condom use is insufficient, which advocates for strengthening prevention of sexual transmission alongside harm reduction programs.
doi:10.1186/1477-7517-9-37
PMCID: PMC3494521  PMID: 22943438
Injecting drug users; HIV; Indonesia; Harm reduction
6.  Drug choice, spatial distribution, HIV risk, and HIV prevalence among injection drug users in St. Petersburg, Russia 
Background
The HIV epidemic in Russia has been driven by the unsafe injection of drugs, predominantly heroin and the ephedrine derived psychostimulants. Understanding differences in HIV risk behaviors among injectors associated with different substances has important implications for prevention programs.
Methods
We examined behaviors associated with HIV risk among 900 IDUs who inject heroin, psychostimulants, or multiple substances in 2002. Study participants completed screening questionnaires that provided data on sociodemographics, drug use, place of residence and injection- and sex-related HIV risk behaviors. HIV testing was performed and prevalence was modeled using general estimating equation (GEE) analysis. Individuals were clustered by neighborhood and disaggregated into three drug use categories: Heroin Only Users, Stimulant Only Users, and Mixed Drug Users.
Results
Among Heroin Only Users, younger age, front/backloading of syringes, sharing cotton and cookers were all significant predictors of HIV infection. In contrast, sharing needles and rinse water were significant among the Stimulant Only Users. The Mixed Drug Use group was similar to the Heroin Only Users with age, front/back loading, and sharing cotton significantly associated with HIV infection. These differences became apparent only when neighborhood of residence was included in models run using GEE.
Conclusion
The type of drug injected was associated with distinct behavioral risks. Risks specific to Stimulant Only Users appeared related to direct syringe sharing. The risks specific to the other two groups are common to the process of sharing drugs in preparation to injecting. Across the board, IDUs could profit from prevention education that emphasizes both access to clean syringes and preparing and apportioning drug with these clean syringes. However, attention to neighborhood differences might improve the intervention impact for injectors who favor different drugs.
doi:10.1186/1477-7517-6-22
PMCID: PMC2731096  PMID: 19646255
7.  HIV infection and risk factors among Bangkok prisoners, Thailand: a prospective cohort study 
Background
Incarceration has been associated with HIV infection among injection drug users. However, data on HIV risk factors of the inmates during incarceration are rarely reported from Thailand.
Methods
A prospective cohort of 689 male inmates in a Bangkok central prison was studied during 2001–2002. Follow up visits were conducted for 5 months, with testing for HIV and other infections and interviewing of demographics and risk behaviors.
Results
Among 689 male inmates, half (50.9 %) were drug injectors. About 49% of the injectors had injection during incarceration. Most (94.9%) of the injectors had shared injection paraphernalia with others. Successful follow up rate was 98.7% after 2,581 person-months observation. HIV incidence was 4.18 per 100 person – years among all inmates, and 11.10 per 100 person – years among the injection inmates. Multivariate analysis identified variables associated with HIV prevalence: history of injection [OR = 2.30, 95%CI: 1.91–2.77], positive urine opiate test [OR = 5.04, 95%CI: 2.63–9.67], history of attendance to drug withdrawal clinics [OR = 2.00, 95%CI: 1.19–3.35] and presence of tattoos on the body [OR = 1.23, 95%CI: 1.01–1.52].
Conclusions
The main HIV risk factors of Bangkok inmates were those related to drug injection. Harm reduction measures and HIV intervention strategies should be implemented to prevent more spread of HIV among the inmates and into the community.
doi:10.1186/1471-2334-3-25
PMCID: PMC270083  PMID: 14580265
8.  HIV Prevalence and Risk among Heterosexual Methamphetamine Injectors in California 
Substance use & misuse  2011;46(9):10.3109/10826084.2011.557136.
This CDC-funded study compares HIV prevalence and risk behavior among heterosexual methamphetamine (n=428) and non-methamphetamine (n=878) injectors in California, USA during 2001–2003. While HIV was not highly prevalent among methamphetamine injectors (3%), sexual and injection risk behaviors were highly prevalent (ranging from 21% to 72%). In multivariate analyses, methamphetamine injectors had higher odds than non-methamphetamine injectors of unprotected vaginal intercourse and sex with five or more sexual partners in the past six months, and of distributive and receptive syringe sharing in the past thirty days. There was no significant difference in HIV sero-status by methamphetamine use. Suggestions are made for designing HIV prevention programs.
doi:10.3109/10826084.2011.557136
PMCID: PMC3813018  PMID: 21391786
Methamphetamine; IDU; HIV; heterosexual; epidemiology; sexual risk
9.  HIV and HCV discordant injecting partners and their association to drug equipment sharing 
Our objective was to examine the association between HIV and HCV discordant infection status and the sharing of drug equipment by injection drug users (IDUs). IDUs were recruited from syringe exchange and methadone treatment programmes in Montreal, Canada. Characteristics of participants and their injecting partners were elicited using a structured questionnaire. Among 159 participants and 245 injecting partners, sharing of syringes and drug preparation equipment did not differ between concordant or discordant partners, although HIV-positive subjects did not share with HIV-negative injectors. Sharing of syringes was positively associated with discordant HIV status (OR = 1.85) and negatively with discordant HCV status (OR = 0.65), but both results were not statistically significant. Sharing of drug preparation equipment was positively associated with both discordant HIV (OR = 1.61) and HCV (OR = 1.18) status, but both results were non-significant. Factors such as large injecting networks, frequent mutual injections, younger age, and male gender were stronger predictors of equipment sharing. In conclusion, IDUs do not appear to discriminate drug equipment sharing partners based at least on their HCV infection status. The results warrant greater screening to raise awareness of infection status, post-test counselling to promote status disclosure among partners, and skill-building to avoid equipment sharing between discordant partners.
doi:10.1080/00365540902721376
PMCID: PMC2929251  PMID: 19172434 CAMSID: cams1471
10.  Refining HIV Risk: The Modifying Effects of Youth, Gender and Education among People Who Inject Drugs in Poland 
PLoS ONE  2013;8(7):e68018.
Objective
The goal of this study was to examine specific factors placing young (aged <30) women who inject drugs at higher risk for HIV, and to establish the need for targeted interventions within this population.
Methods
A national cross-sectional sero-survey was conducted in 2004–2005 in six regions in Poland. A snowball sample of ever-injectors was recruited from drug treatment facilities and the surrounding community. Log-binomial regression was used to estimate adjusted prevalence ratios (PRs).
Results
A total of 491 injection drug users younger than 30 were recruited, of whom 159 were women and 332 were men. The prevalence of HIV was 16.4% and 9.6% among women and men, respectively. In multivariate analysis, young female injectors whose education terminated at the primary level were more likely to be HIV-positive compared to males with a similar level of education (PR = 3.34, 95% CI = 1.86–6.00) and more highly educated women (PR = 4.16, 95% CI = 2.21–7.82).
Conclusions
This study confirms an elevated risk of HIV among under-educated young women. Suggestions for specific interventions to reduce HIV transmission are presented. Additional research is needed to quantify the differential distribution of risk behaviors which amplify their likelihood of transmission.
doi:10.1371/journal.pone.0068018
PMCID: PMC3720710  PMID: 23935852
11.  Mortality among injecting drug users: a critical reappraisal. 
STUDY OBJECTIVE--The aim was to quantify all cause mortality among injecting drug users. DESIGN--This was a retrospective analysis of 1989 data on injecting drug users and mortality obtained from three independent agencies: the Procurator Fiscal's Office, the General Register Office, and the Scottish HIV-test register. SETTING--Greater Glasgow, Scotland. SUBJECTS--Drug injectors, estimated population 9424. MAIN RESULTS--81 names were found using the three sources to identify deaths. After removing duplicates, 51 deaths were found. This represented a mortality rate of 0.54% in the estimated population. Among female injectors the mortality rate was 0.85%, significantly higher than the rate of 0.42% among male injectors (95% CI for the true difference in mortality rates between female and male injectors was 0.31%-0.55%). Over 90% of deaths were attributed to overdose or suicide. Although AIDS caused only one death, 19% of cases (5/27) whose HIV antibody status could be ascertained were positive. The mortality rate among HIV positive injectors (3.8%) was significantly higher than among HIV negative injectors (0.49%). CONCLUSIONS--Comprehensive coverage using three data sources revealed a far greater annual number of all cause deaths among injectors than would have been expected from previous research. The observed mortality rate was lower than in previous studies where the denominators used to calculate rates had an element of underenumeration. For the foreseeable future it is unlikely that AIDS will have much impact on mortality among injectors in Glasgow, because of the low prevalence of HIV infection among injectors in the city, and because HIV positive injectors are dying for reasons other than AIDS; rather, overdose and suicide will continue to be the main causes of death.
PMCID: PMC1059713  PMID: 8436897
12.  An external evaluation of a peer-run “Unsanctioned” syringe exchange program 
In Vancouver, British Columbia, Canada, difficulty accessing syringes at night has been shown to be strongly associated with human immunodeficiency virus (HIV) risk behavior among the city’s injection drug users (IDUs). On September 1, 2001, the Vancouver Area Network of Drug Users (VANDU) initiated an unsanctioned all-night needle-exchange program on a street corner in the heart of the neigh-borbood where many of the city’s IDUs are concentrated. An external evaluation of the population reached by the VANDU exchange was performed through the Vancouver Injection Drug User’s Study, a prospective cohort study of IDUs begun in 1996. Persons accessing syringes through the exchange were compared to those active injectors who acquired their syringes from other sources, including the city’s fixed site exchange, which closes at 8:00 pm. Overall, 587 active IDUs were seen during the period September 2001 to june 2002; of these individuals. 165 (28.1%) reported using the VANDU exchange. In multivariate analyses, participants who used the VANDU table were more likely to frequently inject cocaine (adjusted odds ratio [AOR]=1.56; 95% confidence interval [CI]=1.00–2.44), inject in public (AOR=2.71; 95% CI=1.62–4.53), and require help injecting (OR=2.13; 95% CI=1.33–3.42). Interestingly, use of the table was also independently associated with safer syringe disposal (AOR=2.69; 95% CI-1.38–5.21). Results indicate that the unsanctioned exchange appears to have reached those IDUs at highest risk of HIV infection. Although the cross-sectional nature of the study design warrants caution, we also found that use of the nighttime exchange was strongly associated with higher rates of safe syringe disposal. The data suggest that drug user organizations can play a major role in reducing harm among their peers by reaching the highest risk drug users with harm reduction services. The findings also suggest that other forms of syringe-exchange programs should consider the benefits of offering fixed site nighttime service.
doi:10.1093/jurban/jtg052
PMCID: PMC3455981  PMID: 12930883
Harin reduction; HIV/AIDS; Peer; Vancouver; VANDU
13.  Estimating numbers of injecting drug users in metropolitan areas for structural analyses of community vulnerability and for assessing relative degrees of service provision for injecting drug users 
This article estimates the population prevalence of current injection drug users (IDUs) in 96 large US metropolitan areas to facilitate structural analyses of its predictors and sequelae and assesses the extent to which drug abuse treatment and human immunodeficiency virus (HIV) counseling and testing are made available to drug injectors in each metropolitan area. We estimated the total number of current IDUs in the United States and then allocated the large metropolitan area total among large metropolitan areas using four different multiplier methods. Mean values were used as best estimates, and their validity and limitations were assessed. Prevalence of drug injectors per 10,000 population varied from 19 to 173 (median 60; interquartile range 42–87). Proportions of drug injectors in treatment varied from 1.0% to 39.3% (median 8.6%); and the ratio of HIV counseling and testing events to the estimated number of IDUs varied from 0.013 to 0.285 (median 0.082). Despite limitations in the accuracy of these estimates, they can be used for structural analyses of the correlates and predictors of the population density of drug injectors in metropolitan areas and for assessing the extent of service delivery to drug injectors. Although service provision levels varied considerably, few if any metropolitan areas seemed to be providing adequate levels of services.
doi:10.1093/jurban/jth125
PMCID: PMC3455936  PMID: 15273263
Drug abuse treatment; HIV counseling and testing; Injection drug users; Population prevalence estimates; Service coverage; Structural analysis
14.  HIV among injection drug users in large US metropolitan areas, 1998 
This article estimates HIV prevalence rates among injection drug users (IDUs) in 95 large US metropolitan areas to facilitate social and policy analyses of HIV epidemics. HIV prevalence rates among IDUs in these metropolitan areas were calculated by taking the mean of two estimates: (1) estimates based on regression adjustments to Centers for Disease Control and Prevention (CDC) Voluntary HIV Counseling and Testing data and (2) estimates based on the ratio of the number of injectors living with HIV to the number of injectors living in the metropolitan area. The validity of the resulting estimates was assessed. HIV prevalence rates varied from 2 to 28% (median 5.9%; interquartile range 4.0–10.2%). These HIV prevalence rates correlated with similar estimates calculated for 1992 and with two theoretically related phenomena: laws against over-the-counter purchase of syringes and income inequality. Despite limitations in the accuracy of these estimates, they can be used for structural analyses of the correlates, predictors and consequences of HIV prevalence rates among drug injectors in metropolitan areas and for assessing and targeting the service needs for drug injectors.
doi:10.1093/jurban/jti088
PMCID: PMC3456049  PMID: 16014877
Epidemic modeling; HIV prevalence estimates; Injection drug users; Local epidemics; Structural analysis
15.  Positive deviance control-case life history: a method to develop grounded hypotheses about successful long-term avoidance of infection 
BMC Public Health  2008;8:94.
Background
Prevalence rates for long-term injection drug users in some localities surpass 60% for HIV and 80% for HCV. We describe methods for developing grounded hypotheses about how some injectors avoid infection with either virus.
Methods
Subjects: 25 drug injectors who have injected drugs 8 – 15 years in New York City. 17 remain without antibody to either HIV or HCV; 3 are double-positives; and 5 are positive for HCV but not HIV. "Staying Safe" methodology compares serostatus groups using detailed biographical timelines and narratives; and information about how subjects maintain access to physical resources and social support; their strategies and tactics to remain safe; how they handle problems of addiction and demands by drug dealers and other drug users; and how their behaviors and strategies do or do not become socially-embedded practices. Grounded theory and life-history analysis techniques compare and contrast doubly-uninfected with those infected with both viruses or only with HCV.
Results
Themes and initial hypotheses emerging from analyses included two master hypotheses that, if confirmed, should help shape preventive interventions: 1) Staying uninfected is not simply a question of social structure or social position. It involves agency by drug injectors, including sustained hard work and adaptation to changing circumstances. 2) Multiple intentionalities contribute to remaining uninfected. These conscious goals include balancing one's need for drugs and one's income; developing ways to avoid drug withdrawal sickness; avoiding situations where other drug users importune you to share drugs; and avoiding HIV (and perhaps HCV) infection. Thus, focusing on a single goal in prevention might be sub-optimal.
Other hypotheses specify mechanisms of enacting these intentionalities. One example is finding ways to avoid extreme social ostracism.
Conclusion
We have identified strategies and tactics that some doubly-uninfected IDUs have developed to stay safe. Staying Safe methodology develops grounded hypotheses. These can be tested through cohort studies of incidence and prevention trials of hypothesis-based programs to help drug injectors make their injection and sexual careers safer for themselves and others. This positive deviance control-case life history method might be used to study avoiding other infections like genital herpes among sex workers.
doi:10.1186/1471-2458-8-94
PMCID: PMC2329618  PMID: 18366699
16.  Tobacco Use and Nicotine Dependence among HIV-Infected and Uninfected Injection Drug Users 
Addictive behaviors  2010;36(1-2):61-67.
Introduction
Urban U.S. populations are burdened by intersecting epidemics of HIV-infection, injection drug use, and cigarette smoking. Given the substantial morbidity attributable to tobacco in these populations, we characterized smoking behaviors, nicotine addiction, and tobacco exposure among HIV-infected and HIV-uninfected injection drug users (IDUs) in Baltimore, Maryland.
Methods
Smoking behaviors among participants in the ALIVE Study were assessed using interviewer-administered questionnaires. Smoking history and nicotine dependence (Fagerstrom Index scores) were compared by HIV and drug injecting status. Serum cotinine (a nicotine metabolite) was measured for a sample of participants by enzyme immunoassay.
Results
Among 1,052 participants (29.7% HIV-infected, 39.8% active injectors), 85.2% were current smokers and 9.3% former smokers. Smoking prevalence, age at smoking initiation, and cumulative tobacco exposure were similar by HIV status. Median Fagerstrom scores of 4 for HIV-infected and HIV-uninfected smokers indicated moderate nicotine dependence. Daily cigarette consumption was identical by HIV status (median 10 cigarettes), although HIV-infected participants were less likely to smoke 1+ pack daily compared to HIV-uninfected participants (18.0% vs. 26.9%, p=0.001). Compared to former injectors, active injectors had higher smoking prevalence (90.5% vs. 81.7%, p=0.0001), greater daily cigarette consumption (30.7% vs. 19.6% smoked 1+ pack daily, p=0.0001), and slightly higher Fagerstrom scores (median 5 vs. 4). Cotinine levels paralleled self-reported cigarette consumption.
Discussion
Tobacco use is extremely common among inner city IDUs. Smoking behavior and nicotine dependence did not materially differ by HIV status but were associated with active drug injection. Cessation efforts should target the dual dependence of cigarettes and drugs experienced among this population.
doi:10.1016/j.addbeh.2010.08.022
PMCID: PMC2981673  PMID: 20875704
17.  Needle sharing and participation in the Amsterdam Syringe Exchange program among HIV-seronegative injecting drug users. 
Public Health Reports  1992;107(6):675-681.
To enhance the prevention of human immunodeficiency virus infection, factors related to regular participation in the Amsterdam Syringe Exchange and the borrowing of syringes were studied in 131 HIV-seronegative injecting drug users in a 1989-90 survey. A total of 29 percent of the users reported borrowing syringes, that is injecting drugs at least once in the past 4-6 months with a needle or syringe previously used by someone else. Users at increased risk of borrowing are previous borrowers, long term moderate-to-heavy alcohol users, current cocaine injectors, and drug users without permanent housing. Regular clients of the syringe exchange, when compared with other injecting drug users, were found more often to be frequent, long term injectors. They borrowed slightly less often than other users, but this was not statistically significant, even after controlling for frequency of injecting or other potential confounders. The results suggest that, 5 years after the start of the Amsterdam Syringe Exchange, drug use characteristics govern an individual injecting drug user's choice of exchanging or not exchanging syringes. The conclusion is that it seems more important to direct additional preventive measures at injecting drug users with an increased risk of borrowing rather than at users who do not participate in the syringe exchange or who do so irregularly.
PMCID: PMC1403720  PMID: 1454980
18.  Syringe availability as HIV prevention: A review of modalities 
This review examines recent research into modalities for improving access to sterile syringes for injection drug users (IDUs) as a means to reduce human immunodeficiency virus (HIV) transmission. English language studies with empirical data were collected through Uncover reports and MedLine searches from 1998 to 2000. Although syringe-exchange programs are the most established and well-evaluated means of improving access to sterile syringes, research on alternative modalities—such as pharmacy sale, injector-specific packs, mass distribution, and vending machines—and on coverage of special populations suggests the need to pursue multiple avenues of increasing syringe availability simultaneously and, in particular, to explore modalities other than syringe-exchange programs when HIV incidence is under control. The impacts on HIV transmission of cocaine injection and sex with IDUs need to be explored further. Finally, any evidence of declining hepatitis C incidence among young IDUs might serve as a surrogate for a sharp drop in injection-related HIV risk behaviors in that population.
doi:10.1007/BF02386743
PMCID: PMC3456039  PMID: 10976607
19.  Epidemiology of HIV/AIDS, hepatitis B, hepatitis C, and tuberculosis among minority injection drug users. 
Public Health Reports  2002;117(Suppl 1):S126-S134.
OBJECTIVE: This article reviews the literature on the impact of HIV/AIDS, hepatitis B and C viruses (HBV, HCV), and tuberculosis on minority drug injectors in the United States. OBSERVATIONS: Injection drug use is a key factor in the transmission of blood-borne pathogens, and HIV disease is exacerbated by tuberculosis infection. Minority drug injectors are disproportionately represented in the national statistics on these infections. Behavioral epidemiologic studies show that both injection-related risk factors years of injecting drugs, type of drug injected, direct and indirect sharing of injection paraphernalia) and sex-related risk factors (lack of condom use, multiple sexual partners, survival sex) are conducive to the spread of HIV, HBV, and HCV. CONCLUSIONS: Two issues must be addressed to halt the spread of HIV infection and hepatitis B and C. The capacity of syringe-exchange programs to refer participants to drug treatment programs and facilitate access to health and social services must be increased. Culturally appropriate behavioral interventions targeting risk behaviors among ethnic and racial minorities, especially women, must be developed and put in place.
PMCID: PMC1913689  PMID: 12435836
20.  Effects of increasing syringe availability on syringe-exchange use and HIV risk: Connecticut, 1990–2001 
Syringe-exchange programs (SEPs) in Connecticut operate with caps on the number of syringes exchanged per visit. We investigated the effects of legislation increasing the cap on drug injectors' access to clean syringes through the SEPs in New Haven and Hartford. The mixed design of this study included longitudinal and crosssectional data from individuals and ecological data from program operations. Five parameters—syringe return rate, syringes per visit to the SEP, syringe reuse rate, syringe human immunodeficiency virus (HIV) prevalence, and syringe sharing—were monitored through syringe tracking and testing of SEP syringes and by interviewing injectors. Two increases in the cap—from 5 to 10 and then from 10 to 30—had little effect on the five parameters that measured injectors' access to clean syringes. In contrast, access to clean syringes increased when the New Haven SEP first began operations, when syringes first became available at pharmacies in Hartford, and when the agency running the Hartford SEP changed. Legislation providing piecemeal increases in the cap may not, by themselves, be sufficient to increase injectors' access to clean syringes and decrease the risk of human immunodeficiency virus transmission in this population.
doi:10.1093/jurban/79.4.556
PMCID: PMC3456719  PMID: 12468675
HIV transmission; Injection drug use; Syringe exchange
21.  Correlates of syringe coverage for heroin injection in 35 large metropolitan areas in the US in which heroin is the dominant injected drug 
The International journal on drug policy  2008;19(Suppl 1):S47-S58.
Background
Scientific consensus holds that if, at the outset of the HIV/AIDS epidemic, injection drug users (IDUs) had had better access to sterile syringes, much of the epidemic among IDUs in the U.S. could have been prevented. In the context of preventing infectious diseases, 100% syringe coverage—that is, one sterile syringe per injector for each injection—is a public health goal. Notably, we know little about variations in syringe coverage within the U.S. and elsewhere, or about the social and political factors that might determine this coverage.
Methods
Using data from Holmberg (AJPH, 1996), the 1990 United States Census, the 2000 Beth Israel National Syringe Exchange Survey (n=72), and estimates of IDUs in metropolitan areas (MSAs); (Friedman et al., 2004), we explore the impact of (1) political factors (ACT UP, outreach, early syringe exchange programme (SEP) presence, men who have sex with men (MSM) per capita, drug arrests, and police per capita); (2) local resources for SEPs; and (3) indicators of socioeconomic inequality on SEP coverage. We define “syringe coverage” as the ratio of syringes distributed at SEPs to the number of syringes heroin injectors need in a year. We calculated the number of syringes heroin injectors need in a year by multiplying an estimate of the number of IDUs in each MSA by an estimate of the average number of times heroin injectors inject heroin per year (2.8 times per day times 365 days). In this analysis, the sample was limited to 35 MSAs in which the primary drug of choice among injectors was heroin.
Results
SEP coverage varies greatly across MSAs, with an average of 3 syringes distributed per 100 injection events (std dev = 0.045; range: 2 syringes per 10 injection events, to 3 syringes per 10,000 injection events). In bivariate regression analyses, a 1 unit difference in the proportion of the population that was MSM per 1,000 was associated with a difference of 0.002 in SEP coverage (p=0.052); early SEP presence was associated with a difference of 0.038 in coverage (p=0.012); and having government funding was associated with a 0.040 difference in SEP coverage (p=0.021).
Conclusions
This analysis suggests that longer duration of SEP presence may increase syringe distribution and enhance successful programme utilization. Furthermore, MSAs with greater proportions of MSM tend to have better SEP coverage, perhaps providing further evidence that grassroots activism plays an important role in programme implementation and successful SEP coverage. This research provides evidence that government funding for SEPs contributes to better syringe coverage.
doi:10.1016/j.drugpo.2007.11.011
PMCID: PMC2706511  PMID: 18295468
syringe exchange programmes; coverage; heroin injection events; government funding; grassroots activism
22.  Circular Migration by Mexican Female Sex Workers Who are Injection Drug Users: Implications for HIV in Mexican Sending Communities 
Background
Circular migration and injection drug use increase the risk of HIV transmission in sending communities. We describe female sex workers who are injection drug users’ (FSW-IDUs) circular migration and drug use behaviors.
Methods
Between 2008-2010, 258 migrant FSW-IDUs residing in Tijuana and Ciudad Juarez, Mexico responded to questionnaires.
Results
24% of FSW-IDUs were circular migrants. HIV prevalence was 3.3% in circular migrants and 6.1% in non-circular migrants; 50% of circular and 82% of non-circular migrants were unaware of their HIV infection. Among circular migrants, 44% (n=27) consumed illicit drugs in their birthplace; 70% of these (n=20) injected drugs and one-half of injectors shared injection equipment in their birthplace. Women reporting active social relationships were significantly more likely to return home.
Discussion
Circular migrant FSW-IDUs exhibit multiple HIV risks and opportunities for bridging populations. Regular HIV testing and treatment and access to substance use services is critical for FSW-IDUs and their sexual/drug-using contacts.
doi:10.1007/s10903-011-9512-3
PMCID: PMC3624895  PMID: 21833727
Mexico; HIV; sex workers; drug use; migration
23.  Commentary on Vorobjov et al., "Comparison of injection drug users who obtain syringes from pharmacies and syringe exchange programs in Tallinn, Estonia" 
Recent data suggest that globally, between 5% and 10% of all new HIV cases are the result of unsafe injecting practices, and experts agree that reducing these practices is key to tackling the spread of HIV. And yet, despite the overwhelming evidence that providing sterile syringes to injection drug users (IDU) through syringe exchange programs (SEPs) or other means is an effective way of reducing HIV transmission among high-risk subpopulations, IDU in most settings still do not have access to sterile injecting equipment or if they do, access remains too restricted to effectively reduce the risk of HIV transmission. Vorobjov and colleagues have presented in this journal an interesting and timely study from Estonia comparing individuals who obtain syringes from SEPs and those who obtain syringes from pharmacies. As the authors point out, Estonia faces an unacceptably high HIV incidence rate of 50 new HIV cases per 100,000, this rate driven primarily by injection drug use. As such, the authors argue that Estonia's SEP network does not have the capacity to serve a growing IDU population at risk of transmitting HIV and pharmacy dispensation of clean syringes may be one potential approach to decreasing syringe sharing among high-risk injectors. It may be overly optimistic to consider the impact of higher threshold interventions such as pharmacy-based SEPs, given that IDU populations that engage in HIV risk behaviours such as syringe sharing are often hidden or hard to reach. Despite the need for a cautious approach, however, the findings presented by Vorobjov et al. may chart one potential course towards a more comprehensive societal response to reducing the health harms associated with injection drug use.
doi:10.1186/1477-7517-6-33
PMCID: PMC2789049  PMID: 19943944
24.  Fifteen years of research on preventing HIV infection among injecting drug users: what we have learned, what we have not learned, what we have done, what we have not done. 
Public Health Reports  1998;113(Suppl 1):182-188.
OBJECTIVE: Acquired immunodeficiency syndrome (AIDS) was formally identified among injecting drug users (IDUs) in 1981, and research on preventing human immunodeficiency virus (HIV) infection among drug injectors began shortly thereafter. At the time this research was begun, there was a general assumption that drug user (who were called drug abusers at that time) were too self-destructive and their behavior too chaotic for them to change their behavior to avoid infection with HIV. This chapter reviews the history of research on implementation of programs for prevention of HIV infection among IDUs. METHODS: Reviews of both research and program implementation research were conducted. Consultative discussions of issues and findings were conducted with researcher in the United States and other countries. RESULTS: An extremely large amount of useful information has accumulated during the pat 15 years. We now know that the great majority of IDUs will change their injecting behavior in response to the threat of AIDS and that these behavior changes are effective in reducing HIV transmission among drug injectors. Additional insight is needed regarding the apparent insufficiency of some prevention programs to control HIV, the transmission dynamics of rapid HIV spread, and the persistence of moderate to high incidence of HIV infection in high seroprevalence populations. Despite the current research knowledge base, implementation of effective prevention programs in may countries is nonexistent to incomplete. CONCLUSIONS: The most important barrier to reducing HIV transmission among drug injectors is not a lack of knowledge but the failure to implement effective prevention programs in may parts of the world.
PMCID: PMC1307740  PMID: 9722823
25.  Utilization of on-site primary care services by HIV-seropositive and seronegative drug users in a methadone maintenance program. 
Public Health Reports  1993;108(4):492-500.
The feasibility of on-site primary care services and their use by human immunodeficiency virus HIV-seropositive and seronegative injecting drug users within an outpatient methadone maintenance program are examined. A 16-month prospective study was conducted within an ongoing cohort study of HIV infection at a New York City methadone program with on-site primary care services. The study group consisted of 212 seropositive and 264 seronegative drug injectors. A computerized medical encounter data base, with frequencies of primary care visits and with diagnoses for each visit, was linked to the cohort study data base that contained information on patients' demographic characteristics, serologic status, and CD4+ T-lymphocyte counts. Eighty-one percent of the drug injectors in the study voluntarily used on-site primary care services in the methadone program. Those who were HIV-seropositive made more frequent visits than those who were seronegative (mean annual visits 8.6 versus 4.1, P < .001), which increased with declining CD4+ T-lymphocyte counts; 79 percent of those who were seropositive with CD4 counts of less than 200 cells per cubic millimeter received on-site zidovudine therapy or prophylaxis against Pneumocystis carinii pneumonia, or both. Common primary care diagnoses for patients seropositive for HIV included not only conditions specific to the human immunodeficiency virus but also bacterial pneumonia, tuberculosis, genitourinary infections, asthma, dermatologic disease, psychiatric illness, and complications of substance abuse; those who were seronegative were most frequently seen for upper respiratory infection, psychiatric illness, complications of substance abuse, musculoskeletal disease, hypertension, asthma, and diabetes mellitus. Vaginitis and cervicitis,other gynecologic diseases, and pregnancy were frequent primary care diagnoses among both seropositive and seronegative women.
PMCID: PMC1403415  PMID: 8393579

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