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1.  Liquid Drugs and High Dead Space Syringes May Keep HIV and HCV Prevalence High – A Comparison of Hungary and Lithuania 
European Addiction Research  2010;16(4):220-228.
Despitevery similar political, drug policy and HIV prevention backgrounds, HIV and HCV prevalence is considerably different in Hungary (low HIV and moderate HCV prevalence) and Lithuania (high HCV and moderate HIV prevalence). Wecompared the drug use profile of Hungarian (n = 215) and Lithuanian (n = 300) injecting drug users (IDUs). Overall, compared with IDUs in Hungary, IDUs in Lithuania often injected opiates purchased in liquid form (‘shirka’), used and shared 2-piece syringes (vs. 1-piece syringes) disproportionately more often, were less likely to acquire their syringes from legal sources and had significantly more experience with injected and less experience with non-injected drugs. It may not be liquid drugs per se that contribute to a higher prevalence of HCV and/or HIV, but it is probably factors associated with the injecting of liquid drugs, such as the wide-spread use and sharing of potentially contaminated 2-piece syringes acquired often from non-legal sources, and syringe-mediated drug sharing with 2-piece syringes. Scaling up substitution therapy, especially heroin replacement, combined with reducing the supply of liquid drugs may decrease the prevalence of high-risk injecting behaviours related to the injecting of liquid drugs and drug injecting-related infections among IDUs in Lithuania.
doi:10.1159/000320287
PMCID: PMC2969108  PMID: 20798543
Drugs sold in liquid form; Hungary; Injecting drug use; Lithuania; Syringe type
2.  Unprotected sex in heterosexual partnerships of injecting drug users in St Petersburg, Russia 
AIDS and behavior  2011;15(1):58-64.
We examined the association of individual demographic and behavioral attributes, partnership (dyad) and social network characteristics with unprotected sex in the heterosexual dyads of IDUs in St Petersburg, Russia. Of the individual-level characteristics female gender and younger age; and of the dyad-level characteristics sharing injecting equipment, social exposure to the sex partner (“hanging out with” or seeing each other daily), and both partners self-reporting being HIV infected were associated with unprotected sex. Although self-reported HIV discordant couples were less likely to engage in unprotected sex, it was reported in over half of self-reported HIV discordant relationships. This study highlights the intertwining of sexual risk and injecting risk, and the importance of sero-sorting based on perceived HIV status among IDU sexual partnerships in St Petersburg, Russia. A combination of social network and dyad interventions may be appropriate for this population of IDUs, especially for IDUs who are both injecting and sex partners, supported by free and confidential rapid HIV testing and counseling services to provide a comprehensive response to the wide-spread HIV epidemic among IDUs in St Petersburg.
doi:10.1007/s10461-010-9721-0
PMCID: PMC3048022  PMID: 20532604
Injecting drug users; Risk networks; Sexual risk; HIV infection risk; Dyad analysis; Russia
3.  Evaluation of a comprehensive AIDS education curriculum in Hungary – the role of good educators1 
Journal of adolescence  2002;25(5):495-508.
The aim of this research was to evaluate a school-based AIDS education programme in Eastern Europe. Four evaluation segments were undertaken: process and outcome evaluations of the training of AIDS educators and of the educational activities for students. While most AIDS education curricula focus on the content of the education, our findings demonstrate that other aspects — including the characteristics of those educators who appear to be most effective, the way in which education is affected by teachers’ attitudes, and the cultural implications of transferring programmes from one country to another – also need to be considered, especially in international environments.
PMCID: PMC2925669  PMID: 12234556
4.  Correlates of unsafe injecting among injecting drug users in St Petersburg, Russia 
European addiction research  2009;15(3):163-170.
Aims
To assess among injecting drug users (IDUs) in St Petersburg, Russia, the urban environmental, social norms, and individual correlates of unsafe injecting.
Methods
Between December 2004 and January 2007 IDUs (N=446) were interviewed in St. Petersburg, Russia.
Results
Prevalence of HCV was 96% and HIV 44%; 17% reported receptive syringe sharing after an HIV infected IDU (RSS); 49% distributive syringe sharing (DSS); 76% sharing cookers, 73% sharing filters and 71% syringe mediated drug sharing (SMS) when not all syringes were new. Urban environmental characteristics correlated with sharing cookers and SMS; and social norms correlated with RSS, DSS and sharing cookers. Individual correlates included cleaning used syringes (all five dependent variables) and self-report of HIV infection (RSS and DSS).
Conclusion
HIV status disclosure is an unreliable but frequently used HIV prevention method among IDUs in St. Petersburg, who reported alarmingly high levels of injecting equipment sharing. Voluntary counseling and testing should be widely available for this population. Ethnography is needed to assess the effectiveness of the syringe cleaning process. Prevention interventions need to be ongoing among IDUs in St. Petersburg, and should incorporate urban environmental factors and social norms, which may involve peer education and social network interventions.
doi:10.1159/000220344
PMCID: PMC2794890  PMID: 19506377
Russia; Injecting drug users; Injecting equipment sharing; HIV infection; Hepatitis infections
5.  The association of syringe type and syringe cleaning with HCV infection among IDUs in Budapest, Hungary 
Drug and alcohol dependence  2008;100(3):240-247.
We assessed whether syringe type, syringe cleaning and distributive syringe sharing were associated with self-reported and laboratory confirmed HCV infection among Hungarian IDUs. Injecting drug users (N=215) were recruited from non-treatment settings in Budapest, Hungary between October 2005 and December 2006. Multivariate logistic regression models identified correlates of self-report of being HCV infected and testing positive for HCV. While 37% tested positive for HCV, 14% of the total (39% of those who tested positive) self-reported being HCV infected. Using any two piece syringes was significantly associated with self-reported HCV infection, while distributive syringe sharing was not associated with self-report of being HCV infected. Engaging in receptive sharing of only one-piece syringes but always cleaning before reuse was not associated with testing HCV positive, while any receptive sharing of only one-piece syringes and not always cleaning before reuse was significantly associated with testing HCV positive. Sharing cookers and squirting drugs from one syringe into another syringe were not associated with testing HCV positive. The high percent of those HCV infected who did not know they were infected highlights the need to provide better access to confidential testing and counseling services. Counseling should emphasize secondary prevention of HCV among HCV infected IDUs. Our findings also indicate that syringe type and syringe cleaning practices may play a role in HCV transmission. Ethnographic research should identify the reasons why IDUs may use two-piece syringes and suggest means to reduce their use. Thorough cleaning of one-piece syringes when sterile syringes are unavailable may be an efficient way to reduce the risk of HCV infection.
doi:10.1016/j.drugalcdep.2008.10.014
PMCID: PMC2628960  PMID: 19058925
HCV infection; one-piece and two-piece syringes; syringe cleaning; minorities; Central Europe
6.  The relationship of sexual dyad and personal network characteristics and individual attributes to unprotected sex among young injecting drug users 
AIDS and behavior  2007;13(2):196-206.
We examine in the heterosexual partnerships (dyads) of IDUs the correlates of engaging in unprotected sex on three levels: individual attributes, social network characteristics, and dyad characteristics. Unprotected sex was significantly less likely to occur in dyads where the participant injected daily or had high safe-sex attitude scores, and in dyads where both members encouraged each other to use condoms. Unprotected sex was significantly more likely to occur in dyads that smoked crack together, shared needles with each other, and where the participant knew that the sex partner had concurrent sex partners. In the sexual dyads of IDUs there is a combined risk of unsafe injecting and unsafe sex. Both injecting and sexual risk, and their combination need to be addressed in interventions that target the sexual partnerships of IDUs. Such interventions should also aim to reduce injected and non-injected crack and other stimulant use associated with high-risk sex.
doi:10.1007/s10461-007-9285-9
PMCID: PMC2651987  PMID: 17690975
Injecting drug users; Risk behaviors; Risk networks; Sexual risk; Dyad analysis
7.  Marginalized and socially integrated groups of IDUs in Hungary – potential bridges of HIV infection 
The discrepancy in HIV rates among Eastern and Central European injecting drug users (IDUs) suggests that, in addition to risk behaviors, social contact patterns also play an important role. We identify two groups of IDUs in Budapest, Hungary, marginalized IDUs (M-IDUs) and socially integrated IDUs (SI-IDUs), and compare their HIV/HBV/HCV social and risk network characteristics, risk behaviors, and travel patterns. Between 05/2003 and 01/2004, 29 non-treatment-recruited young IDUs in Budapest participated in ethnographic interviews and focus groups. The mean age was 23.6 years (SD=3.6); eight were female and two Roma/Gypsy. Most injected heroin (n=23) and/or amphetamines (n=10) in the past 30 days. M-IDUs had no legal employment, injected heroin and sniffed glue, and stopped using drugs in treatment/prison. SI-IDUs had regular jobs or were students, injected heroin and sniffed cocaine, and stopped using drugs before exams/tests. Both M-IDUs and SI-IDUs shared injecting equipment on occasion and used condoms rarely. M-IDUs had a large social network of “buddies” and a small risk network of “friends”. SI-IDUs had two separate large social networks of “buddies”: a M-IDU and a non-IDU network; and a small risk network of “friends”. Both groups reported monogamous sexual relationships. M-IDUs traveled within Hungary whereas SI-IDUs traveled to Western Europe. If an HIV epidemic among IDUs in Hungary is not prevented, SI-IDUs may form a potential “bridge” of HIV infection between high-risk IDU populations and the low-risk, general population, while M-IDUs may become cores of infection. Different approaches may be appropriate for M-IDUs and SI-IDUs to prevent HIV.
doi:10.1093/jurban/jti112
PMCID: PMC2656943  PMID: 16107433
Human immunodeficiency virus; Hepatitis B virus; Hepatitis C virus; injecting drug users; social marginalization; Central and Eastern Europe; risk behaviors; risk networks
8.  Individual and social factors associated with participation in treatment programs for drug users 
Substance use & misuse  2008;43(12-13):1865-1881.
Since only about one third of people who are dependent on drugs are in treatment, there is a need to promote both treatment entry and retention. Previous research has described the role of individual and social characteristics in drug treatment participation, but little is known about the interaction of individual and social factors. Injecting and non-injecting drug users (2002–2004; N=581) were recruited in Baltimore, MD (SHIELD Study) and were administered a structured questionnaire. The mean age of participants was 43.6 years, 41% were female, 50% had high school education, and 16% self-reported being HIV infected. Logistic regression analyses of interaction terms revealed that compared to those with no plans to stop and no friends encouraging them to enter treatment those who planned to cease drug use or whose friends encouraged treatment were more likely to attend a 12-step program. Furthermore, compared to those with no problems with drug use and no friends encouraging them to enter treatment those with greater perceived drug problem severity or with friends encouraging treatment were more likely to attend methadone maintenance, as were those who did not receive free drugs from others. The influence of friends may have a crucial modifying effect by getting into treatment less addicted individuals who have higher chances of successful recovery.
doi:10.1080/10826080802293038
PMCID: PMC2626660  PMID: 19016169
drug treatment; injecting and non-injecting drug users; interaction; relapse; treatment entry; treatment retention; sustained treatment
9.  HIV and selected blood-borne and sexually transmitted infections in a predominantly Roma (Gypsy) neighbourhood in Budapest, Hungary 
We assessed the prevalence of HIV and selected blood-borne and sexually transmitted infections among a convenience sample of 64 residents of Dzsumbuj, a predominantly Roma (Gypsy) neighbourhood in Budapest, Hungary. No cases of HIV were detected, while the prevalence of Hepatitis B infection (anti-HBc) was 27% and syphilis prevalence was 2%. Romas (n=50) were significantly more likely than non-Romas (n=14) to have HAV antibodies (80% vs. 43%) and less likely to be HBV immunized (anti-HBs only; 6% vs. 29%). Current drug injectors (n=13) were more likely than non-injectors (n=51) to have antibodies against HAV (85% vs. 69%) and HCV (85% vs. 8%). While HIV has not been introduced in this population, risk conditions for a potentially explosive HIV epidemic are present. Health care policies should focus on expanding coverage for HAV and HBV immunizations, and access to HIV preventive services needs to be extended to marginalized, mostly minority populations, such as the Roma in Europe.
PMCID: PMC2626659  PMID: 18935777
HIV/AIDS; Hepatitis infections; Illicit drug use; Minority populations; Central Europe
10.  Strong HIV and hepatitis disclosure norms and frequent risk behaviors among Hungarian drug injectors 
Drug and alcohol dependence  2006;82(Suppl 1):S65-S69.
Ethnographic interviews and focus groups were conducted (05/2003-01/2004) among injecting drug users (IDUs; n=29) in Budapest, Hungary to assess HIV, Hepatitis B and C (HBV and HCV) related knowledge, norms, attitudes and behaviors. Participants perceived themselves at low risk for infection with HIV but high risk for hepatitis through injection but not sexual exposure. They reported strong disclosure norms for HIV and hepatitis infections, while sexual and injecting risk behaviors were influenced by trust about partners' self-report of infection status. Injecting networks were small, with infrequent syringe sharing among a few close friends. Cookers and drug filters were often shared, and filters were re-used as a backup drug supply. Most sexual relationships were monogamous, where condoms were rarely used. Although participant norms supported HIV/HBV/HCV testing, the lack of available testing facilities was a barrier to getting tested. Strong norms for infection disclosure and for getting tested coexist with engaging in risk behaviors with injecting and sex partners who are close friends. Network interventions among IDUs in Hungary should build on disclosure norms and trust to reduce injecting and sex risk. Testing services should be expanded and access increased so that IDUs can act on and reinforce their norms for testing.
PMCID: PMC2597792  PMID: 16769448
Injecting Drug Users (IDUs); Disclosure of infection status; HIV and Hepatitis infections; Risk behaviors; Risk networks
11.  The urgent need for HIV and hepatitis prevention in drug treatment programs in Hungary 
We assess HIV and hepatitis testing and counseling in drug treatment programs in Hungary, a country with low rates of HIV but high rates of HCV among injecting drug users. The official context of drug treatment programs is described, and, using key informants from representative drug treatment programs, the practice of HIV and hepatitis testing and counseling in such programs is assessed. While HIV testing and counseling occurs, testing and counseling for HBV and HCV are rare, especially in outpatient settings; and sexual risk in the drug use context is ineffectively addressed by treatment programs. Drug treatment centers are not adequately addressing the need to provide either HIV or hepatitis prevention services. There is an urgent need for preventing HIV and related infections among drug users by integrating HIV and hepatitis B and C prevention with drug treatment.
doi:10.1521/aeap.16.3.276.35435
PMCID: PMC2562463  PMID: 15237056
drug users; drug treatment; testing and counseling; HIV infections; Hepatitis infection; Hungary
12.  The association between social marginalisation and the injecting of alcohol among IDUs in Budapest, Hungary 
Background
Alcohol injecting may cause intense irritation, serious vein damage, and additional risks. What little is known about alcohol injecting points to the potential role of social marginalisation.
Methods
Injecting drug users (N=215) were recruited between October 2005 and December 2006 in Budapest, Hungary from non-treatment settings. Multivariate logistic regression models identified correlates of lifetime alcohol injecting.
Results
About a quarter (23%) reported ever injecting alcohol – only 3% reported injecting alcohol in the past 30 days. In multivariate analysis, six variables were statistically significantly associated with ever injecting alcohol: male gender, being homeless, ever sharing cookers or filters and injecting mostly in public places showed a positive association, while Roma ethnicity and working at least part time showed a negative association.
Conclusions
Our study suggests that alcohol injecting is more of a rare event than a so far undiscovered research and prevention priority. Still, providers of harm reduction services should be aware that alcohol injecting happens, albeit rarely, especially among socially marginalised IDUs, who should be counselled about the risks of and discouraged from alcohol injecting.
doi:10.1016/j.drugpo.2011.05.001
PMCID: PMC3227543  PMID: 21764285
Alcohol; injecting drug use; Hungary; Central Europe; risk behaviours
13.  Infection disclosure in the injecting dyads of Hungarian and Lithuanian injecting drug users who self-reported being infected with hepatitis C virus or human immunodeficiency virus 
The aim of this study was to assess the prevalence and correlates of disclosure to network members of being hepatitis C virus (HCV)- or human immunodeficiency virus (HIV)-infected among injecting dyads of infected injection drug users (IDUs) in Budapest, Hungary and Vilnius, Lithuania,. Multivariate generalized estimating equations (GEE) were used to assess associations. Very strong infection disclosure norms exist in Hungary, and HCV disclosure was associated with using drugs and having sex within the dyad. Non-ethnic Russian IDUs in Lithuania were more likely to disclose HCV infection to non-Roma, emotionally close and HCV-infected network members, and to those with whom they shared cookers, filters, drug solutions or rinse water or got used syringes from, and if they had fewer non-IDU or IDU network members. Ethnic Russian Lithuanian IDUs were more likely to disclose HCV if they had higher disclosure attitude and knowledge scores, ‘trusted’ network members, and had lower non-injecting network density and higher injecting network density. HIV-infected Lithuanian IDUs were more likely to disclose to ‘trusted’ network members. Disclosure norms matched disclosure behaviour in Hungary, while disclosure in Lithuania to ‘trusted’ network members suggests possible stigmatization. Ongoing free and confidential HCV/HIV testing services for IDUs are needed to emphasize and strengthen disclosure norms, and to decrease stigma.
doi:10.3109/00365548.2010.513064
PMCID: PMC3074185  PMID: 20840002
14.  Injecting Equipment Sharing in Russian Drug Injecting Dyads 
AIDS and behavior  2009;14(1):141-151.
In this study, we investigated how individual attributes, dyad characteristics and social network characteristics may influence engaging in receptive syringe sharing, distributive syringe sharing and sharing cookers in injecting partnerships of IDUs in St Petersburg, Russia. We found that all three levels were associated with injecting equipment sharing, and that dyad characteristics were modified by characteristics of the social network. Self-reported HIV discordance and male gender concordance played a role in the risk of equipment sharing. Dyad interventions may not be sufficient to reduce injecting risk in IDU partnerships, but a combination of dyad and network interventions that target both IDU partnerships and the entire IDU population may be more appropriate to address injecting risk among IDUs.
doi:10.1007/s10461-008-9518-6
PMCID: PMC2818991  PMID: 19214731
Injecting drug users; Risk networks; Injecting risk; Dyad analysis; Russia
15.  Greater Drug Injecting Risk for HIV, HBV, and HCV Infection in a City Where Syringe Exchange and Pharmacy Syringe Distribution are Illegal 
Journal of Urban Health   2008;85(3):309-322.
Comparing drug-injecting risk between cities that differ in the legality of sterile syringe distribution for injection drug use provides a natural experiment to assess the efficacy of legalizing sterile syringe distribution as a structural intervention to prevent human immunodeficiency virus (HIV) and other parenterally transmitted infections among injection drug users (IDUs). This study compares the parenteral risk for HIV and hepatitis B (HBV) and C (HCV) infection among IDUs in Newark, NJ, USA, where syringe distribution programs were illegal during the period when data were collected, and New York City (NYC) where they were legal. IDUs were nontreatment recruited, 2004–2006, serotested, and interviewed about syringe sources and injecting risk behaviors (prior 30 days). In multivariate logistic regression, adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) for city differences are estimated controlling for potential city confounders. IDUs in Newark (n = 214) vs. NYC (n = 312) were more likely to test seropositive for HIV (26% vs. 5%; AOR = 3.2; 95% CI = 1.6, 6.1), antibody to the HBV core antigen (70% vs. 27%; AOR = 4.4; 95% CI = 2.8, 6.9), and antibody to HCV (82% vs. 53%; AOR = 3.0; 95% CI = 1.8, 4.9), were less likely to obtain syringes from syringe exchange programs or pharmacies (AOR = 0.004; 95% CI = 0.001, 0.01), and were more likely to obtain syringes from street sellers (AOR = 74.0; 95% CI = 29.9, 183.2), to inject with another IDU’s used syringe (AOR = 2.3; 95% CI = 1.1, 5.0), to reuse syringes (AOR = 2.99; 95% CI = 1.63, 5.50), and to not always inject once only with a new, sterile syringe that had been sealed in a wrapper (AOR = 5.4; 95% CI = 2.9, 10.3). In localities where sterile syringe distribution is illegal, IDUs are more likely to obtain syringes from unsafe sources and to engage in injecting risk behaviors. Legalizing and rapidly implementing sterile syringe distribution programs are critical for reducing parenterally transmitted HIV, HBV, and HCV among IDUs.
doi:10.1007/s11524-008-9271-1
PMCID: PMC2329750  PMID: 18340537
HIV; HBV; HCV; Drug injectors; IDU; Risk behaviors; Syringe exchange; Needle exchange; Pharmacy syringes.
16.  INJECTING EQUPMENT SHARING AND PERCEPTION OF HIV AND HEPATITIS RISK AMONG INJECTING DRUG USERS IN BUDAPEST 
AIDS care  2007;19(1):59-66.
In Central European states, rates of HIV among IDUs have been low although HCV infection is widespread. The goal of our study was to assess HIV infection, risk perceptions and injecting equipment sharing among injection drug users in Budapest, Hungary. Altogether 150 IDUs were interviewed (121 structured between 1999-2000 and 29 ethnographic between 2003-2004). The majority of them injected heroin (52% and 79%) and many injected amphetamines (51% and 35%). One person tested positive for HIV. Two thirds (68% of 121) shared injecting equipment (syringes, cookers and filters). Some participants said they shared syringes because they were not carrying them for fear of police harassment, and that they reused filters as a backup drug supply. In multivariate analysis, sharing of injecting equipment was associated with higher perceived susceptibility to HIV/AIDS, lower self-efficacy for sterile equipment use, higher motivation to comply with peer pressure to use dirty injecting equipment, and with having a criminal record. The high levels of injecting risk behaviors found in this study are a cause for serious concern. HIV prevention interventions need to address not only sharing syringes but also sharing and reusing other injecting equipment and drug filters.
doi:10.1080/09540120600722742
PMCID: PMC2597713  PMID: 17129858
17.  Injecting and sexual risk correlates of HBV and HCV seroprevalence among new drug injectors 
Drug and alcohol dependence  2007;89(2-3):234-243.
We examine injecting and sexual risk correlates of hepatitis B (HBV) and hepatitis C (HCV) seroprevalence among new injecting drug users (IDUs) (age 18–30 years, injecting ≤6 years). Participants were interviewed/serotested (HIVab, HBVcAb, HCVab) in New York City, 2/1999–2/2003. Gender-stratified, multivariate logistic regression was conducted. Participants (N=259) were: 68% male; 81% white. Women were more likely to test HCV seropositive (42% vs. 27%) and men HBV seropositive (24% vs. 12%); HIV seroprevalence was low (3%). Among both men and women, HBV seropositivity was associated with ever selling sex, and HCV seropositivity with ever having had infected (HIV, HBV or HCV) sex partners (among those ever sharing injecting equipment). Among women only, HBV seropositivity was associated with ever having had infected sex partners (regardless of ever sharing injecting equipment), and HCV seropositivity with ≥300 lifetime drug injections. Among men only, HCV seropositivity was associated with ≥40 lifetime number of sex partners (among those never sharing injecting equipment). In this new IDU sample, HBV and HCV seroprevalence differed by gender and were considerably higher than HIV seroprevalence. Early interventions, targeting injecting and sexual risks and including HBV vaccination, are needed among new IDUs to prevent HBV, HCV and, potentially, HIV epidemics.
doi:10.1016/j.drugalcdep.2007.01.003
PMCID: PMC1947004  PMID: 17289298
HIV; HBV; HCV; drug injectors; injecting risk; sexual risk

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