Transcript Paradoxes and Problems in Preventing HIV Infection among

Paradoxes and Problems in Preventing HIV
Infection among Injecting Drug Users and
Their Sexual Partners in Eastern Europe
and Asia
Don C. Des Jarlais, Ph.D.
Director of Research
Baron Edmond de Rothschild
Chemical Dependency Institute
Beth Israel Medical Center
New York
Potential for Very Rapid Spread of HIV
among Injecting Drug Users--Incidence of
20% to 50% Per Year
• New York City
• Bangkok
• Eastern Europe, Russia, Newly
Independent States
• Some areas in Asia and South Asia
Effective Prevention--National Institutes of
Health Consensus Development Conference
• Syringe access/exchange, e.g., New York City
(Des Jarlais, et al.)
• Community Outreach, e.g., Chicago
(Weibel, et al.)
• Drug Abuse Treatment (Methadone), e.g.
Philadelphia (Metzger, et al.)
Reductions of 70% to 83% in rates of new HIV
infections
Successful Prevention at the Community
and Country Level
• United Kingdom
• Australia
• Many individual cities, e.g., Tacoma, WA
Reversing High Seroprevalence
Epidemics among IDUs
• New York City
Will HIV Prevention Programs for IDUs
Work in Developing Transitional Countries?
Sharing/Risky Injection Behaviors of Central and Eastern
European Syringe Exchange Participants N=595
Prague
N = 122
Budapest
N = 60
Skopje
N = 132
n
(%)
n
(%)
n
(%)
35
12
(30)
(10)
<.0001
15
5
(31)
(10)
<.01
31
10
(24)
(8)
<.0001
68
90
(57)
(75)
<.01
38
32
(63)
(53)
ns
111
100
(85)
(76)
<.05
Frontloading/Backloading
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
46
48
(44)
(46)
ns
24
17
(60)
(43)
.052
99
84
(78)
(66)
<.005
Shared Cotton, Cooker, Water
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
95
75
(79)
(62)
<.001
51
46
(85)
(77)
<.05
113
92
(87)
(71)
<.01
Injected with Syringe Used by Someone
Else
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Daily Injection at Least One Drug
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Sharing/Risky Injection Behaviors of Central and Eastern
European Syringe Exchange Participants N=595
Krakow
N = 87
n (%)
Injected with Syringe Used by Someone Else
30 Days Prior to Ising SEP
Last 30 Days While Using SEP
p
Daily Injection At Least One Drug
30 Days Prior to using SEP
last 30 days while using SEP
p
Frontloading/Backloading
30 Days Prior To Using SEP
Last 30 Days While Using SEP
p
Shared Cotton, Cooker, Water
30 Days Prior To Using SEP
Last 30 Days While Using SEP
p
Poltava
N = 194
n (%)
18
5
(23)
(6)
<.001
14
1
(7)
(1)
<.001
76
76
(88)
(88)
ns
174
181
(90)
(93)
<.01
22
14
(37)
(24)
<.06
45
38
(24)
(20)
ns
30
19
(35)
(22)
<.02
96
83
(51)
(44)
<.01
Sharing/Risky Injection Behaviors of Central and Eastern
European Syringe Exchange Participants N=595
Prague
N = 122
Injected at Anonymous Injecting
Venue
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Bought Drugs Loaded in Syringes
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Used Blood in Preparation
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Saw Blood Used in Preparation
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Budapest
N = 60
Skopje
N = 132
n
(%)
n
(%)
n
(%)
57
68
(49)
(59)
.06
10
6
(18)
(11)
ns
37
27
(29)
(21)
<.02
11
8
(9)
(7)
ns
6
3
(11)
(5)
ns
5
3
(4)
(2)
ns
10
3
(10)
(3)
.0082
0
5
(0)
(9)
<.05
0
0
(0)
(0)
ns
23
3
(23)
(3)
<.0001
4
5
(7)
( 9)
ns
1
1
(1)
(1)
ns
Sharing/Risky Injection Behaviors of Central and Eastern
European Syringe Exchange Participants N=595
Krakow
N = 87
n
Injected at Anonymous Injecting Venue
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Bought Drugs Loaded In Syringes
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Used Blood in Preparation
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Saw Blood Used in Preparation
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Poltava
N = 194
(%)
n
(%)
51 (62)
39 (48)
<.01
50
29
(28)
(16)
<.0001
28 (34)
27 (33)
ns
21
15
(11)
(8)
ns
0 (0)
19 (23)
<.001
11
2
(6)
(1)
<.02
3 (4)
17 (20)
<.001
29
7
(15)
(4)
<.0001
Sharing/Risky Injection Behaviors of
Russian Syringe Exchange Participants N = 1,076
Nizhniy Novgorod
N = 236
Injected With Syringe Used by Someone
Else
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Daily Injection At Least One Drug
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Frontloading/Backloading
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Shared Cotton, Cooker, Water
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Pskov
N = 201
Rostov-NaDonu
N = 199
n (%)
n
(%)
n
(%)
94
21
(41)
(9)
<.0001
52
7
(26)
(4)
<.0001
77
17
(39)
(9)
<.0001
150
152
(64)
(64)
ns
49
22
(25)
(11)
<.0001
104
71
(52)
(36)
<.0001
153
122
(67)
(54)
<.0001
92
72
(46)
(36)
<.005
98
60
(50)
(30)
<.0001
169
125
(72)
(53)
<.0001
187
172
(93)
(86)
<.002
170
146
(85)
(73)
<.0001
Sharing/Risky Injection Behaviors of
Russian Syringe Exchange Participants N = 1,076
St. Petersburg
N = 221
Volgograd
N = 219
n
(%)
n
(%)
104
63
(47)
(29)
<.0001
77
7
(37)
(3)
<.0001
Daily Injection at least One Drug
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
144 (66)
168 (77)
<.005
161
155
(74)
(71)
ns
Frontloading/Backloading
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
129 (64)
135 (67)
ns
125
104
(63)
(52)
<.001
Shared Cotton, Cooker, Water
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
195 (88)
199 (90)
ns
165
141
(75)
(64)
<.0001
Injected with Syringe Used by Someone Else
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Sharing/Risky Injection Behaviors of
Russian Syringe Exchange Participants N = 1,076
Nizhniy
Novgorod
N=236
n
(%)
Injected at Anonymous Injecting Venue
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Bought Drugs Loaded in Syringes
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Used Blood in Preparation
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Saw Used Blood in Preparation
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Pskov
N=201
(%)
Rostov-NaDonu
N=199
n
(%)
140 (62)
106 (47)
<.0001
49 (25)
17 (9)
<.0001
107 (54)
56 (28)
<.0001
20 (9)
5 (2)
<.0001
8 (4)
1 (1)
<.001
37 (19)
22 (11)
.0003
12 (5)
0 (0)
<.01
19 (10)
18 (10)
ns
14 (8)
9 (5)
ns
57 (25)
8 (4)
<.0001
60 (33)
25 (14)
<.0001
57 (31)
23 (13)
<.0001
n
Sharing/Risky Injection Behaviors of
Russian Syringe Exchange Participants N = 1,076
St. Petersburg
N=221
n (%)
Volgograd
N=219
n (%)
80 (37)
41 (19)
<.0001
92 (45)
68 (33)
<.0001
31 (14)
2 (1)
<.0001
28 (13)
1 (1)
<.0001
Injected at Anonymous Injecting Venue
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Bought Drugs Loaded in Syringes
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
Used Blood in Preparation
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
17 (10)
3 (2)
<.002
6
4
(7)
(4)
ns
Saw Blood Used in Preparation
30 Days Prior to Using SEP
Last 30 Days while Using SEP
p
37 (21)
3 (2)
<.0001
23 (26)
7 (8)
<.0005
Current Prevention Programming for IDUs in
Eastern Europe and Central Asia, South Asia
and East Asia
• Outreach/Syringe Exchange
– 184 programs in Eastern Europe, Russia and
Central Asia
– A few programs in rest of the area
• Methadone Maintenance
– approximately 7000 patients
– 50% in Slovenia and Croatia
– None in Russia and China
Coverage at the Local Level
• “Criterion” of 60% of local IDU population
• Probably very few current programs reach
this level
Prevention of Sexual Transmission of HIV
from Injecting Drug Users to Non-injecting
Heterosexual Partners
• Recent meta-analysis of 33 methodologically
rigorous studies (conducted by CDC, Semaan et al.
2002)
• Some programming is modestly effective compared
to no programming
• Components of effective programming cannot yet
be identified
• Likely issues in adapting/translating to developing
countries, e.g., levels of stigmatization and HIV
drug use
Possibility that HIV among IDUs Will
Lead to Generalized HIV Epidemics
• Appears to have occurred in Manipur,
India
• Use of commercial sex workers by male
IDUs
• Participation in commercial sex work by
female IDUs
• High prevalence of other STDs facilitating
HIV transmission
Issues for Consideration
• Stigmatization of drug use and HIV-denial of
problems
• Simultaneous epidemics of HIV and injecting drug
use
• Policy support for effective HIV prevention
programs
• Local adaptation
• Support on the streets-lack of police interference
• Coverage (60%? at local level)
• Sustainability