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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. - PowerPoint PPT Presentation
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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 (%)
Injected with Syringe Used by SomeoneElse
30 Days Prior to Using SEPLast 30 Days while Using SEP
p
35 (30)12 (10)
<.0001
15 (31)5 (10)
<.01
31 (24)10 (8)
<.0001
Daily Injection at Least One Drug30 Days Prior to Using SEP
Last 30 Days while Using SEPp
68 (57)90 (75)
<.01
38 (63)32 (53)
ns
111 (85)100 (76)
<.05
Frontloading/Backloading30 Days Prior to Using SEP
Last 30 Days while Using SEPp
46 (44) 48 (46) ns
24 (60) 17 (43) .052
99 (78) 84 (66) <.005
Shared Cotton, Cooker, Water30 Days Prior to Using SEP
Last 30 Days while Using SEPp
95 (79)75 (62)
<.001
51 (85)46 (77)
<.05
113 (87)92 (71)
<.01
Sharing/Risky Injection Behaviors of Central and Eastern European Syringe Exchange Participants N=595
Krakow N = 87
Poltava N = 194
n (%) n (%)
Injected with Syringe Used by Someone Else30 Days Prior to Ising SEP
Last 30 Days While Using SEP p
18 (23)5 (6)
<.001
14 (7)1 (1)
<.001Daily Injection At Least One Drug
30 Days Prior to using SEPlast 30 days while using SEP
p
76 (88)76 (88)
ns
174 (90)181 (93)
<.01Frontloading/Backloading
30 Days Prior To Using SEPLast 30 Days While Using SEP
p
22 (37)14 (24)
<.06
45 (24)38 (20)
nsShared Cotton, Cooker, Water
30 Days Prior To Using SEPLast 30 Days While Using SEP
p
30 (35)19 (22)
<.02
96 (51)83 (44)
<.01
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 (%)
Injected at Anonymous InjectingVenue
30 Days Prior to Using SEPLast 30 Days while Using SEP
p
57 (49)68 (59)
.06
10 (18)6 (11)
ns
37 (29)27 (21)
<.02
Bought Drugs Loaded in Syringes30 Days Prior to Using SEP
Last 30 Days while Using SEPp
11 (9)8 (7)
ns
6 (11)3 (5)
ns
5 (4)3 (2)
nsUsed Blood in Preparation
30 Days Prior to Using SEPLast 30 Days while Using SEP
p
10 (10)3 (3)
.0082
0 (0)5 (9)
<.05
0 (0)0 (0)
nsSaw Blood Used in Preparation
30 Days Prior to Using SEPLast 30 Days while Using SEP
p
23 (23)3 (3)
<.0001
4 (7)5 ( 9)
ns
1 (1)1 (1)
ns
Sharing/Risky Injection Behaviors of Central and Eastern European Syringe Exchange Participants N=595
Krakow N = 87
Poltava N = 194
n (%) n (%)
Injected at Anonymous Injecting Venue30 Days Prior to Using SEP
Last 30 Days while Using SEPp
51 (62)39 (48)
<.01
50 (28)29 (16)
<.0001Bought Drugs Loaded In Syringes
30 Days Prior to Using SEPLast 30 Days while Using SEP
p
28 (34)27 (33)
ns
21 (11)15 (8)
nsUsed Blood in Preparation
30 Days Prior to Using SEPLast 30 Days while Using SEP
p
0 (0)19 (23)
<.001
11 (6)2 (1)
<.02Saw Blood Used in Preparation
30 Days Prior to Using SEPLast 30 Days while Using SEP
p
3 (4)17 (20)
<.001
29 (15)7 (4)
<.0001
Sharing/Risky Injection Behaviors of Russian Syringe Exchange Participants N = 1,076
Nizhniy Novgorod N = 236
Pskov N = 201
Rostov-Na- Donu
N = 199 n (%) n (%) n (%)
Injected With Syringe Used by SomeoneElse
30 Days Prior to Using SEPLast 30 Days while Using SEP
p
94 (41)21 (9)
<.0001
52 (26)7 (4)
<.0001
77 (39)17 (9)
<.0001
Daily Injection At Least One Drug30 Days Prior to Using SEP
Last 30 Days while Using SEPp
150 (64)152 (64)
ns
49 (25)22 (11)
<.0001
104 (52)71 (36)
<.0001Frontloading/Backloading
30 Days Prior to Using SEPLast 30 Days while Using SEP
p
153 (67)122 (54)
<.0001
92 (46)72 (36)
<.005
98 (50)60 (30)
<.0001Shared Cotton, Cooker, Water
30 Days Prior to Using SEPLast 30 Days while Using SEP
p
169 (72)125 (53)
<.0001
187 (93)172 (86)
<.002
170 (85)146 (73)
<.0001
Sharing/Risky Injection Behaviors of Russian Syringe Exchange Participants N = 1,076
St. Petersburg N = 221
Volgograd N = 219
n (%) n (%)
Injected with Syringe Used by Someone Else30 Days Prior to Using SEP
Last 30 Days while Using SEPp
104 (47)63 (29)
<.0001
77 (37)7 (3)
<.0001
Daily Injection at least One Drug30 Days Prior to Using SEP
Last 30 Days while Using SEPp
144 (66)168 (77)
<.005
161 (74)155 (71)
ns
Frontloading/Backloading30 Days Prior to Using SEP
Last 30 Days while Using SEPp
129 (64)135 (67)
ns
125 (63)104 (52)
<.001
Shared Cotton, Cooker, Water30 Days Prior to Using SEP
Last 30 Days while Using SEPp
195 (88)199 (90)
ns
165 (75)141 (64)
<.0001
Sharing/Risky Injection Behaviors of Russian Syringe Exchange Participants N = 1,076
Nizhniy Novgorod
N=236
Pskov N=201
Rostov-Na- Donu
N=199 n (%) n (%) n (%)
Injected at Anonymous Injecting Venue30 Days Prior to Using SEP
Last 30 Days while Using SEPp
140 (62)106 (47)
<.0001
49 (25) 17 (9)
<.0001
107 (54)56 (28)
<.0001Bought Drugs Loaded in Syringes
30 Days Prior to Using SEPLast 30 Days while Using SEP
p
20 (9)5 (2)<.0001
8 (4)1 (1)<.001
37 (19)22 (11)
.0003Used Blood in Preparation
30 Days Prior to Using SEPLast 30 Days while Using SEP
p
12 (5)0 (0)
<.01
19 (10)18 (10)
ns
14 (8)9 (5)
nsSaw Used Blood in Preparation
30 Days Prior to Using SEPLast 30 Days while Using SEP
p
57 (25)8 (4)<.0001
60 (33)25 (14)
<.0001
57 (31)23 (13)
<.0001
Sharing/Risky Injection Behaviors of Russian Syringe Exchange Participants N = 1,076
St. Petersburg N=221
Volgograd N=219
n (%) n (%)Injected at Anonymous Injecting Venue
30 Days Prior to Using SEPLast 30 Days while Using SEP
p
80 (37)41 (19)
<.0001
92 (45)68 (33)
<.0001Bought Drugs Loaded in Syringes
30 Days Prior to Using SEPLast 30 Days while Using SEP
p
31 (14)2 (1)<.0001
28 (13)1 (1)<.0001
Used Blood in Preparation30 Days Prior to Using SEP
Last 30 Days while Using SEPp
17 (10)3 (2)<.002
6 (7)4 (4)
nsSaw Blood Used in Preparation
30 Days Prior to Using SEPLast 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
