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Substantial progress has been made in reducing HIV among injection drug users (IDUs) in the United States, despite political and social resistance that reduced resources and restricted access to services. The record for HIV prevention among noninjecting drug users is less developed, although they are more numerous than IDUs. Newer treatments for opiate and alcohol abuse can now be integrated into primary HIV care; treatment for stimulant abuse is less developed. All drug users present challenges for newer HIV prevention strategies (eg, "test and treat," nonoccupational postexposure prophylaxis and pre-exposure prophylaxis, contingency management, and conditional cash transfer). A comprehensive HIV prevention program that includes multicomponent, multilevel approaches (ie, individual, network, structural) has been effective in HIV prevention among IDUs. Expanding these approaches to noninjecting drug users, especially those at highest risk (eg, minority men who have sex with men) and incorporating these newer approaches is a public health priority.
BACKGROUND: Pre-exposure prophylaxis (PrEP) prevents human immunodeficiency virus (HIV) infection, but its use remains low among U.S. military men who have sex with men (MSM), likely due to mis-matching with personal preferences. We conducted a study to characterize preferences to PrEP measures within this population. METHODS: HIV-negative military MSM were recruited through a closed, Lesbian, Gay, Bisexual, and Transgendered (LGBT) military social media group. The survey was anonymous, and consisted of five experimentally varied attributes in service delivery: dosing method, provider type, visit location, lab work evaluation location, and dispensing venue. Relative importance and part-worth utility scores were generated using hierarchical bayes (HB) estimation, and the randomized first choice model was used to examine participation interest across eight possible PrEP program scenarios. RESULTS: A total of 429 participants completed the survey. Among the eight scenarios with varying attributes, the most preferred scenario featured a daily tablet, PrEP injection or implant, along with a military provider, smartphone/telehealth visit, and on-base locations for lab evaluation and medication pick-up. The results also emphasized the importance for providers to be familiar with PrEP prescription knowledge, and to provide interactions sensitive to sexual identity and mental health. CONCLUSION: A PrEP program consisting of daily tablet is preferred in military healthcare settings is preferred. Long-acting implants and injections are also desired. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s40779-021-00323-6.
The purpose of this study was to identify HIV risk factors associated with participants who were HIV seropositive at Needle Exchange Program (NEP) entry. A sample of injection drug users (IDUs) who enrolled in an NEP between 1994–1997 were recruited into a prospective study and tested for HIV antibodies. Demographic and recent drug use characteristics were collected. Logistic regression models were constructed to identify factors associated with HIV-seropositive status at NEP entry. Of 811 evaluation participants, 87% were African American, 67% were male, and 30% were HIV seropositive. The multivariate model indicated that daily cocaine injection (Adjusted OR (AOR)=1.98), daily speedball injection (AOR=2.36), daily heroin injection (AOR=0.55), cohabitation with someone (AOR=0.7), and employment (AOR=0.4) were all significantly associated with HIV seroprevalence at NEP entry (p<0.05). These findings indicate that HIV-seropositive individuals entering NEP practice particularly risky behaviors and are more likely to need help in order to minimize the harm of drugs and HIV infection than their HIV-seronegative counterparts.
Needle-exchange programs (NEPs) have been politically controversial, and most studies have focused on evaluating their effectiveness on human immunodeficiency virus (HIV) transmission rates with little emphasis on the process of how they are used. This article shows that the way intravenous drug users use NEPs may influence their effectiveness. Using data from Baltimore's NEP, participants (N=2,574) were classified as low, medium, and high users based on the volume, frequency, and duration of contact with the NEP. Higher NEP use was associated with shorter syringe circulation times and less syringe relay, returning syringes to the NEP originally acquired by someone else. For a subsample that was HIV tested (N=262), syringe relay among women was associated with HIV seroconversion (at a 95% confidence interval). We conclude that exclusive use of the NEP (no relay) provides greater HIV protection than NEP use involving syringe relay. The paradox is that public health goals will not be achieved by prohibiting syringe relay activities and promoting exclusive use. NEPs should broaden their education efforts to have participants understand the value of repeated visits to the NEP.
In May 2000, New York State passed legislation permitting the sale, purchase, and possession of up to 10 needles and syringes without a prescription. The law is intended to reduce the transmission of human immunodeficiency virus (HIV) and hepatitis among injection drug users (IDUs), their sexual partners, and their children. To obtain baseline information about the attitudes and likely practices of New York State pharmacists, we distributed a self-administered questionnaire to attendees of the state pharmacy association meeting in June 2000. Of 48 usable responses, 19% were from New York City and the rest from New York State. Of the 48, 42% were unaware of the new law before the day of the survey, and 60% were somewhat or very willing to sell needles and syringes to an IDU. Of those who were not willing to sell to an IDU, 82% cited familiarity of the customer as a very important consideration in their decision making. Those who were not willing to sell to an IDU were more concerned about the detrimental impact of syringe sales on the community, were less likely to be aware of the new law, and were more likely to be concerned about legal liability for syringe sales. Over 80% of all pharmacists believed that syringe sales to IDUs are an important preventive health measure. The majority also favored learning more about the law. Compared to other state surveys of pharmacists, these preliminary data show a similar level of interest in becoming involved with syringe availability programs.
Project Red Box, a pilot project undertaken by the Baltimore City Health Department, is designed to decrease the number of needles and syringes discarded in public locations. The qualitative evaluation consisted of focus groups with a total of 73 people, including injection drug users (IDUs), community residents, police officers, and local pharmacists. Mixed feelings were expressed about the project in each group. Community residents felt that discarded syringes pose a threat but having the boxes acknowledges drug use and send the message that drug use is acceptable. IDUs agreed that the project was a good idea, however, many maintained that the boxes would not be used. The majority of police officers and pharmacists felt that the boxes would not be used due to a lack of concern by IDUs regarding syringe disposal. Follow-up groups revealed that the boxes have had a positive impact on the community. Participants in each of the groups expressed positive opinions about the project and have either used the boxes themselves or have seen others use them. Expansion of the project was recommended.
As part of the baseline survey of a prospective study of the natural history of HIV-1 infection among intravenous (IV) drug users, 1,580 current and former IV drug users (IVDUs) were interviewed about their knowledge of AIDS, acquisition and prevention of HIV-1 infection, and risk behaviors. Using the National Center for Health Statistics's AIDS Knowledge and Attitudes Questionnaire, responses are compared to a cross-section of the U.S. population. The results show few differences between current knowledge of routes of transmission, general AIDS knowledge, unlikely sources of infection, and methods of prevention among IVDUs who are at high risk of acquiring HIV-1 and the general public, presumably at very low risk of infection. Analyses of HIV-1 and AIDS knowledge also demonstrated virtually no differences by HIV-1 antibody status or awareness of their serostatus at baseline, with the exception that those aware of their status were less likely to be hopeless in dealing with the problem. While few consistent differences were found between drug use behaviors and knowledge, IVDUs who reported having been in drug treatment were systematically better informed as to routes of transmission and prevention methods. However, those with a history of treatment were also more likely to see themselves at higher risk of acquiring HIV-1 than those who did not have this history. The data demonstrate that basic knowledge about HIV-1 has diffused to the IVDU community. Increasing treatment opportunities would seem to offer one avenue for assisting in behavior change in light of the HIV-1 epidemic these individuals face.
