Regional differences between people who inject drugs in an HIV prevention trial integrating treatment and prevention (HPTN 074): a baseline analysis

Abstract

IntroductionPeople who inject drugs (PWID) experience high HIV incidence and face significant barriers to engagement in HIV care and substance use treatment. Strategies for HIV treatment as prevention and substance use treatment present unique challenges in PWID that may vary regionally. Understanding differences in the risk structure for HIV transmission and disease progression among PWID is essential in developing and effectively targeting intervention strategies of HIV treatment as prevention.MethodsWe present a baseline analysis of HIV Prevention Trials Network (HPTN) 074, a two‐arm, randomized controlled trial among PWID in Indonesia (n = 258), Ukraine (n = 457) and Vietnam (n = 439). HPTN 074 was designed to determine the feasibility, barriers and uptake of an integrated intervention combining health systems navigation and psychosocial counselling for the early engagement of antiretroviral therapy (ART) and substance use treatment for PWID living with HIV. Discordant PWID networks were enrolled, consisting of an HIV‐positive index and their HIV‐negative network injection partner(s). Among the enrolled cohort of 1154 participants (502 index participants and 652 network partners), we examine regional differences in the baseline risk structure, including sociodemographics, HIV and substance use treatment history, and injection and sexual risk behaviours.ResultsThe majority of participants were male (87%), with 82% of the enrolled females coming from Ukraine. The overall mean age was 34 (IQR: 30, 38). Most commonly injected substances included illegally manufactured methadone in Ukraine (84.2%), and heroin in Indonesia (81.8%) and Vietnam (99.5%). Injection network sizes varied by region: median number of people with whom participants self‐reported injecting drugs was 3 (IQR: 2, 5) in Indonesia, 5 (IQR: 3, 10) in Ukraine and 3 (IQR: 2, 4) in Vietnam. Hazardous alcohol use, assessed using the Alcohol Use Disorders Identification Test – Alcohol Consumption Questions (AUDIT‐C), was prominent in Ukraine (54.7%) and Vietnam (26.4%). Reported sexual risk behaviours in the past month, including having two or more sex partners and giving/receiving money or drugs in exchange for sex, were uncommon among all participants and regions.ConclusionsWhile regional differences in risk structure exist, PWID particularly in Ukraine need immediate attention for risk reduction strategies. Substantial regional differences in risk structure will require flexible, tailored treatment as prevention interventions for distinct PWID populations.

Estimating the Effect of Depression on HIV Transmission Risk Behaviors Among People Who Inject Drugs in Vietnam: A Causal Approach

“…Although there is substantial evidence that depression increases sexual risk behaviors among men who have sex with men (MSM) [25][26][27][28][29], few studies have focused on PWID and assessed injecting behaviors. Specifically, in Vietnam, the focus of this study and a setting where the HIV epidemic is concentrated among men who inject drugs [30,31], there have been no prior studies of the relationship of depression with injecting and sexual behaviors.…”

Community-based psychosocial substance use disorder interventions in low-and-middle-income countries: a narrative literature review

“…Family ‘units’ consisting of three individuals: an adult woman, her male husband or partne r (who must be a hazardous drinker according to AUDIT scores), ages ≥ 18, and one of her children (male or female, ages 8 – 17) CETA: an adaptable mental health intervention that targets cognitive and behavior change through a variety of intervention components. CETA was specifically adapted in this intervention to be delivered in group settings and to include a CBT - based substance use (SU) reduction element Lancaster et al [ 76 ], data also extracted from sister article Miller et al [ 77 ] Kyiv, Ukraine (one community site), Thai Nguyen, Vietnam (two district health center sites), and Jakarta, Indonesia (one hospital site) Two-arm RCT designed to determine the feasibility, barriers and uptake of an integrated intervention combining health systems navigation and psychosocial counselling for the early engagement and adherence of antiretroviral therapy (ART) and medication-assisted treatment for substance use (MAT) for people who inject drugs (PWID) living with HIV People who inject drugs (PWID) more than 12 times per 3 months (n = 502), who were HIV - positive (viral load of 1000 copies) and their non - infected injection partners (n = 806) were recruited as network units. Ages 18–60 Conditions: intravenous substance use and HIV Harm reduction, improved retention and adherence to SU treatment and HIV care, psychosocial counselling , and referral for ART at any CD4 count L’Engle et al [ 75 ] Three health drop-in centers in Mombasa, Kenya RCT to assess whether a brief alcohol intervention leads to reduced alcohol use and sexually transmitted infection (STI)/HIV incidence and related sexual risk behaviors among moderate drinking female sex workers Population: Female sex workers of ages ≥ 18 with hazardous drinking (AUDIT score 7–19) Conditions: Alcohol use disorder and STIs Brief intervention based on WHO Brief Intervention for Alcohol Use.…”

“…This also led to an increase in the sample size to 248 families. Lancaster et al [ 76 ], data also extracted from sister article Miller et al [ 77 ] Index participants in the standard of care group received referrals to existing HIV and MAT clinics where they were given primarily methadone; a standardized harm - reduction package… and the WHO package of care for PWID… Intervention group received the standard harm - reduction package plus the following interventions: systems navigation to facilitate engagement, retention, and adherence in HIV care and MAT, and to negotiate the logistics and… costs of any required laboratory testing (e.g., tuberculosis testing) and transportation; psychosocial counselling by use of motivational interviewing, problem solving, skills building, and goal setting to facilitate initiation of ART and MAT, and if started, medication adherence; and ART initiation. The primary goal for systems navigation was to address individual - level or systems - level barriers to ART and MAT enrolment… A minimum of two psychosocial counselling sessions ( Lasting 16–60 min ) focused on ART and MAT adherence… tailored to the participant’s needs.…”

“…Lancaster et al [76], data also extracted from sister article Miller et al [ strategies were modified to address these (see Table 5)…”

“…Second, during the Thai brief intervention study, "the Thai Government launched a new initiative… [to decrease the number of substance] users by 400,000" in 1 year through a number of strategies, including compulsory treatment [86]; although the authors claim that this initiative likely influenced the study's favorable outcomes, there was no discussion about the mechanisms by which this could have happened, that is, for example, whether the government initiative was genuinely effective in reducing substance use, or whether it influenced participants' self-report of substance use to possibly avoid compulsory treatment. Third, authors from the Indonesia-Ukraine-Vietnam study reported that although access to medication assisted treatment (MAT) is still limited in these settings, it has been increasing "due to changes in health policy" in the three countries, therefore, more positive results may be seen in future follow-ups [76]. Lastly, although government funding and/or collaborations were not discussed as facilitators per se, it is worth noting that six studies were at least partly supported by national governmental organizations; the rest received funding from international health/development organizations such as the National Institutes of Health (NIH), the United States Agency for International Development (USAID), the World Health Organization (WHO), and the United States Centers for Disease Control and Prevention (CDC).…”