Injection drug use and HIV/AIDS transmission in China

After nearly three decades of being virtually drug free, use of heroin and other illicit drugs has re-emerged in China as a major public health problem. One result is that drug abuse, particularly heroin injection, has come to play a predomi- nant role in fueling China’s AIDS epidemic. The first outbreak of HIV among China’s IDUs was reported in the border area of Yunnan province between China and Myanmar where drug trafficking is heavy. Since then drug-related HIV has spread to all 31 provinces, autonomous regions and municipalities. This paper provides an overview to HIV/AIDS transmission through injection drug use in China. It begins with a brief history of the illicit drug trade in China, followed by a discussion of the emergence of drug related AIDS, and a profile of drug users and their sexual partners who have contracted the virus or who are vulnerable to infection. It ends by summarizing three national strategies being used by China to address both drug use and AIDS as major health threats.

Therapeutic effect of transcatheter arterial chemoembolization and percutaneous injection of acetic acids on primary liver cancer

BACKGROUND: The resection rate of primary liver tumor in China is only about 20%. A lot of patients with moderate and advanced liver tumor may lose the chance of opera- tion. The objective of present research was to study the ef- ficacy of transcatheter arterial chemoembolization (TACE) combined with percutaneous injection of chemical agents and acetic acids in the treatment of patients with primary liver cancer (PLC). METHODS: Thirty-three patients with middle and ad- vanced stage of PLC were divided into two groups: percu- taneous injection of chemical agents and acetic acids (15 patients, group A) and TACE (18 patients, group B). RESULTS: Tumor diameter and serum AFP level reduced to 86.6% and 83.3% in group A, and 55.5% and 40% in group B, respectively. There was significant difference be- tween the two groups ( P < 0 . 0 1 ) . The 1-, 2-, 3-, 4-year survival rates of group A were 96.7%, 86.6%, 51.3%, 33.3%, respectively and in group B were 66.7%, 44.4%, 16.7%, 0%, respectively (P<0.01). CONCLUSION: TACE combined with percutaneous injec- tion of chemical agents and acetic acids is efficacious to in- crease the survival rate of patients with PLC.

Eligibility of persons who inject drugs for treatment of hepatitis C virus infection

In this decade, an increase is expected in end-stageliver disease and hepatocellular carcinoma, most commonly caused by hepatitis C virus(HCV) infection.Although people who inject drugs(PWID) are the ma-jor source for HCV infection, they were excluded fromantiviral treatments until recently. Nowadays there isincontrovertible evidence in favor of treating these patients, and substitution therapy and active substanceuse are no longer contraindications for antiviral treatment. The viral clearance in PWID after HCV antiviraltreatment with interferon or pegylated interferon combined with ribavirin is comparable to the viral clearancein non-substance users. Furthermore, multidisciplinary approaches to delivering treatment to PWID are advised, and their treatment should be considered on anindividualized basis. To prevent the spread of HCV inthe PWID community, recent active PWID are eligiblefor treatment in combination with needle exchange programs and substitution therapy. As the rate of HCV reinfection is low after HCV antiviral treatment, there is no need to withhold HCV treatment due to concerns about reinfection alone. Despite the advances in treatment efficacies and data supporting their success, HCV assessment of PWID and initiation of antiviral treatment remains low. However, the proportion of PWID assessed and treated for HCV is increasing, which can be further enhanced by understanding the barriers to and facilitators of HCV care. Removing stigmatization and implementing peer support and group treatment strategies, in conjunction with greater involvement by nurse educators/practitioners, will promote greater treatment seeking and adherence by PWID. Moreover, screening can be facilitated by noninvasive methods for detecting HCV antibodies and assessing liver fibrosis stages. Recently, HCV clearance has become a major endpoint in the war against drugs for the Global Commission on Drug Policy. This review highlights the most recent evidence concerning HCV infection and treatment strategies in PWID.

A mimic of soft tissue infection: intra-arterial injection drug use producing hand swelling and digital ischemia

BACKGROUND: Inadvertent intra-arterial injection of illicit substances is a known complication of injection drug use and can lead to severe complications, including infection, ischemia and compartment syndrome. Identifying complications of intra-arterial injection can be difficult, as clinical manifestations overlap with other more common conditions such as cellulitis and soft tissue infection, and a history of injection drug use is frequently not disclosed.METHODS: A 37-year-old male patient presented with 24 hours of right hand pain, erythema and swelling. Despite classic "track marks", he denied a history of injection drug use, and vascular insults were not initially considered. After failing to respond to three days of aggressive treatment for suspected deep-space infection, an arteriogram demonstrated findings consistent with digital ischemia of embolic etiology.RESULTS: As a result of the delay in diagnosis, the lesion was not amenable to reperfusion and the patient required amputation of the distal digit.CONCLUSION: Practitioners should be alert to the possibility of intra-arterial injection and resulting complications when evaluating unusual extremity infections or unexplained ischemic symptoms, even in the absence of a definite history of injection drug use.

HIV-1 Transmission among Injecting Drug Users is Principally Derived from Local Circulating Strains in Guangxi, China

Objective The mode of human immunodeficiency virus(HIV) transmission via injection drug use(IDU)still exists, and the recent shift in IDU-related transmission of HIV infection is largely unknown. The purpose of this study was to analyze the spatiotemporal sources and dynamics of HIV-1 transmission through IDU in Guangxi.Methods We performed a molecular epidemiological investigation of infections across Guangxi from2009 to 2019. Phylogenetic and Bayesian time-geographic analyses of HIV-1 sequences were performed to confirm the characteristics of transmission between IDUs in combination with epidemiological data.Results Among the 535 subjects, CRF08_BC(57.4%), CRF01_AE(28.4%), and CRF07_BC(10.7%) were the top 3 HIV strains;72.6% of infections were linked to other provinces in the transmission network;93.6% of sequence-transmitted strains were locally endemic, with the rest coming from other provinces,predominantly Guangdong and Yunnan;92.1% of the HIV transmission among people who inject drugs tended to be transmitted between HIV-positive IDUs.Conclusion HIV recombinants were high diversity, and circulating local strains were the transmission sources among IDUs in Guangxi. However, there were still cases of IDUs linked to other provinces.Coverage of traditional prevention strategies should be expanded, and inter-provincial collaboration between Guangxi, Yunnan, and Guangdong provinces should be strengthened.

Modelling Key Population Attrition in the HIV and AIDS Programme in Kenya Using Random Survival Forests with Synthetic Minority Oversampling Technique-Nominal Continuous

HIV and AIDS has continued to be a major public health concern, and hence one of the epidemics that the world resolved to end by 2030 as highlighted in sustainable development goals (SDGs). A colossal amount of effort has been taken to reduce new HIV infections, but there are still a significant number of new infections reported. HIV prevalence is more skewed towards the key population who include female sex workers (FSW), men who have sex with men (MSM), and people who inject drugs (PWID). The study design was retrospective and focused on key population enrolled in a comprehensive HIV and AIDS programme by the Kenya Red Cross Society from July 2019 to June 2021. Individuals who were either lost to follow up, defaulted (dropped out, transferred out, or relocated) or died were classified as attrition;while those who were active and alive by the end of the study were classified as retention. The study used density analysis to determine the spatial differences of key population attrition in the 19 targeted counties, and used Kilifi county as an example to map attrition cases in smaller administrative areas (sub-county level). The study used synthetic minority oversampling technique-nominal continuous (SMOTE-NC) to balance the datasets since the cases of attrition were much less than retention. The random survival forests model was then fitted to the balanced dataset. The model correctly identified attrition cases using the predicted ensemble mortality and their survival time using the estimated Kaplan-Meier survival function. The predictive performance of the model was strong and way better than random chance with concordance indices greater than 0.75.

Global elimination of hepatitis C virus infection:Progresses and the remaining challenges

Today, with the introduction of interferon-free direct-acting antivirals and outstanding progresses in the prevention, diagnosis and treatment of hepatitis C virus(HCV) infection, the elimination of HCV infection seems more achievable. A further challenge is continued transmission of HCV infection in high-risk population specially injecting drug users(IDUs) as the major reservoir of HCV infection. Considering the fact that most of these infections remain undiagnosed, unidentified HCVinfected IDUs are potential sources for the rapid spread of HCV in the community. The continuous increase in the number of IDUs along with the rising prevalence of HCV infection among young IDUs is harbinger of a forthcoming public health dilemma, presenting a serious challenge to control transmission of HCV infection. Even the changes in HCV genotype distribution attributed to injecting drug use confirm this issue. These circumstances create a strong demand for timely diagnosis and proper treatment of HCV-infected patients through risk-based screening to mitigate the risk of HCV transmission in the IDUs community and, consequently, in the society. Meanwhile, raising general awareness of HCV infection, diagnosis and treatment through public education should be the core activity of any harm reduction intervention, as the root cause of failure in control of HCV infection has been lack of awareness among young drug takers. In addition, effective prevention, comprehensive screening programs with a specific focus on high-risk population, accessibility to the new anti-HCV treatment regimens and public education should be considered as the top priorities of any health policy decision to eliminate HCV infection.

Hepatitis A virus infection and hepatitis A vaccination in human immunodeficiency virus-positive patients: A review

Hepatitis A virus(HAV)is one of the most common infectious etiologies of acute hepatitis worldwide.The virus is known to be transmitted fecal-orally,resulting in symptoms ranging from asymptomatic infection to fulminant hepatitis.HAV can also be transmitted through oral-anal sex.Residents from regions of low endemicity for HAV infection often remain susceptible in their adulthood.Therefore,clustered HAV infections or outbreaks of acute hepatitis A among men who have sex with men and injecting drug users have been reported in countries of low endemicity for HAV infection.The duration of HAV viremia and stool shedding of HAV may be longer in human immunodeficiency virus(HIV)-positive individuals compared to HIV-negative individuals with acute hepatitis A.Current guidelines recommend HAV vaccination for individuals with increased risks of exposure to HAV(such as from injecting drug use,oral-anal sex,travel to or residence in endemic areas,frequent clotting factor or blood transfusions)or with increased risks of fulminant disease(such as those with chronic hepatitis).The seroconversion rates following the recommended standard adult dosing schedule(2doses of HAVRIX 1440 U or VAQTA 50 U administered6-12 mo apart)are lower among HIV-positive individuals compared to HIV-negative individuals.While the response rates may be augmented by adding a booster dose at week 4 sandwiched between the first dose and the 6-mo dose,the need of booster vaccination remain less clear among HIV-positive individuals who have lost anti-HAV antibodies.

New hope for hepatitis C virus:Summary of global epidemiologic changes and novel innovations over 20 years

Hepatitis C virus(HCV)is a global health concern associated with significant morbidity and mortality.Before the approval of second-generation direct-acting antiviral agents(DAAs),interferon therapy and liver transplantation constituted the mainstay of treatment.The introduction of well-tolerated oral DAAs in late 2013 has revolutionized HCV management with over 95%cure rates.The predominance of HCV-related liver transplantations has declined following the widespread approval of DAAs.Despite the unparallel efficacy observed among these novel therapies,pharmaceutical costs continue to limit equitable access to healthcare and likely contribute to the differential HCV infection rates observed globally.To reduce the burden of disease worldwide,essential agenda items for all countries must include the prioritization of integrated care models and access to DAAs therapies.Through transparent negotiations with the pharmaceutical industry,the consideration for compassionate release of medications to promote equitable division of care is paramount.Here we provide a literature review of HCV,changes in epidemiologic trends,access issues for current therapies,and global inequities in disease burden.

Lurking epidemic of hepatitis C virus infection in Iran: A call to action

Despite having a relatively low prevalence in the Iranian general population, the burden of hepatitis C virus(HCV) infection is on the rise, and hepatitis C is predicted to be the most important leading cause of viral hepatitis-related mortality in the near future in Iran. The recent population-based epidemiological studies have revealed the predominant role of injecting drug use in increasing prevalence of HCV infection. Undoubtedly, new management paradigm is required to drive down the rising wave of hepatitis C in Iran. Priority should be given to young injecting drug users as the cornerstone of the lurking epidemic of HCV infection in Iran.

Dried blood spots,valid screening for viral hepatitis and human immunodeficiency virus in real-life

AIM To detect chronic hepatitis B(CHB),chronic hepatitis C(CHC) and human immunodeficiency virus(HIV) infections in dried blood spot(DBS) and compare these samples to venous blood sampling in real-life.METHODS We included prospective patients with known viral infections from drug treatment centers,a prison and outpatient clinics and included blood donors as negative controls. Five drops of finger capillary blood were spotted on filter paper,and a venous blood sample was obtained. The samples were analyzed for HBs Ag,antiHBc,anti-HBs,anti-HCV,and anti-HIV levels as well as subjected to a combined nucleic acid test(NAT) for HBV DNA,HCV RNA and HIV RNA.RESULTS Samples from 404 subjects were screened(85 CHB,116 CHC,114 HIV and 99 blood donors). DBS had a sensitivity of > 96% and a specificity of > 98% for the detection of all three infections. NAT testing did not improve sensitivity,but correctly classified 95% of the anti-HCV-positive patients with chronic and past infections. Anti-HBc and anti-HBS showed low sensitivity in DBS(68% and 42%).CONCLUSION DBS sampling,combined with an automated analysis system,is a feasible screening method to diagnose chronic viral hepatitis and HIV infections outside of the health care system.

Outreach onsite treatment with a simplified pangenotypic directacting anti-viral regimen for hepatitis C virus micro-elimination in a prison

BACKGROUND Prisoners are at risk of hepatitis C virus(HCV)infection,especially among the people who inject drugs(PWID).We implemented an outreach strategy in combination with universal mass screening and immediate onsite treatment with a simplified pan-genotypic direct-acting antivirals(DAA)regimen,12 wk of sofosbuvir/velpatasvir,in a PWID-dominant prison in Taiwan.AIM To implement an outreach strategy in combination with universal mass screening and immediate onsite treatment with a simplified pan-genotypic DAA regimen in a PWID-dominant prison in Taiwan.METHODS HCV-viremic patients were recruited for onsite treatment program for HCV micro-elimination with a pangenotypic DAA regimen,12 wk of sofosbuvir/velpatasvir,from two cohorts in Penghu Prison,either identified by mass screen or in outpatient clinics,in September 2019.Another group of HCV-viremic patients identified sporadically in outpatient clinics before mass screening were enrolled as a control group.The primary endpoint was sustained virological response(SVR12,defined as undetectable HCV ribonucleic acid(RNA)12 wk after end-of-treatment).RESULTS A total of 212 HCV-viremic subjects were recruited for HCV micro-elimination campaign;91 patients treated with sofosbuvir/Ledipasvir or glecaprevir/pibrentasvir before mass screening were enrolled as a control.The HCV microelimination group had significantly lower proportion of diabetes,hypertension,hyperlipidemia,advanced fibrosis and chronic kidney diseases,but higher levels of HCV RNA.The SVR12 rate was comparable between the HCV microelimination and control groups,95.8%(203/212)vs 94.5%(86/91),respectively,in intent-to-treat analysis,and 100%(203/203)vs 98.9%(86/87),respectively,in perprotocol analysis.There was no virological failure,treatment discontinuation,and serious adverse event among sofosbuvir/velpatasvir-treated patients in the HCV micro-elimination group.CONCLUSION Outreach mass screening followed by immediate onsite treatment with a simplified pangenotypic DAA regimen,sofosbuvir/velpatasvir,provides successful strategies toward HCV micro-elimination among prisoners.

Determining hepatitis C virus genotype distribution among high-risk groups in Iran using real-time PCR

AIM: To assess hepatitis C virus (HCV) genotype patterns among high-risk Iranian groups, using real-time RT-PCR.

Controversies in and challenges to our understanding of hepatitis C

Discovered in 1989, the hepatitis C virus (HCV) continues to cause signifi cant morbidity and mortality world-wide despite a huge research commitment to defining and understanding the virus and the disease it causes. This paper discusses a number of areas where progress in the management of the HCV have not kept pace with the scientifi c understanding of the HCV. It is suggested that in the fi elds of HCV prevention and providing access to treatment, practice falls short of what could be achieved. The role of alcohol in the pathogenesis of HCV liver injury is discussed. Discrimination against those with HCV infection and particularly those in prison settings fails to match good clinical practice. The complicated processes of sharing information between specialty groups is also discussed in an attempt to optimise knowledge dissemination in this field.

Epidemiology of hepatitis E virus in Iran

Iran is known as an endemic country for hepatitis E virus(HEV) infection, while there are variations in the epidemiology of HEV infection throughout the country. The available epidemiological studies in different regions of Iran show HEV seroprevalence of 1.1%-14.2% among general population, 4.5%-14.3% among blood donors, 6.1%-22.8% among injecting drug users, 6.3%-28.3% among hemodialysis patients, 1.6%-11.3% among patients infected with other hepatitis viruses, 27.5% among patients with chronic liver disease, 30.8% among kidney transplant recipient patients, and 10%-16.4% among human immunodeficiency virus-infected patients. These variations reflect differences in the status of public health and hygiene, risk factors, and routes of transmission in different regions and groups. Therefore, it is necessary to review the epidemiology of HEV infection to determine the most prevalent risk factors and routes of transmission, and to evaluate the effectiveness of preventive strategies employed in the public health services of the country. Moreover, the other epidemiological aspects of HEV, including the genotypic pattern, extra hepatic manifestations, and incidence of chronic infection need to be investigated among Iranian population to expand the current knowledge on the epidemiology of HEV and to clarify the real burden of HEV infection. Therefore, this review was performed to provide a general overview regarding the epidemiology of HEV in Iran.

Real-world effectiveness of direct-acting antivirals in people living with human immunodeficiency virus and hepatitis C virus genotype 6 infections

BACKGROUND Hepatitis C virus(HCV)genotype 6(HCV-6)infection is prevalent predominantly in Southeast Asia,and the data on the virologic response of HCV-6 to direct-acting antivirals(DAAs)are sparse in people living with human immunodeficiency virus(HIV)(PLWH).AIM To assess the virologic response of HCV-6 to DAAs in PLWH.METHODS From September 2016 to July 2019,PLWH coinfected with HCV-6 initiating DAAs were included.Laboratory investigations were performed at baseline,the end of treatment,and 12 wk off-therapy.RESULTS Of the 349 PLWH included(mean age 48.9 years,82.5%men),80.5%comprised people who inject drugs,18.1%men who have sex with men,and 1.4%heterosexuals.Coexistent hepatitis B virus infection was present in 12.3%of the included PLWH,liver cirrhosis 10.9%,hepatocellular carcinoma 0.9%,and previous HCV treatment experience 10.9%.The mean baseline plasma HCV RNA was 6.2 log10 IU/m L.Treatment with glecaprevir/pibrentasvir was initiated in 51.9%,sofosbuvir/ledipasvir 41.5%,sofosbuvir/velpatasvir 6.3%,and sofosbuvir/daclatasvir 0.3%.At DAA initiation,antiretroviral therapy containing tenofovir alafenamide was given in 26.4%,tenofovir disoproxil fumarate 34.4%,non-tenofovir alafenamide/tenofovir disoproxil fumarate 39.3%,non-nucleoside reverse-transcriptase inhibitors 30.4%,protease inhibitors 4.0%,and integrase strand transfer inhibitors 66.8%;94.8%of the included patients had CD4 counts≥200 cells/mm3 and 96.0%had plasma HIV RNA<50 copies/m L.Overall,96.8%achieved undetectable plasma HCV RNA(<30 IU/m L)at end of treatment;and 92.3%achieved sustained virologic response 12 wk off-therapy in the intention-to-treat analysis(93.5%in patients receiving sofosbuvir-based DAAs and 91.2%in those receiving glecaprevir/pibrentasvir).CONCLUSION Similar to the observation made in HIV-negative patients,sustained virologic response 12 wk offtherapy with DAAs is high in PLWH coinfected with HCV-6.

Clinicosocial Profile of People Who Inject Drugs Receiving Opioid Substitution Therapy at New Delhi

Introduction:Injecting drug use is a public health concern due to its clinical,social,economic,and legal consequences.Objective:(1)To evaluate the prevalence of infections associated with injecting drug use;and(2)To assess the social profile of substance users and high-risk behaviors among people who inject drugs(PWID)receiving opioid substitution therapy(OST).Materials and Methods:A cross-sectional study was conducted among 100 PWID who were deemed eligible using inclusion and exclusion criteria.Data were collected through an interviewer-administered structured questionnaire after obtaining informed written consent.Results:The results revealed that 14%of PWID had human immunodeficiency virus(HIV),7%had tuberculosis,and 2%had hepatitis B virus(HBV).None of the PWID self-reported hepatitis C virus(HCV)infection.Importantly,71%of PWID were living on the streets(i.e.homeless),and 41%of PWID had a history of sharing needles with other users in the preceding 3 months.Unmarried or single PWID had significantly increased risk of homelessness(χ^(2)=4.570;P=0.032)and reported high-risk sexual practices with commercial sexual partners in the preceding 3 months(χ^(2)=4.163;P=0.041).Homeless PWID had significantly increased frequency of injecting practices(P=0.020).Conclusion:Despite the higher global prevalence of HCV compared with HBV and HIV among PWID,HCV testing is not currently conducted at most OST centers in India.Access to free needles and syringes should be enhanced to reduce the morbidity associated with injecting drug use.

Factors associated with needle sharing among people who inject drugs in Yunnan, China: a combined network and regression analysis

Background:Network analyses have been widely utilized to evaluate large datasets,but have not yet been used to explore factors associated with risk behaviours.In combination with traditional regression analysis,network analyses may provide useful information and highlight key factors for reducing needle sharing behaviours among people who inject drugs(PWID).Methods:Sociodemographic data,and information on injection behaviour and sexual practices were collected from a cross-sectional survey that was conducted with PWID in five prefectures of Yunnan province,China.A combination of logistic regression and correlation network analyses were used to explore key factors for reducing needle-sharing behaviours among PWID.Results:In a total of 1049 PWID,37.5%had a history of needle or syringe sharing.The logistic analysis showed that Zhaotong,Qujing,Dehong,or Lincang residents,diazepam use,longer injection duration,needle reuse,and infection with HIV,viral hepatitis,tuberculosis and/or malaria were independently associated with needle sharing.The correlation network analyses showed that,compared to PWID who had never shared needles,PWID who did share needles would achieve harm reduction goals faster and more permanently.HIV serostatus and marital status were found to be closely associated with other risk factors.By combining regression analyses with network analyses,it was shown that PWID who are HIV seropositive will be an ideal target group for harm reduction programs.Conclusion:Needle-sharing behaviours are common among PWID in Yunnan,and harm reduction programs may help PWID who are HIV seropositive reduce risk behaviours and prevent blood borne diseases.

Intervention effect and dose-dependent response of Tanreqing injection on airway inflammation in lipopolysaccharide-induced rats

OBJECTIVE: To assess the effect of Tanreqing injection on airway inflammation in rats. METHODS: A rat model of airway inflammation was generated with lipopolysaccharide (LPS). Tanreqing injection was given by intratracheal instillation, and bronchoalveolar lavage fluid (BALF) from the right lung was collected. BALF total cell and neutrophil counts were then determined. In addition, BALF levels of inflammatory cytokines interleukin-1β, cytokine-induced neutrophil chemoattractant-1, and tumor necrosis factor-α were measured using enzyme linked immunosorbent assay.The middle lobe of the right lung was stained with hematoxylin-eosin and histological changes examined. RESULTS: LPS increased airway inflammation, decreased BALF inflammatory cell count, inflammatory cytokine levels, and suppressed leukocyte influx of the lung. The LPS-induced airway inflammation peaked at 24 h, decreased beginning at 48 h, and had decreased markedly by 96 h. CONCLUSION: Tanreqing injection contains anti-inflammatory properties, and inhibits airway inflammation in a dose-dependent manner.