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Relevance. According to US scientists, the percentage of people who do not know about their positive status is 20% of all people living with HIV. Moreover, this group provides 49% of new infections. Therefore, it can be assumed that information about HIV status has a significant epidemiological effect. Aim. To assess the change in risk behavior of HIV-infected persons after informing about the diagnosis and the frequency of occurrence of nonspecific symptoms of HIV infection. Materials and methods. For information on changing the behavior profile was developed, consisting of three sections. The first and third sections are aimed at elucidating the characteristics of sexual and drug behavior from the moment of probable infection to the moment of diagnosis, in comparison with the time period from the moment of reporting the diagnosis to the present. The second section of questions is aimed at determining the frequency of occurrence of nonspecific symptoms of early HIV infection. In the survey agreed to participate in 79 HIV-infected patients. The reliability of the results obtained was determined using the Wilcoxon Sign Test. Results. The message of the diagnosis of HIV infection contributed to the desire to abandon the systematic use of intravenous drugs. The proportion of people who denied drug use increased from 13 to 65% (p < 0.05). The number of people infected intensively (30 and more doses / month) using drugs has more than halved – from 38 to 17% (p < 0.05). The number of people denying drug use in groups increased from 10 to 45% (p < 0.05). From 55 to 12% (p < 0.05), the proportion of people who pass their syringe (needle) to another person to inject drugs has decreased. The number of persons who noted the presence of more than 5 partners per year after diagnosis decreased three times (p < 0.05). Only 23% of the respondents did not present any complaints in the period preceding the detection of HIV infection. Symptoms of acute respiratory disease marked 48%, 37% had fever, and other non-specific clinical manifestations of HIV infection. Conclusion. Communicating a positive HIV status to a patient reduces the likelihood of HIV transmission by drugs by 3–4 times and sexually by 2–3 times by changing risky behavior. Nonspecific symptoms of an acute viral disease before the detection of HIV infection were recorded in 48% of cases.

The term Munchausen syndrome is used to describe a situation where a person inflicts an illness or injury on self. Munchausen syndrome by proxy is when a person fabricates an illness on behalf of another. We report the case of an injection drug user admitted to the hospital for a spinal epidural abscess which was drained, treated with antibiotics and doing well, suddenly becoming very sick and febrile on day 17. The blood cultures grew a total of 12 organisms including 2 fungi. Someone who visited the patient in the hospital around this time was suspected to have injected a solution of drugs brought from home directly into the patient’s intravenous line used to administer antibiotics resulting in a polymicrobial bacteremia/fungemia. Presence of Lactobacilli in one blood culture raised the suspicion that the girl friend who was also a drug user, may have been responsible as Lactobacilli are more frequently found in hands of females. We caution physicians and nurses to be vigilant when handling injection drug users and other drug abusers admitted to hospital. Materials brought to the patient’s room from outside must be screened. New onset of unexpected symptoms should alert caregivers of the possibility of such abuse.

The clinical spectrum of human disease caused by Trueperella bernardiae is poorly described, partly as a result of historical difficulties with microbial identification. With the introduction of powerful new technologies, such as matrix-assisted desorption ionization–time of flight mass spectrometry, into routine microbiology laboratories, new insights into diseases caused by such organisms are being made. Here we report a case of septic thrombophlebitis with bacteraemia caused by this organism, together with a retrospective description of laboratory isolation of this organism over a period of 6 years in a hospital in London, UK. Keywords: Bacteraemia, injection drug user, MALDI-TOF, thrombophlebitis, Trueperella bernardiae

Background To evaluate nasal carriage, antibiotic susceptibility and molecular characteristics of methicillin-resistant Staphylococcus aureus (MRSA), as well as the risk factors of MRSA colonization, in human immunodeficiency virus (HIV)-infected patients in northern Taiwan. Methods From September 2014 to November 2015, HIV-infected patients seeking outpatient care at four hospitals were eligible for this study. A nasal specimen was obtained from each subject for the detection of S. aureus and a questionnaire was completed by each subject. MRSA isolates once identified were characterized. Results Of 553 patients surveyed, methicillin-susceptible S. aureus (MSSA) was detected in 119 subjects (21.5%) and MRSA in 19 subjects (3.4%). Female gender, injection drug use, smoking, hepatitis C virus carrier, cancer and antibiotic use within 1 year were positively associated with MRSA colonization. By multivariate analysis, only cancer (adjust odds ratio (aOR) 7.78, [95% confidence interval (CI), 1.909–31.731]) and antibiotic use within 1 year (aOR 3.89, [95% CI, 1.219–12.433]) were significantly associated with MRSA colonization. Ten isolates were characterized as sequence type (ST) 59/staphylococcal chromosome cassette (SCC) IV or VT, endemic community strains in Taiwan, four isolates as ST 8/SCCmec IV (USA 300) and one isolate as ST 239/SCCmec IIIA, a hospital strain. All the community-associated MRSA isolates were susceptible to trimethoprim-sulfamethoxazole (TMP-SMX). Conclusions Nasal MRSA carriage in HIV-infected patients seeking outpatient care was low (3.4%) in northern Taiwan. Most of the colonizing isolates were genetically endemic community strains and exhibited high susceptibility to TMP-SMX and fluoroquinolones. Cancer and antibiotic use within 1 year were associated with MRSA colonization.

Clostridium sordellii infections are known to be associated with high morbidity and mortality. To date, only a small number of cases with necrotizing soft tissue infection due to C. Sordellii have been reported. We report a case presented with necrotizing soft tissue infection of the right upper extremity caused by C. sordellii in a patient with known use of injected heroin. Despite broad spectrum antibiotics and surgical debridement, the patient's clinical course became rapidly fatal, within 24 h of admission. C. sordellii necrotizing soft tissue infections are particularly virulent. Even in the context of appropriate surgical debridement, these infections can be rapidly fatal. This case highlights the importance of high suspicion for C. sordellii as potential pathogen of necrotizing soft tissue infection in injection drug users.

Background: Human immunodeficiency virus (HIV) is one of the very much concerning issues and nearly 30 million people have died because of HIV related causes, which are found mostly low and lower income countries of the world. Objective: The objective of this study was to evaluate knowledge and practice to reduce risk factors of getting HIV among urban and rural men in Bangladesh with the comparative analysis among them. Methodology: This is a cross sectional study among 3997 men (urban=1437 and rural=2560). Frequency and percentage on knowledge and practice to reduce risk factors of getting HIV were counted to describe and also urban-rural significance levels of knowledge and practice issues regarding HIV were tested. Result: Knowledge and practice regarding HIV among urban-rural men were comparatively different where 93.7% urban and 81.9% rural men heard about HIV; 88.3% urban and 74.8% rural men thought that HIV can get by using unsterilized needle or syringe; 90.3% urban and 75.6% rural men thought that unsafe blood transfusions resulted HIV; 78.3% urban and 62.2% rural men use condom always during sex; and these urban-rural knowledge and practice related differences are statistically significant at P

The aim: of the prospective cohort study was a TB screening evaluation in HIV-infected current and released prisoners and homeless people in comparison to the local HIV-infected residents in the pilot territories. Methods: Prospective data collection of newly registered HIV and TB co-infected cases was provided inSt. Petersburg,VologdaandLeningradregions between 2008 and 2011. The patients’ social and demographic, clinical and epidemiological characteristics were analyzed and predictors of TB-attributable mortality were evaluated. Results: A total of 2888 patients were included in the analysis: 1570 local residents, 777 released prisoners, 404 prisoners and 137 homeless persons. There was no significant difference in age, but prisoners, released prisoners and homeless persons were more likely to be male, urban resident, unemployed and injection drug user, less likely to have microbiological confirmation, presented with a greater incidence of disseminated lung TB, lower CD4 cell count. Significant predictors of TB-attributable morality were current or prior incarceration, urban residence, unemployment, symptoms lasting over 1 year, extra-pulmonary TB at presentation and CD4 cell count less than 200 cell/mkl. Conclusions: Found TB cases in HIV-infected prisoners, released prisoners and homeless persons were at a significantly more advanced disease stage and presented with greater morbidity and mortality to compare to the local residents. Targeted early screening and on time started treatment interventions could improve TB outcomes in these highly vulnerable social groups.

Traveling homeless youth (i.e., youth who migrate from city to city, after a short period of time) exhibit elevated levels of risky substance use behaviors compared to non-traveling youth. Using sociometric data, we examined the characteristics of homeless youth who are connected to at least one traveler and how at least one connection to travelers was associated with substance use of travelers and non-travelers. Data were collected from 386 homeless youth at two drop-in centers in Los Angeles, CA. Results indicated that, comparing to what would be expected by chance, youth who reported at least one connection to travelers were more likely to use substances, more travelers reported at least one tie to another traveler, and more substance-using travelers reported at least one tie to other substance-using travelers. Multivariate analyses revealed that binge drinking and marijuana use were associated with homeless youth reporting connections to at least one substance-using traveler. Injection drug use was associated with reporting at least one connection to an injection drug user, regardless of traveler status, once we controlled for demographic characteristics and traveler status. We suggest the need for substance-using traveler-specific services using brief one-on-one interventions to prevent further engagement in risky substance use.

Background Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterial pathogen resistance to antibiotics including methicillin. The resistance first emerged in 1960 in a healthcare setting only after two years of using methicillin as a viable treatment for methicillin-susceptible Staphylococcus aureus. MRSA leads to infections in different parts of the body including the skin, bloodstream, lungs, or the urinary tract. Methods A deterministic model for methicillin-resistant Staphylococcus aureus (MRSA) with injection drug users is designed. The model incorporates transmission of MRSA among non-injection drug users and injection drug users (IDUs) who are both low-and high-risk users. A reduced MRSA transmission model with only non-IDUs is fitted to a 2008-2013 MRSA data from the Agency for Healthcare and Research and Quality (AHRQ). The parameter estimates obtained are projected onto the parameters for the low-and high-risk IDUs subgroups using risk factors obtained by constructing a risk assessment ethogram. Sensitivity analysis is carried out to determine parameters with the greatest impact on the reproduction number using the reduced non-IDUs model. Change in risk associated behaviors was studied using the full MRSA transmission model via the increase in risky behaviors and enrollment into rehabilitation programs or clean needle exchange programs. Three control effectiveness levels determined from the sensitivity analysis were used to study control of disease translation within the subgroups. Results The sensitivity analysis indicates that the transmission probability and recovery rates within the subgroup have the highest impact on the reproduction number of the reduced non-IDU model. Change in risk associated behaviors from non-IDUs to low-and high-risk IDUs lead to more MRSA cases among the subgroups. However, when more IDUs enroll into rehabilitation programs or clean needle exchange programs, there was a reduction in the number of MRSA cases in the community. Furthermore, MRSA burden within the subgroups can effectively be curtailed in the community by implementing moderate- and high-effectiveness control strategies. Conclusions MRSA burden can be curtailed among and within non-injection drug users and both low-and high-risk injection drug users by encouraging positive change in behaviors and by moderate- and high-effectiveness control strategies that effectively targets the transmission probability and recovery rates within the subgroups in the community.

Introduction Injection drug users (IDUs) often develop acute bacterial skin and skin structure infections (ABSSSI) and use emergency departments as their primary source for medical care. Methods A post hoc subgroup analysis of two randomized trials examined the efficacy and safety of tedizolid in the treatment of ABSSSI in IDUs. IDUs (n = 389) were identified from two pooled phase 3 trials (NCT01170221, NCT01421511) in patients with ABSSSI (n = 1333). Patients were randomly assigned to tedizolid phosphate (200 mg once daily, 6 days) or linezolid (600 mg twice daily, 10 days). Primary endpoint was ≥ 20% reduction in lesion area from baseline at 48 –72 h. Secondary endpoints included investigator-assessed clinical and microbiological response at the post-therapy evaluation (PTE). Results Wound infection was more common in IDUs (52.2%), while cellulitis/erysipelas was more common in non-IDUs (55.9%). Most infections were due to Staphylococcus aureus (IDUs, 75.2%; non-IDUs, 85.6%), while oral pathogens were more prevalent in IDUs. Early clinical success rates for tedizolid and linezolid were 82.5% and 79.6% in IDUs and 81.3% and 79.3% for non-IDUs, respectively; responses at PTE were similar. Microbiological response per pathogen was similar between treatment groups. Rates of treatment-emergent adverse events (AEs) in IDUs were comparable between tedizolid (46.2%) and linezolid (47.8%) arms, while lower incidence of gastrointestinal AEs was observed with tedizolid (20.3%) than with linezolid (25.1%). Conclusion Efficacy and safety of tedizolid and linezolid in the treatment of ABSSSI was similar in IDUs and non-IDUs, supporting the use of oxazolidinones in treating ABSSSIs in IDUs. Funding Merck & Co., Inc., Kenilworth, NJ, USA.

Injection drug user (IDU) experience and perceptions of police practices may alter syringe exchange program (SEP) use or influence risky behaviour. Previously, no community-level data had been collected to identify the prevalence or correlates of police encounters reported by IDUs in the United States.New York City IDUs recruited through respondent-driven sampling were asked about past-year police encounters and risk behaviours, as part of the National HIV Behavioural Surveillance study. Data were analysed using multiple logistic regression.A majority (52%) of respondents (n=514) reported being stopped by police officers; 10% reported syringe confiscation. In multivariate modelling, IDUs reporting police stops were less likely to use SEPs consistently (adjusted odds ratio [AOR]=0.59; 95% confidence interval [CI]=0.40-0.89), and IDUs who had syringes confiscated may have been more likely to share syringes (AOR=1.76; 95% CI=0.90-3.44), though the finding did not reach statistical significance.Findings suggest that police encounters may influence consistent SEP use. The frequency of IDU-police encounters highlights the importance of including contextual and structural measures in infectious disease risk surveillance, and the need to develop approaches harmonizing structural policing and public health.

SUMMARYWe examined and described colonization of MRSA in the anterior nares and throat from 184 community-recruited injection drug users. Thirty-seven (20%) were positive for MRSA: most (34, 92%) were carriers in the nares; while only three (8%) were carriers detected by throat swabs alone. The majority (29, 78%) of MRSA isolates were PVL positive.

To estimate the epidemic history of HIV-1 CRF01_AE in Vietnam and adjacent Guangxi, China, we determined near full-length nucleotide sequences of CRF01_AE from a total of 33 specimens collected in 1997–1998 from different geographic regions and risk populations in Vietnam. Phylogenetic and Bayesian molecular clock analyses were performed to estimate the date of origin of CRF01_AE lineages. Our study reconstructs the timescale of CRF01_AE expansion in Vietnam and neighboring regions and suggests that the series of CRF01_AE epidemics in Vietnam arose by the sequential introduction of founder strains into new locations and risk groups. CRF01_AE appears to have been present among heterosexuals in South-Vietnam for more than a decade prior to its epidemic spread in the early 1990s. In the late 1980s, the virus spread to IDUs in Southern Vietnam and subsequently in the mid-1990s to IDUs further north. Our results indicate the northward dissemination of CRF01_AE during this time.

HIV-1 CRF07_BC became prevalent in Taiwan after the epidemic among injection drug users (IDUs). We describe a unique recombinant form (URF) consisting of CRF01_AE and CRF07_BC (named URF_0107-H8) genes detected from an IDU. The 8.8 kb near full-length genome of URF_0107-H8 had a CRF01_AE backbone with two CRF07_BC fragments in the reverse transcriptase and integrase region [RT-Int; HXB2 nucleotide (nt) positions 2942-4709] and within the envelop (nt 8467-8722) gene. Phylogenetic analyses revealed that its 1.8 kb RT-Int sequence clustered with those of CRF07_BC strains from Taiwan, while sequences of CRF01_AE portions were more similar to those of Central African origin than contemporaneous CRF01_AE isolates in Taiwan or prevalent in East or Southeast Asia. Recombination breakpoints and phylogenetic relationships of URF_0107-H8 were different from those of CRF01_AE/CRF07_BC URFs previously reported from China. This highlighted the importance of continual monitoring of genetic evolution of HIV strains and the emergence of new recombinants.

The present study evaluated subjective importance weighting using data collected with the Injection Drug User Quality of Life Scale (IDUQOL). Weighted and unweighted IDUQOL scores from 241 adults were correlated with convergent, discriminant, and criterion measures. Regression analysis was used to examine the contribution of importance ratings to scores on a global measure of life satisfaction and the corrected weighted IDUQOL total scores. Overall, the results showed that weighted scores did not perform better than unweighted scores in measuring quality of life. However, the mean satisfaction ratings for important domains correlated significantly higher with convergent measures than did the mean satisfaction ratings for unimportant domains. This finding suggests further attention needs to be paid to the meaning and measurement of subjective importance and how it may be incorporated more effectively into measures of quality of life.

Background: We describe incarceration history (jail or prison) among a community‐based sample of young injection drug users (IDU) (age

Although infective endocarditis is certainly not the most common infection seen in injecting drug users, it is the infection that clinicians most commonly think of when they consider infectious complications of injected drug use. The microbiology of infective endocarditis in injection drug users has remained relatively stable over the last several decades. Tricuspid valve endocarditis has been associated most frequently with injection drug use, but recent reports have suggested that involvement of left-sided valves is seen more often now than in the past. The use of transesophageal echocardiography has greatly advanced the ability to diagnose infective endocarditis and the cardiac complications of valvular infection.

Objective To review community-acquired needle stick injuries (CANSIs) in children reported to a Canadian emergency room-based injury surveillance program. Design Analysis of 1991 to 1996 CANSI records followed by chart review to determine use of prophylactic interventions and outcome information. Setting The Canadian Hospitals Injury Reporting and Prevention Program network of 10 paediatric and six general hospitals. Patients Nonoccupational injuries to patients younger than age 20 years involving used needles were reviewed. Main results Of 116 children injured, most were male (74%); the median age was 6.6 years. Needles were picked up before injury in 77% of the cases. Most injuries (78%) were from needles presumed to have been discarded by an injection drug user. Parks were the most common site of injury (21%). Six per cent of injuries occurred in medical settings. Treatment information was obtained for 71 (61%) patients. Only 1.7% had been immunized against hepatitis B virus before injury. Hepatitis B immune globulin and hepatitis B virus vaccine were given to 78% and 76% of children, respectively. None received human immunodeficiency virus prophylaxis. Conclusions Programs teaching needle avoidance may help prevent many CANSIs. The safety of outdoor, home and medical environments also needs to be ensured. Treatment guidelines for CANSIs will help ensure appropriate postinjury management.

This paper examines the influence of syringe exchange programs (SEPs) in three ethnically diverse Chicago neighborhoods on changes in injection risk behaviors and the settings in which they occur. Despite community diversity, findings show a trend away from large, traditional “cash” or “free” galleries, housed in neighborhood apartments or in abandoned buildings, to smaller, “cash” or “taste” galleries, located in drug associates’ residences or other spots requiring an injection drug user (IDU) to be known to others in order to obtain entry. The modification of IDUs’ injecting practices as a result of legal supplies of sterile syringes is described. Socioeconomic factors affecting shooting galleries, such as the rise of crack cocaine, gentrification, and community policing programs, are discussed. Impediments to SEP use and continuing risk behaviors among IDUs are addressed. Finally, recommendations for reaching greater numbers of IDUs with harm‐reduction information are outlined.

Background Population size estimation is critical for planning public health programmes for injection drug users. Estimation is difficult, as these populations are considered 'hidden’ or 'hard to reach’. The currently accepted population size estimate for greater Victoria, Canada is between 1,500 and 2,000 individuals, which is dated prior to the year 2000, and is likely an underestimate. Methods We used three mark-recapture methods (the Lincoln-Petersen estimator, Huggins' model, and Pledger's model) to estimate population size using cross-sectional survey data collected in 2003 and 2005. Data come from a closed population with two time-ordered samples from the same source. We compare our estimates with the currently accepted estimate that is based on the registry of a Victoria needle exchange. Results All methods provided population size estimates that were higher than the currently accepted estimate. Huggins' method produced wider confidence intervals. Point estimates of population size from the three methods ranged from 3,329 to 3,342. Conclusions Our estimates will aid health authorities in planning for harm reduction programmes. Repeating the methods as further phases of I-Track data become available will ensure that the population estimates remain up to date.

A 35-year-old woman presented with a 1-week history of fever and malaise. She was in an acutely ill state. An HIV screening test was negative. No heart murmurs were noted on auscultation. Computed tomography revealed multiple patchy nodules throughout both lungs, some with cavitation and infiltration. The nodules were randomly distributed throughout a background of multifocal consolidation; however, they favored the peripheral zones (Picture). Blood cultures were positive for Staphylococcus aureus. Transthoracic echocardiography demonstrated areas of vegetation involving the tricuspid valve. Patients with tricuspid valve infective endocarditis (IE) often do not have detectable heart murmurs (1). The patient later confessed that she was an injection drug user (IDU). Unlike in Western countries (2), right-sided endocarditis is rare in Japan, although the prevalence of IDUs is increasing. Japanese clinicians should consider right-sided IE even in patients without murmurs when septic pulmonary emboli with staphylococcemia are detected.

Sources of HFV information were examined for 4,329 residents in five inner-city neighborhoods. Half of the respondents were female; 58% were African American, 21% Hispanic, and 21% White. Fortynine percent of participants reported one or more practices contributing to HIV risk: injection drug use (35%), sexual contact with an injection drug user (31%), prostitution (27%), or for men, anal sex with a male partner (5% of males). Most had received HIV information in the prior three months through mass or small media sources (78%), and 47% had spoken with someone about HIV. Television was the most frequently mentioned media source (48% of all respondents), while friends and family were the most frequently cited interpersonal source (20%). Exposure to specific mass and small media sources was related to gender, ethnicity, and risk status. Women and individuals at-risk of HIV infection were most likely to have talked with someone about HIV in the past three months. African Americans, however, were less likely to have discussed HIV. Differences associated with gender, ethnicity, and risk status were also observed for interpersonal information sources. Implications for future HIV education efforts are discussed.

In the previous chapter, we were concerned to trace the way that PrEP as a pill, PrEP RCTs and bioethics were collectively and mutually singularized. By focusing on various entities, not least through an engagement with expert and practitioner accounts, we showed how these were enacted as quantitative objects: that is to say, they were stabilized in relation to a set of criteria, measurements, parameterizations or standards that seemingly stood ‘outside’ of the complex events that comprise the trialling of the PrEP pill.

Distribution of sterile syringes to reduce the circulation of HIV-infection among injection drug user (IDU) communities is vital in curbing the spread of HIV among IDUs. In addition to other methods of distribution, syringe exchange programmes (SEPs) have been shown to be necessary in the dissemination of sterile syringes. Secondary syringe exchange (SSE) is an organic process by which IDUs distribute syringes to other IDUs and is an important complement to SEPs. This paper examines the motivations for people who provide SSE to other IDUs and the reasons why some IDUs do not use the Baltimore Needle Exchange Program (BNEP). Approximately 5000 individuals had obtained clean syringes from the BNEP between 1994 and 1997. In 1997, qualitative interviews were conducted in Baltimore with 20 providers of SSE and 10 SSE recipients who had never used the BNEP. Data from qualitative interviews were transcribed, coded and compiled. SSE providers reported economic gain and altruism as incentives. SSE recipients reported privacy, convenience of location and time, force of habit, and concern for carrying paraphernalia around as reasons influencing them to obtain syringes from secondary syringe exchangers rather than the needle exchange programme. Results from this study illuminate the social context in which SSE occurs and indicate the importance of SSE as a method for distributing sterile syringes.

BACKGROUND The prevalence and correlates of rectal sexually transmitted infections are well described among men who report receptive anal intercourse (AI); however, little is known about the epidemiology of rectal sexually transmitted infections among women. METHODS We conducted a cross-sectional study of women attending public sexually transmitted disease clinics in Los Angeles County, California. Women were eligible for inclusion in this study if they reported AI in the previous 90 days, were tested for rectal chlamydia and gonorrhea, and were seen between January 2008 and December 2010. RESULTS Among the 2084 clinic visits by women in this analysis, chlamydia and gonorrhea percent positivity by anatomic site was 12% (n = 144) for urogenital chlamydia, 14.6% (n = 171) for rectal chlamydia, 3.3% (n = 66) for urogenital gonorrhea, and 3.0% (n = 60) for rectal gonorrhea, with 25% of chlamydia cases and 19% of gonorrhea cases having rectal-only infections. Among women 25 years or younger, rectal infections were higher in visits in which women reported sex with an injection drug user (46.5% vs. 15.5%; P < 0.01) or sex with a HIV-positive partner (66.7% vs. 15.8%; P = 0.02). Among women older than 25 years, rectal infections were higher in visits where women reported substance use (10.6% vs. 5.8%; P ≤ 0.01). In multivariable models controlling for age and the presence of a urogenital infection, these associations remained. CONCLUSIONS Chlamydia and gonorrhea positivity was high among women reporting AI, and a large proportion of these cases would be missed in the absence of rectal testing. The high-risk behaviors of women with rectal infections highlight the need for rectal screening recommendations.

The history of HIV/AIDS prevention is, without question, a great, unfinished work. True, there have been important milestones in the three decades since the epidemic was first described in the United States [1]—accomplishments in science, advances in policy and the evolution of organized efforts to prevent the spread of the human immunodeficiency virus [2]. Yet, the epidemic is far from over, either in the United States or elsewhere in the world. According to the UNAIDS, there were 33 million people living with HIV in 2007 and almost 3 million new infections that same year [3]. In the United States, an estimated 56,300 persons became newly infected with HIV in 2006—roughly 40 % higher than previous estimates of HIV incidence [4]. Continued gaps in knowledge, notably in the domains of vaccine and microbicide development, have blunted efforts to prevent continued HIV transmission [5] and failure to bring proven HIV prevention interventions and programs to scale [6] has impeded optimal progress.

Advances in HIV prevention technologies such as the use of HIV treatments as prevention (TasP) offer new tools in the fight against AIDS. This chapter examines how biomedical devices have morphed into behavioral interventions over the past 30 years. Of particular interest are sterile syringes, condoms, and HIV antibody testing; medical technologies now thought of as behavioral interventions. These highly effective prevention tools have been stymied by politics, misguided policies, poor allocation of resources, and failure to invest in behavioral components to their use. These experiences offer important insights into how treatments could fail as prevention. The chapter concludes with recommendations for avoiding the pitfalls of past prevention technologies.

Conventional harm reduction (HR) projects overlook IDUs’ capabilities in offering them services but no active roles to play in preventing HIV. In contrast, “peer-driven interventions” (PDIs) offer IDUs rewards to educate and recruit peers for services. All IDU-recruits receive the opportunity to play both roles.

In previous chapters, focus was placed on the description of the most important infectious disease parameters. The next chapters will make the connection between the mathematical models and statistical models in order to estimate these parameters from data. In this chapter, we present a range of datasets that are analyzed repeatedly throughout the book. The datasets are used to motivate and illustrate the methods discussed in the text. Three main data sources are being used. The first are serological data, representing the age-specific prevalence of past infection in a population.

Objective To determine the experiences, practices, and challenges associated with nonprescription syringe sales (NPSS) among pharmacists whose pharmacies were enrolled in the Disease Prevention Demonstration Project in San Francisco, CA. Methods Self-administered survey mailed to 69 pharmacies and interviews with pharmacists and technicians. Results A total of 55 of 69 pharmacies (80%) returned the survey, and eight pharmacy managers and three pharmacy technicians were interviewed in person. Of pharmacists, 72% reported none or very few problems with NPSS in the previous year, although surveys and interviews illustrated challenges associated with NPSS in terms of time management, educating patients about syringe disposal, and understanding patient preferences for syringes. Of pharmacists, 62% reported NPSS to no more than 10 to 20 patients per week and 67% collected more than 400 syringes in the previous year. One-third of pharmacists perceived that their pharmacies were located in areas where drug activity was high and that the majority of NPSS patients injected illegal drugs. Conclusion Access to sterile syringes is a prominent public health issue, and pharmacists can play an important role in injection drug user (IDU) education and disease prevention. This evaluation suggests that pharmacies are selling nonprescription syringes to individuals perceived to be IDUs with no major problems. Additional evaluations from health department programs are needed to demonstrate the efficacy of NPSS in California.

Background Opioid overdose is a leading cause of death among injection drug users. Over half of injection drug users report at least one nonfatal overdose during their lifetime. Death from opioid overdose rarely occurs instantaneously, but rather over the course of one to three hours, allowing ample time for providing life-saving measures. In response to the prevalence of overdoses in the U.S., there are a growing number of overdose prevention and naloxone distribution programs targeting the injection drug using community. Methods We explored injection drug users' experiences with opioid overdose response, examining differences between overdose responses in which naloxone was and was not used. The current study is based upon qualitative interviews (N = 31) with clients of the Chicago Recovery Alliance needle exchange program who had witnessed an overdose in the past six months. The interviews explored participants' drug use history, personal overdose experiences, and details concerning their last witnessed overdose. Verbatim transcripts were coded and analyzed thematically to address major study questions. Results Participants were 81% were male, their median age was 38. They reported having injected a median of 10 years and having witnessed a median of six overdoses in their lifetime. All described overdoses were recognized and responded to quickly. None of the overdoses resulted in a fatality and naloxone was successfully administered in 58% of the last witnessed overdoses. Administering naloxone for the first time was characterized by trepidation, but this feeling dissipated as the naloxone quickly took effect. Emergency medical personnel were called in 10 of the 31 described overdoses, including four in which participants administered naloxone. The overwhelming majority of experiences with police and paramedics were positive Conclusion Overall, our small study found that the overdose prevention efforts build on extensive knowledge possessed by IDUs. Teaching IDUs how to use naloxone is an effective risk reduction strategy.

Using social network analysis, we investigated how communal meeting places can link injection drug user (IDU) populations and create opportunities for the transmission of bloodborne pathogens. In our locale, specific hotels played a key role in the injection drug scene. Within this hotel network some IDU injected at only one hotel while others injected at multiple hotels; this latter group potentially acted as spatial bridges linking relatively distinct hotel networks. Pathogen prevalence showed a gradation with the highest prevalence occurring at the centre of the network. Consistent with pathogen prevalence, people most central to the network were more likely to engage in risky injection practices. Incorporating geographic place into analyses involving IDU can contribute to an understanding of pathogen transmission patterns in an area and assist public health efforts to develop targeted intervention programs.

The twin epidemics of drug addiction and HIV simultaneously emerged in the Eurasia region in the late 1990s. Both were unanticipated by health establishments. Failure to act slowed the collection of detailed data and effective responses. In this chapter, we report on our observations and on those of our colleagues. To provide a proper sense of the problem created by the slow response of most of the governments in the region, this chapter combines a description of our experiences with the limited data available from scholarly sources.

Context There is considerable concern about the spread of HIV disease among Aboriginal peoples in British Columbia. Objective To estimate the number of Aboriginal British Columbians infected with HIV. Design and setting A population-based analysis of Aboriginal men and women in British Columbia, Canada from 1980 to 2001. Participants Epidemic curves were fit for gay and bisexual men, injection drug users, men and women aged 15 to 49 years and persons over 50 years of age. Main outcome measures HIV prevalence for the total Aboriginal population was modeled using the UNAIDS/WHO Estimation and Projection Package (EPP). Monte Carlo simulation was used to estimate potential number infected for select transmission group in 2001. Results A total of 170,025 Aboriginals resided in British Columbia in 2001, of whom 69% were 15 years and older. Of these 1,691 (range 1,479 – 1,955) men and women aged 15 years and over were living with HIV with overall prevalence ranging from 1.26% to 1.66%. The majority of the persons infected were men. Injection drug users (range 1,202 – 1,744) and gay and bisexual men (range 145, 232) contributed the greatest number of infections. Few persons infected were from low risk populations. Conclusion More than 1 in every 100 Aboriginals aged 15 years and over was living with HIV in 2001. Culturally appropriate approaches are needed to tailor effective HIV interventions to this community.

The objective of this study is to determine the allocation of resources within a multi-site needle exchange program (NEP) that achieves the largest possible reduction in new HIV infections at minimum cost. We present a model that relates the number of injection drug user (IDU) clients and the number of syringes exchanged per client to both the costs of the NEP and the expected reduction in HIV infections per unit time. We show that cost-effective allocation within a multi-site NEP requires that sites be located where the density of IDUs is highest, and that the number of syringes exchanged per client be equal across sites. We apply these optimal allocation rules to a specific multi-site needle exchange program, Prevention Point Philadelphia (PPP). This NEP, we find, needs to add 2 or 3 new sites in neighborhoods with the highest density of IDU AIDS cases, and to increase its total IDU client base by about 28%, from approximately 6400 to 8200 IDU clients. The case-study NEP also needs to increase its hours of operation at two existing sites, where the number of needles distributed per client is currently sub-optimal, by 50%. At the optimal allocation, the estimated cost per case of HIV averted would be $2800 (range $2300–$4200). Such a favorable cost-effectiveness ratio derives primarily from PPP's low marginal costs per distributed needle. Copyright © 2005 John Wiley & Sons, Ltd.

Gabrielle was a 17-year-old African-American woman living in Brooklyn, New York. Her boyfriend, Tony, had been in jail upstate for a year, but had recently returned home and gotten a job at the local dry-goods store. He loved her and she loved him; they had talked about a baby being the reflection of their love. When Gabrielle missed her first period and went for the pregnancy test, she found out that she was HIV positive. She was scared to tell Tony; she had had one boyfriend prior to Tony and maybe her first boyfriend was responsible for her contracting HIV. She wanted the baby, but was afraid this was the end of her relationship. How would she handle her HIV status? Devon was a 19-year-old Latino young man who dated women, but who was also attracted to men. While he had a girlfriend, he sometimes went downtown to the public baths to check out men’s bodies and, occasionally a relationship resulted. His basketball team routinely donated blood; one month he was called aside and informed that he was HIV positive. He started withdrawing from all social activities. He had told no one that he had any desires for men and certainly would tell no one that he was HIV positive. In this chapter, we will address interventions for young people living with HIV (YPLH). Adolescents whose parents are living with HIV are also affected by their parents or siblings or family-members’ infections

In this paper an optimal control model describing the influence of methadone maintenance treatment (MMT) on the spread of blood-borne diseases like Hepatitis C Virus (HCV) and Human Immunodeficiency Virus (HIV) among injection drug users is analyzed. The aim of the model is to find the optimal policy to minimize the discounted stream of the overall costs arising from MMT and the social costs caused by new infections from HIV and HCV.

To evaluate the New York State Expanded Syringe Access Demonstration Program (ESAP) through injection drug user (IDU) surveys, discarded needles and syringes studies, and pharmacy sales and experiences surveys.Pre-post comparison.In Harlem, New York City, risk surveys among street-recruited IDUs, needle/syringe street counts on 27 systematically sampled city blocks, and Harlem pharmacist reports of sales and experiences.Number and types of IDU syringe sources, block mean counts of discarded needles and syringes, level of pharmacy nonprescription syringe sales (NPSS), and pharmacists' experiences.Comparing 209 pre-ESAP with 396 post-ESAP IDUs, pharmacies as a primary syringe source increased: 3.4% to 5.3% (P.001, and ever pharmacy use increased: 4.9% to 12.5% (P.001), respectively. Compared with pre-ESAP IDUs, post-ESAP IDUs tended to be younger and more often black. Harlem pharmacy participation in ESAP increased considerably from March 1, 2001, to March 1, 2002, 49% to 79%, respectively. Among three Harlem pharmacies, there was a modest increase in NPSS; pharmacists reported no problems, and no discarded needles and syringes were observed in pharmacy areas. In the three pharmacies, the proportion of syringe sales that were NPSS was 46% (110 to 240 NPSS/month), 3% (25 to 90 NPSS/month), and 0%. The mean ratios of needles/syringes to background trash have not increased in Harlem since ESAP began.To date, no evidence of harmful effects discarded needles/syringes, pharmacy altercations) resulting from ESAP were observed. While NPSS have increased in Harlem, pharmacy use among IDUs remains low. In Harlem, efforts are underway to increase ESAP awareness and reduce socioenvironmental barriers to ESAP.

Developing and implementing successful interventions often depend upon effectively addressing ethnicity and social class factors, as these influence sexual behavior and its risks. Sexual attitudes differ across cultures. In most cultures, there are strong standards regarding sexual behavior which differ for men and women. Cultural differences also affect the extent to which early sexual behavior is considered acceptable.

Studies indicate that HIV risk behaviors vary greatly among injection drug users (IDUs). The source of such variation is often ascribed to individual differences, but much of it is due to how IDUs are grouped into social networks. Nevertheless, given the turbulent and uncertain lives led by many IDUs, it would not be surprising if their social networks changed substantially over time. We used data from a study of the social networks of IDUs in Chicago and Washington, DC, to examine changes in individual behavior and network characteristics over time. The results indicated few changes in standard network measures, such as density of ties or network size, over time. However, specific network change measures, that is, indicators of movement into and out of networks, showed significant movement of network members over time. Moreover, movement of members into a network significantly predicted a higher likelihood of risky injection drug use over time. We suggest that these movements are indicative of a lack of a stable resource base among IDU networks.

We described the first case, to the best of our knowledge, of cutaneous abscess due to Eubacterium lentum in a parenteral drug user, after complete fracture of the right femor. The case underlines the importance of carefully performed microbiological tests, due to the peculiar cultural needs of the micro-organism.