1. HIV Risks Among Injection Drug Using Populations: Past, Present, and Projections for the future Steffanie A. Strathdee (1) Timothy B. Hallett (2) Natalia Bobrova (3) Tim Rhodes (4) Robert Booth (5) Reychad Abdool (6) Catherine Hankins (7) ( 1) University of California San Diego, Department of Medicine, CA, USA (2) Imperial College London, London, United Kingdom (3) University College London, United Kingdom (4) London School of Hygiene & Tropical Medicine, University of London, UK (5) University of Colorado at Denver, CO, USA (6) UNODC, Regional Office for Eastern Africa, Kenya (7) Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland 2010 Funding: NIDA R01DA027772-S1 & DA17620; Office of AIDS Research Wellcome Trust

2. The HIV risk environment Levels: – Macro – Micro Types: – Physical – Social – Economic – Policy Adapted from Rhodes 1999 and Glass and McAttee 2006

3. 1) Review research on HIV risk factors among IDUs over the last decade To what extent is this literature consistent with the risk environment framework? 2) Illustrate how varying levels of environmental influence affect IDUs’ risk behaviours, HIV incidence and attributable risks in 3 citiesObjectives

4. 2,722 documents collected from peer-reviewed literature 146 documents selected after reviewing title, keywords, abstracts 94 documents with data on risk factors, correlates, determinants Only 25% aimed to identify at least one micro- or macro- level environmental determinant, but 86% nevertheless did so Review of HIV epidemiology literature among IDUs: 1999-2009

5. Results of Review Over the past decade: Only 31% of studies were conducted in countries with high HIV burdens among IDUs. Most studies identified: Micro- rather than macro-level influences Physical and social rather than economic or policy influences Future studies should draw from social science literature, using a mixed methods approach

6. -How HIV epidemics may continue with and without future changes in proximate determinants of HIV risk in 3 cities: Modelling Scenarios Odessa, UkraineKarachi, PakistanNairobi, Kenya HIV epidemic among IDUs Established Emerging HIV epidemic among population GeneralizedConcentratedGeneralized Change in proximate determinant Police brutality (associated with needle sharing) Transition from non-injection to injection drug use Law prohibiting opioid substitution therapies (OST)

7. Inadequate ART provision and Sexual transmission can play key roles in some IDU-related epidemics Karachi Odessa

8. Impact of Scaling up Combination HIV Interventions: Example from Odessa Reducing unmet need of OST, NSP and ART by 60% could prevent 41% of incident HIV infections

9. Need to Optimize Intervention Coverage and Efficacy when Force of Infection is High: Nairobi Need to Optimize Intervention Coverage and Efficacy when Force of Infection is High: Nairobi

10. 8-12% reduction in transition from non-injecting to injecting could prevent 65–98% of incident HIV infections in Karachi Local HIV epidemics are sensitive to different types of structural changes: Karachi

11. Eliminating laws prohibiting OST and scaling up NSP and OST to 80% coverage could prevent 29% of new HIV infections among IDUs in Nairobi by 2015

12. Conclusions HIV epidemics among IDUs can be significantly curtailed if interventions are: -Evidence and Rights-based -Including scale up of OST, NSP and ART - Take into account local risks operating at multiple levels of influence Structural HIV prevention interventions are a crucial element of a combination prevention approach Shifts responsibility for change away from individuals, towards social/political contexts.

13. Acknowledgements Study Coauthors Drs. Hallett, Bobrova, Rhodes, Booth, Abdool, Hankins Reviewers (incl. D. Burrows, P. Vickerman, G. Stimson, R.White) US National Institute on Drug Abuse grants: -R01 DA027772-S1, R01 DA17620 Office of AIDS Research The Wellcome Trust (UK)

14. Christy Anderson Richard Armenta Annick Borquez Philippe Bourgois David Celentano Jessica Cubeta Penny Coppernoll-Blach Anna Dovbahk Faran Emmanuel Samuel R. Friedman Micah Gell-Redman Eleanor Gouws Mauro Guarinieri Peter Hartsock Brian Houle Francisco Inacio Bastos Natalia Kitsenko Acknowledgments Carl Latkin Robert Malow Bradley Mathers Lisovska Oksana Jane Marie Ongo’lo Samiran Panda Natalia Rehtina Diana Rossi Richard Rothenberg Tatyana Saliuk Oleg Semeryk Ani Shakarishvili Alexandra Thomas Emily To Lucas Wiessing Daniel Wolfe

15. Extra Slides

16. Example: HIV infections averted by eliminating Police Beatings in Three Cities in Ukraine Strathdee SA, Hallett TB, Bobrova N, et al. HIV and the Risk Environment among People Who Inject Drugs: Past, Present, and Projections for the Future. Lancet. In press.

17. Model projection, Odessa Strathdee SA, Hallett TB, Bobrova N, et al. HIV and the Risk Environment among People Who Inject Drugs: Past, Present, and Projections for the Future. Lancet. In press.

18. Projected number of HIV infections, 2010-15, Odessa Strathdee SA, Hallett TB, Bobrova N, et al. HIV and the Risk Environment among People Who Inject Drugs: Past, Present, and Projections for the Future. Lancet. In press.

19. Estimated attributable risk, 2010-15, Odessa Strathdee SA, Hallett TB, Bobrova N, et al. HIV and the Risk Environment among People Who Inject Drugs: Past, Present, and Projections for the Future. Lancet. In press.

20. Number of HIV infections among IDUs, 2010-15, Karachi Strathdee SA, Hallett TB, Bobrova N, et al. HIV and the Risk Environment among People Who Inject Drugs: Past, Present, and Projections for the Future. Lancet. In press.

21. Model projections, Karachi Strathdee SA, Hallett TB, Bobrova N, et al. HIV and the Risk Environment among People Who Inject Drugs: Past, Present, and Projections for the Future. Lancet. In press.

22. Projected number of HIV infections, 2010-15, Karachi Strathdee SA, Hallett TB, Bobrova N, et al. HIV and the Risk Environment among People Who Inject Drugs: Past, Present, and Projections for the Future. Lancet. In press.

23. Estimated attributable risk, 2010-15, Karachi Strathdee SA, Hallett TB, Bobrova N, et al. HIV and the Risk Environment among People Who Inject Drugs: Past, Present, and Projections for the Future. Lancet. In press.

24. Number of HIV infections among IDUs, 2010-15, Karachi Strathdee SA, Hallett TB, Bobrova N, et al. HIV and the Risk Environment among People Who Inject Drugs: Past, Present, and Projections for the Future. Lancet. In press.

25. Projected number of HIV infections, Kenya Strathdee SA, Hallett TB, Bobrova N, et al. HIV and the Risk Environment among People Who Inject Drugs: Past, Present, and Projections for the Future. Lancet. In press.

26. Number of HIV infections in IDUs, 2010-15, Kenya Strathdee SA, Hallett TB, Bobrova N, et al. HIV and the Risk Environment among People Who Inject Drugs: Past, Present, and Projections for the Future. Lancet. In press.

27. Databases searched: BIOSIS (ISI-CE Biosis previews), PubMed, and EMBASE for the period 2000 to 2009 Search components: 1."HIV"OR "HIV Infections“ or “HIV” or “AIDS” or "human immunodeficiency virus" or "acquired immunodeficiency syndrome" or "acquired immune deficiency syndrome" 2."Substance Abuse, Intravenous“ or “IDU” or “IDUs” or "injecting drug" or "intravenous drug" or "intravenous substance" or "injecting substance" or “injecting drug use” 3.“Risk factor” or “correlate” or “determinant” Search criteria Strathdee SA, Hallett TB, Bobrova N, et al. HIV and the Risk Environment among People Who Inject Drugs: Past, Present, and Projections for the Future. Lancet. In press.

28. Physical risk factors: Summary of HIV risks among IDUs according to the risk environment framework* (2000-2009) Micro-environmentCitationsMacro-environmentCitations Drug injecting locations 57–67 Drug trafficking and distribution routes Homelessness 67–73 Trade routes and population mobility 74 Prisons and incarceration 63,64,69,71,75–82 Geographical population shifts, neighbourhood and population mixing 83,84 Exposure to violence, trauma 84 Deportation 85 Spatial inequalities 5,40,58,71,85–95 Distance from HIV epicenter 96 Location of recruitment 83 *adapted from Rhodes and Simic, 2005 (12) (will seek appropriate permissions) Strathdee SA, Hallett TB, Bobrova N, et al. HIV and the Risk Environment among People Who Inject Drugs: Past, Present, and Projections for the Future. Lancet. In press.

29. Social risk factors: Summary of HIV risks among IDUs according to the risk environment framework* (2000-2009) Social and peer group norms Gender inequalities and gendered risk 75,90,94,97–100 Relationship/network dynamics 5,40,57,71,73,79,80,85,86,90,91,91,94,101–115 Stigmatization and marginalization of drug users Sexuality and sexual orientation 106 57,66,83,99,109,111,115–120 Weak civil society and community advocacy Local policing practices and ‘crackdowns’ 85,94,121 Police per capita 121 Community health and welfare service access and delivery 99 Exposure to war/conflict/disasters Education 57,61,66,71,100 Ethnic/racial inequities 59,69,70,72,89– 91,109,112– 114,120,122,122–126 Drugs easy to obtain 112 Peer outreach 127 *adapted from Rhodes and Simic, 2005 (12) (will seek appropriate permissions) Strathdee SA, Hallett TB, Bobrova N, et al. HIV and the Risk Environment among People Who Inject Drugs: Past, Present, and Projections for the Future. Lancet. In press.

30. Economic risk factors: Summary of HIV risks among IDUs according to the risk environment framework* (2000-2009) Cost of living and of health treatments Lack of health service revenue and spending Cost of syringes Correction Expenditures 121 Cost of condoms Growth of informal economies Lack of income generation and employment 61,77,82,95,102,103,109,128,129 Uncertain economic transition Survival sex trade/sex work 59,103,106,109,111,115, 117,130 *adapted from Rhodes and Simic, 2005 (12) (will seek appropriate permissions) Strathdee SA, Hallett TB, Bobrova N, et al. HIV and the Risk Environment among People Who Inject Drugs: Past, Present, and Projections for the Future. Lancet. In press.

31. Policy risk factors: Summary of HIV risks among IDUs according to the risk environment framework* (2000-2009) Coverage of sterile needles and syringes 131,132 Policy and laws governing syringe access and exchange – and enforcement status 123 Coverage of drug treatment 61,69,103,104,112,130,132, 133 Policy and laws governing drug treatment Coverage of HIV testing and Counselling 118 Policy and laws governing free HAART coverage Coverage of HAART 72 Public health policy governing sex work -- and enforcement status Program-level policies governing distribution of injection equipment Laws governing possession of drugs and drug paraphernalia – and enforcement status 96,134 Access to low-threshold and social housing Immigration policies and laws Laws governing protection of human and health rights *adapted from Rhodes and Simic, 2005 (12) (will seek appropriate permissions) Strathdee SA, Hallett TB, Bobrova N, et al. HIV and the Risk Environment among People Who Inject Drugs: Past, Present, and Projections for the Future. Lancet. In press.

32. 1.Abstracts examined to determine eligibility for inclusion 2.Search included all languages 3.Excluded manuscripts where: -HIV infection was not an outcome, -no primary data presented, -data on IDUs not presented separately -manuscripts were commentaries, editorials or reviews 4.Data extracted by two independent reviewers and entered into a systematic coding form 5.Random 10% verified by a third reviewer 6.Coded data mapped onto various levels and types of environmental influence according to the risk environment framework Search methods Strathdee SA, Hallett TB, Bobrova N, et al. HIV and the Risk Environment among People Who Inject Drugs: Past, Present, and Projections for the Future. Lancet. In press.