Mortality among injection drug users in northern Thailand: a prospective cohort study.

OBJECTIVES: : To measure mortality rates and assess predictors of all-cause mortality in a cohort of Thai injection drug users (IDUs) who were enrolled and followed up from 2004 through 2006. METHODS: : In this prospective cohort study, we enrolled 314 community-dwelling IDUs (95% being men; 42% of ethnic minority; median age, 29 years [range, 18-69 years]) and followed up them at 6-month intervals. Mortality rates were calculated based on person-years of follow-up. Marginal Cox proportional hazards models for clustered data were constructed to determine the factors associated with all-cause mortality. FINDINGS: : During 445.7 person-years of follow-up, 17 of 314 (5.4%) IDUs died. The all-cause mortality rate was 3.8 per 100 person-years (95% confidence interval [CI] = 2.2-6.1). The standardized mortality ratio was 5.8 (95% CI = 3.5-9.1). The mortality rate among HIV-positive IDUs was 13.4 per 100 person-years (95% CI = 5.4-27.6). In a marginal Cox proportional-hazards model for clustered data, the excess mortality was associated with HIV-positivity (hazard ratio [HR] = 7.0, 95% CI = 2.8-17.6), benzodiazepine use (HR = 3.1, 95% CI = 1.1-9.4), and excessive alcohol consumption at enrollment (HR = 3.5, 95% CI = 1.3-9.1). CONCLUSIONS: : The all-cause mortality among the drug injectors is high. The increased mortality was associated with HIV infection, benzodiazepine use, and excessive alcohol consumption.

Relationships between social norms, social network characteristics, and HIV risk behaviors in Thailand and the United States.

OBJECTIVE: Social norms have been associated with a wide range of health behaviors. In this study, the authors examined whether the social norms of HIV risk behaviors are clustered within social networks and whether the norms of network members are linked to the risk behaviors of their social network members. DESIGN: Data were collected from the baseline assessment of 354 networks with 933 participants in a network-oriented HIV prevention intervention targeting injection drug users in Philadelphia, United States, and Chiang Mai, Thailand. MAIN OUTCOME MEASURES: Four descriptive HIV risk norms of sharing needles, cookers, and cotton and front- or back-loading among friends who inject were assessed. RESULTS: Three of 4 injection risk norms (sharing needle, cookers, and cotton) were found to be significantly clustered. In Philadelphia, 1 network member's (the index participant) norms of sharing needles and front- or back-loading were found to be significantly associated with the network members' risk behaviors, and the norm of sharing cotton was marginally associated. CONCLUSION: The results of this study suggest that among injection drug users, social norms are clustered within networks; social networks are a meaningful level of analyses for understanding how social norms lead to risk behaviors, providing important data for intervening to reduce injection-related HIV risks.

The efficacy of a network intervention to reduce HIV risk behaviors among drug users and risk partners in Chiang Mai, Thailand and Philadelphia, USA.

This HIV Prevention Trials Network study assessed the efficacy of a network-oriented peer education intervention promoting HIV risk reduction among injection drug users and their drug and sexual network members in Chiang Mai, Thailand and Philadelphia, USA. The study was designed to test impact on HIV infection, but the infection rate was low and the study was terminated early. This paper reports efficacy on outcomes of self-reported HIV risk behaviors. We enrolled 414 networks with 1123 participants. The experimental intervention consisted of six small group peer educator training sessions and two booster sessions delivered to the network index only. All participants in both arms received individual HIV counseling and testing. Follow-up visits occurred every six months for up to 30 months. There were 10 HIV seroconversions, 5 in each arm. The number of participants reporting injection risk behaviors dropped dramatically between baseline and follow-up in both arms at both sites. Index members in the intervention arm engaged in more conversations about HIV risk following the intervention compared to control indexes. There was no evidence of change in sexual risk as a result of the intervention. Reductions in injection risk behaviors were observed: 37%, 20%, and 26% reduction in odds of sharing cottons, rinse water and cookers, respectively, and 24% reduction in using a syringe after someone else. Analysis of the individual sites suggested a pattern of reductions in injection risk behaviors in the Philadelphia site. In both sites, the intervention resulted in index injection drug users engaging in the community role of discussing reduction in HIV injection risk behaviors. The intervention did not result in overall reductions in self-reported sexual risk behaviors, and although reductions in injection risk behaviors were observed, the overall efficacy in reducing risk was not established.

Identification of CRF34_01B, a second circulating recombinant form unrelated to and more complex than CRF15_01B, among injecting drug users in northern Thailand.

In Thailand, the circulating HIV-1 strains include CRF01_AE, subtype B, and their recombinants. Genotyping and full-genome sequencing had previously identified circulating recombinant form CRF15_01B within a cohort of 347 HIV-1-infected individuals enrolled in the Opiate Users Research (OUR) study in northern Thailand. Using an improved MHAbce in six to eight genome regions and archived OUR serum samples, seven strains were identified with a new and complex 01/B recombinant pattern in common, different from that of CRF15_01B. Complete sequencing of three strains, amplified from serum as overlapping half-genomes, confirmed their common recombinant structure, mostly CRF01_AE, but with segments of subtype B in pol and gp41, plus a region of frequent 01/B crossovers in pol. OUR strains 1969P, 2275P, and 2478P were from individuals without direct epidemiological linkage and thus establish CRF34_01B. More comprehensive HIV-1 prevention and treatment programs in IDU can help to limit the growing complexity of HIV-1 strains in Thailand.

Predictors of mortality among injecting and non-injecting HIV-negative drug users in northern Thailand.

AIMS: To estimate mortality rates among HIV-negative injecting drug users (IDUs) and non-injecting drug users (non-IDUs), and to assess predictors for mortality among the IDUs. DESIGN: Prospective cohort study in northern Thailand with 2-year follow-up. SETTING: IDUs and non-IDUs who were admitted for detoxification treatment for opiate or amphetamine dependence in a regional drug treatment center were screened. After discharge, HIV-negative individuals were followed-up in the community. PARTICIPANTS: A total of 821 HIV-negative drug users [346 IDUs (42%) and 475 non-IDUs, median age = 32; 51% were ethnic minorities]. MEASUREMENTS: All-cause mortality. FINDINGS: There were 33 deaths over 1360 person-years of follow-up. The all-cause mortality rate was 39 per 1000 person-years among IDUs [standardized mortality ratio (SMR) = 13.9], and was 14 per 1000 person-years among non-IDUs (SMR = 4.4). Among male IDUs, the hazards for all-cause deaths were ethnic minority status [adjusted hazard ratio (HR) = 2.9, 95% CI = 1.2-7.2], incident HIV infection (HR = 2.8, 95% CI = 1.1-7.7) and longer duration of drug injection (HR = 1.07, 95% CI = 1.01-1.14). CONCLUSIONS: The mortality among IDUs is high. Being from an ethnic minority, recent HIV acquisition, and a greater number of years of drug injection are predictors of mortality among the IDUs in this region.

Risk factors associated with injection initiation among drug users in Northern Thailand.

BACKGROUND: Circumstances surrounding injection initiation have not been well addressed in many developing country contexts. This study aimed to identify demographic factors, sexual behaviors and drug use characteristics related to injection initiation among drug users in northern Thailand. METHODS: A cross-sectional survey was conducted among 2,231 drug users admitted to the Northern Drug Treatment Center in Mae Rim, Chiang Mai, Thailand, between February 1, 1999 and December 31, 2000. A multiple logistic regression was employed to identify the independent effects from potential risk factors of transition into injection. RESULTS: After controlling for other covariates, being 20 years of age or older, single, ever receiving education, urban residence, and having a history of smoking or incarceration were significantly associated with higher likelihood of injection initiation. Multiple sex partners and an experience of sex abuse were associated with an increased risk of injection initiation. Comparing to those whose first drug was opium, individuals using heroin as their initiation drug had greater risk of injection initiation; conversely, those taking amphetamine as their first drug had less risk of injection initiation. Age of drug initiation was negatively associated with the risk of injection initiation: the older the age of drug initiation, the less the risk of injection initiation. CONCLUSION: Injection initiation was related to several demographic factors, sexual behaviors and drug use characteristics. Understanding these factors will benefit the design of approaches to successfully prevent or delay transition into injection.

High HIV, hepatitis C and sexual risks among drug-using men who have sex with men in northern Thailand.

BACKGROUND: Men who have sex with men (MSM) and who use drugs have shown high HIV risks in Europe, and the Americas. We investigated MSM-drug user demographics, HIV sexual and drug use risks and behaviors in Chiang Mai, northern Thailand to identify prevention targets. METHODS: A total of 2005 males aged 13 years and older were enrolled during inpatient drug treatment from 1999-2000 and assessed for HIV, hepatitis C virus (HCV), syphilis, and for demographics and risks by questionnaire. Data were analyzed using chi and multiple logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Of 2005 males in treatment, 1752 (87.4%) had ever had sex, and 66 of 1752 (3.8%) reported ever having sex with another man; mostly Katoey (transgendered male) partners. MSM had higher HIV rates (OR, 2.32; 95% CI, 1.36-3.96) and were younger (P = 0.002); more likely to be Thai (P < 0.0001); better educated (P < 0.0001); had more lifetime sex partners (P < 0.0001), more female partners (P = 0.002), more female paid partners (P < 0.0001), and been paid for sex (P < 0.0001). MSM were more likely to have ever injected (P < 0.0001), sold drugs, been in prison, injected in prison, used heroin, and to have HCV (OR, 2.59; 95% CI, 1.55-4.34). CONCLUSIONS: Northern Thai MSM-drug users are at high HIV and HCV risk. In addition to sex risks with men, they have more sex with women and sex workers than other men, which fits Thai MSM patterns but not Western ones. Prevention must take into account their high rates of substance use and multiple partner types.

HIV infection among female drug users in Northern Thailand.

Reports on HIV infection and risk behaviors among female drug users in developing countries, particularly in Asia, are limited. In this study, we investigated HIV prevalence and risk factors for HIV infection among 200 women admitted for 21-day inpatient drug detoxification in Chiang Mai, Thailand. Volunteers completed a face-to-face interview using a structured interview, HIV pre-test counseling, specimen collection for HIV and STD tests, and were provided test results and HIV post-test counseling 1 week later. Two-third of participants (68%) were ethnic minorities with no formal education. Overall, 14 (7%) were HIV positive: 25% among 28 heroin injectors and 4.1% among 172 opium or methamphetamine smokers (p<0.001). History of drug injection and sexual abuse were associated with HIV infection. HIV prevention strategies for drug-using women in Thailand should consider both harm reduction strategies for drug use and promoting safer sex measures in a culturally appropriate context.