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High prevalence of syringe lending among HIV-positive people who inject drugs in Bangkok, Thailand Voon, Pauline; Hayashi, Kanna; Ti, Lianping; Kaplan, Karyn; Suwannawong, Paisan; Wood, Evan; Kerr, Thomas Jun 2, 2015

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BRIEF REPORT Open AccessHigh prevalence of syringHIV-positive people who ilaIntroductionSyringe sharing among people who inject drugs (PWID)crucial component of HIV prevention efforts amongPWID [2]. However, in Thailand, despite endorsementPs, efforts areterile syringesHIV-positivef sterile syrin-e operated byVoon et al. Harm Reduction Journal  (2015) 12:16 DOI 10.1186/s12954-015-0050-5Vancouver, BC, CanadaFull list of author information is available at the end of the articlecivil society and international organizations [5]. In light ofthese efforts, we investigated the prevalence and correlatesHIV/AIDS, St. Paul’s Hospital, 608 - 1081 Burrard Street, Vancouver, BC V6Z1Y6, Canada4Department of Medicine, University of British Columbia, St. Paul’s Hospital,tions is caused by injection drug use [1]. The WorldHealth Organization and other United Nations agenciesconsider needle and syringe programs (NSPs) to be acoverage as low as <1 % among PWID in TDespite the legal controversy regarding NScurrently underway to enhance access to sand promote secondary prevention amongPWID in Thailand, including the provision oges within drop-in centers for PWID that ar* Correspondence: uhri-tk@cfenet.ubc.ca1Urban Health Research Initiative, British Columbia Centre for Excellence incontinues to be a major driver of the global HIV/AIDSpandemic. Globally, an estimated 1 in 10 new HIV infec-of NSPs by public health authorities, such programscontinue to be regarded as illegal [3], resulting in NSPhailand [4].AbstractBackground: Syringe sharing continues to be a major driver of the HIV pandemic. In light of efforts to enhanceaccess to sterile syringes and promote secondary prevention among HIV-positive individuals, we sought to identifythe prevalence and correlates of used syringe lending among self-reported HIV-positive people who inject drugs(PWID) in Bangkok, Thailand.Findings: We used bivariable statistics to examine factors associated with self-reported syringe lending amongself-reported HIV-positive PWID participating in the Mitsampan Community Research Project, a serial cross-sectionalstudy of PWID in Bangkok, between June 2009 and October 2011. In total, 127 individuals were eligible for thisanalysis, including 25 (19.7 %) women. Twenty-one (16.5 %) participants reported syringe lending in the prior6 months. Factors significantly associated with syringe lending included daily methamphetamine injection (oddsratio (OR) = 10.2, 95 % CI, 2.1–53.6), daily midazolam injection (OR = 3.1, 95 % CI, 1.1–8.7), use of drugs in combination(OR = 4.5, 95 % CI, 1.0–41.6), injecting with others on a frequent basis (OR = 4.25, 95 % CI, 1.3–18.3), and not receivingantiretroviral therapy (OR = 2.9, 95 % CI, 1.1–7.9).Conclusions: A high prevalence of syringe lending was observed among self-reported HIV-positive PWID in Bangkok,which was associated with high intensity drug use, polysubstance use, and frequently injecting with others. It isparticularly concerning that individuals who lent syringes were more likely to be untreated for HIV disease given theknown benefits of antiretroviral provision on the prevention of HIV transmission. These findings underscore the needto expand access to sterile syringes and HIV treatment among HIV-positive PWID in Thailand.Keywords: HIV, Injection drug use, People who inject drugs, Syringe lending, Syringe sharing, Bangkok, Thailand,Polysubstance use, Harm reduction, AntiretroviralBangkok, ThailandPauline Voon1,2, Kanna Hayashi1, Lianping Ti1,2, Karyn Kapand Thomas Kerr1,4*© 2015 Voon et al. This is an Open Access art(http://creativecommons.org/licenses/by/4.0),provided the original work is properly creditedcreativecommons.org/publicdomain/zero/1.0/e lending amongnject drugs inn3, Paisan Suwannawong3, Evan Wood1,4icle distributed under the terms of the Creative Commons Attribution Licensewhich permits unrestricted use, distribution, and reproduction in any medium,. The Creative Commons Public Domain Dedication waiver (http://) applies to the data made available in this article, unless otherwise stated.Voon et al. Harm Reduction Journal  (2015) 12:16 Page 2 of 5of syringe lending among a community-recruited sampleof HIV-positive PWID in Bangkok, Thailand.MethodsThe Mitsampan Community Research Project is a col-laborative research project involving the MitsampanHarm Reduction Center (Bangkok, Thailand), the ThaiAIDS Treatment Action Group (Bangkok, Thailand),Chulalongkorn University (Bangkok, Thailand), and theBritish Columbia Centre for Excellence in HIV/AIDS/University of British Columbia (Vancouver, Canada). Be-tween June 2009 and October 2011, the research part-ners undertook a serial cross-sectional study involving650 unique community-recruited PWID. Potential par-ticipants were recruited through peer outreach and wordof mouth and were invited to attend the MitsampanHarm Reduction Center or O-Zone House (local drop-incenters for people who use drugs) to be part of thestudy. Adults residing in Bangkok or adjacent provinceswho had injected drug(s) in the previous 6 months wereeligible for participation in the study. All participantsprovided oral informed consent and completed aninterviewer-administered questionnaire eliciting demo-graphic data as well as information about drug use pat-terns, HIV risk behavior, and experiences with healthcareservices. Participants received a stipend of 350 Thai Baht(approximately $11 USD) upon completion of the ques-tionnaire. The study was approved by the research ethicsboards at Chulalongkorn University and the University ofBritish Columbia.The present analysis was restricted to PWID who re-ported being HIV-positive. The primary outcome ofinterest was reporting syringe lending in the 6 monthsprior to the time of interview, as defined by responding“Yes” to the question: “Have you lent your used needles/syringes to someone else in the last six months?” Wecompared the demographic, behavioral, and social/struc-tural characteristics of PWID who did and did not re-port syringe lending using Pearson’s X2 test and Fisher’sexact test (when one or more cells contained values lessthan or equal to five). Variables considered included thefollowing: median age (<38 years vs. ≥38 years), gender(male vs. female), education level (<secondary educationvs. ≥secondary education), incarceration (yes vs. no), fre-quent heroin injection (≥daily vs. <daily), frequent meth-amphetamine injection (≥daily vs. <daily), frequentmidazolam injection (≥daily vs. <daily), binge drug use(yes vs. no), use of drugs in combination (yes vs. no),injecting with others on a frequent basis (≥25 % of thetime vs. <25 % of the time), enrollment in voluntarydrug treatment (including methadone treatment) (yes vs.no), reporting difficulty accessing sterile syringes (yesvs. no), and receiving antiretroviral therapy (ART) atthe time of interview (receiving vs. not receiving). Allbehavioral variables refer to the previous 6 months un-less otherwise indicated. All p values were two-sided.ResultsA total of 650 unique individuals were seen during thestudy period, of which 127 (19.5 %) HIV-positive indi-viduals with complete data were eligible for this study.Among the 127 individuals included in this study, 25(19.7 %) were female. The median age was 38 years(interquartile range, 34–43 years). In total, 21 (16.5 %)participants reported that they had lent a used syringe toanother person within the 6 months prior to their inter-view. As indicated in Table 1, factors significantly andpositively associated with syringe lending in bivariableanalyses included the following: daily methamphetamineinjection (odds ratio (OR) = 10.20, 95 % CI, 2.08–53.60),daily midazolam injection (OR = 3.14, 95 % CI, 1.13–8.72), use of drugs in combination (OR = 4.49, 95 % CI,0.98–41.60), injecting with others on a frequent basis(OR = 4.25, 95 % CI, 1.26–18.30), and not receiving ART(OR = 2.93, 95 % CI, 1.09–7.86).DiscussionA high prevalence of used syringe lending was observedamong our sample of HIV-positive PWID in Bangkok,with 16.5 % of participants reporting syringe lending inthe past 6 months. Individuals who reported syringelending were more likely to report high intensity druguse (i.e., daily injection of methamphetamine or midazo-lam), polysubstance use, frequently injecting with others,and not receiving ART.It is particularly concerning that individuals who lentsyringes were more likely to be untreated for HIV, giventhe known benefits of ART in preventing HIV transmis-sion [6]. This finding may suggest that individuals re-ceiving ART may have greater access to NSPs and/oreducation on safer injecting practices secondary to theirengagement in HIV care, compared to PWID not receiv-ing ART, who may lack access to such education or ser-vices. Furthermore, HIV testing rates remain low in theAsia-Pacific region, with approximately 20 % of PWIDhaving been previously tested [7] and approximately13 % of PWID avoiding HIV testing in one study inThailand [8]. Similarly, PWID in Thailand demonstrateconsiderably low rates of ART coverage, with only 2 % ofHIV-positive PWID estimated to have ever accessedART [4], compared to a reported ART coverage rate of65 % among all eligible people living with HIV inThailand [9]. Given Thailand’s system of universalhealthcare that provides ART for free or at a reducedcost [10], the comparatively lower rates of ART uptakeamong PWID may be attributable to the Thai govern-ment’s aggressive drug law enforcement strategies thatmay serve as barriers or deterrents for PWID to accessTable 1 Bivariable analysis of factors associated with syringe lending among a community-recruited sample ofHIV-positive PWID in Bangkok, Thailand (n = 127)Characteristic Syringe lendinga Odds ratio (95 % CI) p valueYes 21 (16.5 %) No 106 (83.5 %)Age<38 years 11 (52.4) 52 (49.1) 1.14 (0.45–2.92) 0.781≥38 years 10 (47.6) 54 (50.9)GenderMale 19 (90.5) 83 (78.3) 0.38 (0.04–1.78) 0.246Female 2 (9.5) 23 (21.7)Education level<Secondary education 11 (52.4) 42 (39.6) 1.68 (0.65–4.29) 0.279≥Secondary education 10 (47.6) 64 (60.4)IncarcerationaYes 3 (14.3) 13 (12.3) 1.19 (0.20–4.99) 0.728No 18 (85.7) 93 (87.7)Heroin injection frequencya≥Daily 2 (9.5) 15 (14.2) 0.64 (0.07–3.14) 0.736<Daily 19 (90.5) 91 (85.8)Methamphetamine injection frequencya≥Daily 6 (28.6) 4 (3.8) 10.20 (2.08–53.59) 0.001<Daily 15 (71.4) 102 (96.2)Midazolam injection frequencya≥Daily 15 (71.4) 47 (44.3) 3.14 (1.13–8.72) 0.023<Daily 6 (28.6) 59 (55.7)Binge drug useaYes 11 (52.4) 34 (32.1) 2.33 (0.90–6.01) 0.076No 10 (47.6) 72 (67.9)Use of drugs in combinationaYes 19 (90.5) 72 (67.9) 4.49 (0.98–41.55) 0.037No 2 (9.5) 34 (32.1)Injected with others on a frequent basisa≥25 % of the time 17 (81.0) 53 (50.0) 4.25 (1.26–18.33) 0.015<25 % of the time 4 (19.0) 53 (50.0)Enrolled in voluntary drug treatment (including methadone)aYes 8 (38.1) 38 (35.8) 1.10 (0.42–2.89) 0.845No 13 (61.9) 68 (64.2)Difficulty accessing sterile syringesaYes 0 (0.0) 5 (4.7) 0.590No 21 (100.0) 101 (95.3)Receiving antiretroviral therapybReceiving 7 (33.3) 63 (59.4)Not receiving 14 (66.7) 43 (40.6) 2.93 (1.09–7.86) 0.028PWID people who inject drugsaDenotes events/activities during the 6 months prior to the interviewbDenotes events/activities at the time of the interviewVoon et al. Harm Reduction Journal  (2015) 12:16 Page 3 of 5Voon et al. Harm Reduction Journal  (2015) 12:16 Page 4 of 5health care [11, 12]. In this context, the lower odds ofreceiving ART among PWID who lent syringes in thisstudy may suggest that aggressive enforcement may beshaping HIV risk behavior and ART uptake by discour-aging access to HIV treatment and prevention programs.Therefore, targeted efforts to reduce the public healthburden of aggressive drug law enforcement strategies(e.g., compulsory drug detention) within this settingshould occur alongside initiatives to scale up evidence-based public health interventions including HIV testing,ART, peer-based HIV education, and NSPs, as describedbelow [13]. Strategies to address these gaps are currentlyunderway in Thailand, including plans to provide ARTirrespective of CD4 count and harmonize health insur-ance schemes for greater service deliver efficiency [14].Other interventions to enhance access to and implemen-tation of early ART initiation should be also supportedfor HIV-positive PWID in Thailand. Finally, given thehigh prevalence (85–90 %) of HIV and hepatitis C(HCV) co-infection among PWID in Thailand [15, 16],as well as the greater transmissibility of HCV comparedto HIV, these findings warrant further research on syr-inge lending behaviors among HCV-infected PWID andincreased HCV testing, treatment, and education forPWID in Thailand.The associations between syringe lending and high in-tensity drug use are consistent with previous literatureon PWID in Thailand. Specifically, the association be-tween daily methamphetamine injection and syringelending in this study is consistent with a 2011 study thatfound that frequent methamphetamine injection waspositively and independently associated with syringesharing among Thai PWID [17]. Additionally, previousstudies have found associations between syringe sharingand polysubstance use [18]. Given that midazolam iscommonly used in combination with other drugs, theobserved association between daily midazolam injectionand syringe lending in this study may reflect the highprevalence of polysubstance use among midazolam in-jectors in Bangkok [19, 20]. Finally, our finding that syr-inge lending was associated with frequent injection withothers complements previous associations found be-tween frequent injection with others and syringe bor-rowing among Thai PWID [21].These findings add to the growing body of literaturepointing to the high prevalence of risk behaviors forHIV and other infectious diseases (e.g., hepatitis C)among Thai PWID and the importance of harm reduc-tion programs as an essential response to these epi-demics [22]. In particular, NSPs have been shown todramatically reduce the prevalence of high-risk injectionbehaviors, as evidenced by a decrease in syringe sharingamong PWID by more than 38 % due to the distributionof sterile injection equipment in one Canadian setting[23]. Furthermore, NSPs have been shown to preventHIV and hepatitis C transmission among PWID [24].Previous studies have highlighted the various difficultiesthat Thai PWID face in accessing sterile syringes, in-cluding distance from NSPs, limited pharmacy hours,and being refused syringes at pharmacies [21]. In orderto reduce the harms associated with injection drug use,particularly the risk of HIV and other infectious diseasetransmission, urgent action is needed to address thesebarriers and expand access to NSPs in Thailand.This study has several limitations. First, due to thecross-sectional study design, we were unable to deter-mine temporal relationships between the explanatoryvariables and the outcome. Thus, we are unable to infercausation from this observational study. Additionally, be-cause we observed only 21 participants reporting syringelending, we were unable to conduct multivariable analysesto examine the independent relationships between the ex-planatory variables and the outcome. Therefore, the asso-ciations observed in the present study should be furtherexamined through multivariable, longitudinal analyseswith a larger sample size. Third, the data collected wereself-reported, including HIV serostatus, and may be sub-jected to reporting biases such as socially desirable report-ing and recall bias. However, self-reported data arecommonly used in observational studies involving PWIDand have been repeatedly found to be valid [25, 26].Nevertheless, it is possible that the use of self-reportedserostatus in this study may confound the association be-tween syringe lending and enrolment in antiretroviraltherapy, such that individuals who are on ART may moreaccurately report their HIV serostatus compared to indi-viduals not receiving ART, who may not have been for-mally tested for HIV. Fourth, given that the study samplewas not randomly selected, the study findings may not begeneralizable to Thai PWID or PWID in other settings. Fi-nally, we did not collect data on number of injection part-ners; however, given past research highlighting thepotential influence of social networks on syringe sharingbehaviors among PWID [24, 27], this is an area that wouldbenefit from further investigation.In sum, 16.5 % of our sample of HIV-positive PWID inBangkok reported used syringe lending in the 6 monthsprior to being interviewed. This high-risk behavior wasassociated with high intensity drug use, polysubstanceuse, injecting with others on a frequent basis, and not re-ceiving ART. These findings emphasize the need to expandevidence-based public health interventions for HIV-positivePWID in Thailand, particularly through the expansion ofearly ART, NSPs, and peer-based HIV education.AbbreviationsAIDS: acquired immune deficiency syndrome; ART: antiretroviral therapy;CI: confidence interval; HIV: human immunodeficiency virus; PWID: peoplewho inject drugs; NSP: needle and syringe program; OR: odds ratio.9. Thailand AIDS response progress report. Reporting period: 2010‐2011.Joint United Nations Program on HIV/AIDS. 2012. 2012. Available at:http://www.unaids.org/sites/default/files/en/dataanalysis/knowyourresponse/countryprogressreports/2012countries/ce_th_narrative_report.pdf.Voon et al. Harm Reduction Journal  (2015) 12:16 Page 5 of 5Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsPV, KH and TK designed the study. KH conducted the statistical analyses. PVdrafted the manuscript and incorporated revisions from all co-authors. PV,KH, LT, KK, PS, EW, and TK made significant contributions to the conceptionof the analyses, interpretation of the data, and drafting of the manuscript. Allauthors read and approved the final manuscript.AcknowledgementsWe would particularly like to thank the study participants for theircontribution to the research, as well as the staff and volunteers at theMitsampan Harm Reduction Center, Thai AIDS Treatment Action Group, andO-Zone House for their support. We also thank Dr. Niyada Kiatying-Angsulee,Director of Social Research Institute, Chulalongkorn University, for herassistance with developing this project. We also thank Tricia Collingham,Deborah Graham, Caitlin Johnston, Calvin Lai, and Peter Vann for theirresearch and administrative assistance and Prempreeda Pramoj Na Ayutthaya,Arphatsaporn Chaimongkon, Sattara Hattirat, and Puripakorn Pakdirat fortheir assistance with data collection.FundingThe project was funded by the Michael Smith Foundation for HealthResearch. This research was also undertaken, in part, thanks to funding fromthe Canada Research Chairs program through a Tier 1 Canada Research Chairin Inner City Medicine which supports EW. KH is supported by a CanadianInstitutes of Health Research Fellowship. PV is supported by the CanadianInstitutes of Health Research.Author details1Urban Health Research Initiative, British Columbia Centre for Excellence inHIV/AIDS, St. Paul’s Hospital, 608 - 1081 Burrard Street, Vancouver, BC V6Z1Y6, Canada. 2School of Population and Public Health, University of BritishColumbia, Vancouver, BC, Canada. 3Thai AIDS Treatment Action Group,Bangkok, Thailand. 4Department of Medicine, University of British Columbia,St. Paul’s Hospital, Vancouver, BC, Canada.Received: 18 February 2015 Accepted: 18 May 2015References1. World Health Organization. Injecting drug use. In: HIV/AIDS. World HealthOrganization. 2014. http://www.who.int/hiv/topics/idu/about/en/. Accessed26 May 2014.2. World Health Organization (WHO). 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