Associations between Injection of Methamphetaminetype Stimulants and HIV Risk in the Russian Federat

1
Associations between Injection of
Methamphetamine-type Stimulants and HIV Risk in
the Russian Federation

• Robert Heimer
• Kevin S. Irwin
• Olga Borodkina
• Jean-Paul C. Grund
• Nadia Abdala
• Andrei P. Kozlov

2
DRUG PRODUCTION IN RUSSIA

• Injection drug use has increased at least tenfold
  since the collapse of the Soviet Union.
• Home manufacture of drugs -- both opioids and
  amphetamine like stimulants -- is common.
• Some studies in single locations have linked
  homemade drug use to increased HIV prevalence.

3
HOME PRODUCTION OF STIMULANTS

• The most common starting material is ephedrine.

4
HOMEMADE DRUGS AND HIV

• Rapidity of the HIV epidemic has led to an
  invocation of unusual causes.
• Anecdotal reports of the use of blood during
  homemade drug preparation has led to speculation
  that contaminated drugs may be fundamental to the
  epidemic.
• Led to denigration of harm reduction -- if drugs
  themselves are transmitting the virus, then
  providing clean needles or safer injection
  education will not protect injectors.

5
HOMEMADE DRUGS AND HIV RESEARCH QUESTIONS

• Hypothesis 1 HIV-contaminated drug
  preparations contribute to the unique features of
  the epidemic in Russia.
• HIV can survive during homemade drug manufacture.
• HIV remains infectious in drug preparations
  stored or distributed in contaminated needles.
• Hypothesis 2 Homemade drug use throughout
  Russia is linked to the HIV epidemic.
• Homemade drug use is correlated with heightened
  injection risk behaviors.
• Homemade drug use is associated with community
  norms that countenance syringe sharing.

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HOME PRODUCTION OF AMPHETAMINE-LIKE STIMULANTS

• Methcathinone
• Room temperature, or slight heating of large
  volumes of solution
• Mildly acidic pH (between 2.6 and 6)

• Methamphetamine
• Intense heating (10-30 min) of small volumes
  (2ml) of solution
• Addition of strong acids (pH 1-2)

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CAN HOMEMADE METHAMPHETAMINE (VINT) BE
CONTAMINATED WITH VIABLE HIV?

• Laboratory studies reveal that HIV is inactivated
  following exposure to extremely acidic liquids.

HIV Recovery
8
MIXING HIV-1 CONTAMINATED BLOOD WITH HOMEMADE
METHCATHINONE (JEFF)

• Viable HIV-1 was recovered after methcathinone
  solutions (pH 2.6) were mixed with HIV-1
  contaminated blood.

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CONCLUSIONS ON CONTAMINATION OF DRUGS AND HIV
TRANSMISSION RISK

• The stimulant drugs themselves are not promoting
  HIV transmission.
• If anything, the injection of methamphetamine is
  inhibiting it by reducing HIV viability.
• The injection of methcathinone has less of an
  impact in reducing HIV transmissibility.

10
DOES THE USE OF HOMEMADE DRUGS INCREASE INJECTION
RISK?

• Homemade drug manufacture is often a social event
  that occurs in the kitchens of drug users.
• Do these social aspects promote unsafe injection
  practices?

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LIQUID DRUG STUDY CONDUCTED IN ELEVEN CITIES
ACROSS RUSSIA

• 826 injectors interviewed in 2003-05 about
• Who injected, in the 30 days prior to interview,
  homemade stimulants and what was the drug of
  choice (injected most)?
• Who initiated injection with amphetamine-like
  stimulants versus opioids?
• What stimulants were actually being injected.

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STIMULANT INJECTION, INDIVIDUAL BEHAVIOR, AND HIV
RISK

• Based on current use
• Commercial heroin users were significantly more
  likely to share syringes than were injectors of
  other drugs.
• Based on type of drug injected, there were no
  significant differences were detected in
  paraphernalia sharing, frequency of injecting
  with others, or unsafe sex
• Based on initiation, there were no significant
  differences detected in any of the risky
  practices.

13
CONFUSION ABOUT WHICH STIMULANT IS BEING PRODUCED

• Analysis of qualitative data obtained from study
  participants revealed
• Confusion between oxidation to jeff and reduction
  to vint in about a third of the descriptions of
  drug preparation.
• Most often, producers or users were describing
  jeff production but calling it vint.

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STIMULANT INJECTION IN 11 CITIES

• Stimulant injection ever and last 30 days tightly
  correlated (p 0.0018).
• Neither correlated with HIV prevalence among IDUs
  interviewed (p 0.60 for ever and p 0.98 for
  last 30 days).

of IDUs Interviewed
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HYPOTHESES ABOUT SOCIAL ROLE OF HOMEMADE DRUGS
NOT CONFIRMED

• Increases in risk behaviors are not associated
  with current or past use of homemade injectable
  drugs.
• At the city level, stimulant injection and HIV
  prevalence not associated.
• So, what then can explain the rapid increases in
  HIV among drug injectors?

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DIFFERENCES AT THE CITY LEVEL

• In five cities, homemade heroin was the
  predominant form of drug injected.
• In six cities, commercial heroin predominated.
• No differences detected in any of the risky
  injection practices or sexual behaviors.
• However, large differences in HIV prevalences,
  with higher rates in the cities where heroin
  predominated.

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HIV EPIDEMIC LINKED TO COMMERCIAL HEROIN
PREDOMINANCE
Key White and gray -- cities visited by
Heimer, Borodkina et al., in 2002-2004 Pink --
cities visited by Grund, Des Jarlais et al., in
1999 Orange -- city visited by Rhodes et al., in
2001
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ACKNOWLEDGEMENTS

• Funds for this study were provided by the U.S
  National Institute on Drug Abuse and the Fogarty
  International Center at the National Institutes
  of Health.
• Our partners in the 11 cities.
• Russian stimulant manufacturers who allowed us to
  sit in their kitchens and learn their methods.
• Kevin Irwin for his photography.