Don Des Jarlais
Professor of Epidemiology
Dr. Don Des Jarlais is a leader in the fields of AIDS and injecting drug use, and has published extensively on these topics including articles in The New England Journal of Medicine, JAMA, Science, and Nature.
He is active in international research, having collaborated on studies in many different countries. He serves as a consultant to various institutions, including the U.S. Centers for Disease Control and Prevention, the National Institute of Drug Abuse, the National Academy of Sciences, and the World Health Organization.
Dr. Des Jarlais’ research has received numerous awards, including a New York State Department of Health Commissioner’s award for promoting the health of persons who use drugs. He formerly served as avcommissioner for the National Commission on AIDS; as a core group member of the UNAIDS Reference Group on HIV and Injecting Drug Use; and as a member of the President’s Emergency Plan for AIDS Relief (PEPFAR) Scientific Advisory Board.
Dr. Des Jarlais is also an adjunct faculty of psychiatry and preventive medicine at Icahn School of Medicine at Mount Sinai, and guest investigator at Rockefeller University in New York.
BA, Behavioral Science, Rice University, Houston, TXPhD, Social Psychology, University of Michigan, Ann Arbor, MI
Cost-effectiveness of Direct Antiviral Agents for Hepatitis C Virus Infection and a Combined Intervention of Syringe Access and Medication-assisted Therapy for Opioid Use Disorders in an Injection Drug Use PopulationStevens, E. R., Nucifora, K. A., Hagan, H., Jordan, A. E., Uyei, J., Khan, B., Dombrowski, K., Des Jarlais, D., & Braithwaite, R. S.
Journal titleClinical Infectious Diseases
Page(s)2652-2662BACKGROUND: There are too many plausible permutations and scale-up scenarios of combination hepatitis C virus (HCV) interventions for exhaustive testing in experimental trials. Therefore, we used a computer simulation to project the health and economic impacts of alternative combination intervention scenarios for people who inject drugs (PWID), focusing on direct antiviral agents (DAA) and medication-assisted treatment combined with syringe access programs (MAT+). METHODS: We performed an allocative efficiency study, using a mathematical model to simulate the progression of HCV in PWID and its related consequences. We combined 2 previously validated simulations to estimate the cost-effectiveness of intervention strategies that included a range of coverage levels. Analyses were performed from a health-sector and societal perspective, with a 15-year time horizon and a discount rate of 3%. RESULTS: From a health-sector perspective (excluding criminal justice system-related costs), 4 potential strategies fell on the cost-efficiency frontier. At 20% coverage, DAAs had an incremental cost-effectiveness ratio (ICER) of $27 251/quality-adjusted life-year (QALY). Combinations of DAA at 20% with MAT+ at 20%, 40%, and 80% coverage had ICERs of $165 985/QALY, $325 860/QALY, and $399 189/QALY, respectively. When analyzed from a societal perspective (including criminal justice system-related costs), DAA at 20% with MAT+ at 80% was the most effective intervention and was cost saving. While DAA at 20% with MAT+ at 80% was more expensive (eg, less cost saving) than MAT+ at 80% alone without DAA, it offered a favorable value compared to MAT+ at 80% alone ($23 932/QALY). CONCLUSIONS: When considering health-sector costs alone, DAA alone was the most cost-effective intervention. However, with criminal justice system-related costs, DAA and MAT+ implemented together became the most cost-effective intervention.
DSM-5 substance use disorder symptom clusters and HIV antiretroviral therapy (ART) adherencePaschen-Wolff, M. M., Campbell, A. N., Tross, S., Choo, T. H., Pavlicova, M., & Jarlais, D. D.
Journal titleAIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIV
Page(s)645-650This study examines self-reported 30-day antiretroviral therapy (ART) adherence among 101 people living with HIV and substance use disorders (SUD) in New York City in terms of Diagnostic and Statistical Manual–5th Edition (DSM-5) SUD symptom clusters: impaired control, social impairment, risky use and pharmacological criteria. Overall, 60.4% met DSM-5 criteria for stimulant, 55.5% for alcohol, 34.7% for cannabis and 25.7% for opioid SUD. Of the 76 participants with a current ART prescription, 75.3% reported at least 90% 30-day adherence. Participants with vs. without alcohol SUD were significantly less likely to report ART adherence (64.3% vs. 88.2%, p =.017). Endorsement of social impairment significantly differed among adherent vs. non-adherent participants with alcohol SUDs (74.1% vs. 100%, p =.038) and with opioid SUDs (94.1% vs. 50.0%, p =.040). Understanding specific SUD symptom clusters may assist providers and patients in developing strategies to improve ART adherence.
Hepatitis C incidence and prevalence among Puerto Rican people who use drugs in New York CityArasteh, K., Des Jarlais, D. C., Feelemyer, J., & McKnight, C.
Journal titleGlobal Public HealthBackground: Hepatitis C virus (HCV) infection is associated with substantial morbidity and mortality among people who use drugs (PWUD). Health disparities related to race/ethnicity and immigration status also increase the risk of HCV infection and decrease the probability of linkage to care. Effective, curative treatment is now available for HCV infection and, alongside prevention, may eliminate HCV epidemics. Methods: We examined HCV incidence, prevalence and associated risk factors among 5459 Puerto Rican (both PR-born and U.S.-born) and non-Puerto Rican (only U.S.-born) entrants to Mount Sinai Beth Israel drug treatment programs in New York City, from August 2005 to January 2018, to assess the need for HCV screening, prevention and treatment in this population. Results: HCV incidence and prevalence among Puerto Rican PWUD was significantly greater than the non-Puerto Ricans PWUD. Among people who inject drugs (PWID), there was no difference in injection risk behaviours by ethnicity/birth place. Conclusions: Findings suggest HCV treatment is a necessary component of a strategy to eliminate HCV epidemics among PWUD. Findings also underline the interconnectedness of epidemics across regions, such that to eliminate the HCV epidemic in one location may depend on eliminating the HCV epidemics in other locations.
High-risk behaviors and their association with awareness of HIV status among participants of a large-scale prevention intervention in Athens, GreecePavlopoulou, I. D., Dikalioti, S. K., Gountas, I., Sypsa, V., Malliori, M., Pantavou, K., Jarlais, D. D., Nikolopoulos, G. K., & Hatzakis, A.
Journal titleBMC public health
Issue1Background: Aristotle was a seek-test-treat intervention during an outbreak of human immunodeficiency virus (HIV) infection among people who inject drugs (PWID) in Athens, Greece that started in 2011. The aims of this analysis were: (1) to study changes of drug injection-related and sexual behaviors over the course of Aristotle; and (2) to compare the likelihood of risky behaviors among PWID who were aware and unaware of their HIV status. Methods: Aristotle (2012-2013) involved five successive respondent-driven sampling rounds of approximately 1400 PWID each; eligible PWID could participate in multiple rounds. Participants were interviewed using a questionnaire, were tested for HIV, and were classified as HIV-positive aware of their status (AHS), HIV-positive unaware of their status (UHS), and HIV-negative. Piecewise linear generalized estimating equation models were used to regress repeatedly measured binary outcomes (high-risk behaviors) against covariates. Results: Aristotle recruited 3320 PWID (84.5% males, median age 34.2 years). Overall, 7110 interviews and blood samples were collected. The proportion of HIV-positive first-time participants who were aware of their HIV infection increased from 21.8% in round A to 36.4% in the last round. The odds of dividing drugs at least half of the time in the past 12 months with a syringe someone else had already used fell from round A to B by 90% [Odds Ratio (OR) (95% Confidence Interval-CI): 0.10 (0.04, 0.23)] among AHS and by 63% among UHS [OR (95% CI): 0.37 (0.19, 0.72)]. This drop was significantly larger (p = 0.02) among AHS. There were also decreases in frequency of injection and in receptive syringe sharing in the past 12 months but they were not significantly different between AHS (66 and 47%, respectively) and UHS (63 and 33%, respectively). Condom use increased only among male AHS from round B to the last round [OR (95% CI): 1.24 (1.01, 1.52)]. Conclusions: The prevalence of risky behaviors related to drug injection decreased in the context of Aristotle. Knowledge of HIV infection was associated with safer drug injection-related behaviors among PWID. This highlights the need for comprehensive interventions that scale-up HIV testing and help PWID become aware of their HIV status.
HIV control programs reduce HIV incidence but not HCV incidence among people who inject drugs in HaiPhong, VietnamMolès, J. P., Vallo, R., Khue, P. M., Huong, D. T., Oanh, K. T. H., Thoa, N. T., Giang, H. T., Thanh, N. T. T., Vinh, V. H., Bui Thi, T. A., Peries, M., Arasteh, K., Quillet, C., Feelemyer, J., Michel, L., Jarlais, D. D., Laureillard, D., & Nagot, N.
Journal titleScientific reports
Issue1In Vietnam, harm reduction programs to control HIV among people who inject drugs (PWID) were implemented approximately 10 years ago. Since then, the HIV prevalence has declined in this population, however, the impact of these programs on the rate of new HIV and Hepatitis C (HCV) infections remains unknown as high mortality can exceed the rate of new infections. We evaluated HIV and HCV incidences in a cohort of active PWID in HaiPhong in 2014, who were recruited from a community-based respondent driven sampling (RDS) survey and followed for 1 year. Only HIV-negative or HCV-negative participants not on medication assisted treatment (MAT) were eligible. HIV/HCV serology was tested at enrollment and at 32- and 64-week follow-up visits. Among 603 RDS participants, 250 were enrolled in the cohort, including 199 HIV seronegative and 99 HCV seronegative PWID. No HIV seroconversion was reported during the 206 person-years (PY) of follow-up (HIV incidence of 0/100PY, one-sided 97.5%CI:0-1.8/100 PY). Eighteen HCV seroconversions were reported for an incidence of 19.4/100 PY (95%CI;11.5-30.7). In multivariate analysis, “Injecting more than twice daily” was associated with HCV seroconversion with an adjusted odds ratio of 5.8 (95%CI;1.8–18.1). In Hai Phong, in a context that demonstrates the effectiveness of HIV control programs, the HCV incidence remains high. New strategies such as mass access to HCV treatment should be evaluated in order to tackle HCV transmission among PWID.
HIV Treatment Knowledge in the Context of “Treatment as Prevention” (TasP)Paschen-Wolff, M. M., Campbell, A. N., Tross, S., Castro, M., Berg, H., Braunstein, S., Borges, C., & Jarlais, D. D.
Journal titleAIDS and Behavior
Page(s)2984-2994According to 2012 universal ART guidelines, as part of “treatment as prevention” (TasP), all people living with HIV (PLWH) should immediately initiate antiretroviral therapy post-diagnosis to facilitate viral suppression. PLWH who are virally suppressed have no risk of sexually transmitting HIV. This study used descriptive analysis of quantitative data (N = 99) and thematic analysis of qualitative interviews (n = 36) to compare participants recruited from a hospital-based detoxification (detox) unit, largely diagnosed with HIV pre-2012 (n = 63) vs. those recruited from public, urban sexual health clinics (SHCs), mainly diagnosed in 2012 or later (n = 36). Detox participants were significantly more knowledgeable than SHC participants about HIV treatment, except regarding TasP. SHC participants’ desire for rapid linkage to care and ART initiation was in line with 2012 universal ART guidelines and TasP messaging regarding viral suppression. More targeted messaging to PLWH pre-2012 could ensure that all PLWH benefit from scientific advances in HIV treatment.
Mortgage Discrimination and Racial/Ethnic Concentration Are Associated with Same-Race/Ethnicity Partnering among People Who Inject Drugs in 19 US CitiesLinton, S. L., Cooper, H. L., Chen, Y. T., Khan, M. A., Wolfe, M. E., Ross, Z., Des Jarlais, D. C., Friedman, S. R., Tempalski, B., Broz, D., Semaan, S., Wejnert, C., & Paz-Bailey, G.
Journal titleJournal of Urban Health
Page(s)88-104Racial/ethnic homophily in sexual partnerships (partners share the same race/ethnicity) has been associated with racial/ethnic disparities in HIV. Structural racism may partly determine racial/ethnic homophily in sexual partnerships. This study estimated associations of racial/ethnic concentration and mortgage discrimination against Black and Latino residents with racial/ethnic homophily in sexual partnerships among 7847 people who inject drugs (PWID) recruited from 19 US cities to participate in CDC’s National HIV Behavioral Surveillance. Racial/ethnic concentration was defined by two measures that respectively compared ZIP code-level concentrations of Black residents to White residents and Latino residents to White residents, using the Index of Concentration at the Extremes. Mortgage discrimination was defined by two measures that respectively compared county-level mortgage loan denial among Black applicants to White applicants and mortgage loan denial among Latino applicants to White applicants, with similar characteristics (e.g., income, loan amount). Multilevel logistic regression models were used to estimate associations. Interactions of race/ethnicity with measures of racial/ethnic concentration and mortgage discrimination were added to the final multivariable model and decomposed into race/ethnicity-specific estimates. In the final multivariable model, among Black PWID, living in ZIP codes with higher concentrations of Black vs. White residents and counties with higher mortgage discrimination against Black residents was associated with higher odds of homophily. Living in counties with higher mortgage discrimination against Latino residents was associated with lower odds of homophily among Black PWID. Among Latino PWID, living in ZIP codes with higher concentrations of Latino vs. White residents and counties with higher mortgage discrimination against Latino residents was associated with higher odds of homophily. Living in counties with higher mortgage discrimination against Black residents was associated with lower odds of homophily among Latino PWID. Among White PWID, living in ZIP codes with higher concentrations of Black or Latino residents vs. White residents was associated with lower odds of homophily, but living in counties with higher mortgage discrimination against Black residents was associated with higher odds of homophily. Racial/ethnic segregation may partly drive same race/ethnicity sexual partnering among PWID. Future empirical evidence linking these associations directly or indirectly (via place-level mediators) to HIV/STI transmission will determine how eliminating discriminatory housing policies impact HIV/STI transmission.
Alternative kinship structures, resilience and social support among immigrant trans Latinas in the USAHwahng, S. J., Allen, B., Zadoretzky, C., Barber, H., McKnight, C., & Des Jarlais, D.
Journal titleCulture, Health and Sexuality
Page(s)1-15Latinas comprise the largest racial/ethnic group of trans women (male-to-female transgender people) in New York City, where HIV seroprevalence among trans Latinas has been found to be as high as 49%. Despite this population’s high risk of HIV, little is known about resilience among trans Latinas that may provide protective health factors. Six focus groups and one in-depth interview were conducted with 34 low-income trans/gender-variant people of colour who attended transgender support groups at harm reduction programmes in New York City. This paper reports on data from 13 participants who identified as immigrant trans Latinas. Focus groups were coded and analysed using thematic qualitative methods. The majority of immigrants were undocumented but reported having robust social support. Unique characteristics of immigrant trans Latinas included alternative kinship structures and sources of income. Social creativity was used to develop achievable ways in which to improve their health outcomes. Resilience was evident in informal kinship dynamics, formal support groups, gender-transition, educational access and skills training and substance use reduction. Individual-level resilience increased as a result of strong community-level resilience.
Feasibility of a simple and scalable cognitive-behavioral intervention to treat problem substance useBarnes, D. M., & Des Jarlais, D.
Journal titleJournal of Substance Use
Page(s)693-695Our proof-of-concept study tested a simple cognitive-behavioral strategy to help people achieve substance use goals–using non-first person self-talk when facing substance use cues or cravings–based on experimental psychology research that draws on the concept of self-distancing and is consistent with mindfulness principles. We evaluated participants’ understanding, use, and utility of the intervention at follow-up. Method: We recruited 17 New York City residents who used drugs non-medically. At baseline, we collected demographic and substance use data and conducted the intervention. At one-week follow-up, participants were asked about their understanding, use, and perceived utility of the intervention, and asked to complete an anonymous five-item assessment of the intervention. Results: Sixteen participants completed follow-up. Understanding was judged “acceptable” or better for 15; 11 used their scripts during follow-up; four described their scripts as very useful, one as moderately, five as a little, and one as not useful. Nine returned assessments; ratings were strongly favorable. Conclusions: Results from our pilot are encouraging and point to further research on this intervention. The intervention is suitable for integration into longer-term therapy and we envision non-first person self-talk as one strategy alongside others individuals can employ to moderate their substance use.
Geographic distribution of risk ("Hotspots") for HIV, HCV, and drug overdose among persons who use drugs in New York City: The importance of local historyDes Jarlais, D. C., McKnight, C., Arasteh, K., Feelemyer, J., Ross, Z., & Cooper, H. L.
Journal titleHarm Reduction Journal
Issue1Aims: To identify geographic "hotspots" for potential transmission of HIV and HCV and for drug overdose among persons who use heroin and cocaine in New York City and to examine historical continuities in problem drug use hotspots in the city. Methods: A total of 2714 study participants were recruited among persons entering Beth Israel substance use treatment programs. A structured questionnaire was administered and blood samples for HIV and HCV testing were collected. Hotspots for potential virus transmission were defined as ZIP codes with 10+ participants, 2+ persons infected with the virus and engaging in transmission behavior, and 2+ persons not infected and engaging in acquisition behavior. ZIP codes with 3+ persons with previous overdoses were considered potential hotspots for future overdoses. Results: Participants resided in 166/178 (93%) of the ZIP codes in New York City. Injecting drug use was reported in 150/178 (84%) of the ZIP codes. No zip codes were identified for injecting-related HIV transmission, 5 zip codes were identified for sexual HIV transmission, 3 for HCV transmission, and 8 for drug overdose. Many of the ZIP code potential hotspots were in neighborhoods long associated with drug use: Lower Eastside and Harlem in Manhattan, the South Bronx, and Central Brooklyn. Discussion: Heroin and cocaine use requiring treatment were reported from almost all ZIP codes in New York City, indicating needs for widely dispersed harm reduction services. Identified hotspots should be targeted for reducing sexual transmission of HIV, transmission of HCV, and drug overdoses. Some of the hotspots have persisted as problem drug use areas for 40 to over 100 years. Monitoring of drug use patterns in historical hotspot neighborhoods may permit early identification of and response to emerging drug use-related health problems. Persistent historical hotspots for problem drug use present a complex problem for implementing harm reduction services that deserve additional research.
Global, regional, and national burden of suicide mortality 1990 to 2016: Systematic analysis for the Global Burden of Disease Study 2016Orpana, H. M., Marczak, L. B., Arora, M., Abbasi, N., Abdulkader, R. S., Abebe, Z., Abraha, H. N., Afarideh, M., Afshari, M., Ahmadi, A., Aichour, A. N., Aichour, I., Aichour, M. T. E., Akseer, N., Al‐raddadi, R. M., Alahdab, F., Alkerwi, A., Allebeck, P., Alvis‐guzman, N., Anber, N. H., Anjomshoa, M., Antonio, C. A. T., Arora, A., Aryal, K. K., Asgedom, S. W., Awasthi, A., Quintanilla, B. P. A., Badali, H., Barker‐collo, S. L., Bärnighausen, T. W., Bazargan‐hejazi, S., Benjet, C., Bensenor, I. M., Berfeld, N., Beuran, M., Bhutta, Z. A., Biadgo, B., Bililign, N., Borges, G., Borschmann, R., Brazinova, A., Breitborde, N. J., Brugha, T., Butt, Z. A., Carrero, J. J., Carvalho, F., Malta, D. C., Castañeda‐orjuela, C. A., Catalá‐lópez, F., Ciobanu, L. G., Dachew, B. A., Dandona, L., Dandona, R., Dargan, P. I., Daryani, A., Davitoiu, D. V., Davletov, K., Degenhardt, L., Demoz, G. T., Jarlais, D. C., Dharmaratne, S. D., Djalalinia, S., Doan, L., Doku, D. T., Dubey, M., El‐khatib, Z., Eskandarieh, S., Esteghamati, A., Esteghamati, S., Faro, A., Farzadfar, F., Fekadu, W., Fernandes, E., Ferrari, A. J., Filip, I., Fischer, F., Foreman, K. J., Fukumoto, T., Gebre, A. K., Grosso, G., Gupta, R., Haagsma, J. A., Bidgoli, H. H., Haj‐mirzaian, A., Hamidi, S., Hankey, G. J., Haro, J. M., Hassen, H. Y., Hay, S. I., Heidari, B., Hendrie, D., Rad, E. H., Hosseini, S. M., Hostiuc, S., Irvani, S. S. N., Islam, S. M. S., Jakovljevic, M., James, S., Jayatilleke, A. U., Jha, R. P., Jonas, J. B., Jozwiak, J. J., Kadel, R., Kahsay, A., Kasaeian, A., Kassa, G. M., Kawakami, N., Kefale, A. T., Kemp, G. R., Khader, Y. S., Khafaie, M. A., Khalil, I. A., Khan, E. A., Khan, M. A., Khan, M. S., Khang, Y. H., Khubchandani, J., Kiadaliri, A. A., Kieling, C., Kim, Y. E., Kisa, A., Knudsen, A. K. S., Kokubo, Y., Koyanagi, A., Krish, V. S., Defo, B. K., Kumar, G. A., Kumar, M., Lamichhane, P., Lang, J. J., Latifi, A., Lee, P. H., Leung, J., Lim, L. L., Lopez, A. D., Lorkowski, S., Lotufo, P. A., Lozano, R., Lunevicius, R., Mahesh, P. A., Majdan, M., Majdzadeh, R., Malekzadeh, R., Manda, A. L., Mansournia, M. A., Mantovani, L. G., Maravilla, J. C., Martinez‐raga, J., Mathur, M. R., Maulik, P. K., McGrath, J. J., Mehrotra, R., Mekonen, T., Mendoza, W., Meretoja, T. J., Mestrovic, T., Miller, T. R., Mini, G. K., Mirrakhimov, E. M., Mitchell, P. B., Moazen, B., Mohammad, K. A., Mohammadi, M., Mohammed, S., Mokdad, A. H., Monasta, L., Moosazadeh, M., Moradi, G., Moradi‐lakeh, M., Moradinazar, M., Velásquez, I. M., Morisaki, N., Morrison, S. D., Moschos, M. M., Mousavi, S. M., Mustafa, G., Nagel, G., Naheed, A., Naik, G., Najafi, F., Negoi, I., Negoi, R. I., Nguyen, H. L. T., Nguyen, L. H., Nixon, M. R., Ofori‐asenso, R., Ogbo, F. A., Oh, I. H., Olagunju, A. T., Olagunju, T. O., Øverland, S., Owolabi, M. O., Panda‐jonas, S., Parry, C. D., Pati, S., Patten, S. B., Patton, G. C., Petzold, M., Phillips, M. R., Plana‐ripoll, O., Postma, M. J., Pourshams, A., Poustchi, H., Qorbani, M., Radfar, A., Rafay, A., Rafiei, A., Rahim, F., Rahimi‐movaghar, A., Rahimi‐movaghar, V., Rahman, M. A., Rai, R. K., Rezaeian, S., Roever, L., Ronfani, L., Roshandel, G., Rostami, A., Sachdev, P. S., Safari, H., Safiri, S., Salamati, P., Salimi, Y., Salomon, J. A., Samy, A. M., Santos, I. S., Santric‐milicevic, M. M., Sartorius, B., Sarvi, S., Satpathy, M., Sawhney, M., Schwebel, D. C., Sepanlou, S. G., Shaikh, M. A., Sharif, M., Shibuya, K., Shigematsu, M., Shiri, R., Shiue, I., Siabani, S., Siddiqi, T. J., Sigfusdottir, I. D., Silva, J. P., Singh, J. A., Filho, A. M. S., Sobhani, S., Stein, D. J., Stein, M. B., Sufiyan, M. B., Sunguya, B. F., Tabarés‐seisdedos, R., Tabb, K. M., Tavakkoli, M., Tehrani‐banihashemi, A., Temsah, M. H., Topor‐madry, R., Tran, B. X., Tran, K. B., Ullah, I., Unutzer, J., Usman, M. S., Uthman, O. A., Valdez, P. R., Vasankari, T. J., Vasconcelos, C., Vlassov, V., Vos, T., Vujcic, I. S., Waheed, Y., Wang, Y. P., Weiderpass, E., Werdecker, A., Westerman, R., Whiteford, H. A., Wyper, G. M., Yaseri, M., Yimer, E. M., Yisma, E., Yonemoto, N., Yoon, S. J., Yotebieng, M., Yousefifard, M., Yu, C., Zaidi, Z., Zamani, M., Murray, C. J., & Naghavi, M.
Journal titleBMJ (Online)
Volume364Objectives To use the estimates from the Global Burden of Disease Study 2016 to describe patterns of suicide mortality globally, regionally, and for 195 countries and territories by age, sex, and Socio-demographic index, and to describe temporal trends between 1990 and 2016. Design Systematic analysis. Main outcome measures Crude and age standardised rates from suicide mortality and years of life lost were compared across regions and countries, and by age, sex, and Socio-demographic index (a composite measure of fertility, income, and education). Results The total number of deaths from suicide increased by 6.7% (95% uncertainty interval 0.4% to 15.6%) globally over the 27 year study period to 817 000 (762 000 to 884 000) deaths in 2016. However, the age standardised mortality rate for suicide decreased by 32.7% (27.2% to 36.6%) worldwide between 1990 and 2016, similar to the decline in the global age standardised mortality rate of 30.6%. Suicide was the leading cause of age standardised years of life lost in the Global Burden of Disease region of high income Asia Pacific and was among the top 10 leading causes in eastern Europe, central Europe, western Europe, central Asia, Australasia, southern Latin America, and high income North America. Rates for men were higher than for women across regions, countries, and age groups, except for the 15 to 19 age group. There was variation in the female to male ratio, with higher ratios at lower levels of Socio-demographic index. Women experienced greater decreases in mortality rates (49.0%, 95% uncertainty interval 42.6% to 54.6%) than men (23.8%, 15.6% to 32.7%). Conclusions Age standardised mortality rates for suicide have greatly reduced since 1990, but suicide remains an important contributor to mortality worldwide. Suicide mortality was variable across locations, between sexes, and between age groups. Suicide prevention strategies can be targeted towards vulnerable populations if they are informed by variations in mortality rates.
Global, regional, and national incidence, prevalence, and mortality of HIV, 1980-2017, and forecasts to 2030, for 195 countries and territories: A systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017Failed generating bibliography.Abstract
Journal titleThe Lancet HIV
Page(s)e831-e859Background Understanding the patterns of HIV/AIDS epidemics is crucial to tracking and monitoring the progress of prevention and control efforts in countries. We provide a comprehensive assessment of the levels and trends of HIV/AIDS incidence, prevalence, mortality, and coverage of antiretroviral therapy (ART) for 1980-2017 and forecast these estimates to 2030 for 195 countries and territories. Methods We determined a modelling strategy for each country on the basis of the availability and quality of data. For countries and territories with data from population-based seroprevalence surveys or antenatal care clinics, we estimated prevalence and incidence using an open-source version of the Estimation and Projection Package - a natural history model originally developed by the UNAIDS Reference Group on Estimates, Modelling, and Projections. For countries with cause-specific vital registration data, we corrected data for garbage coding (ie, deaths coded to an intermediate, immediate, or poorly defined cause) and HIV misclassification. We developed a process of cohort incidence bias adjustment to use information on survival and deaths recorded in vital registration to back-calculate HIV incidence. For countries without any representative data on HIV, we produced incidence estimates by pulling information from observed bias in the geographical region. We used a re-coded version of the Spectrum model (a cohort component model that uses rates of disease progression and HIV mortality on and off ART) to produce agesex- specific incidence, prevalence, and mortality, and treatment coverage results for all countries, and forecast these measures to 2030 using Spectrum with inputs that were extended on the basis of past trends in treatment scale-up and new infections. Findings Global HIV mortality peaked in 2006 with 1·95 million deaths (95% uncertainty interval 1·87-2·04) and has since decreased to 0·95 million deaths (0·91-1·01) in 2017. New cases of HIV globally peaked in 1999 (3·16 million, 2·79-3·67) and since then have gradually decreased to 1·94 million (1·63-2·29) in 2017. These trends, along with ART scale-up, have globally resulted in increased prevalence, with 36·8 million (34·8-39·2) people living with HIV in 2017. Prevalence of HIV was highest in southern sub-Saharan Africa in 2017, and countries in the region had ART coverage ranging from 65·7% in Lesotho to 85·7% in eSwatini. Our forecasts showed that 54 countries will meet the UNAIDS target of 81% ART coverage by 2020 and 12 countries are on track to meet 90% ART coverage by 2030. Forecasted results estimate that few countries will meet the UNAIDS 2020 and 2030 mortality and incidence targets. Interpretation Despite progress in reducing HIV-related mortality over the past decade, slow decreases in incidence, combined with the current context of stagnated funding for related interventions, mean that many countries are not on track to reach the 2020 and 2030 global targets for reduction in incidence and mortality. With a growing population of people living with HIV, it will continue to be a major threat to public health for years to come. The pace of progress needs to be hastened by continuing to expand access to ART and increasing investments in proven HIV prevention initiatives that can be scaled up to have population-level impact.
Identifying Which Place Characteristics are Associated with the Odds of Recent HIV Testing in a Large Sample of People Who Inject Drugs in 19 US Metropolitan AreasFailed generating bibliography.Abstract
Journal titleAIDS and Behavior
Page(s)318-335This exploratory analysis investigates relationships of place characteristics to HIV testing among people who inject drugs (PWID). We used CDC’s 2012 National HIV Behavioral Surveillance (NHBS) data among PWID from 19 US metropolitan statistical areas (MSAs); we restricted the analytic sample to PWID self-reporting being HIV negative (N = 7477). Administrative data were analyzed to describe the 1. Sociodemographic Composition; 2. Economic disadvantage; 3. Healthcare Service/Law enforcement; and 4. HIV burden of the ZIP codes, counties, and MSAs where PWID lived. Multilevel models tested associations of place characteristics with HIV testing. Fifty-eight percent of PWID reported past-year testing. MSA-level per capita correctional expenditures were positively associated with recent HIV testing among black PWID, but not white PWID. Higher MSA-level household income and imbalanced sex ratios (more women than men) in the MSA were associated with higher odds of testing. HIV screening for PWID is suboptimal (58%) and needs improvement. Identifying place characteristics associated with testing among PWID can strengthen service allocation and interventions in areas of need to increase access to HIV testing.
Implementing an Updated “Break the Cycle” Intervention to Reduce Initiating Persons into Injecting Drug Use in an Eastern European and a US “opioid epidemic” SettingDes Jarlais, D., Uuskula, A., Talu, A., Barnes, D. M., Raag, M., Arasteh, K., Org, G., Demarest, D., Feelemyer, J., Berg, H., & Tross, S.
Journal titleAIDS and Behavior
Page(s)2304-2314We tested the hypothesis that an updated “Break the Cycle” (BtC) intervention, based in social cognitive theory and motivational interviewing, would reduce the likelihood that current persons who inject drugs (PWID) would assist persons who do not inject drugs (non-PWID) with first injections in Tallinn, Estonia and Staten Island, New York City. 402 PWID were recruited, a baseline interview covering demographics, drug use, and assisting non-PWID with first drug injections was administered, followed by BtC intervention. 296 follow-up interviews were conducted 6 months post-intervention. Percentages assisting with first injections declined from 4.7 to 1.3% (73% reduction) in Tallinn (p < 0.02), and from 15 to 6% (60% reduction) in Staten Island (p < 0.05). Persons assisted with first injections declined from 11 to 3 in Tallinn (p = 0.02) and from 32 to 13 in Staten Island. (p = 0.024). Further implementation research on BtC interventions is urgently needed where injecting drug use is driving HIV/HCV epidemics and areas experiencing opioid epidemics.
Injection and Heterosexual Risk Behaviors for HIV Infection Among Non-gay Identifying Men Who Have Sex with Men and WomenArasteh, K., Des Jarlais, D. C., McKnight, C., & Feelemyer, J.
Journal titleAIDS and Behavior
Page(s)3315-3323Non-gay identifying men who have sex with men and women (MSMW) are an important subgroup of men who have sex with men (MSM) and have been underrepresented in studies of MSM that only use gay venues to draw their samples. We assessed heterosexual and drug use risks of MSMW who use drugs in a sample of male entrants to the Mount Sinai Beth Israel drug treatment programs from 2005 to 2018. Blood samples were collected and tested for HIV and HSV-2 infections. Among HIV seronegative participants, MSMW had significantly greater odds of sharing used needles with others, and reporting unprotected sex with female casual partners and female commercial sex partners, compared to their counterparts who reported sex with women exclusively (MSWE). Although not recruited from gay venues, MSMW had a significantly higher HIV prevalence than MSWE (23% vs. 10%, p < 0.001). Interventions that are specifically tailored to HIV prevention among MSMW are needed to ameliorate the prevalence of HIV risks and infection.
Place-based predictors of HIV viral suppression and durable suppression among heterosexuals in New York cityJefferson, K. A., Kersanske, L. S., Wolfe, M. E., Braunstein, S. L., Haardörfer, R., Des Jarlais, D. C., Campbell, A. N., & Cooper, H. L.
Journal titleAIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIV
Page(s)864-874Scant research has explored place-based correlates of achieving and maintaining HIV viral load suppression among heterosexuals living with HIV. We conducted multilevel analyses to examine associations between United Hospital Fund (UHF)-level characteristics and individual-level viral suppression and durable viral suppression among individuals with newly diagnosed HIV in New York City (NYC) who have heterosexual HIV transmission risk. Individual-level independent and dependent variables came from NYC’s HIV surveillance registry for individuals diagnosed with HIV in 2009–2013 (N = 3,159; 57% virally suppressed; 36% durably virally suppressed). UHF-level covariates included measures of food distress, demographic composition, neighborhood disadvantage and affluence, healthcare access, alcohol outlet density, residential vacancy, and police stop and frisk rates. We found that living in neighborhoods where a larger percent of residents were food distressed was associated with not maintaining viral suppression. If future research should confirm this is a causal association, community-level interventions targeting food distress may improve the health of people living with HIV and reduce the risk of forward transmission.
Prescription opiate analgesics, heroin, HIV and HCV among persons who inject drugs in New York City, 2016-2018Des Jarlais, D. C., Arasteh, K., McKnight, C., Feelemyer, J., Perlman, D. C., & Tross, S.
Journal titleDrug and alcohol dependence
Volume204Objectives: Assess relationships among non-medical use of prescription opioid analgesics (POAs), heroin use, and HIV and hepatitis C (HCV) infection among persons who inject drugs (PWID) in New York City, 2016–2018. Methods: PWID (N = 134) were recruited from Mount Sinai Beth Israel drug treatment programs. HIV seropositive persons were oversampled. A questionnaire was administered, and serum samples were collected for HIV and HCV testing. Analyses were stratified by HIV serostatus and compared those who had used POAs to those who had not used POAs. Results: Among the participants, 97% reported injecting heroin, 44% reported injecting cocaine, and 47% reported smoking crack cocaine in the 6 months prior to the interview. There were 66% who reported oral non-medical use of POAs, with 42% using oral POAs in the previous 6 months. There was a clear historical pattern in median year of first injection for different groups: HIV seropositive persons (1985), HIV seronegative persons who never used POAs (1999), and HIV seronegative persons who used POAs (2009). By the time of interview (2016–2018), however, almost all participants (97%) reported injecting heroin. All PWID who reported using POAs also reported injecting heroin. Conclusions: Non-medical POA use among PWID was very common and should not be considered a separate drug use epidemic, but as an additional component of the continuing heroin/poly-drug use epidemic, itself a part of the syndemic of opioid use, stimulant use, overdose, HCV and HIV occurring in New York City.
Struggling to achieve a ‘normal life’: A qualitative study of Vietnamese methadone patientsNguyen, T. T., Luong, A. N., Nham, T. T. T., Chauvin, C., Feelemyer, J., Nagot, N., Jarlais, D. D., Le, M. G., & Jauffret-Roustide, M.
Journal titleInternational Journal of Drug Policy
Page(s)18-26Background: Methadone maintenance treatment, initially introduced in Vietnam for HIV harm reduction, has marked a significant switch in the country's drug policy – from addiction as a moral issue to addiction as a brain disease. After the some initial outstanding achievements, the programme is facing a high dropout rate that threatens both goals of HIV prevention and drug treatment. This sociological study, as part of an HIV intervention research project, explores the challenges and opportunities that individuals who use drugs are faced with in relation to addiction treatment. Methods: A qualitative study among drug users with and without methadone maintenance treatment experiences recruited by peer outreach workers. We conducted 58 in-depth interviews and 2 focus groups between 2016 and 2017. Results: The start of treatment brought about significant feelings of success as heroin use was no longer compulsive. However, being in treatment programmes is also challenging with respect to continuing the recovery process. Barriers to retention include a popular fear of methadone as another harmful drug, a feeling of dependence related to the current practices of methadone treatment programmes and a poor therapeutic relationship. In the face of such challenges, the two major motivations that keep patients in care come from the desire to completely break up with heroin and the pursuit of family happiness. Conclusion: The current practices of methadone programmes pose challenges to patients’ recovery efforts from addiction and threaten treatment retention. Prompt interventions are needed to help Vietnam attain its objective of providing better care for larger vulnerable populations.
A qualitative study of persons who inject drugs but who have never helped others with first injections: How their views on helping contrast with the views of persons who have helped with first injections, and implications for interventionsBarnes, D. M., Des Jarlais, D. C., Wolff, M., Feelemyer, J., & Tross, S.
Journal titleHarm Reduction Journal
Issue1Background: Transitioning from non-injection to injection drug use dramatically escalates health risks. Evidence suggests that people who inject drugs (PWID) help in a majority of others' first injections, yet these helpers represent only a minority of experienced PWID. Recent research has provided insight into this helping process, as reported by helpers. PWID who have never helped, although the majority of PWID, have not previously been the focus of study. To address this gap, we give primary voice to non-helpers' perspectives on the helping process, while also comparing their views with persons in our sample who have helped with first injections. Finally, we consider how non-helpers' perspectives can inform harm reduction interventions to reduce, or make safer, initiation into injecting drug use. Methods: We conducted audio-recorded, qualitative interviews with 23 current opioid injectors on Staten Island, NY, where the opioid epidemic is pronounced. Seventeen had never helped with first injections and 6 had. Interviews were transcribed verbatim, and three coders used a consensus-developed codebook to code all interviews. Framework analysis was used to identify overarching themes. Results: We identified three key themes in non-helpers' discourse around not helping: altruistic motivations to prevent immediate and delayed harms to individuals injecting for the first time; inhibition due to negative assessments of their own injecting skills; and absolutist ethical convictions against helping. Non-helpers differed from helpers on each theme. Conclusions: Because most PWID have never helped with first injections, their perspectives on helping warrant consideration and can inform harm reduction interventions to reduce, or make safer, transitions to injection drug use. Their perspectives can be used to broaden the factors PWID consider around questions of promoting injection and helping with others' first injections, including considerations of the moral issues involved in choosing to help or not to help.
Adolescent health in the Eastern Mediterranean Region: findings from the global burden of disease 2015 studyFailed generating bibliography.Abstract
Journal titleInternational Journal of Public Health
Page(s)79-96Objectives: The 22 countries of the East Mediterranean Region (EMR) have large populations of adolescents aged 10–24 years. These adolescents are central to assuring the health, development, and peace of this region. We described their health needs. Methods: Using data from the Global Burden of Disease Study 2015 (GBD 2015), we report the leading causes of mortality and morbidity for adolescents in the EMR from 1990 to 2015. We also report the prevalence of key health risk behaviors and determinants. Results: Communicable diseases and the health consequences of natural disasters reduced substantially between 1990 and 2015. However, these gains have largely been offset by the health impacts of war and the emergence of non-communicable diseases (including mental health disorders), unintentional injury, and self-harm. Tobacco smoking and high body mass were common health risks amongst adolescents. Additionally, many EMR countries had high rates of adolescent pregnancy and unmet need for contraception. Conclusions: Even with the return of peace and security, adolescents will have a persisting poor health profile that will pose a barrier to socioeconomic growth and development of the EMR.
Alcohol use and burden for 195 countries and territories, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016Failed generating bibliography.Abstract
Journal titleThe Lancet
Page(s)1015-1035Background: Alcohol use is a leading risk factor for death and disability, but its overall association with health remains complex given the possible protective effects of moderate alcohol consumption on some conditions. With our comprehensive approach to health accounting within the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, we generated improved estimates of alcohol use and alcohol-attributable deaths and disability-adjusted lifeyears (DALYs) for 195 locations from 1990 to 2016, for both sexes and for 5-year age groups between the ages of 15 years and 95 years and older. Methods: Using 694 data sources of individual and population-level alcohol consumption, along with 592 prospective and retrospective studies on the risk of alcohol use, we produced estimates of the prevalence of current drinking, abstention, the distribution of alcohol consumption among current drinkers in standard drinks daily (defined as 10 g of pure ethyl alcohol), and alcohol-attributable deaths and DALYs. We made several methodological improvements compared with previous estimates: first, we adjusted alcohol sales estimates to take into account tourist and unrecorded consumption; second, we did a new meta-analysis of relative risks for 23 health outcomes associated with alcohol use; and third, we developed a new method to quantify the level of alcohol consumption that minimises the overall risk to individual health. Findings: Globally, alcohol use was the seventh leading risk factor for both deaths and DALYs in 2016, accounting for 2·2% (95% uncertainty interval [UI] 1·5-3·0) of age-standardised female deaths and 6·8% (5·8-8·0) of agestandardised male deaths. Among the population aged 15-49 years, alcohol use was the leading risk factor globally in 2016, with 3·8% (95% UI 3·2-4·3) of female deaths and 12·2% (10·8-13·6) of male deaths attributable to alcohol use. For the population aged 15-49 years, female attributable DALYs were 2·3% (95% UI 2·0-2·6) and male attributable DALYs were 8·9% (7·8-9·9). The three leading causes of attributable deaths in this age group were tuberculosis (1·4% [95% UI 1·0-1·7] of total deaths), road injuries (1·2% [0·7-1·9]), and self-harm (1·1% [0·6-1·5]). For populations aged 50 years and older, cancers accounted for a large proportion of total alcohol-attributable deaths in 2016, constituting 27·1% (95% UI 21·2-33·3) of total alcohol-attributable female deaths and 18·9% (15·3-22·6) of male deaths. The level of alcohol consumption that minimised harm across health outcomes was zero (95% UI 0·0-0·8) standard drinks per week. Interpretation: Alcohol use is a leading risk factor for global disease burden and causes substantial health loss. We found that the risk of all-cause mortality, and of cancers specifically, rises with increasing levels of consumption, and the level of consumption that minimises health loss is zero. These results suggest that alcohol control policies might need to be revised worldwide, refocusing on efforts to lower overall population-level consumption. Funding Bill & Melinda Gates Foundation.
Another frontier for harm reduction: Contraceptive needs of females who inject drugs in Estonia, a cross-sectional studyUusküla, A., Raag, M., Vorobjov, S., & Jarlais, D. D.
Journal titleHarm Reduction Journal
Issue1Background: Despite increasing contraceptive availability, unintended pregnancy remains a global problem. Developing strategies to reverse this trend and increasing occurrence of withdrawal syndrome among newborn children of females currently injecting drugs warrants special attention. The knowledge base on the uptake of effective contraception among females who inject drugs (FWID) is scant. We aimed to examine the prevalence of and factors associated with the use of non-condom contraceptives among sexually active FWID with the focus on effective contraception. Methods: In a series of cross-sectional studies (2007-2013), 265 current FWID were recruited through respondent-driven sampling (RDS), interviewed, and tested for HIV. RDS weights were used to estimate the prevalence of effective contraception (hormonal contraception, intrauterine device, sterilization) use in the last 6 months. Results: Of the sexually active women with main partners (n = 196) 4.8% (95% CI 2.3-9.7) were using effective contraception, 52.7% (95% CI 42.5-62.7) less-effective or no contraception. 42.5% (95% CI 32.7-52.9) relied on condoms for contraception. The odds for using effective contraception were higher among women with > 10 years of education (OR 7.29, 95% CI 1.4-38.8). None of the women lacking health insurance (n = 84) were using effective contraception. Conclusions: The very low coverage with effective contraception highlights the need to improve contraceptive services for FWID. Reproductive health service including contraception should be considered essential components of harm reduction and of comprehensive prevention and care for HIV among persons who use drugs.
Association of IFNλ4 rs12979860 polymorphism with the acquisition of HCV and HIV infections among people who inject drugsJõgeda, E. L., Avi, R., Pauskar, M., Kallas, E., Karki, T., Des Jarlais, D., Uusküla, A., Toompere, K., Lutsar, I., & Huik, K.
Journal titleJournal of Medical Virology
Page(s)1779-1783We investigated the presence of a single-nucleotide polymorphism designated rs12979860 in the interferon λ4 (IFNλ4) gene among 345 people who inject drugs (PWID) and 495 blood donors to evaluate associations between the rs12979860 genotypes and human immunodeficiency virus/hepatitis C virus (HIV/HCV). The rs12979860 TT genotype was over-represented among HIV+ PWID than HIV− PWID and blood donors (16% vs 8% and 10%, P = 0.03, respectively). PWID with TT genotype had approximately twice the probability of being HIV+ (odds ratio [OR], 2.19; 95% confidence interval [CI], 1.11 to 4.33) than PWID without TT. Every additional year of intravenous drug use (IVDU) decreased the OR 1.16 times (OR, 0.86; 95% CI, 0.75 to 0.98). This suggests that rs12979860 TT increases susceptibility to HIV and this impact decreases with increasing duration of IVDU.
Being “hooked up” during a sharp increase in the availability of illicitly manufactured fentanyl: Adaptations of drug using practices among people who use drugs (PWUD) in New York CityMcKnight, C., & Des Jarlais, D. C.
Journal titleInternational Journal of Drug Policy
Page(s)82-88Illicitly manufactured fentanyl (IMF), a category of synthetic opioids 50–100 times more potent than morphine, is increasingly being added to heroin and other drugs in the United States (US). Persons who use drugs (PWUD) are frequently unaware of the presence of fentanyl in drugs. Use of heroin and other drugs containing fentanyl has been linked to sharp increases in opioid mortality. In New York City (NYC), opioid-related mortality increased from 8.2 per 100,000 residents in 2010 to 19.9 per 100,000 residents in 2016; and, in 2016, fentanyl accounted for 44% of NYC overdose deaths. Little is known about how PWUD are adapting to the increase in fentanyl and overdose mortality. This study explores PWUDs’ adaptations to drug using practices due to fentanyl. In-depth qualitative interviews were conducted with 55 PWUD at three NYC syringe services programs (SSP) about perceptions of fentanyl, overdose experiences and adaptations of drug using practices. PWUD utilized test shots, a consistent drug dealer, fentanyl test strips, naloxone, getting high with or near others and reducing drug use to protect from overdose. Consistent application of these methods was often negated by structural level factors such as stigma, poverty and homelessness. To address these, multi-level overdose prevention approaches should be implemented in order to reduce the continuing increase in opioid mortality.
Combination interventions for Hepatitis C and Cirrhosis reduction among people who inject drugs: An agent-based, networked population simulation experimentKhan, B., Duncan, I., Saad, M., Schaefer, D., Jordan, A., Smith, D., Neaigus, A., Jarlais, D. D., Hagan, H., & Dombrowski, K.
Journal titlePloS one
Issue11Hepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with prevalence estimates above 60% for PWID in the United States. Previous modeling studies suggest that direct acting antiviral (DAA) treatment can lower overall prevalence in this population, but treatment is often delayed until the onset of advanced liver disease (fibrosis stage 3 or later) due to cost. Lower cost interventions featuring syringe access (SA) and medically assisted treatment (MAT) have shown mixed results in lowering HCV rates below current levels. However. little is known about the potential cumulative effects of combining DAA and MAT treatment. While simulation experiments can reveal likely long-term effects, most prior simulations have been performed on closed populations of model agents—a scenario quite different from the open, mobile populations known to most health agencies. This paper uses data from the Centers for Disease Control’s National HIV Behavioral Surveillance project, IDU round 3, collected in New York City in 2012 to parameterize simulations of open populations. To test the effect of combining DAA treatment with SA/MAT participation, multiple, scaled implementations of the two intervention strategies were simulated. Our results show that, in an open population, SA/MAT by itself has only small effects on HCV prevalence, while DAA treatment by itself can lower both HCV and HCV-related advanced liver disease prevalence. More importantly, the simulation experiments suggest that combinations of the two strategies can, when implemented together and at sufficient levels, dramatically reduce HCV incidence. We conclude that adopting SA/MAT implementations alongside DAA interventions can play a critical role in reducing the long-term consequences of ongoing HCV infection.