Don Des Jarlais
Don Des Jarlais
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Professor of Epidemiology
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Professional overview
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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.
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Education
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BA, Behavioral Science, Rice University, Houston, TXPhD, Social Psychology, University of Michigan, Ann Arbor, MI
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Areas of research and study
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EpidemiologyHIV/AIDSPsychology
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Publications
Publications
Assessment of methadone clinic staff attitudes toward hepatitis C evaluation and treatment
AbstractTalal, A. H., Dimova, R. B., Seewald, R., Peterson, R. H., Zeremski, M., Perlman, D. C., & Des Jarlais, D. C. (n.d.).Publication year
2013Journal title
Journal of Substance Abuse TreatmentVolume
44Issue
1Page(s)
115-119AbstractWe used a 25-item, self-administered questionnaire to assess staff's perceived barriers and willingness to engage in onsite treatment of hepatitis C virus (HCV) at the Beth Israel Medical Center methadone maintenance treatment program (MMTP) at its Harlem sites. Of 80 participants, 50% were counselors and 24% were directly involved in referral or HCV testing. Although 92% of the MMTP staff indicated that they discuss HCV evaluation and treatment with patients at least annually, 70% believed that less than 25% of patients accept referral for HCV treatment and attend their initial appointment. Most staff (66%) supported onsite HCV evaluation and treatment, although support was higher among those with a bachelor's degree or higher (p=0.046). Lack of infrastructure was perceived as the greatest obstacle to onsite treatment. Educational interventions and skill building for staff to confidently engage and support MMTP patients in HCV treatment may be necessary prerequisites for onsite HCV management in MMTPs.Association between TLR3 rs3775291 and resistance to HIV among highly exposed Caucasian intravenous drug users
AbstractHuik, K., Avi, R., Pauskar, M., Kallas, E., Jõgeda, E. L., Karki, T., Marsh, K., Des Jarlais, D., Uusküla, A., & Lutsar, I. (n.d.).Publication year
2013Journal title
Infection, Genetics and EvolutionVolume
20Page(s)
78-82AbstractBackground: TLR3 recognizes dsRNA and triggers immune responses against RNA and DNA viruses. A polymorphism in TLR3, rs3775291 (Leu412Phe), has been associated with the increased susceptibility to enteroviral myocarditis, protection against tick-borne encephalitis virus and HIV-1 infection. We investigated Caucasian intravenous drug users (IDUs) and blood donors in order to evaluate the associations between TLR3 genotypes and susceptibility to HIV infection. Materials and methods: A total of 345 Caucasian IDUs were recruited, 50% of them were HIV positive, 89% HCV and 77% HBV positive. Based on their history of needle sharing, 20 of the HIV negative IDUs were classified as highly exposed HIV seronegatives (HESNs), 68 as non-HESNs and 85 as unexposed. The control group consisting of 497 blood donors tested negative for all three viruses. TLR3 rs3775291 were determined by using TaqMan Allelic Discrimination Assay. Results: The TLR3 rs3775291 T allele frequency was similar among the HIV negative and HIV positive IDUs and blood donors - 36%, 31% and 34%, respectively. The frequency of persons possessing at least one TLR3 rs3775291 T allele was significantly higher in HESNs compared with blood donors and HIV positive IDUs (80% vs. 55%; p=0.037 and 80% vs. 53%; p=0.031, respectively). In the univariate analysis, persons who possessed at least one T allele had reduced odds of being HIV seropositive (OR=0.29, 95% CI=0.09-0.90). This association remained significant (OR=0.25, 95% CI=0.07-0.87) after the adjustment for other co-variates (HCV, HBV serostatus and duration of intravenous drug use). Conclusions: The TLR3 rs3775291 T allele has a protective effect against HIV infection among HESNs IDUs.Determinants of hepatitis C virus treatment completion and efficacy in drug users assessed by meta-analysis
AbstractDimova, R. B., Zeremski, M., Jacobson, I. M., Hagan, H., Des Jarlais, D. C., & Talal, A. H. (n.d.).Publication year
2013Journal title
Clinical Infectious DiseasesVolume
56Issue
6Page(s)
806-816AbstractBackground. Hepatitis C virus (HCV)-infected drug users (DUs) have largely been excluded from HCV care. We conducted a systematic review and meta-analysis of the literature on treatment completion and sustained virologic response (SVR) rates in DUs. We assessed the effects of different treatment approaches and services to promote HCV care among DUs as well as demographic and viral characteristics. Methods. Studies of at least 10 DUs treated with pegylated interferon/ribavirin that reported SVR were analyzed. Heterogeneity was assessed (Cochran test) and investigated (meta-regression), and pooled rates were estimated (random effects).Results. Thirty-six studies comprising 2866 patients were retrieved. The treatment completion rate among DUs was 83.4% (95% confidence interval [CI], 77.1%-88.9%). Among studies that included addiction-treated and untreated patients during HCV therapy, the higher the proportion of addiction-treated patients, the higher the HCV treatment completion rate (P <. 0001). After adjusting for human immunodeficiency virus (HIV)/HCV coinfection, sex, and treatment of addiction, support services during antiviral therapy increased treatment completion (P <. 0001). The pooled SVR rate was 55.5% (95% CI, 50.6%-60.3%). Genotype 1/4 (P =. 0012) and the proportion of HIV-coinfected DUs (P =. 0173) influenced the SVR rate. After adjusting for HCV genotype 1/4 and HIV/HCV coinfection, the SVR rate was positively correlated with involvement of a multidisciplinary team (P <. 0001). Conclusions. Treatment of addiction during HCV therapy results in higher treatment completion. Our pooled SVR rate is similar to that obtained in registration trials in the general population. Treatment of addiction during HCV therapy will likely be important for HCV-infected DUs undergoing treatment with more complex regimens including direct-acting antivirals.Economic recession and emergence of an HIV-1 outbreak among drug injectors in Athens metropolitan area: A longitudinal study
AbstractParaskevis, D., Nikolopoulos, G., Fotiou, A., Tsiara, C., Paraskeva, D., Sypsa, V., Lazanas, M., Gargalianos, P., Psichogiou, M., Skoutelis, A., Wiessing, L., Friedman, S. R., Des Jarlais, D. C., Terzidou, M., Kremastinou, J., Malliori, M., & Hatzakis, A. (n.d.).Publication year
2013Journal title
PloS oneVolume
8Issue
11AbstractBackground: During 2011, a dramatic increase (1600%) of reported HIV-1 infections among injecting drug users (IDUs) was noted in Athens, Greece. We herein assess the potential causal pathways associated with this outbreak. Methods: Our study employed high resolution HIV-1 phylogenetic and phylogeographic analyses. We examined also longitudinal data of ecological variables such as the annual growth of gross domestic product (GDP) of Greece in association with HIV-1 and HCV sentinel prevalence in IDUs, unemployment and homelessness rates and HIV transmission networks in Athens IDUs before and during economic recession (2008-2012). Results: IDU isolates sampled in 2011 and 2012 suggested transmission networks in 94.6% and 92.7% of the cases in striking contrast with the sporadic networking (5%) during 1998-2009. The geographic origin of most HIV-1 isolates was consistent with the recently documented migratory waves in Greece. The decline in GDP was inversely correlated with annual prevalence rates of HIV and HCV and with unemployment and homelessness rates in IDUs (all p<0.001). The slope of anti-HCV prevalence in the sentinel populations of IDUs and in "new" drug injectors was found 120 and 1.9-fold (p = 0.007, p = 0.08 respectively) higher in 2008-2012 (economic recession) compared with 2002-2006. The median (25th, 75th) size of transmission networks were 34 (12, 58) and 2 (2, 2) (p = 0.057) in 2008-2012 and 1998-2007, respectively. The coverage of harm reduction services was low throughout the study period. Conclusions: Scaling-up harm reduction services and addressing social and structural factors related to the current economic crisis should be urgently considered in environments where HIV-1 outbreaks may occur.Effectiveness of structural-level needle/syringe programs to reduce HCV and HIV infection among people who inject drugs: A systematic review
AbstractAbdul-Quader, A. S., Feelemyer, J., Modi, S., Stein, E. S., Briceno, A., Semaan, S., Horvath, T., Kennedy, G. E., & Des Jarlais, D. C. (n.d.).Publication year
2013Journal title
AIDS and BehaviorVolume
17Issue
9Page(s)
2878-2892AbstractNeedle-syringe programs (NSP) have been effective in reducing HIV and hepatitis C (HCV) infection among people who inject drugs (PWID). Achieving sustainable reductions in these blood-borne infections requires addressing structural factors so PWID can legally access NSP services. Systematic literature searches collected information on NSP coverage and changes in HIV or HCV infection prevalence or incidence at the population level. Included studies had to document biomarkers (HIV or HCV) coupled with structural-level NSP, defined by a minimum 50 % coverage of PWID and distribution of 10 or more needles/syringe per PWID per year. Fifteen studies reported structural-level NSP and changes in HIV or HCV infection prevalence/incidence. Nine reported decreases in HIV prevalence, six in HCV infection prevalence, and three reported decreases in HIV incidence. The results support NSP as a structural-level intervention to reduce population-level infection and implementation of NSP for prevention and treatment of HIV and HCV infection.Gender disparities in HIV infection among persons who inject drugs in Central Asia: A systematic review and meta-analysis
AbstractDes Jarlais, D. C., Boltaev, A., Feelemyer, J., Bramson, H., Arasteh, K., Phillips, B. W., & Hagan, H. (n.d.).Publication year
2013Journal title
Drug and alcohol dependenceVolume
132Page(s)
S7-S12AbstractObjective: Disparities in HIV infection, with females having higher rates of HIV infection than males, have been noted among persons who inject drugs (PWID) in many countries. We examined male/female HIV disparities among PWID in Central Asia and compared these disparities with patterns worldwide. Methods: A systematic review and meta-analyses were conducted for studies reporting HIV prevalence by gender among PWID. To be included in the analyses, reports had to contain (1) samples of PWID from Central Asia, (2) HIV data based on laboratory testing, (3) HIV prevalence reported for males and females, and (4) samples that were not recruited on the basis of HIV status. Results: Data were abstracted from 11 studies in 5 countries in Central Asia: China, Kazakhstan, Russia, Tajikistan, and Uzbekistan; the total sample size was 12,225. The mean weighted OR for HIV prevalence among females to males was 0.913 (95% CI 0.07, 1.26), with high heterogeneity among studies (I2=70.0%) and a possible publication bias among studies with small sample sizes (Eggers test=-1.81, 95% CI -5.18, 0.54). Conclusions: The non-significant higher HIV prevalence among male PWID in Central Asia contrasts with the worldwide findings which show slightly higher HIV prevalence among female PWID. This may reflect the relative recency of the HIV epidemics in Central Asia. The findings also suggest there may be factors that protect female PWID from HIV in some settings. Further examination of transmission dynamics in Central Asia is necessary to better understand the HIV epidemic among PWID.Harm reduction
AbstractNormand, J., Li, J. H., Thomson, N., & Jarlais, D. D. (n.d.).Publication year
2013Journal title
Journal of Food and Drug AnalysisVolume
21Issue
4Page(s)
S10-S12AbstractThe "Harm Reduction" session was chaired by Dr Jacques Normand, Director of the AIDS Research Program of the United States National Institute on Drug Abuse. The three presenters (and their presentation topics) were: Dr Don Des Jarlais (High coverage needle/ syringe programs for people who inject drugs in low and middle income countries: a systematic review), Dr Nicholas Thomson (Harm reduction history, response, and current trends in Asia), and Dr Jih-Heng Li (Harm reduction strategies in Taiwan).Hiv infection among people who inject drugs: The challenge of racial/ethnic disparities
AbstractJarlais, D. C., McCarty, D., Vega, W. A., & Bramson, H. (n.d.).Publication year
2013Journal title
American PsychologistVolume
68Issue
4Page(s)
274-285AbstractRacial/ethnic disparities in HIV infection, with minority groups typically having higher rates of infection, are a formidable public health challenge. In the United States, among both men and women who inject drugs, HIV infection rates are elevated among Hispanics and non-Hispanic Blacks. A meta-analysis of international research concluded that among persons who inject drugs, racial and ethnic minorities were twice as likely to acquire an HIV infection, though there was great variation across the individual studies. To examine strategies to reduce racial/ ethnic disparities among persons who inject drugs, we reviewed studies on injection drug use and its role in HIV transmission. We identified four sets of evidence-based interventions that may reduce racial/ethnic disparities among persons who inject drugs: HIV counseling and testing, risk reduction services, access to antiretroviral therapy, and drug abuse treatment. Implementation of these services, however, is insufficient in many countries, including the United States. Persons who inject drugs appear to be changing drug use norms and rituals to reduce their risks. The challenges are to (a) develop a validated model of how racial/ethnic disparities in HIV infection arise, persist, and are reduced or eliminated over time and (b) implement evidence-based services on a sufficient scale to eliminate HIV transmission among all persons who inject drugs.HSV-2 Infection as a Cause of Female/Male and Racial/Ethnic Disparities in HIV Infection
AbstractDes Jarlais, D. C., Arasteh, K., McKnight, C., Perlman, D. C., Cooper, H. L., & Hagan, H. (n.d.).Publication year
2013Journal title
PloS oneVolume
8Issue
6AbstractObjectives:To examine the potential contribution of herpes simplex virus 2 (HSV-2) infection to female/male and racial/ethnic disparities in HIV among non-injecting heroin and cocaine drug users. HSV-2 infection increases susceptibility to HIV infection by a factor of two to three.Methods:Subjects were recruited from entrants to the Beth Israel drug detoxification program in New York City 2005-11. All subjects reported current use of heroin and/or cocaine and no lifetime injection drug use. A structured questionnaire was administered and serum samples collected for HIV and HSV-2 testing. Population-attributable risk percentages (PAR%s) were calculated for associations between HSV-2 infection and increased susceptibility to HIV.Results:1745 subjects were recruited from 2005-11. Overall HIV prevalence was 14%. Females had higher prevalence than males (22% vs. 12%) (p<0.001), African-Americans had the highest prevalence (15%), Hispanics an intermediate prevalence (12%), and Whites the lowest prevalence (3%) (p<.001). There were parallel variations in HSV-2 prevalence (females 86%, males 51%, African-Americans 66%, Hispanics 47%, Whites 36%), HSV-2 prevalence was strongly associated with HIV prevalence (OR = 3.12 95% CI 2.24 to 4.32). PAR%s for HSV-2 as a cause of HIV ranged from 21% for Whites to 50% for females. Adjusting for the effect of increased susceptibility to HIV due to HSV-2 infection greatly reduced all disparities (adjusted prevalence = males 8%, females 11%; Whites 3%, African-Americans 10%, Hispanics 9%).Conclusions:Female/male and racial/ethnic variations in HSV-2 infection provide a biological mechanism that may generate female/male and racial/ethnic disparities in HIV infection among non-injecting heroin and cocaine users in New York City. HSV-2 infection should be assessed as a potential contributing factor to disparities in sexually transmitted HIV throughout the US.Is the HCV-HIV co-infection prevalence amongst injecting drug users a marker for the level of sexual and injection related HIV transmission?
AbstractVickerman, P., Martin, N. K., Roy, A., Beattie, T., Jarlais, D. D., Strathdee, S., Wiessing, L., Hickman, M., Bao, Y. P., Caiaffa, W., Ralón, G., Rossi, D., Camoni, L., Suligoi, B., Bergant, N., Christensen, P. B., Duarte, Óscar, Santos, S., Ribeiro, C., … Hogge, M. (n.d.).Publication year
2013Journal title
Drug and alcohol dependenceVolume
132Issue
1Page(s)
172-181AbstractBackground: Amongst injecting drug users (IDUs), HIV is transmitted sexually and parenterally, but HCV is transmitted primarily parenterally. We assess and model the antibody prevalence of HCV amongst HIV-infected IDUs (denoted as HCV-HIV co-infection prevalence) and consider whether it proxies the degree of sexual HIV transmission amongst IDUs. Methods: HIV, HCV and HCV-HIV co-infection prevalence data amongst IDU was reviewed. An HIV/HCV transmission model was adapted. Multivariate model uncertainty analyses determined whether the model's ability to replicate observed data trends required the inclusion of sexual HIV transmission. The correlation between the model's HCV-HIV co-infection prevalence and estimated proportion of HIV infections due to injecting was evaluated. Results: The median HCV-HIV co-infection prevalence (prevalence of HCV amongst HIV-infected IDUs) was 90% across 195 estimates from 43 countries. High HCV-HIV co-infection prevalences (>80%) occur in most (75%) settings, but can be lower in settings with low HIV prevalence (<10%) or high HIV/HCV prevalence ratios (HIV prevalence divided by HCV prevalence > 0.75). The model without sexual HIV transmission reproduced some data trends but could not reproduce any epidemics with high HIV/HCV prevalence ratios (>0.85) or low HCV-HIV co-infection prevalence (<60%) when HIV prevalence > 10%. The model with sexual HIV transmission reproduced data trends more closely. The proportion of HIV infections due to injecting correlated with HCV-HIV co-infection prevalence; suggesting that up to 80/60/<20% of HIV infections could be sexually transmitted in settings with HCV-HIV co-infection prevalence between 50-60/70-80/>90%. Conclusion: Substantial sexual HIV transmission may occur in many IDU populations; HCV-HIV co-infection prevalence could signify its importance.Knowing quitters predicts smoking cessation in a homeless population
AbstractGoldade, K., Jarlais, D. D., Everson-Rose, S. A., Guo, H., Thomas, J., Gelberg, L., Joseph, A. M., & Okuyemi, K. S. (n.d.).Publication year
2013Journal title
American Journal of Health BehaviorVolume
37Issue
4Page(s)
517-524AbstractObjectives: To examine the impact of knowing quitters on cessation among homeless smokers. Methods: Secondary analysis of data derived from a community-based randomized controlled trial of 430 homeless smokers. We conducted multivariable logistic regression analysis to determine whether knowing quitters impacted the likelihood of cessation (salivary cotinine ≤ 20 ng/ml) at 26-week follow-up. Results: Multivariable logistic regression showed cessation was more likely for smokers who knew ≥ 5 quitters compared with those who knew no quitters (Odds Ratio = 3.79, CI = 1.17, 12.27, p = .008), adjusting for age, education, income, and time to first cigarette in morning. Conclusions: Knowing former smokers was associated with increased likelihood of achieving smoking abstinence among homeless smokers.Metropolitan Social Environments and Pre-HAART/HAART Era Changes in Mortality Rates (per 10,000 Adult Residents) among Injection Drug Users Living with AIDS
AbstractFriedman, S. R., West, B. S., Pouget, E. R., Hall, H. I., Cantrell, J., Tempalski, B., Chatterjee, S., Hu, X., Cooper, H. L., Galea, S., & Des Jarlais, D. (n.d.).Publication year
2013Journal title
PloS oneVolume
8Issue
2AbstractBackground: Among the largest US metropolitan areas, trends in mortality rates for injection drug users (IDUs) with AIDS vary substantially. Ecosocial, risk environment and dialectical theories suggest many metropolitan areas characteristics that might drive this variation. We assess metropolitan area characteristics associated with decline in mortality rates among IDUs living with AIDS (per 10,000 adult MSA residents) after highly active antiretroviral therapy (HAART) was developed. Methods: This is an ecological cohort study of 86 large US metropolitan areas from 1993-2006. The proportional rate of decline in mortality among IDUs diagnosed with AIDS (as a proportion of adult residents) from 1993-1995 to 2004-2006 was the outcome of interest. This rate of decline was modeled as a function of MSA-level variables suggested by ecosocial, risk environment and dialectical theories. In multiple regression analyses, we used 1993-1995 mortality rates to (partially) control for pre-HAART epidemic history and study how other independent variables affected the outcomes. Results: In multivariable models, pre-HAART to HAART era increases in 'hard drug' arrest rates and higher pre-HAART income inequality were associated with lower relative declines in mortality rates. Pre-HAART per capita health expenditure and drug abuse treatment rates, and pre- to HAART-era increases in HIV counseling and testing rates, were weakly associated with greater decline in AIDS mortality. Conclusions: Mortality among IDUs living with AIDS might be decreased by reducing metropolitan income inequality, increasing public health expenditures, and perhaps increasing drug abuse treatment and HIV testing services. Given prior evidence that drug-related arrest rates are associated with higher HIV prevalence rates among IDUs and do not seem to decrease IDU population prevalence, changes in laws and policing practices to reduce such arrests while still protecting public order should be considered.Migration Narratives: Expanding Methods to Examine the Interaction of Person and Environment Among Aging Gay Men
AbstractVan Sluytman, L., Braine, N., Acker, C., Friedman, S., & DesJarlais, D. C. (n.d.).Publication year
2013Journal title
Journal of Gerontological Social WorkVolume
56Issue
3Page(s)
219-236AbstractAs they age, gay and bisexual men are embedded in multiple environments and communities. This article reanalyzes data collected as part of a larger qualitative study of crystal methamphetamine use in New York City. Focusing on the migration narratives of 30 racially/ethnically diverse men, age 40 years old and older, recruited from multiple venues several key areas emerged: ostracization, lack of affirmation as well as movement activities. Interactively they transformed social practices and increased spaces to explore sexuality, build community engagements and exchange resources. This study suggests that assessment of gay men (and other marginalized groups) may be enhanced through application of migration narratives.Motivational interviewing to enhance nicotine patch treatment for smoking cessation among homeless smokers: A randomized controlled trial
AbstractOkuyemi, K. S., Goldade, K., Whembolua, G. L., Thomas, J. L., Eischen, S., Sewali, B., Guo, H., Connett, J. E., Grant, J., Ahluwalia, J. S., Resnicow, K., Owen, G., Gelberg, L., & Des Jarlais, D. (n.d.).Publication year
2013Journal title
AddictionVolume
108Issue
6Page(s)
1136-1144AbstractAims: To assess the effects of adding motivational interviewing (MI) counseling to nicotine patch for smoking cessation among homeless smokers. Design: Two-group randomized controlled trial with 26-week follow-up. Participants and setting: A total of 430 homeless smokers from emergency shelters and transitional housing units in Minneapolis/St Paul, Minnesota, USA. Intervention and measurements: All participants received 8-week treatment of 21-mg nicotine patch. In addition, participants in the intervention group received six individual sessions of MI counseling which aimed to increase adherence to nicotine patches and to motivate cessation. Participants in the standard care control group received one session of brief advice to quit smoking. Primary outcome was 7-day abstinence from cigarette smoking at 26 weeks, as validated by exhaled carbon monoxide and salivary cotinine. Findings: Using intention-to-treat analysis, verified 7-day abstinence rate at week 26 for the intervention group was non-significantly higher than for the control group (9.3% versus 5.6%, P=0.15). Among participants who did not quit smoking, reduction in number of cigarettes from baseline to week 26 was equally high in both study groups (-13.7±11.9 for MI versus -13.5±16.2 for standard care). Conclusions: Adding motivational interviewing counseling to nicotine patch did not increase smoking rate significantly at 26-week follow-up for homeless smokers.Perceptions of drug users regarding Hepatitis C screening and care: A qualitative study
AbstractJordan, A. E., Masson, C. L., Mateu-Gelabert, P., McKnight, C., Pepper, N., Bouche, K., Guzman, L., Kletter, E., Seewald, R. M., Des-Jarlais, D. C., Sorensen, J. L., & Perlman, D. C. (n.d.).Publication year
2013Journal title
Harm Reduction JournalVolume
10Issue
1AbstractBackground: Illicit drug users have a high prevalence of HCV and represent the majority of newly infected persons in the U.S. Despite the availability of effective HCV treatment, few drug users have been evaluated or treated for HCV. Racial and ethnic minorities have a higher incidence and prevalence of HCV and higher HCV-related mortality. Factors contributing to poor engagement in care are incompletely understood.Methods: Fourteen mixed-gender focus groups of either African American or Latino/a drug users (N = 95) discussed barriers to HCV testing and treatment. Themes were identified through content analysis of focus group discussions.Results: Many drug users were tested for HCV in settings where they were receiving care. Outside of these settings, most were unaware of voluntary test sites. After testing HCV positive, drug users reported not receiving clear messages regarding the meaning of a positive HCV test, the impact of HCV infection, or appropriate next steps including HCV clinical evaluations. Many drug users perceived treatment as unimportant because they lacked symptoms, healthcare providers minimized the severity of the diagnosis, or providers did not recommend treatment. Mistrust of the motivations of healthcare providers was cited as a barrier to pursuing treatment. Social networks or social interactions were a source of HCV-related information and were influential in shaping drug users perceptions of treatment and its utility.Conclusion: Drug users perceived a paucity of settings for self-initiated HCV testing and poor provider-patient communication at test sites and during medical encounters. Notably, drug users reported having an unclear understanding about the meaning of a positive HCV test, the health implications of HCV infection, the importance of clinical evaluations and monitoring, and of treatment options for HCV. Efforts to improve the delivery of clinical messages about HCV infection for drug users at test settings and clinical encounters are needed.Risk for heterosexual HIV transmission among non-injecting female partners of injection drug users in Estonia
AbstractUusküla, A., McMahon, J. M., Kals, M., Talu, A., Abel-Ollo, K., Rüütel, K., & Des Jarlais, D. C. (n.d.).Publication year
2013Journal title
AIDS and BehaviorVolume
17Issue
3Page(s)
879-888AbstractThe HIV epidemic in Estonia, as with other eastern European countries, is currently concentrated among injection drug users (IDUs). Non-IDUs who have IDU sex partners could serve as a potential bridge in an expanding epidemic. We applied HIV transmission modelling to data collected from non-IDU/IDU heterosexual couples in Kohtla-Järve, Estonia to estimate HIV risk from IDUs to their sex partners based on self-reported sexual behaviors shared by the couple. IDUs and their current main non-injecting sex partners were recruited for an interviewer-administered survey and HIV testing. Bernoulli modelling techniques were applied to estimate the risk of HIV transmission (incidence) among HIV negative non-injecting female partners of male IDUs. The estimated HIV incidence in this population of non-injecting women with only main sexual partners in the last 6 months ranged from 3.24 to 4.94 HIV seroconversions per 100 person years depending on the value used in the models for the per act transmission rate during acute stage infection. Non-IDUs who have IDU sex partners are at high risk for HIV and could serve as a potential bridge to a more generalized epidemic. Whether this might lead to an expansion of the HIV epidemic beyond core groups in Estonia or other Eastern European countries warrants closer study.Smoking characteristics and comorbidities in the power to quit randomized clinical trial for homeless smokers
AbstractOkuyemi, K. S., Goldade, K., Whembolua, G. L., Thomas, J. L., Eischen, S., Guo, H., Connett, J., Grant, J., Ahluwalia, J. S., Resnicow, K., Owen, G., Gelberg, L., & Jarlais, D. D. (n.d.).Publication year
2013Journal title
Nicotine and Tobacco ResearchVolume
15Issue
1Page(s)
22-28AbstractIntroduction: Smoking prevalence in homeless populations is strikingly high (~ 70%); yet, little is known about effective smoking cessation interventions for this population. We conducted a community-based clinical trial, Power To Quit (PTQ), to assess the effects of motivational interviewing (MI) and nicotine patch (nicotine replacement therapy [NRT ]) on smoking cessation among homeless smokers. This paper describes the smoking characteristics and comorbidities of smokers in the study. Methods: Four hundred and thirty homeless adult smokers were randomized to either the intervention arm (NRT + MI) or the control arm (NRT + Brief Advice). Baseline assessment included demographic information, shelter status, smoking history, motivation to quit smoking, alcohol/other substance abuse, and psychiatric comorbidities. Results: Of the 849 individuals who completed the eligibility survey, 578 (68.1%) were eligible and 430 (74.4% of eligibles) were enrolled. Participants were predominantly Black, male, and had mean age of 44.4 years (S D=9.9), and the majority were unemployed (90.5%). Most participants reported sleeping in emergency shelters; nearly half had been homeless for more than a year. Nearly all the participants were daily smokers who smoked an average of 20 cigarettes/day. Nearly 40% had patient health questionnaire-9 depression scores in the moderate or worse range, and more than 80% screened positive for lifetime history of drug abuse or dependence. Conclusions: This study demonstrates the feasibility of enrolling a diverse sample of homeless smokers into a smoking cessation clinical trial. The uniqueness of the study sample enables investigators to examine the influence of nicotine dependence as well as psychiatric and substance abuse comorbidities on smoking cessation outcomes.Socio-demographic factors, health risks and harms associated with early initiation of injection among people who inject drugs in Tallinn, Estonia: Evidence from cross-sectional surveys
AbstractVorobjov, S., Des Jarlais, D. C., Abel-Ollo, K., Talu, A., Rüütel, K., & Uusküla, A. (n.d.).Publication year
2013Journal title
International Journal of Drug PolicyVolume
24Issue
2Page(s)
150-155AbstractAim: To explore socio-demographic factors, health risks and harms associated with early initiation of injecting (before age 16) among injecting drug users (IDUs) in Tallinn, Estonia. Methods: IDUs were recruited using respondent driven sampling methods for two cross-sectional interviewer-administered surveys (in 2007 and 2009). Bivariate and multivariate logistic regression analysis was used to identify factors associated with early initiation versus later initiation. Results: A total of 672 current IDUs reported the age when they started to inject drugs; the mean was 18 years, and about a quarter of the sample (. n=. 156) reported early initiation into injecting drugs. Factors significantly associated in multivariate analysis with early initiation were being female, having a lower educational level, being unemployed, shorter time between first drug use and injecting, high-risk injecting (sharing syringes and paraphernalia, injecting more than once a day), involvement in syringe exchange attendance and getting syringes from outreach workers, and two-fold higher risk of HIV seropositivity. Conclusions: Our results document significant adverse health consequences (including higher risk behaviour and HIV seropositivity) associated with early initiation into drug injecting and emphasize the need for comprehensive prevention programs and early intervention efforts targeting youth at risk. Our findings suggest that interventions designed to delay the age of starting drug use, including injecting drug use, can contribute to reducing risk behaviour and HIV prevalence among IDUs.Systematic review research on needle/syringe programs and opiate substitution programs in low- and middle-income countries
AbstractJarlais, D. C. (n.d.).Publication year
2013Journal title
Journal of Food and Drug AnalysisVolume
21Issue
4Page(s)
S59-S61AbstractPeople who inject drugs (PWID) are at an elevated risk of infection by human immunodeficiency virus (HIV) or hepatitis C virus (HCV). In many high-income countries, needle and syringe exchange programs (NSPs) have been associated with reductions in bloodborne infections. However, there is not a good understanding of the effectiveness of NSP in low- and middle-income countries and transitional-economy countries. A systematic literature review, based on the Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) guidelines, was utilized to collect primary study data on the coverage of NSP programs and the changes in HIV and HCV infection over time among PWID in lowand middle-income and transitional countries (LMICs). We included studies that reported laboratory measures of HIV or HCV and at least 50% coverage of the local injecting population (either through direct use or through secondary exchange). We also included national reports of newly reported HIV cases in countries that had national level data for PWID in conjunction with NSP scale-up and NSP implementation. Included in the review were studies of 11 NSPs with high-coverage from Bangladesh, Brazil, China, Estonia, Iran, Lithuania, Taiwan, Thailand, and Vietnam. In five studies, the HIV prevalence decreased (ranged from 3% to 15%) and in three studies the HCV prevalence decreased (ranged from 4.2% to 10.2%). In two studies, the HIV prevalence increased (ranged from 5.6% to 14.8%). The HCV incidence remained stable in one study. Of the four national reports of newly reported HIV cases, three studies reported decreases during the expansion of the NSP, and ranged from 30% to 93.3%; however, one national report documented an increase in HIV cases (37.6%). The estimated incidence among new injectors decreased in three studies with the reductions ranging from 11/100 person-years at risk to 16/100 person-years at risk. The data, although not fully consistent, generally support the effectiveness of NSP in reducing HIV and HCV infection in LMICs. If high coverage is achieved, NSP appears to be as effective in LMICs as in high-income countries. To identify and correct contributing problems, additional monitoring and evaluation research is needed for NSPs in which reductions in HIV/HCV infection among PWID are not occurring.The State of US health, 1990-2010: Burden of diseases, injuries, and risk factors
Failed generating bibliography.AbstractPublication year
2013Journal title
JAMAVolume
310Issue
6Page(s)
591-608AbstractIMPORTANCE: Understanding the major health problems in the United States and how they are changing over time is critical for informing national health policy. OBJECTIVES: To measure the burden of diseases, injuries, and leading risk factors in the United States from 1990 to 2010 and to compare these measurements with those of the 34 countries in the Organisation for Economic Co-operation and Development (OECD) countries. DESIGN: We used the systematic analysis of descriptive epidemiology of 291 diseases and injuries, 1160 sequelae of these diseases and injuries, and 67 risk factors or clusters of risk factors from 1990 to 2010 for 187 countries developed for the Global Burden of Disease 2010 Study to describe the health status of the United States and to compare US health outcomes with those of 34 OECD countries. Years of life lost due to premature mortality (YLLs) were computed by multiplying the number of deaths at each age by a reference life expectancy at that age. Years lived with disability (YLDs) were calculated by multiplying prevalence (based on systematic reviews) by the disability weight (based on population-based surveys) for each sequela; disability in this study refers to any short- or long-term loss of health. Disability-adjusted life-years (DALYs) were estimated as the sum of YLDs and YLLs. Deaths and DALYs related to risk factors were based on systematic reviews and meta-analyses of exposure data and relative risks for risk-outcome pairs. Healthy life expectancy (HALE) was used to summarize overall population health, accounting for both length of life and levels of ill health experienced at different ages. RESULTS: US life expectancy for both sexes combined increased from 75.2 years in 1990 to 78.2 years in 2010; during the same period, HALE increased from 65.8 years to 68.1 years. The diseases and injuries with the largest number of YLLs in 2010 were ischemic heart disease, lung cancer, stroke, chronic obstructive pulmonary disease, and road injury. Age-standardized YLL rates increased for Alzheimer disease, drug use disorders, chronic kidney disease, kidney cancer, and falls. The diseases with the largest number of YLDs in 2010 were low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders. As the US population has aged, YLDs have comprised a larger share of DALYs than have YLLs. The leading risk factors related to DALYs were dietary risks, tobacco smoking, high body mass index, high blood pressure, high fasting plasma glucose, physical inactivity, and alcohol use. Among 34 OECD countries between 1990 and 2010, the US rank for the age-standardized death rate changed from 18th to 27th, for the age-standardized YLL rate from 23rd to 28th, for the age-standardized YLD rate from 5th to 6th, for life expectancy at birth from 20th to 27th, and for HALE from 14th to 26th. CONCLUSIONS AND RELEVANCE: From 1990 to 2010, the United States made substantial progress in improving health. Life expectancy at birth and HALE increased, all-cause death rates at all ages decreased, and age-specific rates of years lived with disability remained stable. However, morbidity and chronic disability now account for nearly half of the US health burden, and improvements in population health in the United States have not kept pace with advances in population health in other wealthy nations.A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: A systematic analysis for the Global Burden of Disease Study 2010
AbstractLim, S. S., Vos, T., Flaxman, A. D., Danaei, G., Shibuya, K., Adair-Rohani, H., Amann, M., Anderson, H. R., Andrews, K. G., Aryee, M., Atkinson, C., Bacchus, L. J., Bahalim, A. N., Balakrishnan, K., Balmes, J., Barker-Collo, S., Baxter, A., Bell, M. L., Blore, J. D., … Ezzati, M. (n.d.).Publication year
2012Journal title
The LancetVolume
380Issue
9859Page(s)
2224-2260AbstractBackground Quantification of the disease burden caused by different risks informs prevention by providing an account of health loss different to that provided by a disease-by-disease analysis. No complete revision of global disease burden caused by risk factors has been done since a comparative risk assessment in 2000, and no previous analysis has assessed changes in burden attributable to risk factors over time. Methods We estimated deaths and disability-adjusted life years; DALYs; sum of years lived with disability [YLD] and years of life lost [YLL]) attributable to the independent effects of 67 risk factors and clusters of risk factors for 21 regions in 1990 and 2010. We estimated exposure distributions for each year, region, sex, and age group, and relative risks per unit of exposure by systematically reviewing and synthesising published and unpublished data. We used these estimates, together with estimates of cause-specific deaths and DALYs from the Global Burden of Disease Study 2010, to calculate the burden attributable to each risk factor exposure compared with the theoretical-minimum-risk exposure. We incorporated uncertainty in disease burden, relative risks, and exposures into our estimates of attributable burden. Findings In 2010, the three leading risk factors for global disease burden were high blood pressure (7 0% [95% uncertainty interval 6 2-7 7] of global DALYs); tobacco smoking including second-hand smoke (6 3% [5 5-7 0]), and alcohol use (5 5% [5 0-5 9]). In 1990, the leading risks were childhood underweight (7 9% [6 8-9 4]), household air pollution from solid fuels; (HAP; 7 0% [5 6-8 3]), and tobacco smoking including second-hand smoke (6 1% [5 4-6 8]). Dietary risk factors and physical inactivity collectively accounted for 10 0% (95% UI 9 2-10 8) of global DALYs in 2010, with the most prominent dietary risks being diets low in fruits and those high in sodium. Several risks that primarily affect childhood communicable diseases, including unimproved water and sanitation and childhood micronutrient deficiencies, fell in rank between 1990 and 2010, with unimproved water ' and sanitation accounting for 0 9% (0 4-1 6) of global DALYs in 2010. However, in most of sub-Saharan Africa childhood underweight, HAP, and non-exclusive and discontinued breastfeeding were the leading risks in 2010, while HAP was the leading risk in south Asia. The leading risk factor in Eastern Europe, most of Latin America, and southern sub-Saharan Africa in 2010 was alcohol use; in most of Asia, North Africa and Middle East, and central Europe it was high blood pressure. Despite declines, tobacco smoking including second-hand smoke remained the leading risk in high-income north America and western Europe. High body-mass index has increased globally and it is the leading risk in Australasia and southern Latin America, and also ranks high in other high-income regions, North Africa and Middle East, and Oceania. Interpretation Worldwide, the contribution of different risk factors to disease burden has changed substantially, with a shift away from risks for communicable diseases in children towards those for non-communicable diseases in adults. These changes are related to the ageing population, decreased mortality among children younger than 5 years, changes in cause-of-death composition, and changes in risk factor exposures. New evidence has led to changes in the magnitude of key risks including unimproved water and sanitation, vitamin A and zinc deficiencies, and ambient particulate matter pollution. The extent to which the epidemiological shift has occurred and what the leading risks currently are varies greatly across regions. In much of sub-Saharan Africa, the leading risks are still those associated with poverty and those that affect children.Controlling HIV epidemics among injection drug users: Eight years of cross-border HIV prevention interventions in Vietnam and China
AbstractHammett, T. M., Des Jarlais, D. C., Kling, R., Kieu, B. T., McNicholl, J. M., Wasinrapee, P., McDougal, J. S., Liu, W., Chen, Y., Meng, D., Doan, N., Huu Nguyen, T., Ngoc Hoang, Q., & Van Hoang, T. (n.d.).Publication year
2012Journal title
PloS oneVolume
7Issue
8AbstractIntroduction: HIV in Vietnam and Southern China is driven by injection drug use. We have implemented HIV prevention interventions for IDUs since 2002-2003 in Lang Son and Ha Giang Provinces, Vietnam and Ning Ming County (Guangxi), China. Methods: Interventions provide peer education and needle/syringe distribution. Evaluation employed serial cross-sectional surveys of IDUs 26 waves from 2002 to 2011, including interviews and HIV testing. Outcomes were HIV risk behaviors, HIV prevalence and incidence. HIV incidence estimation used two methods: 1) among new injectors from prevalence data; and 2) a capture enzyme immunoassay (BED testing) on all HIV+ samples. Results: We found significant declines in drug-related risk behaviors and sharp reductions in HIV prevalence among IDUs (Lang Son from 46% to 23% [p<0.001], Ning Ming: from 17% to 11% [p = 0.003], and Ha Giang: from 51% to 18% [p<0.001]), reductions not experienced in other provinces without such interventions. There were significant declines in HIV incidence to low levels among new injectors through 36-48 months, then some rebound, particularly in Ning Ming, but BED-based estimates revealed significant reductions in incidence through 96 months. Discussion: This is one of the longest studies of HIV prevention among IDUs in Asia. The rebound in incidence among new injectors may reflect sexual transmission. BED-based estimates may overstate incidence (because of false-recent results in patients with long-term infection or on ARV treatment) but adjustment for false-recent results and survey responses on duration of infection generally confirm BED-based incidence trends. Combined trends from the two estimation methods show sharp declines in incidence to low levels. The significant downward trends in all primary outcome measures indicate that the Cross-Border interventions played an important role in bringing HIV epidemics among IDUs under control. The Cross-Border project offers a model of HIV prevention for IDUs that should be considered for large-scale replication.Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: A systematic analysis for the Global Burden of Disease Study 2010
AbstractMurray, C. J., Vos, T., Lozano, R., Naghavi, M., Flaxman, A. D., Michaud, C., Ezzati, M., Shibuya, K., Salomon, J. A., Abdalla, S., Aboyans, V., Abraham, J., Ackerman, I., Aggarwal, R., Ahn, S. Y., Ali, M. K., AlMazroa, M. A., Alvarado, M., Anderson, H. R., … Lopez, A. D. (n.d.).Publication year
2012Journal title
The LancetVolume
380Issue
9859Page(s)
2197-2223AbstractBackground: Measuring disease and injury burden in populations requires a composite metric that captures both premature mortality and the prevalence and severity of ill-health. The 1990 Global Burden of Disease study proposed disability-adjusted life years (DALYs) to measure disease burden. No comprehensive update of disease burden worldwide incorporating a systematic reassessment of disease and injury-specific epidemiology has been done since the 1990 study. We aimed to calculate disease burden worldwide and for 21 regions for 1990, 2005, and 2010 with methods to enable meaningful comparisons over time. Methods: We calculated DALYs as the sum of years of life lost (YLLs) and years lived with disability (YLDs). DALYs were calculated for 291 causes, 20 age groups, both sexes, and for 187 countries, and aggregated to regional and global estimates of disease burden for three points in time with strictly comparable definitions and methods. YLLs were calculated from age-sex-country-time-specific estimates of mortality by cause, with death by standardised lost life expectancy at each age. YLDs were calculated as prevalence of 1160 disabling sequelae, by age, sex, and cause, and weighted by new disability weights for each health state. Neither YLLs nor YLDs were age-weighted or discounted. Uncertainty around cause-specific DALYs was calculated incorporating uncertainty in levels of all-cause mortality, cause-specific mortality, prevalence, and disability weights. Findings: Global DALYs remained stable from 1990 (2·503 billion) to 2010 (2·490 billion). Crude DALYs per 1000 decreased by 23% (472 per 1000 to 361 per 1000). An important shift has occurred in DALY composition with the contribution of deaths and disability among children (younger than 5 years of age) declining from 41% of global DALYs in 1990 to 25% in 2010. YLLs typically account for about half of disease burden in more developed regions (high-income Asia Pacific, western Europe, high-income North America, and Australasia), rising to over 80% of DALYs in sub-Saharan Africa. In 1990, 47% of DALYs worldwide were from communicable, maternal, neonatal, and nutritional disorders, 43% from non-communicable diseases, and 10% from injuries. By 2010, this had shifted to 35%, 54%, and 11%, respectively. Ischaemic heart disease was the leading cause of DALYs worldwide in 2010 (up from fourth rank in 1990, increasing by 29%), followed by lower respiratory infections (top rank in 1990; 44% decline in DALYs), stroke (fifth in 1990; 19% increase), diarrhoeal diseases (second in 1990; 51% decrease), and HIV/AIDS (33rd in 1990; 351% increase). Major depressive disorder increased from 15th to 11th rank (37% increase) and road injury from 12th to 10th rank (34% increase). Substantial heterogeneity exists in rankings of leading causes of disease burden among regions. Interpretation: Global disease burden has continued to shift away from communicable to non-communicable diseases and from premature death to years lived with disability. In sub-Saharan Africa, however, many communicable, maternal, neonatal, and nutritional disorders remain the dominant causes of disease burden. The rising burden from mental and behavioural disorders, musculoskeletal disorders, and diabetes will impose new challenges on health systems. Regional heterogeneity highlights the importance of understanding local burden of disease and setting goals and targets for the post-2015 agenda taking such patterns into account. Because of improved definitions, methods, and data, these results for 1990 and 2010 supersede all previously published Global Burden of Disease results.Drug-related arrest rates and spatial access to syringe exchange programs in New York City health districts: Combined effects on the risk of injection-related infections among injectors
AbstractCooper, H. L., Des Jarlais, D. C., Tempalski, B., Bossak, B. H., Ross, Z., & Friedman, S. R. (n.d.).Publication year
2012Journal title
Health and PlaceVolume
18Issue
2Page(s)
218-228AbstractDrug-related law enforcement activities may undermine the protective effects of syringe exchange programs (SEPs) on local injectors' risk of injection-related infections. We explored the spatial overlap of drug-related arrest rates and access to SEPs over time (1995-2006) in New York City health districts, and used multilevel models to investigate the relationship of these two district-level exposures to the odds of injecting with an unsterile syringe. Districts with better SEP access had higher arrest rates, and arrest rates undermined SEPs' protective relationship with unsterile injecting. Drug-related enforcement strategies targeting drug users should be de-emphasized in areas surrounding SEPs.Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the Global Burden of Disease Study 2010
AbstractLozano, R., Naghavi, M., Foreman, K., Lim, S., Shibuya, K., Aboyans, V., Abraham, J., Adair, T., Aggarwal, R., Ahn, S. Y., AlMazroa, M. A., Alvarado, M., Anderson, H. R., Anderson, L. M., Andrews, K. G., Atkinson, C., Baddour, L. M., Barker-Collo, S., Bartels, D. H., … Murray, C. J. (n.d.).Publication year
2012Journal title
The LancetVolume
380Issue
9859Page(s)
2095-2128AbstractBackground: Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex. Methods: We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions. Findings: In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted. Interpretation: Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis.