HIV and the criminalisation of drug use among people who inject drugs: a systematic review

Clinician's experiences with involuntary commitment for substance use disorder: A qualitative study of moral distress

BACKGROUND

Petitions for involuntary commitment of people living with a substance use disorder (SUD) have almost doubled since 2011 in Massachusetts through the policy Section 35. However, the efficacy of this controversial policy remains unclear, and clinicians differ on whether it ought to be used. This study examines how clinicians decide whether to use Section 35 and their experiences of moral distress, the negative feeling that occurs when a clinician is required to pursue a treatment option against their moral judgement due to institutional constraints, associated with its use.

METHODS

Qualitative semi-structured interviews with clinicians in Massachusetts were conducted between December 2019 and February 2020 and continued until thematic saturation. Thematic and narrative analysis was conducted with recorded and transcribed interviews.

RESULTS

Among 21 clinicians, most (77%) experienced some or high moral distress when utilizing Section 35 for involuntary commitment, with clinicians working in emergency departments experiencing less distress than those working in SUD clinics. Clinicians with low moral distress referenced successful patient anecdotes and held an abstinence-based view of SUD, while clinicians with high moral distress were concerned by systemic treatment failures and understood SUD through a nuanced and harm reduction-oriented view. Clinicians across professional settings were concerned by the involvement of law enforcement and criminal justice settings in the Section 35 process. Clinicians employed a variety of strategies to cope with moral distress, including team-based decision-making and viewing the petition as a last resort. Barriers to utilizing Section 35 included restrictive court hours and lack of post-section aftercare services.

CONCLUSION

Widespread distress associated with use of involuntary commitment and inconsistent approaches to its use highlight the need for better care coordination and guidance on best practices for utilization of this policy.

Impact of cumulative incarceration and the post-release period on syringe-sharing among people who inject drugs in Tijuana, Mexico: a longitudinal analysis

BACKGROUND AND AIMS

Syringe-sharing among people who inject drugs, which can occur during incarceration and post-release, has been linked with increased risk of blood-borne infections. We aimed to investigate the cumulative effect of repeated incarceration and the post-release period on receptive syringe-sharing.

DESIGN

Ongoing community-based cohort, recruited through targeted sampling between 2011 and 2012 with 6-month follow-ups.

SETTING

Tijuana, Mexico.

PARTICIPANTS

Sample of 185 participants (median age 35 years; 67% female) with no history of incarceration at study entry, followed to 2017.

MEASUREMENTS

Cumulative incarceration and post-release period were constructed from incarceration events reported in the past 6 months for each study visit. Receptive syringe-sharing in the past 6 months was assessed as a binary variable. We used logistic regression with generalized estimating equations to examine the association between cumulative incarceration events and the post-release period with receptive syringe-sharing over time. Missing data were handled through multiple imputation.

FINDINGS

At baseline, 65% of participants engaged in receptive syringe-sharing in the prior 6 months. At follow-up, 150 (81%) participants experienced a total of 358 incarceration events [median = 2, interquartile range (IQR) = 1-3]. The risk of receptive syringe-sharing increased with the number of repeated incarcerations. Compared with never incarcerated, those with one incarceration had 1.28 [95% confidence interval (CI) = 0.97-1.68] higher adjusted odds of syringe-sharing; two to three incarcerations, 1.42 (95% CI = 1.02-1.99) and more than three incarcerations, 2.10 (95% CI = 1.15-3.85). Participants released within the past 6 months had 1.53 (95% CI = 1.14-2.05) higher odds of sharing syringes compared with those never incarcerated. This post-release risk continued up to 1.5 years post-incarceration (adjusted odds ratio = 1.41, 95% CI = 1.04-1.91), but then waned.

CONCLUSIONS

A longitudinal community cohort study among people who inject drugs suggested that the effects of incarceration on increased injecting risk, measured through syringe-sharing, are cumulative and persist during the post-release period.

Diversity of incarceration patterns among people who inject drugs and the association with incident hepatitis C virus infection

BACKGROUND

Little is known about the relationship between short-term incarceration and risk of hepatitis C virus (HCV) infection among people who inject drugs (PWID). We investigated whether varying patterns of recent incarceration lasting less than two years are associated with HCV acquisition risk in this population.

METHODS

We followed prospectively PWID at risk of acquiring HCV infection in Montréal (2004-2019). At 6-month (up until 2011), then 3-month intervals, participants were tested for HCV antibodies or RNA, and self-reported whether they have been incarcerated in each of the previous 6 or 3 months. If incarcerated, they reported the setting and time spent in incarceration. We fit three separate multivariable time-updated Cox regression models, one for each measure of incarceration: any incarceration lasting less than two years (yes/no), incarceration stratified by setting (local police station/provincial prison/no) and incarceration stratified by time in incarceration (≤1 week/>1 week and ≤1 month/>1 month and <2 years/no).

RESULTS

Among 709 PWID followed over 2315.2 person-years, HCV incidence was 9.9/100 person-years (95% confidence interval (CI): 8.7-11.2)]. During follow-up, 248 PWID (35.0%) reported at least one recent incarceration episode of less than two years. Overall, compared to PWID who did not experience incarceration in the prior 6 or 3 months, PWID who did were 1.56 (95% CI: 1.13, 2.17) times more likely to acquire HCV. We found no statistically significant difference in the magnitude of associations across categories of setting and time in incarceration (likelihood ratio test P= 0.53 and 0.44, respectively).

CONCLUSION

Any recent incarceration lasting less than two years, regardless of the setting and time in incarceration, was associated with an elevated risk of HCV acquisition among PWID. Findings support the need to expand access to harm-reduction programs in short-term incarceration settings and, in parallel, to prioritise public health-oriented alternatives to incarcerating PWID where possible.

A plea of those who are affected most by HIV: The utterances by women who inject Nyaope residing in the City of Tshwane Municipality, Gauteng

Background

Nyaope injecting practice brought the field of Human Immunodeficiency Virus (HIV) prevention and Substance Use Disorder (SUD) together. It is complex and requires multidisciplinary approach. Women who use drugs face individual, social, and structural factors that fuel their vulnerability to contract HIV, and other blood-borne infections. Women Who Inject Drugs (WWID) are a subpopulation that is neglected from HIV prevention and SUD treatment interventions, and are hardly the subject of surveys. In order to fully address the HIV epidemic among WWID it is imperative that they become part of the process of finding solutions.

Aim

This study explored the strategies to curb HIV incidence among Women Who Inject Nyaope (WWIN), residing in City of Tshwane Municipality, Gauteng Province.

Setting

The research was conducted within COSUP. COSUP was considered more appropriate as it is a harm reduction based organisation.

Methods

The study utilised the qualitative research approach. Semi structured interviews were conducted with 24 women with a history of injecting Nyaope aged between 19 to 35 years. The data was analysed using thematic data analysis.

Results

Health intervention, economic intervention and educational intervention was stressed as key strategies to curb HIV among WWIN. Needle exchange programmes, condom distribution, PrEP, HIV Testing and Counselling, employment opportunities, support groups and awareness campaigns if implemented, can yield positive outcomes in curbing HIV among WWID.

Conclusion

Mechanisms to curb HIV among WWIN exist, and when implemented, they have the potential to address high HIV incidence among women who inject Nyaope.

An application of agent-based modeling to explore the impact of decreasing incarceration rates and increasing drug treatment access on sero-discordant partnerships among people who inject drugs

BACKGROUND

People who inject drugs (PWID) lag behind other key populations in HIV care continuum outcomes. The impacts of criminal justice reform and increasing drug treatment access on HIV have been underexplored.

METHODS

We developed agent-based models (ABM) of sexual partnerships among PWID and non-PWID, and injection equipment-sharing partnerships among PWID in five US cities (Baltimore, Boston, Miami, New York City, San Francisco) over 3 years. The first set of ABM projected changes in partnership discordance among PWID as a function of decreasing ZIP code-level incarceration rates. The second set projected discordance as a function of increasing ZIP code-level drug treatment access. ABM were parameterized and validated overall, and by city and PWID race/ethnicity (Black, Latino, White) using National HIV Behavioral Surveillance data, administrative ZIP code-level data, surveillance reports and prior literature. Informed by research on prisoner release and community-level HIV prevalence, reductions in incarceration rates were fixed at 5% and 30% and respectively projected to increase ZIP code-level HIV prevalence by 2% and 12%. Increases in drug treatment access were fixed at 30% and 58%.

RESULTS

In each city, a 30% reduction in ZIP code-level incarceration rates and 12% increase in ZIP code-level HIV prevalence significantly increased sero-discordance among at least one racial/ethnic group of PWID by 1-3 percentage points. A 5% reduction in incarceration rates, and 30% and 58% increases in drug treatment access, led to isolated significant changes in sero-discordance among Black and White PWID that were less than 1 percentage point.

CONCLUSION

Reductions in incarceration rates may lead to short-term increases in sero-discordant partnerships among some PWID by increasing community-level HIV prevalence. Efforts to increase HIV testing, engagement in care and community reintegration post release, should be strengthened in the wake of incarceration reform. Additional research should confirm these findings and explore the lack of widespread impacts of drug treatment in this study.

Municipal police support for harm reduction services in officer-led referrals of people who inject drugs in Tijuana, Mexico

BACKGROUND

Police constitute a structural determinant of health and HIV risk of people who inject drugs (PWID), and negative encounters with law enforcement present significant barriers to PWID access to harm reduction services. Conversely, police may facilitate access via officer-led referrals, potentiating prevention of HIV, overdose, and drug-related harms. We aimed to identify police characteristics associated with support for officer-led referrals to addiction treatment services and syringe service programs (SSP). We hypothesized that officers who believe harm reduction services are contradictory to policing priorities in terms of safety and crime reduction will be less likely to support police referrals.

METHODS

Between January and June 2018, police officers (n = 305) in Tijuana, Mexico, completed self-administered surveys about referrals to harm reduction services during the 24-month follow-up visit as part of the SHIELD police training and longitudinal cohort study. Log-binomial regression was used to estimate adjusted prevalence ratios and model policing characteristics and attitudes related to officers' support for including addiction treatment and SSP in referrals.

RESULTS

Respondents were primarily male (89%), patrol officers (86%) with a median age of 38 years (IQR 33-43). Overall, 89% endorsed referral to addiction services, whereas 53% endorsed SSP as acceptable targets of referrals. Officers endorsing addiction services were less likely to be assigned to high drug use districts (adjusted prevalence ratio [APR] = 0.50, 95% CI 0.24, 1.08) and more likely to agree that methadone programs reduce crime (APR = 4.66, 95% CI 2.05, 9.18) than officers who did not support addiction services. Officers endorsing SSPs were younger (adjusted prevalence ratio [APR] = 0.96 95% CI 0.93, 0.98), less likely to be assigned to high drug use districts (APR = 0.50, 95% CI 0.29, 0.87), more likely to believe that methadone programs reduce crime (APR = 2.43, 95% CI 1.30, 4.55), and less likely to believe that SSPs increase risk of needlestick injury for police (APR = 0.44, 0.27, 0.71).

CONCLUSIONS

Beliefs related to the occupational impact of harm reduction services in terms of officer safety and crime reduction are associated with support for referral to related harm reduction services. Efforts to deflect PWID from carceral systems toward harm reduction by frontline police should include measures to improve officer knowledge and attitudes about harm reduction services as they relate to occupational safety and law enforcement priorities.

TRIAL REGISTRATION

NCT02444403.

Drug use stigma and its association with active hepatitis C virus infection and injection drug use behaviors among community-based people who inject drugs in India

BACKGROUND

Although drug use stigma is globally pervasive, quantitative evidence of its role in hepatitis C virus (HCV) transmission is limited. We evaluated the psychometric properties of a drug use stigma scale and examined the association between drug use stigma and active HCV infection among a community-based sample of people who inject drugs (PWID) in India.

METHODS

Between 8/2016 and 5/2017, a cross-sectional sample of PWID was recruited from 12 Indian cities (~1000/city) using respondent-driven sampling. Participants were ≥18 years old and reported injection drug use (IDU) in the past 2 years. Multivariable logistic regression with a random-intercept for each city was used to estimate adjusted odds ratios (aOR) of active HCV infection (RNA>30 IU/mL). Analyses incorporated RDS-II weights.

RESULTS

Of 11,663 participants, 73.1% reported IDU in the past 6 months and 33.8% had active HCV infection. Exploratory factor analysis yielded a four-factor solution of enacted, vicarious, felt normative and internalized drug use stigma with high internal consistency (Cronbach's α: 0.85-0.92). In analyses adjusted for age, gender, northeast region, education, homelessness, incarceration, alcohol dependence, HIV status, frequency of IDU, and ever sharing needles/syringes, PWID reporting any enacted stigma had greater odds of active HCV infection (aOR = 1.27 [95% CI = 1.13-1.43]) as did PWID with internalized stigma scores in the highest quartile (vs. lowest quartile; aOR = 1.69 [95% CI = 1.11-2.56]). Among PWID who reported IDU in the past 6 months, multiple forms of stigma were associated with higher frequency of IDU, sharing needles/syringes, having multiple injection partners, and IDU in public spaces.

CONCLUSION

Using a multidimensional drug use stigma scale, various forms of stigma were significantly associated with active HCV infection and injection drug use-related risk behaviors. Collectively, these data suggest that drug use stigma may play a role in HCV transmission and impede efforts to achieve HCV elimination. Strategies to diminish drug use stigma are warranted.

Missed Opportunities for Human Immunodeficiency Virus (HIV) Testing During Injection Drug Use-Related Healthcare Encounters Among a Cohort of Persons Who Inject Drugs With HIV Diagnosed During an Outbreak-Cincinnati/Northern Kentucky, 2017-2018

BACKGROUND

Persons who inject drugs (PWID) have frequent healthcare encounters related to their injection drug use (IDU) but are often not tested for human immunodeficiency virus (HIV). We sought to quantify missed opportunities for HIV testing during an HIV outbreak among PWID.

METHODS

PWID with HIV diagnosed in 5 Cincinnati/Northern Kentucky counties during January 2017-September 2018 who had ≥1 encounter 12 months prior to HIV diagnosis in 1 of 2 Cincinnati/Northern Kentucky area healthcare systems were included in the analysis. HIV testing and encounter data were abstracted from electronic health records. A missed opportunity for HIV testing was defined as an encounter for an IDU-related condition where an HIV test was not performed and had not been performed in the prior 12 months.

RESULTS

Among 109 PWID with HIV diagnosed who had ≥1 healthcare encounter, 75 (68.8%) had ≥1 IDU-related encounters in the 12 months before HIV diagnosis. These 75 PWID had 169 IDU-related encounters of which 86 (50.9%) were missed opportunities for HIV testing and occurred among 46 (42.2%) PWID. Most IDU-related encounters occurred in the emergency department (118/169; 69.8%). Using multivariable generalized estimating equations, HIV testing was more likely in inpatient compared with emergency department encounters (adjusted relative risk [RR], 2.72; 95% confidence interval [CI], 1.70-4.33) and at the healthcare system receiving funding for emergency department HIV testing (adjusted RR, 1.76; 95% CI, 1.10-2.82).

CONCLUSIONS

PWID have frequent IDU-related encounters in emergency departments. Enhanced HIV screening of PWID in these settings can facilitate earlier diagnosis and improve outbreak response.

Current allocations and target apportionment for HIV testing and treatment services for marginalized populations: characterizing PEPFAR investment and strategy

INTRODUCTION

The United States President's Emergency Plan for AIDS Relief (PEPFAR) is a large bilateral funder of the global HIV response whose policy decisions on key populations (KPs) programming determine the shape of the key populations' response in many countries. Understanding the size and relative share of PEPFAR funds going to KPs and the connection between PEPFAR's targets and resulting programming is crucial for successfully serving key populations.

METHODS

Publicly available PEPFAR budgets for key populations' services were assessed by country and geographical region for all 52 countries with budget data in fiscal year (FY) 2020. For the 23 countries which completed a full planning process in FY 2018 and 2019, PEPFAR targets for HIV testing and treatment initiation for key populations were assessed. Expenditures for KP programming were calculated to determine whether shifts in targets translated into programming. Implementing partners were characterized by the level of specialization using the share of assigned targets made up by KPs. The average target per year and implementing partner was calculated for each KP group and indicator.

RESULTS

PEPFAR country KP budgets ranged from US$35,000 to $15.2 million, and the proportion of funding to key populations varied by region, with Eastern and Southern African countries having the lowest proportion. Between FY 2018 and 2019, the KP targets for HIV testing and treatment among KPs increased, whereas expenditures on key populations decreased from US$115.4 to $111.0 million. Of the 11 countries with an increase in HIV testing targets, seven had a decrease in KP expenditures. Of the nine countries with an increase in treatment initiation targets, five had a decrease in KP expenditures. The proportion of targets assigned to partners which do not specialize in key populations increased from FY 2018 to 2019.

CONCLUSIONS

Current key population policies have not resulted in a tight connection between targets and expenditures. This includes assigning a large proportion of key populations programming to partners who do not specialize in key populations, which may weaken the performance management role of the targets. These results signal that a new approach to key populations programming is needed.

Elimination of hepatitis C among HIV-positive population in Asia: old and new challenges

Hepatitis C virus (HCV) prevalence is high among people living with HIV co-infected with HCV, people who inject drugs, men who have sex with men and inmates in correctional settings. The barriers to eliminate HCV among these key populations include diagnosis challenges, lack of awareness, discrimination and stigmatization. In addition, scaling up of HCV treatment has been a challenge in Asia–Pacific with the lack of national policies, targets and unavailability of appropriate direct-acting antivirals regimens. In order to achieve HCV micro elimination within these high-risk populations, novel strategies to improve the cascade of care from diagnosis to treatment with direct-acting antivirals, complemented by behavioral change interventions, harm reduction services for people who inject drugs, civil society led advocacy and policies from the government, will be necessary.

Phylogenetic Analysis of Human Immunodeficiency Virus from People Who Inject Drugs in Indonesia, Ukraine, and Vietnam: HPTN 074

BACKGROUND

HIV Prevention Trials Network (HPTN) 074 evaluated human immunodeficiency virus (HIV) prevention interventions for people who inject drugs (PWID) in Indonesia, Ukraine, and Vietnam. Study interventions included support for HIV infection and substance use treatment. The study enrolled index participants living with HIV and injection partners who were not living with HIV. Seven partners acquired HIV infection during the study (seroconverters). We analyzed the phylogenetic relatedness between HIV strains in the cohort and the multiplicity of infection in seroconverters.

METHODS

Pol region consensus sequences were used for phylogenetic analysis. Data from next-generation sequencing (NGS, env region) were used to evaluate genetic linkage of HIV from the 7 seroconverters and the corresponding index participants (index-partner pairs), to analyze HIV from index participants in pol sequence clusters, and to analyze multiplicity of HIV infection.

RESULTS

Phylogenetic analysis of pol sequences from 445 index participants and 7 seroconverters identified 18 sequence clusters (2 index-partner pairs, 1 partner-partner pair, and 15 index-only groups with 2-7 indexes/cluster). Analysis of NGS data confirmed linkage for the 2 index-partner pairs, the partner-partner pair, and 11 of the 15 index-index clusters. The remaining 5 seroconverters had infections that were not linked to the corresponding enrolled index participant. Three (42.9%) of the 7 seroconverters were infected with more than 1 HIV strain (3-8 strains per person).

CONCLUSIONS

We identified complex patterns of HIV clustering and linkage among PWID in 3 communities. This should be considered when designing strategies for HIV prevention for PWID.

CLINICAL TRIALS REGISTRATION

NCT02935296.

Peer-mediated HIV assisted partner services to identify and link to care HIV-positive and HCV-positive people who inject drugs: a cohort study protocol

INTRODUCTION

Targeted, tailored interventions to test high-risk individuals for HIV and hepatitis C virus (HCV) are vital to achieving HIV control and HCV microelimination in Africa. Compared with the general population, people who inject drugs (PWID) are at increased risk of HIV and HCV and are less likely to be tested or successfully treated. Assisted partner services (APS) increases HIV testing among partners of people living with HIV and improves case finding and linkage to care. We describe a study in Kenya examining whether APS can be adapted to find, test and link to HIV care the partners of HIV-positive PWID using a network of community-embedded peer educators (PEs). Our study also identifies HCV-positive partners and uses phylogenetic analysis to determine risk factors for onward transmission of both viruses.

METHODS

This prospective cohort study leverages a network of PEs to identify 1000 HIV-positive PWID for enrolment as index participants. Each index completes a questionnaire and provides names and contact information of all sexual and injecting partners during the previous 3 years. PEs then use a stepwise locator protocol to engage partners in the community and bring them to study sites for enrolment, questionnaire completion and rapid HIV and HCV testing. Outcomes include number and type of partners per index who are mentioned, enrolled, tested, diagnosed with HIV and HCV and linked to care.

ETHICS AND DISSEMINATION

Potential index participants are screened for intimate partner violence (IPV) and those at high risk are not eligible to enrol. Those at medium risk are monitored for IPV following enrolment. A community advisory board engages in feedback and discussion between the community and the research team. A safety monitoring board discusses study progress and reviews data, including IPV monitoring data. Dissemination plans include presentations at quarterly Ministry of Health meetings, local and international conferences and publications.

TRIAL REGISTRATION NUMBER

NCT03447210, Pre-results stage.

Undetectable viral load and HIV transmission dynamics on an individual and population level: where next in the global HIV response?

PURPOSE OF REVIEW

To examine recent literature on the efficacy and effectiveness of HIV treatment in preventing HIV transmission through sexual exposure, at both an individual and at a population level.

RECENT FINDINGS

Two recent studies on the individual-level efficacy of treatment as prevention (TasP) have added to the now conclusive evidence that HIV cannot be transmitted sexually when the virus is suppressed. However, four large cluster-randomized population-level trials on universal HIV testing and treatment in Africa have not delivered the expected impact in reducing HIV incidence at a population level. Two of these trials showed no differences in HIV incidence between the intervention and control arms, one demonstrated a nonsignificant lower incidence in the intervention arm, and the fourth trial found a reduction between the communities receiving a combination prevention package and the control arm, but no difference between the immediate treatment plus the prevention package and the control arm. Factors contributing to the disconnect between individual high-level efficacy and population-level effectiveness of TasP include undiagnosed infection, delays in linkage to care, challenges in retention and adherence to antiretroviral therapy (ART), time between ART initiation and viral suppression, and stigma and discrimination.

SUMMARY

Suppressive ART renders people living with HIV sexually noninfectious. However, epidemic control is unlikely to be achieved by TasP alone.

Understanding barriers and facilitators to HIV testing in Canada from 2009-2019: A systematic mixed studies review

BACKGROUND

HIV testing is a core pillar of Canada's approach to sexually transmitted and blood-borne infection (STBBI) prevention and treatment and is critical to achieving the first Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target. Despite progress toward this goal, many Canadians remain unaware of their status and testing varies across populations and jurisdictions. An understanding of drivers of HIV testing is essential to improve access to HIV testing and reach the undiagnosed.

OBJECTIVE

To examine current barriers and facilitators of HIV testing across key populations and jurisdictions in Canada.

METHODS

A systematic mixed studies review of peer-reviewed and grey literature was conducted identifying quantitative and qualitative studies of barriers and facilitators to HIV testing in Canada published from 2009 to 2019. Studies were screened for inclusion and identified barriers and facilitators were extracted. The quality of included studies was assessed and results were summarized.

RESULTS

Forty-three relevant studies were identified. Common barriers emerge across key populations and jurisdictions, including difficulties accessing testing services, fear and stigma surrounding HIV, low risk perception, insufficient patient confidentiality and lack of resources for testing. Innovative practices that could facilitate HIV testing were identified, such as new testing settings (dental care, pharmacies, mobile units, emergency departments), new modalities (oral testing, peer counselling) and personalized sex/gender and age-based interventions and approaches. Key populations also face unique sociocultural, structural and legislative barriers to HIV testing. Many studies identified the need to offer a broad range of testing options and integrate testing within routine healthcare practices.

CONCLUSION

Efforts to improve access to HIV testing should consider barriers and facilitators at the level of the individual, healthcare provider and policy and should focus on the accessibility, inclusivity, convenience and confidentiality of testing services. In addition, testing services must be adapted to the unique needs and contexts of key populations.

Injection drug use, depression, and HIV screening in rural primary care settings: A retrospective cross-sectional study

Introduction

Antiretroviral therapy (ART) has reduced HIV viral replication and transmission of disease. However, continuing incidence of new HIV infections has been attributed to undiagnosed HIV infections among injection drug users. This purpose of this retrospective cross-sectional study was to determine whether depression moderates the relationship between injection drug use and HIV screening among people with substance use in the screening, brief intervention, and referral to treatment in Alabama (AL-SBIRT) program.

Methods

Electronic health record data were obtained from three consenting medical facilities (n = 103). Multivariable logistic regression analysis was conducted to determine the moderating effect of depression on the relationship between injection drug use and HIV screening.

Results

Bivariate analyses revealed that HIV screening was more common among individuals not engaged in injection drug use, 75% and 57% respectively. Participants who had never been screened had worse depressive symptoms on the PHQ-2 (M = 3.00, SE = 0.42) than individuals who had been screened for HIV (M = 1.45, SE = 0.17). After controlling for demographic variables, tobacco use, alcohol consumption, and drug abuse, results indicated a moderating effect of depression on the relationship between injection drug use and receipt of HIV screening (aOR = 0.85 [95% CI = 0.84, 0.86).

Discussion

Findings suggest that high risk subgroups such as injection drug users with severe depression may not be using HIV prevention services, leading to possible delays in HIV diagnosis. Integration of behavioral interventions and HIV prevention services may reduce risk factors among depressed injection drug users. Such interventions may improve retention for injection drug users who experience worse depressive symptoms post HIV diagnosis.

Peer driven or driven peers? A rapid review of peer involvement of people who use drugs in HIV and harm reduction services in low- and middle-income countries

Introduction

Peer involvement of people who use drugs within HIV and harm reduction services is widely promoted yet under-utilised. Alongside political and financial barriers is a limited understanding of the roles, impacts, contexts and mechanisms for peer involvement, particularly in low- and middle-income settings. We conducted a rapid review of available literature on this topic.

Methods

Within a community-academic partnership, we used a rapid review approach, framed by realist theory. We used a network search strategy, focused on core journals and reference lists of related reviews. Twenty-nine studies were included. We developed thematic summaries framed by a realist approach of exploring interventions, their mechanisms, outcomes and how they are shaped by contexts.

Results

Reported outcomes of peer involvement included reduced HIV incidence and prevalence; increased service access, acceptability and quality; changed risk behaviours; and reduced stigma and discrimination. Mechanisms via which these roles work were trust, personal commitment and empathy, using community knowledge and experience, as well as ‘bridge’ and ‘role model’ processes. Contexts of criminalisation, under-resourced health systems, and stigma and discrimination were found to shape these roles, their mechanisms and outcomes. Though contexts and mechanisms are little explored within the literature, we identified a common theme across contexts, mechanisms and outcomes. Peer outreach interventions work through trust, community knowledge and expertise, and ‘bridge’ mechanisms (M) to counter criminalisation and constraining clinic and service delivery environments (C), contributing towards changed drug-using behaviours, increased access, acceptability and quality of harm reduction services and decreased stigma and discrimination (O).

Conclusion

Peer involvement in HIV and harm reduction services in low- and middle-income settings is linked to positive health outcomes, shaped by contexts of criminalisation, stigma, and resource scarcity. However, peer involvement is under-theorised, particularly on how contexts shape mechanisms and ultimately outcomes. Efforts to study peer involvement need to develop theory and methods to evaluate the complex mechanisms and contexts that have influence. Finally, there is a need to expand the range of peer roles, to embrace the capacities and expertise of people who use drugs.

Occult HCV and occult HBV coinfection in Iranian human immunodeficiency virus-infected individuals

The presence of hepatitis C virus (HCV) genome in liver biopsy or peripheral blood mononuclear cell (PBMC) specimens in the absence of detectable HCV-RNA in plasma of the people with or without anti-HCV antibodies has defined as occult HCV infection (OCI), whereas occult hepatitis B virus infection (OBI) is detection of hepatitis B virus (HBV) genome in the absence of traceable hepatitis B surface antigen in the plasma samples of patients. The purpose of this study is to determine the presence of OBI and OCI in human immunodeficiency virus (HIV)-infected individuals. In this cross-sectional research, 190 Iranian HIV-infected individuals were enrolled from September 2015 to February 2019. All participants were tested regarding various serological markers for HCV and HBV infections. Viral RNA and DNA were extracted from plasma and PBMC specimens, and the presence of HCV-RNA in plasma and PBMC samples was tested using reverse transcriptase-nested polymerase chain reaction (PCR), HBV viral load was determined in plasma samples using COBAS TaqMan 48 Kit, and also the presence of the HBV-DNA in PBMC samples was tested by real-time PCR. In this study, the prevalence of OBI and OCI in HIV-infected individuals was 3.1% and 11.4%, respectively. The genotypes of HCV in the patients with OCI were as follows: 57.1% were infected with subtype 3a, 35.7% were infected with subtype 1a, and 7.1% was infected with subtype 1b. It is noteworthy that in this study, two patients (1.1%) had OCI/OBI coinfections. The present study revealed that 1.1% of Iranian HIV-infected individuals had OBI and OCI at the same time. Therefore, it seems that designing prospective surveys to determine the presence of this coinfection in HIV-infected individuals is informative.

New psychoactive substances in Eurasia: a qualitative study of people who use drugs and harm reduction services in six countries

Background

This study examines the use of new psychoactive substances (NPS) and the harm reduction response in six Eurasian countries: Belarus, Moldova, Serbia, Kazakhstan, Kyrgyzstan, and Georgia. The aim is to identify current patterns of NPS use and related harms in each country through recording the perspectives and lived experience of people who use drugs and people who provide harm reduction services in order to inform the harm reduction response.

Methodology

The study involved desk-based research and semi-structured interviews/focus groups with 124 people who use drugs and 55 health and harm reduction service providers across the six countries.

Results

People who use drugs in all countries were aware of NPS, primarily synthetic cathinones and synthetic cannabinoids. NPS users generally reflected two groups: those with no prior history of illicit drug use (typically younger people) and those who used NPS on an occasional or regular basis due to the lack of availability of their preferred drug (primarily opiates). In many cases, these respondents reported they would not use NPS if traditional opiates were available. Common factors for choosing NPS included cost and accessibility. Respondents in most countries described NPS markets that use the DarkNet and social media for communication, secretive methods of payment and hidden collection points. A recurring theme was the role of punitive drug policies in driving NPS use and related harms. Respondents in all countries agreed that current harm reduction services were important but needed to be enhanced and expanded in the context of NPS.

Conclusions

The study identified patterns and drivers of NPS use, risk behaviours and drug-related harms. It identified gaps in the current harm reduction response, particularly the needs of non-injectors and overdose response, as well as the harmful effects of punitive drug policies. These findings may inform and improve current harm reduction services to meet the needs of people who use NPS.

Overdose among mothers: The association between child removal and unintentional drug overdose in a longitudinal cohort of marginalised women in Canada

BACKGROUND

Accidental overdose is a major public health concern in North America with research primarily focused on cisgender men. Little is known about the burden of overdose among marginalised women, particularly in the context of child custody loss. This study aims to examine the prevalence of overdose and the association with child removal in a cohort of marginalised women.

METHODS

This study draws on a merged dataset (2010-2018) of two community-based longitudinal cohorts of over 1000 marginalised women in Canada recruited using time-location sampling. After restricting to women who had ever had a live birth, bivariate and multivariable logistic regression using generalised estimating equations (GEE) were used to examine the association between child removal and overdose. Joint effects of child removal and Indigeneity were also investigated.

RESULTS

Of the 696 women who reported ever having a live birth, 39.7% (n = 276) reported child removal at baseline. Unintended, non-fatal overdose rates were high, with 35.1% (n = 244) of women reporting ever having an overdose. Using bivariate GEE analyses, having a child apprehended and being Indigenous were positively correlated with overdose. Using multivariable GEE, child removal increased the odds of overdose by 55% (AOR: 1.55; 95% CI 1.01-2.39) after adjusting for education and Indigenous ancestry. Using multivariable joint-effects analysis, Indigenous women who had experienced child removal had over twice the odds of an unintended overdose than non-Indigenous women who had not lost custody after adjusting for education, food insecurity, and sex work (AOR: 2.09; 95% CI 1.15-3.79).

CONCLUSION

This analysis suggests that, after controlling for known confounders, women who have a child removed experience higher odds of overdose, and these odds are highest among Indigenous women. The high prevalence of overdose in this cohort suggests the need for further strategies to prevent overdose among pregnant and parenting women.

Calls for Access to Safe Injecting Supplies as a Critical Public Health Measure During the COVID-19 Pandemic

: More than 3 decades of research has provided compelling evidence regarding the effectiveness, safety, and cost-effectiveness of needle and syringe programs in reducing syringe-sharing and transmission of HIV, HCV, and other bloodborne infections. However, repressive drug policies and drug law enforcement practices around the world continue to undermine their operations and scale-up, as well as access to harm reduction among people who inject drugs. The COVID-19 pandemic has heightened access barriers to needle and syringe programs, raising concerns about unsafe injecting practices due to inadequate access to safe injecting supplies. This commentary discusses the robust public health responses that are needed at this particularly vulnerable and critical juncture to ensure access to safe injecting supplies and minimize the risk for transmission of bloodborne infections among people who inject drugs.

COVID-19, HIV and key populations: cross-cutting issues and the need for population-specific responses

INTRODUCTION

Key populations at elevated risk to contract or transmit HIV may also be at higher risk of COVID-19 complications and adverse outcomes associated with public health prevention measures. However, the conditions faced by specific populations vary according to social, structural and environmental factors, including stigma and discrimination, criminalization, social and economic safety nets and the local epidemiology of HIV and COVID-19, which determine risk of exposure and vulnerability to adverse health outcomes, as well as the ability to comply with measures such as physical distancing. This commentary identifies common vulnerabilities and cross-cutting themes in terms of the impacts of COVID-19 on key populations before addressing issues and concerns specific to particular populations.

DISCUSSION

Cross-cutting themes include direct impacts such as disrupted access to essential medicines, commodities and services such as anti-retroviral treatment, HIV pre-exposure prophylaxis, opioid agonist treatment, viral load monitoring, HIV and sexually transmitted infections testing, condoms and syringes. Indirect impacts include significant collateral damage arising from prevention measures which restrict human rights, increase or impose criminal penalties, and expand police powers to target vulnerable and criminalized populations. Significant heterogeneity in the COVID-19 pandemic, the underlying HIV epidemic and the ability of key populations to protect themselves means that people who inject drugs and sex workers face particular challenges, including indirect impacts as a result of police targeting, loss of income and sometimes both. Geographical variations mean that transgender people and men who have sex with men in regions like Africa and the middle east remain criminalized, as well as stigmatized and discriminated against, increasing their vulnerability to adverse outcomes in relation to COVID-19.

CONCLUSIONS

Disruptions to both licit and illicit supply chains, loss of income and livelihoods and changes in behaviour as a result of lockdowns and physical distancing have the potential to exacerbate the impacts of the COVID-19 pandemic on key populations. While these impacts will vary significantly, human-rights approaches to COVID-19 emergency laws and public health prevention measures that are population-specific and sensitive, will be key to reducing adverse health outcomes and ensuring that no one is left behind.

ART uptake and adherence among women who use drugs globally: A scoping review

OBJECTIVE

To assess the state of peer-reviewed literature surrounding uptake and adherence of antiretroviral therapy (ART) among HIV-positive women who use drugs (WWUD).

METHODS

Consistent with PRISMA-ScR guidelines, we conducted a scoping literature review on ART uptake and adherence among WWUD, searching PubMed, Embase, CINAHL, PsycInfo, and Sociological Abstracts. Eligibility criteria included: reporting at least one ART uptake or adherence related result among WWUD aged 18 or older; peer-reviewed; published in English between 1996-2018.

RESULTS

Our search identified 6735 studies; 86 met eligibility requirements. ART uptake ranged from 30 % to 76 % and adherence ranged from 27 % to 95 %. Substance use, co-morbid psychiatric disorders, and side effects emerged as the primary ART uptake and adherence barriers among this population. Few facilitators were identified.

CONCLUSION

This study is the first scoping review to look at ART uptake and adherence among WWUD globally. The wide range in uptake and adherence outcomes indicates the need for gold standard assessments, which may differ between high and low resource settings. This study offers rich insight into uptake and adherence barriers and facilitators, primarily at the intrapersonal level. More research is needed to examine interventions that focus on additional levels of the SEM (e.g., community and policy levels). These review findings can inform ART interventions, future research, and offer guidance to other support services with WWUD, such as PrEP interventions.

Hepatitis C treatment uptake among people who inject drugs in the oral direct-acting antiviral era

BACKGROUND

Increased uptake of hepatitis C virus (HCV) treatment among people who inject drugs (PWID) will be critical to achieve HCV elimination goals. There are limited data on HCV treatment uptake among PWID recruited from community-based settings in the HCV direct-acting antiviral (DAA) era.

METHODS

We analysed data from PWID with HCV newly recruited into the Baltimore, Maryland-based AIDS Linked to the IntraVenous Experience (ALIVE) cohort between 2015 and 2018. We characterized the HCV care continuum and evaluated factors associated with HCV treatment uptake.

RESULTS

Of the 418 PWID with HCV, the median age was 49 years and most (88%) reported recent injection drug use (IDU). Overall, 23% had ever been evaluated by a provider for HCV treatment, 17% ever initiated DAA treatment and 13% were cured of HCV infection. Treatment uptake approximately doubled between 2015 and 2018 (13% to 26%, P = .01). In multivariable analyses, HIV infection (adjusted Odds Ratio [aOR] 2.5 [95% Confidence Interval (CI) 1.3, 4.8]), current employment (aOR 4.1 [CI 1.2, 14.4]), having a primary care provider (aOR 4.3 [CI 1.2, 14.9) and longer duration of IDU (aOR 1.3 [CI 1.1, 1.6]) were positively associated with HCV treatment. PWID with a lower annual income (≤$5000) were less likely to have initiated HCV treatment (aOR 0.5 [CI 0.3, 0.98]).

CONCLUSIONS

Although HCV treatment uptake among PWID in this community-based setting in the DAA era remains suboptimal, it is encouraging that treatment uptake has increased in recent years. Innovative strategies are needed to reach all PWID infected with HCV.

Impact evaluations of drug decriminalisation and legal regulation on drug use, health and social harms: a systematic review

OBJECTIVES

To review the metrics and findings of studies evaluating effects of drug decriminalisation or legal regulation on drug availability, use or related health and social harms globally.

DESIGN

Systematic review with narrative synthesis.

DATA SOURCES

We searched MEDLINE, Embase, PsycINFO, Web of Science and six additional databases for publications from 1 January 1970 through 4 October 2018.

INCLUSION CRITERIA

Peer-reviewed articles or published abstracts in any language with quantitative data on drug availability, use or related health and social harms collected before and after implementation of de jure drug decriminalisation or legal regulation.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened titles, abstracts and articles for inclusion. Extraction and quality appraisal (modified Downs and Black checklist) were performed by one reviewer and checked by a second, with discrepancies resolved by a third. We coded study-level outcome measures into metric groupings and categorised the estimated direction of association between the legal change and outcomes of interest.

RESULTS

We screened 4860 titles and 221 full-texts and included 114 articles. Most (n=104, 91.2%) were from the USA, evaluated cannabis reform (n=109, 95.6%) and focussed on legal regulation (n=96, 84.2%). 224 study outcome measures were categorised into 32 metrics, most commonly prevalence (39.5% of studies), frequency (14.0%) or perceived harmfulness (10.5%) of use of the decriminalised or regulated drug; or use of tobacco, alcohol or other drugs (12.3%). Across all substance use metrics, legal reform was most often not associated with changes in use.

CONCLUSIONS

Studies evaluating drug decriminalisation and legal regulation are concentrated in the USA and on cannabis legalisation. Despite the range of outcomes potentially impacted by drug law reform, extant research is narrowly focussed, with a particular emphasis on the prevalence of use. Metrics in drug law reform evaluations require improved alignment with relevant health and social outcomes.

What shapes resilience among people living with HIV? A multi-country analysis of data from the PLHIV Stigma Index 2.0

OBJECTIVE

To inform efforts to promote greater resilience among people living with HIV (PLHIV), we examined associations between resilience and factors at the individual, interpersonal and structural/policy levels in three countries.

DESIGN

Data come from the PLHIV Stigma Index 2.0, a cross-sectional survey with PLHIV, implemented from 2017 to 2019 in Cambodia (n = 1207), the Dominican Republic (n = 891), and Uganda (n = 391).

METHODS

Hierarchical multiple regression was used to assess associations between resilience and factors at the individual/interpersonal/structural-policy levels, controlling for potential confounders. Resilience was measured by the previously tested PLHIV Resilience Scale.

RESULTS

About 60% of respondents were women; mean time since HIV diagnosis was 11 years in Cambodia and seven in the Dominican Republic /Uganda. Resilience varied substantially across the six province/districts per country (all p < 0.001). In multivariable analyses, higher resilience was associated with lower internalized stigma (all three countries), no experience of human rights abuses (Dominican Republic), no food/housing insecurity (Uganda), and greater community awareness of legal protections for PLHIV (Cambodia and Dominican Republic). HIV-related enacted stigma (i.e., discrimination) in the community was associated with lower resilience in Cambodia, but higher resilience in the Dominican Republic. The set of structural/policy-level factors in Cambodia and the Dominican Republic, and individual-level in Uganda, explained the most variance in resilience.

CONCLUSION

Factors at multiple levels affect whether PLHIV in Cambodia, the Dominican Republic, and Uganda report resilience. Multilevel interventions are required to promote resilience among PLHIV, and should incorporate efforts to reduce internalized stigma and promote supportive structural/legal environments including broader awareness of legal protections for PLHIV.

Some notes on the use, concept and socio-political framing of 'stigma' focusing on an opioid-related public health crisis

Canada has been home to a longstanding public health crisis related to opioids, including an extensive mortality and morbidity toll in the face of substantive intervention gaps. Recently (2019), two extensive reports from preeminent federal authorities - the Chief Public Health Officer and the Mental Health Commission of Canada - have been tabled with detailed, core focus on the phenomenon of 'stigma' and its impacts on substance/opioid use and harms. The reports present extensive descriptions of the nature and effects, as well as a multitude of prescriptions for remedial measures and actions to "stop the cycle of stigma". Closer reading of the documents, however, suggests substantial conceptual and empirical limitations in the characterization of the - multi-faceted and challenging - nature and workings of 'stigma' as a socio-political, structural or individual process or force, specifically as it applies to and negatively affects substance use and related outcomes, primarily the wellbeing of substance users. Concretely, it is unclear how the remedial actions proposed will materially alleviate stigma process and impacts, especially given apparent gaps in the issues examined, including essential strategies - for example, reform of drug user criminalization as a fundamental element and driver of structural stigma - for action that directly relate to the jurisdictions and privileged mandates of the report sources themselves as health and policy leaders. The commentary provides some concrete while subjective notes and observations on the dynamics of stigma as applies to and framed for substance/opioid use, as well as strategies and measures necessary to both tangibly address the material health and wellbeing of substance users, and related forces of stigma, in the distinct context of the opioid crisis in Canada.

Development of a global index measuring national policy commitments to HIV prevention and treatment among people who inject drugs

BACKGROUND

People who inject drugs (PWID) around the world are disproportionately affected by the HIV epidemic. National policy responses to the epidemic heavily influence risk factors for HIV acquisition among this key group. Prior efforts to monitor national policy responses to HIV/AIDS among PWID were limited both in scope and coverage. In this paper we develop and validate the HIV-PWID Policy Index (HPPI) to benchmark and monitor national commitments to HIV prevention and treatment among PWID.

METHODS

Composite indicator was constructed employing fuzzy multilayer data envelopment analysis (FMLDEA). Model inputs based on data from 105 countries included 27 variables measured across six conceptual domains, including needle and syringe programs, opioid substitution treatment, testing and counseling, information and education, monitoring and evaluation, and legal and policy climate.

RESULTS

According to the HPPI, which ranges from 0 to 1, the top performing countries in policy commitments to HIV prevention and treatment among PWID were Spain (0.988), Switzerland (0.982), Luxembourg (0.970), Moldova (0.970), and Kyrgyzstan (0.945), whereas the poorest performing included Nicaragua (0.094), Japan, (0.094), Cape Verde (0.097), Syria (0.174), and Benin (0.185). Regionally, commitment to HIV services targeting PWID was highest among European countries (0.81) and lowest among African countries (0.50), with Oceania (0.76), Asia (0.66), and the Americas (0.56) in the mid-range. Subregional differences were even more prominent, with West and Central European nations (0.84) and Central American nations (0.22) earning the highest and lowest HPPI scores, respectively.

CONCLUSIONS

The HPPI documented substantial national and regional variation in policy responses to the HIV epidemic among PWID. Our analysis also revealed that many countries have limited HIV/AIDS data collection and monitoring capabilities. Continued enhancement and standardization of global HIV/AIDS monitoring efforts are therefore vital to articulated national and international benchmarking and performance assessment goals.

COVID-19 - Enacting a 'new normal' for people who use drugs

The COVID-19 crisis has magnified existing social, economic and political inequities. People who use drugs are particularly vulnerable due to criminalisation and stigma and often experience underlying health conditions, higher rates of poverty, unemployment and homelessness, as well as a lack of access to vital resources – putting them at greater risk of infection. On the other hand, COVID-19 presents an opportunity to confront the mistakes of the past and re-negotiate a new social contract. The International Network of People who use Drugs (INPUD) believe that this crisis must be an occasion to rethink the function of punishment, to reform the system and to work towards ending the war on drugs. This commentary presents a set of recommendations to UN agencies, governments, donor agencies, academics, researchers and civil society, challenging these actors to work alongside people who use drugs to enact a new reality based on solidarity and cooperation, protection of health, restoration of rights and dignity and most importantly to mobilise to win the peace.

Examining Overdose and Homelessness as Predictors of Willingness to Use Supervised Injection Facilities by Services Provided Among Persons Who Inject Drugs

BACKGROUND AND OBJECTIVES

Internationally, supervised injection facilities (SIFs) have demonstrated efficacy in reducing rates of overdose and promoting entry into treatment among persons who inject drugs (PWID); however, they remain unavailable in the United States. Early findings examining American PWID illustrate high overall willingness to use SIFs. The current study expands upon this research by examining PWID's likelihood to use SIFs based on services offered (eg, provides clean needles, linkage to treatment programs) and whether known risk factors (prior overdose, homelessness) influence PWID's willingness to use a SIF.

METHODS

Participants (n = 184) were patients entering short-term inpatient opioid withdrawal management in Massachusetts between May 2018 and February 2019 who reported injection drug use in the prior 30 days. We examined PWID's likelihood to use a SIF if eight unique services were available, and compared if this differed by overdose history and homelessness status using ordered logistic regression and Pearson's χ² -tests of independence.

RESULTS

Participants (34.2 [±8.3 SD] years of age, 68.5% male, 85.9% white, 8.2% Hispanic) reported being most likely to use SIFs that provided safety from police intervention (86.7%), entry into withdrawal management (85.9%), or clean needles (83.2%). Drug works disposal and safety from police were particularly important for PWID with a history of overdose.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

Overall, treatment-seeking PWIDs reported greater willingness to utilize SIFs if particular services were provided. These findings point to features of SIFs that may enhance treatment-seeking PWID's amenability to utilizing these services if such sites open in the United States. (Am J Addict 2021;30:21-25).

Progress Toward Hepatitis C Virus Elimination: Therapy and Implementation

The World Health Organization has called for the elimination of hepatitis C virus (HCV) as a public health threat by 2030. Highly effective direct-acting antiviral agents provide the therapeutic tools required for elimination. In the absence of a vaccine, HCV elimination will require enhanced primary prevention and an increase in the proportions of people diagnosed and treated. Given that globally only 20% of people with chronic HCV are diagnosed, and around 5% have initiated HCV treatment, the task ahead is enormous. But, global public health needs optimism, and countries currently on track for HCV elimination provide a pathway forward.

"Am I gonna get in trouble for acknowledging my will to be safe?": Identifying the experiences of young sexual minority men and substance use in the context of an opioid overdose crisis

BACKGROUND

North America and other parts of the globe are in the midst of a public health emergency related to opioid overdoses and a highly contaminated illicit drug supply. Unfortunately, there is a substantial gap in our understandings about how this crisis affects key populations not conventionally identified within overdose-related surveillance data. This gap is particularly pronounced for gay, bisexual, and other men who have sex with men (sexual minority men)-a population that experiences substance use-related inequities across adolescence and young adulthood.

METHODS

We draw on in-depth semi-structured interviews conducted in 2018 with a diverse sample (N = 50) of sexual minority men ages 15-30 who use substances and live in Vancouver, Canada, to identify how patterns and contexts of substance use are occurring in the context of the opioid overdose crisis.

RESULTS

Our analysis revealed three themes: awareness, perceptions, and experiences of risk; strategies to mitigate risk; and barriers to safer substance use. First, participants described how they are deeply impacted by the contaminated illicit drug supply, and how there is growing apprehension that fatal and non-fatal overdose risk is high and rising. Second, participants described how procuring substances from "trustworthy" drug suppliers and other harm reduction strategies (e.g., drug checking technologies, Naloxone kits, not using alone) could reduce overdose risk. Third, participants described how interpersonal, service-related, and socio-structural barriers (e.g., drug criminalization and the lack of a regulated drug supply) limit opportunities for safer substance use.

CONCLUSIONS

Equity-oriented policies and programming that can facilitate opportunities for safer substance use among young sexual minority men are critically needed, including community- and peer-led initiatives, access to low-barrier harm reduction services within commonly frequented social spaces (e.g., Pride, night clubs, bathhouses), nonjudgmental and inclusive substance use-related health services, the decriminalization of drug use, and the provision of a safe drug supply.

Prevalence and risk factors associated with HIV-1 infection among people who inject drugs in Dar es Salaam, Tanzania: a sign of successful intervention?

Background

Prevalence of HIV infection among people who inject drugs (PWID) has been reported to be higher than that of the general population. The present study aimed to estimate the prevalence of HIV infection and associated risk factors among PWID in Dar es Salaam, Tanzania, following the introduction of a comprehensive HIV intervention package (CHIP) for PWID in the country in 2014.

Methods

We conducted an integrated bio-behavioral survey (IBBS) among PWID using respondent-driven sampling (RDS) in Dar es Salaam, Tanzania, between October and December 2017. Data on socio-demographic characteristics and risky behaviors were collected through face-to-face interviews. Blood samples were collected and tested for HIV infection. We accounted for weighting in the analyses, and logistic regression was performed to assess risk factors for HIV infection.

Results

A total of 611 PWID (94.4% males and 5.6% females) with a median age of 34 years (IQR 29–38) were recruited. The overall prevalence of HIV infection was 8.7% (95% CI 6.5–10.9). The prevalence of HIV infections for males and females were 6.8% (95% CI 4.7–8.9%) and 41.2% (95% CI 23.7–58.6%) respectively. Adjusted weighted logistic regression analysis (WLRA) showed that being a female (aOR 19.1; 95% CI 5.9–61.8), injecting drugs for more than 10 years (aOR = 7.32; 95% CI 2.1–25.5) compared to 1 year or less and being 45 years or older (aOR = 34.22; 95% CI 2.4–489.5) compared to being 25 years or younger were associated with increased odds of HIV infection. Use of a sterile needle at last injection decreased odds of HIV infection (aOR = 0.3; 95% CI 0.1–0.8).

Conclusions

The present study observed a decline in prevalence of HIV infections among PWID in Dar es Salaam (8.7%) compared to a previous estimate of 15.5% from an IBBS conducted in 2013. Despite the decrease, HIV prevalence remains high among PWID compared to the general population, and women are disproportionally affected. The decline may be possibly attributed to the on-going implementation of CHIP for PWID, highlighting the need for strengthening the existing harm reduction interventions by incorporating access to sterile needle/syringe and addressing the layered risks for women.

Global systematic review and ecological analysis of HIV in people who inject drugs: National population sizes and factors associated with HIV prevalence

BACKGROUND

People who inject drugs (PWID) are at elevated risk of HIV infection. Data on population sizes of PWID living with HIV are needed to inform the implementation of prevention, treatment and care programs. We estimated national population sizes of people who recently (past 12 months) injected drugs living with HIV and evaluated ecological associations with HIV prevalence in PWID.

METHODS

We used national data on the prevalence of injecting drug use and of HIV among PWID, derived from systematic reviews, to estimate national population sizes of PWID living with HIV. Uncertainty was estimated using Monte Carlo simulation with 100,000 draws. We extracted data on sample characteristics from studies of HIV prevalence among PWID, and identified national indicators that have been observed or hypothesised to be associated with HIV prevalence in PWID. We used linear regression to evaluate associations between these variables and HIV prevalence in PWID.

RESULTS

Four countries comprised 55% of the estimated global population of PWID living with HIV: Russia (572,500; 95% uncertainty interval (UI) 235,500-1,036,500); Brazil (462,000; 95% UI 283,500-674,500); China (316,500; 95% UI 171,500-493,500), and the United States (195,500; 95% UI 80,000-343,000). Greater anti-HCV prevalence and national income inequality were associated with greater HIV prevalence in PWID.

CONCLUSION

The countries with the largest populations of PWID living with HIV will need to dramatically scale up prevention, treatment and care interventions to prevent further increases in population size. The association between anti-HCV prevalence and HIV prevalence among PWID corroborates findings that settings with increasing HCV should implement effective interventions to prevent HIV outbreaks. The association between income inequality and HIV among PWID reinforces the need to implement structural interventions alongside targeted individual-level strategies.

A Global Meta-analysis of the Prevalence of HIV, Hepatitis C Virus, and Hepatitis B Virus Among People Who Inject Drugs-Do Gender-Based Differences Vary by Country-Level Indicators?

BACKGROUND

Women-specific factors exist that increases vulnerability to drug-related harms from injection drug use, including blood-borne viruses (BBVs), but gender-based differences in BBV prevalence have not been systematically examined.

METHODS

We conducted meta-analyses to estimate country, regional, and global prevalence of serologically confirmed human immunodeficiency virus (HIV), hepatitis C virus (HCV; based on detection of anti-HCV antibody), and hepatitis B virus (HBV; based on detection of HBV surface antigen) in people who inject drugs (PWID), by gender. Gender-based differences in the BBV prevalence (calculated as the risk among women relative to the risk among men) were regressed on country-level prevalence and inequality measures (Gender inequality index, Human development index, Gini coefficient, and high, low or middle income of the country).

RESULTS

Gender-based differences varied by countries and regions. HIV prevalence was higher among women than men in sub-Saharan Africa (relative risk [RR], 2.8; 95% confidence interval [CI], 1.8-4.4) and South Asia (RR, 1.7; 95% CI, 1.1-2.7); anti-HCV was lower among women in the Middle East and North Africa (RR, 0.6; 95% CI, .5-.7) and East and Southeast Asia (RR, 0.8; 95% CI, .7-.9). Gender-based differences varied with country-levels of the BBV prevalence in the general population, human development, and income distribution.

CONCLUSION

HIV was more prevalent in women who inject drugs as compared to their male counterparts in some countries, but there is variation between and within regions. In countries where women are at higher risks, there is a need to develop gender-sensitive harm-reduction services for the particularly marginalized population of women who inject drugs.

Dental caries and periodontal disease among people who use drugs: a systematic review and meta-analysis

BACKGROUND

The aim of our study was to perform a systematic review of the literature and meta-analysis in order to investigate relationship between drug use and oral health.

METHODS

We searched for studies in English published before July 1, 2019 on PsycINFO, PubMed, SciELO, Scopus, and Web of Science. We assessed the relationship between drug use (methamphetamines, heroin; opiates; crack, cocaine and cannabis as dependent variables) and reported tooth loss, periodontal disease, or decayed, missing, and filled teeth index as an independent variable. The data were analyzed using Stata 12.0 software.

RESULTS

We initially identified 1836 potential articles (with 1100 duplicates) and screened the remaining 736 titles and abstracts, comprising 54 studies. In the next step, we evaluated the full-texts; 44 studies were excluded, accordingly. In total, we included 10 publications in the meta-analysis. Drug type was associated with periodontal disease (OR 1.44; 95% CI 0.8-2.6) and pooled estimates showed that type of drug used increased the odds of the number of decayed, missed and filled teeth (DMFT) (OR 4.11; 95% CI 2.07-8.15) respectively.

CONCLUSIONS

The analytical challenges of segregating the impact of individual drug types on oral health diseases mean that investigations on the direct relationship between oral health status and drug use are limited. Developing programs to improve potential confounding with various substances and addressing the dental health needs of people who use drugs is vital if we are to improve their overall quality of life.

Policing Practices and Risk of HIV Infection Among People Who Inject Drugs

Drug-law enforcement constitutes a structural determinant of health among people who inject drugs (PWID). Street encounters between police and PWID (e.g., syringe confiscation, physical assault) have been associated with health harms, but these relationships have not been systematically assessed. We conducted a systematic literature review to evaluate the contribution of policing to risk of human immunodeficiency virus (HIV) infection among PWID. We screened MEDLINE, sociological databases, and gray literature for studies published from 1981 to November 2018 that included estimates of HIV infection/risk behaviors and street policing encounters. We extracted and summarized quantitative findings from all eligible studies. We screened 8,201 abstracts, reviewed 175 full-text articles, and included 27 eligible analyses from 9 countries (Canada, China, India, Malaysia, Mexico, Russia, Thailand, Ukraine, and the United States). Heterogeneity in variable and endpoint selection precluded meta-analyses. In 5 (19%) studies, HIV infection among PWID was significantly associated with syringe confiscation, reluctance to buy/carry syringes for fear of police, rushed injection due to a police presence, fear of arrest, being arrested for planted drugs, and physical abuse. Twenty-one (78%) studies identified policing practices to be associated with HIV risk behaviors related to injection drug use (e.g., syringe-sharing, using a "shooting gallery"). In 9 (33%) studies, policing was associated with PWID avoidance of harm reduction services, including syringe exchange, methadone maintenance, and safe consumption facilities. Evidence suggests that policing shapes HIV risk among PWID, but lower-income settings are underrepresented. Curbing injection-related HIV risk necessitates additional structural interventions. Methodological harmonization could facilitate knowledge generation on the role of police as a determinant of population health.

People who inject drugs (PWID) and HIV/aids cases in Mexico City: 1987-2015

Background

The purpose of this study is to describe the characteristics of individuals who inject drugs, to explore use trends in the past 25 years, and to review the profile of users of various drugs, both legal and illegal, that have been used intravenously without medical prescription in Mexico City.

Methods

Information was drawn from the Drug Information Reporting System (SRID, 1987–2015) and data from the National Center for the Prevention and Control of HIV/aids (CENSIDA, 1983–2018). SRID is based on two 30-day cross-sectional evaluations carried out during June and November. It has served as an uninterrupted epidemiological surveillance system for 32 years, operating both in health and justice institutions in Mexico City and the metropolitan area. The timely identification of changes in use patterns is regarded as the most consistent tool to track the trajectory of the phenomenon. CENSIDA cases were analyzed based on the number of HIV and aids positive injectable drug users during the same period of time in Mexico City.

Results

Cocaine users represented the highest number of cases, with a total of N = 293. Back in 2000, the use of this substance showed a significant increase of up to 50%. In turn, heroine and opiates user trends by sex increased from being almost non-existent in 1987 to 13% in 1994. Results provide evidence of the changes in the number of users over the years, with the largest increases being recorded in 1996 (16.5%), 1999 (17%), and 2010 (13%).

Conclusions

The increase observed in the results coincides with domestic and world political situations that have caused an upturn in the use of some substances over the years. It is not far-fetched to think that in the coming years there will be an increase in the number of individuals who inject drugs due to the high production and availability of heroin in Mexico and the emergence of fentanyl use as indicated by ethnographic research in Mexico City and the deaths linked to its consumption. The latest reports, published in 2018, documented at least five cases of fentanyl users.

Critical studies of harm reduction: Overdose response in uncertain political times

North America continues to witness escalating rates of opioid overdose deaths. Scale-up of existing and innovative life-saving services - such as overdose prevention sites (OPS) as well as sanctioned and unsanctioned supervised consumption sites - is urgently needed. Is there a place for critical theory-informed studies of harm reduction during times of drug policy failures and overdose crisis? There are different approaches to consider from the critical literature, such as those that, for example, interrogate the basic principles of harm reduction or those that critique the lack of pleasure in the discourses surrounding drug use. Influenced by such work, we examine the development of OPS in Canada, with a focus on recent experiences from the province of Ontario, as an important example of the impacts associated with moving from grassroots harm reduction to institutionalised policy and practice. Services appear to be most innovative, dynamic, and inclusive when people with lived experience, allies, and service providers are directly responding to fast-changing drug use patterns and crises on the ground, before services become formally bureaucratised. We suggest a continuing need to both critically theorise harm reduction and to build strong community relationships in harm reduction work, in efforts to overcome political moves that impede collaboration with and inclusiveness of people who use drugs.

Responding to global stimulant use: challenges and opportunities

We did a global review to synthesise data on the prevalence, harms, and interventions for stimulant use, focusing specifically on the use of cocaine and amphetamines. Modelling estimated the effect of cocaine and amphetamine use on mortality, suicidality, and blood borne virus incidence. The estimated global prevalence of cocaine use was 0·4% and amphetamine use was 0·7%, with dependence affecting 16% of people who used cocaine and 11% of those who used amphetamine. Stimulant use was associated with elevated mortality, increased incidence of HIV and hepatitis C infection, poor mental health (suicidality, psychosis, depression, and violence), and increased risk of cardiovascular events. No effective pharmacotherapies are available that reduce stimulant use, and the available psychosocial interventions (except for contingency management) had a weak overall effect. Generic approaches can address mental health and blood borne virus infection risk if better tailored to mitigate the harms associated with stimulant use. Substantial and sustained investment is needed to develop more effective interventions to reduce stimulant use.

Different transmission routes and the risk of advanced HIV disease: A systematic review and network meta-analysis of observational studies

BACKGROUND

A substantial proportion of people living with HIV (PLHIV) present for care with advanced HIV disease (AHD), which may result in difficulty reaching the "90-90-90" target to end AIDS in 2030. We assessed the risk of AHD for different transmission routes to summarize the evidence for priority prevention strategies for key populations.

METHODS

Observational studies published before September 10th, 2019 in the PubMed, EMBASE, Web of Science and Chinese electronic databases were analysed. The outcomes of interest were the number of PLHIV and AHD patients and their associated transmission routes. We assessed the risk of AHD among the different transmission routes using the multi-armed network meta-analysis based on the Bayesian method. The associations between AHD and regional policies for sex work and compulsory drug treatment were estimated using ecological linear regression.

FINDINGS

One hundred and one articles were included, covering 129,780 PLHIV with 478,830 patients who developed AHD. The network analysis revealed that among PLHIV, heterosexual contact was associated with the highest risk of AHD, followed by injection drug use (odds ratio [OR]=0•56, 95% credible interval [CrI] 0•47-0•68), and men who have sex with men (OR=0•54, 95% CrI 0•46-0•63). Regions that criminalized sex work and compulsory drug treatment had higher risks for AHD than those that did not.

INTERPRETATION

Our findings suggest HC is at a higher risk of AHD compared to IDU and MSM. This justifies the need to expand prevention campaigns and maintain efforts to increase HIV testing in the heterosexual population.

Global patterns of opioid use and dependence: harms to populations, interventions, and future action

We summarise the evidence for medicinal uses of opioids, harms related to the extramedical use of, and dependence on, these drugs, and a wide range of interventions used to address these harms. The Global Burden of Diseases, Injuries, and Risk Factors Study estimated that in 2017, 40·5 million people were dependent on opioids (95% uncertainty interval 34·3-47·9 million) and 109 500 people (105 800-113 600) died from opioid overdose. Opioid agonist treatment (OAT) can be highly effective in reducing illicit opioid use and improving multiple health and social outcomes-eg, by reducing overall mortality and key causes of death, including overdose, suicide, HIV, hepatitis C virus, and other injuries. Mathematical modelling suggests that scaling up the use of OAT and retaining people in treatment, including in prison, could avert a median of 7·7% of deaths in Kentucky, 10·7% in Kiev, and 25·9% in Tehran over 20 years (compared with no OAT), with the greater effects in Tehran and Kiev being due to reductions in HIV mortality, given the higher prevalence of HIV among people who inject drugs in those settings. Other interventions have varied evidence for effectiveness and patient acceptability, and typically affect a narrower set of outcomes than OAT does. Other effective interventions focus on preventing harm related to opioids. Despite strong evidence for the effectiveness of a range of interventions to improve the health and wellbeing of people who are dependent on opioids, coverage is low, even in high-income countries. Treatment quality might be less than desirable, and considerable harm might be caused to individuals, society, and the economy by the criminalisation of extramedical opioid use and dependence. Alternative policy frameworks are recommended that adopt an approach based on human rights and public health, do not make drug use a criminal behaviour, and seek to reduce drug-related harm at the population level.

'It's too much, I'm getting really tired of it': Overdose response and structural vulnerabilities among harm reduction workers in community settings

BACKGROUND

In response to the devastating overdose epidemic across Canada, overdose education and naloxone distribution programs (OEND) targeted at people who use drugs have been scaled-up. The ways in which people who use drugs (PWUD) - who experience social and structural vulnerabilities due to their drug use - enact advice from these health education campaigns remains underexplored. This study examines structural vulnerabilities that constrain PWUD as they attempt to implement OEND program advice.

METHODS

Data were drawn from an ethnographic study of "Satellite Sites", a program where PWUD are employed by a community health center to operate satellite harm reduction programs within their homes. Data collection included participant observation within the Satellite Sites, complemented by semi-structured interviews and a focus group with Satellite Site workers. Thematic analysis was used to explore impacts of responding to overdose.

RESULTS

OEND advice includes not injecting alone, carrying naloxone, and calling 911 if overdose occurs. The ability of Satellite Site workers to respond according to public health guidelines is complicated by contextual and structural factors, including a lack of supervised injection services, vulnerability to eviction, and continued criminalization of drug use. Participants described how responding to increasing numbers of overdoses was stressful, with stress compounded by their close relationships with those who were overdosing. These factors were impacting the willingness of Satellite Site workers to continue to supervise drug use.

CONCLUSION

OEND programs are essential and effective; however, they are a response to a crisis within a policy and legal environment framed by the criminalization of drug use. Efforts to expand access to complementary interventions, such as supervised injection services, safer supply interventions, and protection against evictions, are necessary to complement OEND programs and address multiple contextual factors within the risk environment for overdose. Additionally, criminalization will continue to impede and constrain the public health response to drug use.

Linkage and retention in HCV care for HIV-infected populations: early data from the DAA era

Introduction

There is currently no published data on the effectiveness of DAA treatment for elimination of HCV infection in HIV‐infected populations at a population level. However, a number of relevant studies and initiatives are emerging. This research aims to report cascade of care data for emerging HCV elimination initiatives and studies that are currently being evaluated in HIV/HCV co‐infected populations in the context of implementation science theory.

Methods

HCV elimination initiatives and studies in HIV co‐infected populations that are currently underway were identified. Context, intervention characteristics and cascade of care data were synthesized in the context of implementation science frameworks.

Results

Seven HCV elimination initiatives and studies were identified in HIV co‐infected populations, mainly operating in high‐income countries. Four were focused mainly on HCV elimination in HIV‐infected gay and bisexual men (GBM), and three included a combination of people who inject drugs (PWID), GBM and other HIV‐infected populations. None were evaluating treatment delivery in incarcerated populations. Overall, HCV RNA was detected in 4894 HIV‐infected participants (range within studies: 297 to 994): 48% of these initiated HCV treatment (range: 21% to 85%; within studies from a period where DAAs were broadly available the total is 57%, range: 36% to 74%). Among studies with treatment completion data, 96% of 1109 initiating treatment completed treatment (range: 94% to 99%). Among those who could be assessed for sustained virological response at 12 weeks (SVR12), 1631 of 1757 attained SVR12 (93%, range: 86% to 98%).

Conclusions

Early results from emerging research on HCV elimination in HIV‐infected populations suggest that HCV treatment uptake is higher than reported levels prior to DAA treatment availability, but approximately half of patients remain untreated. These results are among diagnosed populations and additional effort is required to increase diagnosis rates. Among those who have initiated treatment, completion and SVR rates are promising. More data are required in order to evaluate the effectiveness of these elimination programmes in the long term, assess which intervention components are effective, and whether they need to be tailored to particular population groups.

"We don't got that kind of time, man. We're trying to get high!": Exploring potential use of drug checking technologies among structurally vulnerable people who use drugs

BACKGROUND

Novel public health interventions are being considered to address the opioid overdose epidemic, including drug checking technologies. We examined the willingness to use various drug checking technologies among structurally-vulnerable people who use drugs (PWUD).

METHODS

We conducted one-to-one qualitative semi-structured interviews with 20 PWUD in Vancouver, Canada's Downtown Eastside. Participants were purposively recruited from ongoing cohort studies of PWUD.

RESULTS

Overall willingness to use drug checking technologies was low among participants. A range of factors undermined potential use of various drug checking technologies including: having to give up a drug sample; time dedication; discrepancies regarding measurements and accuracy; recourse following positive fentanyl results; ambivalence to overdose risk; and availability and accessibility of drug checking technologies.

CONCLUSIONS

Participants discussed numerous factors that undermined potential willingness to use drug checking technologies. These factors underscore the structural vulnerabilities experienced by PWUD and how they may constrain uptake of drug checking technologies. Future drug checking programming should consider these influencing factors prior to the implementation of drug checking technologies to ensure that drug checking interventions are appropriate and meeting the needs of target populations.