51
|
Irwin A, Jozaghi E, Weir BW, Allen ST, Lindsay A, Sherman SG. Mitigating the heroin crisis in Baltimore, MD, USA: a cost-benefit analysis of a hypothetical supervised injection facility. Harm Reduct J 2017; 14:29. [PMID: 28532488 PMCID: PMC5441005 DOI: 10.1186/s12954-017-0153-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 05/05/2017] [Indexed: 12/14/2022] Open
Abstract
Background In Baltimore, MD, as in many cities throughout the USA, overdose rates are on the rise due to both the increase of prescription opioid abuse and that of fentanyl and other synthetic opioids in the drug market. Supervised injection facilities (SIFs) are a widely implemented public health intervention throughout the world, with 97 existing in 11 countries worldwide. Research has documented the public health, social, and economic benefits of SIFs, yet none exist in the USA. The purpose of this study is to model the health and financial costs and benefits of a hypothetical SIF in Baltimore. Methods We estimate the benefits by utilizing local health data and data on the impact of existing SIFs in models for six outcomes: prevented human immunodeficiency virus transmission, Hepatitis C virus transmission, skin and soft-tissue infection, overdose mortality, and overdose-related medical care and increased medication-assisted treatment for opioid dependence. Results We predict that for an annual cost of $1.8 million, a single SIF would generate $7.8 million in savings, preventing 3.7 HIV infections, 21 Hepatitis C infections, 374 days in the hospital for skin and soft-tissue infection, 5.9 overdose deaths, 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations, while bringing 121 additional people into treatment. Conclusions We conclude that a SIF would be both extremely cost-effective and a significant public health and economic benefit to Baltimore City.
Collapse
Affiliation(s)
- Amos Irwin
- Law Enforcement Action Partnership, Silver Spring, MD, USA. .,Criminal Justice Policy Foundation, Silver Spring, MD, USA.
| | - Ehsan Jozaghi
- British Columbia Centre for Disease Control, University of British Columbia, Vancouver, Canada.,School of Population and Public Health, University of British Columbia, Baltimore, MD, USA
| | - Brian W Weir
- Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sean T Allen
- Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Andrew Lindsay
- Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Susan G Sherman
- Criminal Justice Policy Foundation, Amherst College, Silver Spring, MD, USA
| |
Collapse
|
52
|
Welch-Lazoritz M, Habecker P, Dombrowski K, Villegas AR, Davila CA, Colón YR, Miranda De León S. Differential access to syringe exchange and other prevention activities among people who inject drugs in rural and urban areas of Puerto Rico. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 43:16-22. [PMID: 28160735 PMCID: PMC5420501 DOI: 10.1016/j.drugpo.2016.12.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 12/15/2016] [Accepted: 12/16/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Injection drug use and its associated blood-borne infections has become a rapidly increasing problem in rural areas of the US recently. Syringe exchange programs have been shown to be effective for reducing transmission of blood borne infections, however access to these prevention efforts may be limited in rural areas. METHODS This paper utilizes two separate community samples of people who inject drugs (PWID) in Puerto Rico to achieve the following research objectives: (1) compare rural and urban access to syringe exchange programs, free sterile syringes and other HIV/HCV prevention activities, and (2) examine whether utilization of prevention activities is associated with lower injection risk behaviors. Two samples were recruited with RDS (n=315 rural sample; n=512 urban sample) and included adults aged 18 years and older who have injected drugs within the past month. RESULTS 78.5% of the urban sample utilized a syringe exchange program in the past year, compared to 58.4% of the rural sample (p<.001). 71.4% of the urban sample received free sterile needles, compared to 58.4% of the rural sample (p<.001). 66% of the urban sample received free works compared to 59% of the rural sample (p=.034). 29% of urban PWID had a conversation with an outreach worker about HIV prevention compared to 18% of the rural sample (p<0.001). Receiving free needles significantly increases the frequency of using a sterile needle to inject (p<.001). CONCLUSION Urban PWID were significantly more likely to have utilized syringe exchange programs, received free sterile needles, received free works, and to have talked about HIV prevention with an outreach worker during the past year than PWID residing in rural areas. Individuals who accessed these prevention activities were significantly less likely to exhibit risky injection behavior. Policy implications call for increasing access to prevention services in rural areas to reduce disease transmission.
Collapse
Affiliation(s)
| | - Patrick Habecker
- 216 Benton Hall, University of Nebraska-Lincoln, Lincoln, NE 68588,
| | - Kirk Dombrowski
- 206 Benton Hall, University of Nebraska-Lincoln, Lincoln, NE 68588,
| | | | - Carmen Ana Davila
- University of Nebraska-Lincoln, 63 Calle Jose de Diego, Cidra, PR 00739,
| | - Yadira Rolón Colón
- Puerto Rico Department of Health, PO Box 70184, San Juan, PR 00936-8184,
| | | |
Collapse
|
53
|
Prangnell A, Dong H, Daly P, Milloy MJ, Kerr T, Hayashi K. Declining rates of health problems associated with crack smoking during the expansion of crack pipe distribution in Vancouver, Canada. BMC Public Health 2017; 17:163. [PMID: 28158995 PMCID: PMC5292004 DOI: 10.1186/s12889-017-4099-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 02/01/2017] [Indexed: 11/23/2022] Open
Abstract
Background Crack cocaine smoking is associated with an array of negative health consequences, including cuts and burns from unsafe pipes, and infectious diseases such as HIV. Despite the well-established and researched harm reduction programs for injection drug users, little is known regarding the potential for harm reduction programs targeting crack smoking to reduce health problems from crack smoking. In the wake of recent crack pipe distribution services expansion, we utilized data from long running cohort studies to estimate the impact of crack pipe distribution services on the rates of health problems associated with crack smoking in Vancouver, Canada. Methods Data were derived from two prospective cohort studies of community-recruited people who inject drugs in Vancouver between December 2005 and November 2014. We employed multivariable generalized estimating equations to examine the relationship between crack pipe acquisition sources and self-reported health problems associated with crack smoking (e.g., cut fingers/sores, coughing blood) among people reported smoking crack. Results Among 1718 eligible participants, proportions of those obtaining crack pipes only through health service points have significantly increased from 7.2% in 2005 to 62.3% in 2014 (p < 0.001), while the rates of reporting health problems associated with crack smoking have significantly declined (p < 0.001). In multivariable analysis, compared to those obtaining pipes only through other sources (e.g., on the street, self-made), those acquiring pipes through health service points only were significantly less likely to report health problems from smoking crack (adjusted odds ratio: 0.82; 95% confidence interval: 0.73–0.93). Conclusions These findings suggest that the expansion of crack pipe distribution services has likely served to reduce health problems from smoking crack in this setting. They provide evidence supporting crack pipe distribution programs as a harm reduction service for crack smokers.
Collapse
Affiliation(s)
- Amy Prangnell
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Urban Health Research Initiative, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.,School of Population and Public Health, University of British Columbia, 206 E Mall, Vancouver, BC, V6T 1Z9, Canada
| | - Huiru Dong
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Urban Health Research Initiative, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.,School of Population and Public Health, University of British Columbia, 206 E Mall, Vancouver, BC, V6T 1Z9, Canada
| | - Patricia Daly
- Vancouver Coastal Health, #800-601 West Broadway, Vancouver, BC, V5Z 4C2, Canada
| | - M J Milloy
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Urban Health Research Initiative, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Urban Health Research Initiative, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Kanna Hayashi
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Urban Health Research Initiative, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. .,Faculty of Health Sciences, Simon Fraser University, Blusson Hall, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada.
| |
Collapse
|
54
|
Irwin A, Jozaghi E, Bluthenthal RN, Kral AH. A Cost-Benefit Analysis of a Potential Supervised Injection Facility in San Francisco, California, USA. JOURNAL OF DRUG ISSUES 2016. [DOI: 10.1177/0022042616679829] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Supervised injection facilities (SIFs) have been shown to reduce infection, prevent overdose deaths, and increase treatment uptake. The United States is in the midst of an opioid epidemic, yet no sanctioned SIF currently operates in the United States. We estimate the economic costs and benefits of establishing a potential SIF in San Francisco using mathematical models that combine local public health data with previous research on the effects of existing SIFs. We consider potential savings from five outcomes: averted HIV and hepatitis C virus (HCV) infections, reduced skin and soft tissue infection (SSTI), averted overdose deaths, and increased medication-assisted treatment (MAT) uptake. We find that each dollar spent on a SIF would generate US$2.33 in savings, for total annual net savings of US$3.5 million for a single 13-booth SIF. Our analysis suggests that a SIF in San Francisco would not only be a cost-effective intervention but also a significant boost to the public health system.
Collapse
Affiliation(s)
- Amos Irwin
- Criminal Justice Policy Foundation, Silver Spring, MD, USA
- Law Enforcement Against Prohibition, Medford, MA, USA
| | - Ehsan Jozaghi
- BC Centre for Disease Control, University of British Columbia, Vancouver, Canada
| | | | - Alex H. Kral
- Research Triangle Institute, San Francisco, CA, USA
| |
Collapse
|
55
|
Voon P, Joe R, Fairgrieve C, Ahamad K. Treatment of opioid use disorder in an innovative community-based setting after multiple treatment attempts in a woman with untreated HIV. BMJ Case Rep 2016; 2016:bcr-2016-215557. [PMID: 27402654 DOI: 10.1136/bcr-2016-215557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Opioid use disorder is associated with significant health and social harms. Various evidence-based interventions have proven successful in mitigating these harms, including harm reduction strategies and pharmacological treatment such as methadone. We present a case of a 35-year-old HIV-positive woman who was off antiretroviral therapy due to untreated opioid use disorder, and had a history of frequently self-discharging from hospital against medical advice. During the most recent hospital admission, the patient was transferred to an innovative community-based clinical support residence that supported harm reduction. Initially, she received methadone to only manage the withdrawal symptoms rather than for long-term maintenance therapy. However, with gradual dose increases to treat cravings and withdrawal, she ultimately discontinued all drug use and reinitiated antiretroviral therapy. This case highlights that patients whose goal is not abstinence can be successfully treated for acute medical illnesses and comorbid substance use disorders using harm reduction approaches, including appropriate dosing of pharmacotherapy.
Collapse
Affiliation(s)
- Pauline Voon
- Urban Health Research Initiative, BC Centre for Excellence in HIV/AIDS, UBC, Vancouver, British Columbia, Canada Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ronald Joe
- Department of Vancouver Community, Vancouver Coastal Health, Vancouver, British Columbia, Canada Faculty of Medicine, Department of Family Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher Fairgrieve
- Urban Health Research Initiative, BC Centre for Excellence in HIV/AIDS, UBC, Vancouver, British Columbia, Canada
| | - Keith Ahamad
- Urban Health Research Initiative, BC Centre for Excellence in HIV/AIDS, UBC, Vancouver, British Columbia, Canada
| |
Collapse
|
56
|
Affiliation(s)
- Ahmed M Bayoumi
- Division of General Internal Medicine and Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON M5B 1W8, Canada; Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.
| | - Carol J Strike
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Centre for Addiction and Mental Health, Toronto, Canada
| |
Collapse
|
57
|
Pedersen JS, Dong H, Small W, Wood E, Nguyen P, Kerr T, Hayashi K. Declining trends in the rates of assisted injecting: a prospective cohort study. Harm Reduct J 2016; 13:2. [PMID: 26817687 PMCID: PMC4728798 DOI: 10.1186/s12954-016-0092-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 12/24/2015] [Indexed: 11/18/2022] Open
Abstract
Background Assisted injecting has been associated with increased risk of blood-borne infections, overdose, and other harms among people who inject drugs (PWID), particularly women. Given the changing availability of relevant harm reduction interventions in Vancouver, Canada, in recent years, we conducted a gender-based analysis to examine changes in rates and correlates of assisted injecting over time among active PWID. Methods Using data from a prospective cohort of PWID in Vancouver, we employed gender-stratified multivariable generalized estimating equations to examine trends in assisted injecting and identify the correlates during two periods: June 2006–November 2009 and December 2009–May 2014. Results Among 1119 participants, 376 (33.6 %) were females. Rates of assisted injecting declined between 2006 and 2014 among males (21.9 to 13.8 %) and females (37.0 to 25.6 %). In multivariable analyses, calendar year of interview also remained independently and negatively associated with assisted injecting among males (adjusted odds ratio [AOR] 0.95, 95 % confidence interval [CI] 0.92–0.99) and females (AOR 0.93, 95 % CI 0.89–0.97). Syringe borrowing remained independently associated with assisted injecting throughout the study period among females (AOR 1.53, 95 % CI 1.10–2.11 during 2006–2009; AOR 2.15, 95 % CI 1.24–3.74 during 2009–2014) and during 2009–2014 among males (AOR 1.88, 95 % CI 1.02–3.48). Conclusions Our findings demonstrate assisted injecting has significantly decreased for both males and females over the past decade. Nevertheless, rates of assisted injecting remain high, especially among women, and are associated with high-risk behavior, indicating a need to provide safer assisted injecting services to these vulnerable sub-populations of PWID.
Collapse
Affiliation(s)
- Jeanette Somlak Pedersen
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.
| | - Huiru Dong
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Will Small
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. .,Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, 15A 1S6, Canada.
| | - Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. .,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Paul Nguyen
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. .,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Kanna Hayashi
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. .,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. .,B.C. Centre for Excellence in HIV/AIDS, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| |
Collapse
|
58
|
Fischer B, Murphy Y, Rudzinski K, MacPherson D. Illicit drug use and harms, and related interventions and policy in Canada: A narrative review of select key indicators and developments since 2000. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 27:23-35. [PMID: 26359046 DOI: 10.1016/j.drugpo.2015.08.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 08/04/2015] [Accepted: 08/05/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND By the year 2000, Canada faced high levels of illicit drug use and related harms. Simultaneously, a fundamental tension had raisen between continuing a mainly repression-based versus shifting to a more health-oriented drug policy approach. Despite a wealth of new data and numerous individual studies that have emerged since then, no comprehensive review of key indicators and developments of illicit drug use/harm epidemiology, interventions and law/policy exist; this paper seeks to fill this gap. METHODS We searched and reviewed journal publications, as well as key reports, government publications, surveys, etc. reporting on data and information since 2000. Relevant data were selected and extracted for review inclusion, and subsequently grouped and narratively summarized in major topical sub-theme categories. RESULTS Cannabis use has remained the principal form of illicit drug use; prescription opioid misuse has arisen as a new and extensive phenomenon. While new drug-related blood-borne-virus transmissions declined, overdose deaths increased in recent years. Acceptance and proliferation of - mainly local/community-based - health measures (e.g., needle exchange, crack paraphernalia or naloxone distribution) aiming at high-risk drug users has evolved, though reach and access limitations have persisted; Vancouver's 'supervised injection site' has attracted continued attention yet remains un-replicated elsewhere in Canada. While opioid maintenance treatment utilization increased, access to treatment for key (e.g., infectious disease, psychiatric) co-morbidities among drug users remained limited. Law enforcement continued to principally focus on cannabis and specifically cannabis users. 'Drug treatment courts' were introduced but have shown limited effectiveness; several attempts cannabis control law reform have failed, except for the recent establishment of 'medical cannabis' access provisions. CONCLUSIONS While recent federal governments introduced several law and policy measures reinforcing a repression approach to illicit drug use, lower-level jurisdictions (e.g., provincial/municipal levels) and non-governmental organizations increasingly promoted social- and health-oriented intervention frameworks and interventions, therefore creating an increasingly bifurcated - and inherently contradictory - drug policy landscape and reality in Canada.
Collapse
Affiliation(s)
- Benedikt Fischer
- Social and Epidemiological Research Department, Centre for Addiction and Mental Health, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada; Centre for Applied Research in Mental Health and Addiction, Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada.
| | - Yoko Murphy
- Social and Epidemiological Research Department, Centre for Addiction and Mental Health, Toronto, Canada
| | - Katherine Rudzinski
- Social and Epidemiological Research Department, Centre for Addiction and Mental Health, Toronto, Canada
| | - Donald MacPherson
- Canadian Drug Policy Coalition, Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
| |
Collapse
|
59
|
Kulesza M, Teachman BA, Werntz AJ, Gasser ML, Lindgren KP. Correlates of public support toward federal funding for harm reduction strategies. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2015; 10:25. [PMID: 26122408 PMCID: PMC4490612 DOI: 10.1186/s13011-015-0022-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 06/26/2015] [Indexed: 12/31/2022]
Abstract
Background Historically, US federal policy has not supported harm reduction interventions, such as safe injection facilities (SIFs) and needle and syringe programs (NSPs), which can reduce the burden associated with injection drug use. Given recent increases in abuse of both legal and illegal opioids, there has been a renewed debate about effective ways to address this problem. The current study (1) assessed participants’ support for SIFs and NSPs, and (2) evaluated several demographic factors (e.g., age, gender, race, education, political ideology, and religiosity) and individual differences in stigmatizing beliefs about people who inject drugs (PWID) that might relate to support for these interventions. Methods U.S. adults (N = 899) completed a web-based study that assessed self-reported support for NSPs and SIFs, and stigma about PWID. Results The majority of participants were at least somewhat supportive of both NSPs and SIFs. Regression analyses indicated greater support for NSPs and SIFs was predicted by more liberal political ideology, more agreement that PWID deserve help rather than punishment, older age, and male gender. Also, participants who endorsed lower stigma about PWID were more supportive of NSPs and SIFs. Race, religiosity, and education did not predict support for NSPs and SIFs. Conclusions Most participants tended to report support for harm reduction strategies. Age, political ideology, and individual differences in stigmatizing beliefs about PWID were significantly associated with support. Given the potential malleability of stigmatizing beliefs, efforts that seek to shift stigma about PWID could have important implications for public policy towards harm reduction strategies for PWID.
Collapse
Affiliation(s)
- Magdalena Kulesza
- Department of Psychiatry, University of Washington, 1100 NE 45th Street, Seattle, WA, 98105, USA. .,RAND Corporation, 1776 Main St, Santa Monica, CA, 90407, USA.
| | - Bethany A Teachman
- University of Virginia, Department of Psychology, 102 Gilmer Hall, Charlottesville, VA, 22904, USA.
| | - Alexandra J Werntz
- University of Virginia, Department of Psychology, 102 Gilmer Hall, Charlottesville, VA, 22904, USA.
| | - Melissa L Gasser
- Department of Psychiatry, University of Washington, 1100 NE 45th Street, Seattle, WA, 98105, USA.
| | - Kristen P Lindgren
- Department of Psychiatry, University of Washington, 1100 NE 45th Street, Seattle, WA, 98105, USA.
| |
Collapse
|
60
|
|
61
|
McNeil R, Kerr T, Lampkin H, Small W. "We need somewhere to smoke crack": An ethnographic study of an unsanctioned safer smoking room in Vancouver, Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:645-52. [PMID: 25683138 DOI: 10.1016/j.drugpo.2015.01.015] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Revised: 12/15/2014] [Accepted: 01/13/2015] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Many cities around the globe have experienced substantial increases in crack cocaine use. Public health programmes have begun to address crack smoking, primarily through the distribution of safer crack use equipment, but their impacts have been limited. More comprehensive safer environmental interventions, specifically safer smoking rooms (SSR), have been implemented only in select European cities. However, none have been subjected to rigorous evaluation. This ethnographic study was undertaken at an 'unsanctioned' SSR operated by a drug user-led organization in Vancouver, Canada, to explore how this intervention shaped crack smoking practices, public crack smoking, and related harms. METHODS Ethnographic fieldwork was undertaken at this SSR from September to December 2011, and included approximately 50 hours of ethnographic observation and 23 in-depth interviews with people who smoke crack. Data were analyzed by drawing on the 'Risk Environment' framework and concepts of 'symbolic', 'everyday', and 'structural' violence. FINDINGS Our findings illustrate how a high demand for SSRs was driven by the need to minimize exposure to policing (structural violence), drug scene violence (everyday violence), and stigma (symbolic violence) that characterized unregulated drug use settings (e.g., public spaces). Although resource scarcity and social norms operating within the local drug scene (e.g., gendered power relations) perpetuated crack pipe-sharing within unregulated drug use settings, the SSR fostered harm reduction practices by reshaping the social-structural context of crack smoking and reduced the potential for health harms. CONCLUSION Given the significant potential of SSRs in reducing health and social harms, there is an urgent need to scale up these interventions. Integrating SSRs into public health systems, and supplementing these interventions with health and social supports, has potential to improve the health and safety of crack-smoking populations.
Collapse
Affiliation(s)
- Ryan McNeil
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.
| | - Thomas Kerr
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hugh Lampkin
- Vancouver Area Network of Drug Users, Vancouver, British Columbia, Canada
| | - Will Small
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| |
Collapse
|
62
|
Lappalainen L, Hayashi K, Dong H, Milloy MJ, Kerr T, Wood E. Ongoing impact of HIV infection on mortality among people who inject drugs despite free antiretroviral therapy. Addiction 2015; 110:111-9. [PMID: 25203392 PMCID: PMC4270909 DOI: 10.1111/add.12736] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Revised: 08/01/2014] [Accepted: 08/27/2014] [Indexed: 11/27/2022]
Abstract
AIMS To determine the impact of HIV infection on mortality over time among people who inject drugs (PWID) in settings with free HIV/AIDS care. DESIGN AND SETTING Prospective cohort study of PWID in Vancouver, Canada, recruited between May 1996 and December 2011. We ascertained morality rates and causes of death through a confidential linkage with the provincial vital statistics registry. PARTICIPANTS A total of 2283 individuals were followed for a median of 60.9 months (interquartile range: 34.4-113.1), among whom 622 (27.2%) individuals were HIV-positive at baseline, and 179 (7.8%) seroconverted during follow-up. MEASUREMENTS The primary and secondary outcomes of interests were all-cause mortality and cause of death, respectively. The main independent variable of interest was HIV serostatus (positive versus negative). We used Cox proportional hazards regression to determine factors associated with mortality, including socio-demographic variables, drug use behaviors and other risk behaviors. FINDINGS During the study period, 491 (21.5%) individuals died. In multivariate analyses, HIV infection remained associated independently with all-cause mortality (adjusted hazard ratio = 3.15; 95% CI: 2.59-3.82). While all-cause mortality rates declined markedly during the study period (P < 0.001), the independent effect of HIV infection on mortality remained unchanged over time (P = 0.640). Among HIV-positive individuals, significant changes in causes of death from infectious and AIDS-related causes to non-AIDS-related etiologies were observed. CONCLUSIONS HIV infection continues to have a persistent impact on mortality rates among people who inject drugs in settings with free HIV/AIDS care, although causes of death have shifted markedly from infectious and AIDS-related causes to non-AIDS-related etiologies.
Collapse
Affiliation(s)
- Leslie Lappalainen
- Department of Family Medicine, University of British Columbia, Vancouver, Canada
| | - Kanna Hayashi
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, Canada,Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Huiru Dong
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, Canada
| | - M-J Milloy
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, Canada,Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, Canada,Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, Canada,Department of Medicine, University of British Columbia, Vancouver, Canada
| |
Collapse
|
63
|
|
64
|
Potier C, Laprévote V, Dubois-Arber F, Cottencin O, Rolland B. Supervised injection services: what has been demonstrated? A systematic literature review. Drug Alcohol Depend 2014; 145:48-68. [PMID: 25456324 DOI: 10.1016/j.drugalcdep.2014.10.012] [Citation(s) in RCA: 311] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 10/14/2014] [Accepted: 10/14/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Supervised injection services (SISs) have been developed to promote safer drug injection practices, enhance health-related behaviors among people who inject drugs (PWID), and connect PWID with external health and social services. Nevertheless, SISs have also been accused of fostering drug use and drug trafficking. AIMS To systematically collect and synthesize the currently available evidence regarding SIS-induced benefits and harm. METHODS A systematic review was performed via the PubMed, Web of Science, and ScienceDirect databases using the keyword algorithm [("supervised" or "safer") and ("injection" or "injecting" or "shooting" or "consumption") and ("facility" or "facilities" or "room" or "gallery" or "centre" or "site")]. RESULTS Seventy-five relevant articles were found. All studies converged to find that SISs were efficacious in attracting the most marginalized PWID, promoting safer injection conditions, enhancing access to primary health care, and reducing the overdose frequency. SISs were not found to increase drug injecting, drug trafficking or crime in the surrounding environments. SISs were found to be associated with reduced levels of public drug injections and dropped syringes. Of the articles, 85% originated from Vancouver or Sydney. CONCLUSION SISs have largely fulfilled their initial objectives without enhancing drug use or drug trafficking. Almost all of the studies found in this review were performed in Canada or Australia, whereas the majority of SISs are located in Europe. The implementation of new SISs in places with high rates of injection drug use and associated harms appears to be supported by evidence.
Collapse
Affiliation(s)
- Chloé Potier
- Department of Addiction Medicine, CHRU de Lille, Univ Lille Nord de France, F-59037 Lille, France; University of Lille 2, Faculty of Medicine, F-59045 Lille, France.
| | - Vincent Laprévote
- CHU Nancy, Maison des Addictions, Nancy F-54000, France; CHU Nancy, Centre d'Investigation Clinique CIC-INSERM 9501, Nancy F-54000, France
| | - Françoise Dubois-Arber
- Institute of Social and Preventive Medicine, University Hospital Center and University of Lausanne, Chemin de la Corniche 10, 1010 Lausanne, Switzerland
| | - Olivier Cottencin
- Department of Addiction Medicine, CHRU de Lille, Univ Lille Nord de France, F-59037 Lille, France; University of Lille 2, Faculty of Medicine, F-59045 Lille, France
| | - Benjamin Rolland
- Department of Addiction Medicine, CHRU de Lille, Univ Lille Nord de France, F-59037 Lille, France; University of Lille 2, Faculty of Medicine, F-59045 Lille, France
| |
Collapse
|
65
|
Hayden A, Hayashi K, Dong H, Milloy MJ, Kerr T, Montaner JSG, Wood E. The impact of drug use patterns on mortality among polysubstance users in a Canadian setting: a prospective cohort study. BMC Public Health 2014; 14:1153. [PMID: 25377274 PMCID: PMC4246520 DOI: 10.1186/1471-2458-14-1153] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 10/09/2014] [Indexed: 11/10/2022] Open
Abstract
Background Illicit drug use is a well-established risk factor for morbidity and mortality. However, few studies have examined the impact of different drug use patterns on mortality among polysubstance using populations. This study aimed to identify drug-specific patterns of mortality among a cohort of polysubstance using persons who inject drugs (PWIDs). Methods PWIDs in Vancouver, Canada were prospectively followed between May 1996 and December 2011. Participants were linked to the provincial vital statistics database to ascertain mortality rates and causes of death. We used multivariate Cox proportional hazards regression to investigate the relationships between drug use patterns (daily alcohol use, heroin injection and non-injection use, cocaine injection, amphetamine injection and non-injection use, crack smoking and speedball injecting) and time to all-cause mortality. Results 2330 individuals were followed for a median of 61 months (inter-quartile range: 33 – 112). In total, 466 (19.1%) individuals died for an incidence density of 3.1 (95% confidence interval [CI]: 2.8 – 3.4) deaths per 100 person-years. In multivariate analyses, after adjusting for HIV infection and other potential confounders, only daily cocaine injection remained independently associated with all-cause mortality (adjusted hazard ratio [AHR] = 1.36, 95% CI: 1.06 – 1.76). Conclusions Although heroin injecting is traditionally viewed as carrying the highest risk of mortality, in this setting, only daily cocaine injecting was associated with all-cause mortality. These findings highlight the urgent need to identify novel treatments and harm reduction strategies for cocaine injectors.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, St, Paul's Hospital, 608 - 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
| |
Collapse
|
66
|
Kinnard EN, Howe CJ, Kerr T, Skjødt Hass V, Marshall BDL. Self-reported changes in drug use behaviors and syringe disposal methods following the opening of a supervised injecting facility in Copenhagen, Denmark. Harm Reduct J 2014; 11:29. [PMID: 25352296 PMCID: PMC4226898 DOI: 10.1186/1477-7517-11-29] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 09/22/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Denmark, the first standalone supervised injecting facility (SIF) opened in Copenhagen's Vesterbro neighborhood on October 1, 2012. The purpose of this study was to assess whether use of services provided by the recently opened SIF was associated with changes in injecting behavior and syringe disposal practices among people who inject drugs (PWID). We hypothesized that risk behaviors (e.g., syringe sharing), and unsafe syringe disposal (e.g., dropping used equipment on the ground) had decreased among PWID utilizing the SIF. METHODS Between February and August of 2013, we conducted interviews using a survey (in English and Danish) with forty-one people who reported injecting drugs at the SIF. We used descriptive statistics and McNemar's test to examine sociodemographic characteristics of the sample, current drugs used, sites of syringe disposal before and after opening of the SIF, and perceived behavior change since using the SIF. RESULTS Of the interviewed participants, 90.2% were male and the majority were younger than 40 years old (60.9%). Three-quarters (75.6%) of participants reported reductions in injection risk behaviors since the opening of the SIF, such as injecting in a less rushed manner (63.4%), fewer outdoor injections (56.1%), no longer syringe sharing (53.7%), and cleaning injecting site(s) more often (43.9%). Approximately two-thirds (65.9%) of participants did not feel that their frequency of injecting had changed; five participants (12.2%) reported a decrease in injecting frequency, and only two participants (4.9%) reported an increase in injecting frequency. Twenty-four (58.5%) individuals reported changing their syringe disposal practices since the opening of the SIF; of those, twenty-three (95.8%) reported changing from not always disposing safely to always disposing safely (McNemar's test p-value < 0.001). CONCLUSIONS Our findings suggest that use of the Copenhagen SIF is associated with adoption of safer behaviors that reduce harm and promote health among PWID, as well as practices that benefit the Vesterbro neighborhood (i.e., safer syringe disposal). As a public health intervention, Copenhagen's SIF has successfully reached PWID engaging in risk behavior. To fully characterize the impacts of this and other Danish SIFs, further research should replicate this study with a larger sample size and prospective follow-up.
Collapse
Affiliation(s)
- Elizabeth N Kinnard
- />Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main Street, Box G-S-121-4 Providence, RI 02912 USA
| | - Chanelle J Howe
- />Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S-121-2, Providence, RI 02912 USA
| | - Thomas Kerr
- />Faculty of Medicine, University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC V6T 1Z3 Canada
- />Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, 608 – 1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
| | - Vibeke Skjødt Hass
- />The Saxo Institute, Faculty of Humanities, University of Copenhagen, Karen Blixens Vej 4, DK-2300 Copenhagen, Denmark
| | - Brandon DL Marshall
- />Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S-121-2, Providence, RI 02912 USA
| |
Collapse
|
67
|
Smith ME, Robinowitz N, Chaulk P, Johnson KE. Self-care and risk reduction habits in older injection drug users with chronic wounds: a cross-sectional study. Harm Reduct J 2014; 11:28. [PMID: 25326686 PMCID: PMC4213493 DOI: 10.1186/1477-7517-11-28] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 09/22/2014] [Indexed: 11/25/2022] Open
Abstract
Background We surveyed a population of injection drug users (IDUs) frequenting the mobile Baltimore City Needle Exchange Program (BNEP) to investigate self-care factors associated with chronic wounds, a significant cause of morbidity especially among older IDUs. Methods Participants ≥18 years old completed a survey regarding chronic wounds (duration ≥8 weeks), injection and hygiene practices. Study staff visually verified the presence of wounds. Participants were categorized into four groups by age and wound status. Factors associated with the presence of chronic wounds in participants ≥45 years were analyzed using logistic regression. Results Of the 152 participants, 19.7% had a chronic wound. Of those with chronic wounds, 18 were ≥45 years old (60.0%). Individuals ≥45 years old with chronic wounds were more likely to be enrolled in a drug treatment program (Odds ratio (OR) 3.4, 95% Confidence interval (CI) 1.0–10.8) and less likely to use cigarette filters when drawing up prepared drug (OR 0.2, 95% CI 0.03–0.7) compared to the same age group without chronic wounds. Compared to individuals <45 years old without chronic wounds, individuals ≥45 with a chronic wound were more likely to report cleaning reused needles with bleach (OR 10.7, 95% CI 1.2–93.9) and to use the clinic, rather than an emergency room, as a primary source of medical care (OR 3.4, 95% CI 1.1–10.4). Conclusions Older IDUs with chronic wounds have different, and perhaps less risky, injection and hygiene behaviors than their peers and younger IDUs without wounds in Baltimore City. Because of these differences, older IDUs with wounds may be more receptive to community-based healthcare and substance abuse treatment messages.
Collapse
Affiliation(s)
| | | | | | - Kristine E Johnson
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins Medical Institutions, 5200 Eastern Avenue, MFL Building, Center Tower, 3rd Floor, Baltimore, MD 21224, USA.
| |
Collapse
|
68
|
Marrazzo JM, del Rio C, Holtgrave DR, Cohen MS, Kalichman SC, Mayer KH, Montaner JSG, Wheeler DP, Grant RM, Grinsztejn B, Kumarasamy N, Shoptaw S, Walensky RP, Dabis F, Sugarman J, Benson CA. HIV prevention in clinical care settings: 2014 recommendations of the International Antiviral Society-USA Panel. JAMA 2014; 312:390-409. [PMID: 25038358 PMCID: PMC6309682 DOI: 10.1001/jama.2014.7999] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Emerging data warrant the integration of biomedical and behavioral recommendations for human immunodeficiency virus (HIV) prevention in clinical care settings. OBJECTIVE To provide current recommendations for the prevention of HIV infection in adults and adolescents for integration in clinical care settings. DATA SOURCES, STUDY SELECTION, AND DATA SYNTHESIS Data published or presented as abstracts at scientific conferences (past 17 years) were systematically searched and reviewed by the International Antiviral (formerly AIDS) Society-USA HIV Prevention Recommendations Panel. Panel members supplied additional relevant publications, reviewed available data, and formed recommendations by full-panel consensus. RESULTS Testing for HIV is recommended at least once for all adults and adolescents, with repeated testing for those at increased risk of acquiring HIV. Clinicians should be alert to the possibility of acute HIV infection and promptly pursue diagnostic testing if suspected. At diagnosis of HIV, all individuals should be linked to care for timely initiation of antiretroviral therapy (ART). Support for adherence and retention in care, individualized risk assessment and counseling, assistance with partner notification, and periodic screening for common sexually transmitted infections (STIs) is recommended for HIV-infected individuals as part of care. In HIV-uninfected patients, those persons at high risk of HIV infection should be prioritized for delivery of interventions such as preexposure prophylaxis and individualized counseling on risk reduction. Daily emtricitabine/tenofovir disoproxil fumarate is recommended as preexposure prophylaxis for persons at high risk for HIV based on background incidence or recent diagnosis of incident STIs, use of injection drugs or shared needles, or recent use of nonoccupational postexposure prophylaxis; ongoing use of preexposure prophylaxis should be guided by regular risk assessment. For persons who inject drugs, harm reduction services should be provided (needle and syringe exchange programs, supervised injection, and available medically assisted therapies, including opioid agonists and antagonists); low-threshold detoxification and drug cessation programs should be made available. Postexposure prophylaxis is recommended for all persons who have sustained a mucosal or parenteral exposure to HIV from a known infected source and should be initiated as soon as possible. CONCLUSIONS AND RELEVANCE Data support the integration of biomedical and behavioral approaches for prevention of HIV infection in clinical care settings. A concerted effort to implement combination strategies for HIV prevention is needed to realize the goal of an AIDS-free generation.
Collapse
Affiliation(s)
| | | | - David R Holtgrave
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | | | | | | | | | | | - Beatriz Grinsztejn
- Evandro Chagas Clinical Research Institute (IPEC)-FIOCRUZ, Rio de Janeiro, Brazil
| | - N Kumarasamy
- YR Gaitonde Centre for AIDS Research and Education, Chennai, India
| | | | | | | | | | | |
Collapse
|
69
|
Burr CK, Storm DS, Hoyt MJ, Dutton L, Berezny L, Allread V, Paul S. Integrating health and prevention services in syringe access programs: a strategy to address unmet needs in a high-risk population. Public Health Rep 2014; 129 Suppl 1:26-32. [PMID: 24385646 DOI: 10.1177/00333549141291s105] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Injection drug users are at a high risk for a number of preventable diseases and complications of drug use. This article describes the implementation of a nurse-led health promotion and disease prevention program in New Jersey's syringe access programs. Initially designed to target women as part of a strategy to decrease missed opportunities for perinatal HIV prevention, the program expanded by integrating existing programs and funding streams available through the state health department. The program now offers health and prevention services to both men and women, with 3,488 client visits in 2011. These services extend the reach of state health department programs, such as adult vaccination and hepatitis and tuberculosis screening, which clients would have had to seek out at multiple venues. The integration of prevention, treatment, and health promotion services in syringe access programs reaches a vulnerable and underserved population who otherwise may receive only urgent and episodic care.
Collapse
Affiliation(s)
- Carolyn K Burr
- Rutgers, The State University of New Jersey, School of Nursing, François-Xavier Bagnoud Center, Newark, NJ
| | - Deborah S Storm
- Rutgers, The State University of New Jersey, School of Nursing, François-Xavier Bagnoud Center, Newark, NJ
| | - Mary Jo Hoyt
- Rutgers, The State University of New Jersey, School of Nursing, François-Xavier Bagnoud Center, Newark, NJ
| | - Loretta Dutton
- New Jersey Department of Health, Division of HIV, STD and TB Services, Trenton, NJ
| | - Linda Berezny
- New Jersey Department of Health, Division of HIV, STD and TB Services, Trenton, NJ
| | - Virginia Allread
- Rutgers, The State University of New Jersey, School of Nursing, François-Xavier Bagnoud Center, Newark, NJ
| | - Sindy Paul
- New Jersey Department of Health, Division of HIV, STD and TB Services, Trenton, NJ
| |
Collapse
|
70
|
McNeil R, Small W, Lampkin H, Shannon K, Kerr T. "People knew they could come here to get help": an ethnographic study of assisted injection practices at a peer-run 'unsanctioned' supervised drug consumption room in a Canadian setting. AIDS Behav 2014; 18:473-85. [PMID: 23797831 DOI: 10.1007/s10461-013-0540-y] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
People who require help injecting are disproportionately vulnerable to drug-related harm, including HIV transmission. North America's only sanctioned SIF operates in Vancouver, Canada under an exemption to federal drug laws, which imposes operating regulations prohibiting assisted injections. In response, the Vancouver Area Network of Drug Users (VANDU) launched a peer-run unsanctioned SIF in which trained peer volunteers provide assisted injections to increase the coverage of supervised injection services and minimize drug-related harm. We undertook qualitative interviews (n = 23) and ethnographic observation (50 h) to explore how this facility shaped assisted injection practices. Findings indicated that VANDU reshaped the social, structural, and spatial contexts of assisted injection practices in a manner that minimized HIV and other health risks, while allowing people who require help injecting to escape drug scene violence. Findings underscore the need for changes to regulatory frameworks governing SIFs to ensure that they accommodate people who require help injecting.
Collapse
Affiliation(s)
- Ryan McNeil
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | | | | | | | | |
Collapse
|
71
|
Crabtree A, Mercer G, Horan R, Grant S, Tan T, Buxton JA. A qualitative study of the perceived effects of blue lights in washrooms on people who use injection drugs. Harm Reduct J 2013; 10:22. [PMID: 24099145 PMCID: PMC3853159 DOI: 10.1186/1477-7517-10-22] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 09/28/2013] [Indexed: 12/01/2022] Open
Abstract
Background Blue lights are sometimes placed in public washrooms to discourage injection drug use. Their effectiveness has been questioned and concerns raised that they are harmful but formal research on the issue is limited to a single study. We gathered perceptions of people who use injection drugs on the effects of blue lights with the aim of informing harm reduction practice. Methods We interviewed 18 people in two Canadian cities who currently or previously used injection drugs to better understand their perceptions of the rationale for and consequences of blue lights in public washrooms. Results Participants described a preference for private places to use injection drugs, but explained that the need for an immediate solution would often override other considerations. While public washrooms were in many cases not preferred, their accessibility and relative privacy appear to make them reasonable compromises in situations involving urgent injecting. Participants understood the aim of blue lights to be to deter drug use. The majority had attempted to inject in a blue-lit washroom. While there was general agreement that blue lights do make injecting more difficult, a small number of participants were entirely undeterred by them, and half would use a blue-lit washroom if they needed somewhere to inject urgently. Participants perceived that, by making veins less visible, blue lights make injecting more dangerous. By dispersing public injection drug use to places where it is more visible, they also make it more stigmatizing. Despite recognizing these harms, more than half of the participants were not opposed to the continued use of blue lights. Conclusions Blue lights are unlikely to deter injection drugs use in public washrooms, and may increase drug use-related harms. Despite recognizing these negative effects, people who use injection drugs may be reluctant to advocate against their use. We attempt to reconcile this apparent contradiction by interpreting blue lights as a form of symbolic violence and suggest a parallel with other emancipatory movements for inspiration in advocating against this and other oppressive interventions.
Collapse
|
72
|
MacArthur GJ, van Velzen E, Palmateer N, Kimber J, Pharris A, Hope V, Taylor A, Roy K, Aspinall E, Goldberg D, Rhodes T, Hedrich D, Salminen M, Hickman M, Hutchinson SJ. Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2013; 25:34-52. [PMID: 23973009 DOI: 10.1016/j.drugpo.2013.07.001] [Citation(s) in RCA: 208] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Revised: 06/25/2013] [Accepted: 07/03/2013] [Indexed: 01/23/2023]
Abstract
BACKGROUND Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality. METHODS A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed. RESULTS Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission. CONCLUSION Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.
Collapse
Affiliation(s)
- Georgina J MacArthur
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK.
| | - Eva van Velzen
- NHS Sutton and Merton/London KSS Specialty School of Public Health, UK
| | | | - Jo Kimber
- University of New South Wales, Sydney, Australia
| | | | - Vivian Hope
- Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, London, UK; Health Protection Services, Health Protection Agency, London, UK
| | - Avril Taylor
- University of the West of Scotland, Paisley, Scotland, UK
| | | | - Esther Aspinall
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | | | - Tim Rhodes
- Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, London, UK
| | - Dagmar Hedrich
- European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | - Mika Salminen
- European Centre for Disease Prevention and Control, Solna, Sweden
| | - Matthew Hickman
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Sharon J Hutchinson
- Health Protection Scotland, Glasgow, UK; University of the West of Scotland, Paisley, Scotland, UK
| |
Collapse
|
73
|
Deans GD, Raffa JD, Lai C, Fischer B, Krajden M, Amin J, Walter SR, Dore GJ, Grebely J, Tyndall MW. Mortality in a large community-based cohort of inner-city residents in Vancouver, Canada. CMAJ Open 2013; 1:E68-76. [PMID: 25077106 PMCID: PMC3985976 DOI: 10.9778/cmajo.20130002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The Downtown Eastside is a robust and densely populated neighbourhood in Vancouver, Canada, that is characterized by low-income housing and drug use and a high prevalence of HIV infection. We evaluated mortality and excess mortality among the broader community of individuals living in this neighbourhood. METHODS The Community Health and Safety Evaluation is a community-based study of inner-city residents in the Downtown Eastside who were recruited in 2003 and 2004. Participants' data were linked with data in provincial virology and mortality databases retrospectively and prospectively for the period 1991-2009. Mortality and standardized mortality ratios (SMRs) were calculated for the period 2003-2009 to compare death rates in the study population with rates in the population of Vancouver. RESULTS Among 2913 participants, 374 deaths occurred, for an all-cause mortality of 223 per 10 000 person-years (95% confidence interval [CI] 201-247 per 10 000 person-years). Compared with the population of Vancouver, significant excess mortality was observed in the study population (SMR 7.1, 95% CI 6.4-7.9). Excess mortality was higher among women (SMR 15.4, 95% CI 12.8-18.5) than among men (SMR 5.8, 95% CI 5.1-6.6). Although crude mortality increased with age, excess mortality was greatest among participants less than 35 years old (SMR 13.2, 95% CI 9.4-18.5) and those 35-39 years old (SMR 13.3, 95% CI 10.3-17.1). Excess risk was also elevated among participants with hepatitis C virus (HCV), HIV and HCV/HIV infection, with SMRs of 5.9 (95% CI 4.9-7.1), 19.2 (95% CI 12.8-28.9) and 23.0 (95% CI 19.3-27.4), respectively. INTERPRETATION Our study showed high mortality in this inner-city population, particularly when compared with the general population of Vancouver. Excess mortality was highest among women, younger participants and those infected with either HCV or HIV or both.
Collapse
Affiliation(s)
- Gregory D Deans
- Division of Infectious Diseases, Department of Medicine, University of British Columbia, Vancouver, BC
| | - Jesse D Raffa
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, Ont
| | - Calvin Lai
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC
| | - Benedikt Fischer
- Centre for Applied Research in Mental Health and Addiction, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC
| | - Mel Krajden
- British Columbia Centre for Disease Control, Vancouver, BC
| | - Janaki Amin
- The Kirby Institute for infection and immunity in society, University of New South Wales, Sydney, Australia
| | - Scott R Walter
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, Australia
| | - Gregory J Dore
- The Kirby Institute for infection and immunity in society, University of New South Wales, Sydney, Australia
| | - Jason Grebely
- The Kirby Institute for infection and immunity in society, University of New South Wales, Sydney, Australia
| | - Mark W Tyndall
- Division of Infectious Diseases, Department of Medicine, University of Ottawa, Ottawa, Ont
| |
Collapse
|
74
|
Pauly BB, Reist D, Belle-Isle L, Schactman C. Housing and harm reduction: what is the role of harm reduction in addressing homelessness? THE INTERNATIONAL JOURNAL OF DRUG POLICY 2013; 24:284-90. [PMID: 23623720 DOI: 10.1016/j.drugpo.2013.03.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 03/11/2013] [Accepted: 03/15/2013] [Indexed: 10/26/2022]
Abstract
Homelessness and drug use often overlap and the harms of substance use are exacerbated by homelessness. Responding to the twin problems of homelessness and substance use is an important aspect of strategies to end homelessness. The introduction and development of ten year plans to end homelessness in North America heralds a new era of systemic responses to homelessness. Central to many of these plans is the adoption of 'Housing First' as a policy response. Housing First focuses directly on housing people regardless of current patterns of substance use. As such, harm reduction is a key principle of Housing First. In this paper, we examine Housing First as an example of the integration of housing and harm reduction and then put forth a community level policy framework to further promote the integration of harm reduction as part of a response to homelessness. Drawing on Rhodes' risk environment framework and current evidence of Housing First and harm reduction, we describe four key policy areas for action: (1) social inclusion policies; (2) adequate and appropriate supply of housing; (3) on demand harm reduction services and supports and (4) systemic and organizational infrastructure. We conclude by identifying areas for future research.
Collapse
|
75
|
Hyshka E, Bubela T, Wild TC. Prospects for scaling-up supervised injection facilities in Canada: the role of evidence in legal and political decision-making. Addiction 2013; 108:468-76. [PMID: 23286831 DOI: 10.1111/add.12064] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 10/22/2012] [Accepted: 11/13/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND North America's first supervised injection facility-Insite-opened in Vancouver in 2003 under a special federal legal exemption. Insite has faced significant political and legal opposition, which culminated in a recent Supreme Court of Canada ruling that ordered the federal Minister of Health to extend the facility's exemption and cited evidence that the facility is life-preserving and does not increase public disorder. Officials in several other cities have initiated or accelerated preparations for new facilities due to speculation that the ruling provides sufficient legal basis to expand supervised injection in Canada. However, a comprehensive assessment of the barriers and facilitators to supervised injection facility scale-up is lacking. METHODS This policy case study reviews a corpus of jurisprudence, legislation, scientific research and media texts to: describe the role of evidence in legal and political decision-making around Insite; analyze the implications of the Insite decision for new facilities; and discuss alternative avenues for supervised injection facility expansion. RESULTS The Insite decision does not simplify the path towards new supervised injection facilities, but nor does it does pose an insurmountable hurdle. Whether new facilities will be established depends largely upon how the Minister of Health interprets the ruling, the proponents' ability to demonstrate need and support from municipal and provincial governments and community members. Formally defining supervised injection as within nurses' scope of practice could further efforts to establish new facilities. CONCLUSION Additional court action may be required to establish a stable legal and policy basis for supervised injection facilities in Canada.
Collapse
Affiliation(s)
- Elaine Hyshka
- Addiction and Mental Health Research Laboratory, School of Public Health, University of Alberta, Edmonton, AB, Canada.
| | | | | |
Collapse
|
76
|
Mago VK, Bakker L, Papageorgiou EI, Alimadad A, Borwein P, Dabbaghian V. Fuzzy cognitive maps and cellular automata: An evolutionary approach for social systems modelling. Appl Soft Comput 2012. [DOI: 10.1016/j.asoc.2012.02.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
77
|
Jozaghi E. Science versus politics: The need for supervised injection facilities in Montreal, Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2012; 23:420-1. [DOI: 10.1016/j.drugpo.2012.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2012] [Revised: 06/07/2012] [Accepted: 06/08/2012] [Indexed: 11/26/2022]
|
78
|
Cohen MS, Muessig KE, Smith MK, Powers KA, Kashuba AD. Antiviral agents and HIV prevention: controversies, conflicts, and consensus. AIDS 2012; 26:1585-98. [PMID: 22507927 PMCID: PMC3651739 DOI: 10.1097/qad.0b013e3283543e83] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Antiviral agents can be used to prevent HIV transmission before exposure as preexposure prophylaxis (PrEP), after exposure as postexposure prophylaxis, and as treatment of infected people for secondary prevention. Considerable research has shed new light on antiviral agents for PrEP and for prevention of secondary HIV transmission. While promising results have emerged from several PrEP trials, the challenges of poor adherence among HIV-negative clients and possible increase in sexual risk behaviors remain a concern. In addition, a broader pipeline of antiviral agents for PrEP that focuses on genital tract pharmacology and safety and resistance issues must be developed. Antiretroviral drugs have also been used to prevent HIV transmission from HIV-infected patients to their HIV-discordant sexual partners. The HIV Prevention Trials Network 052 trial demonstrated nearly complete prevention of HIV transmission by early treatment of infection, but the generalizability of the results to other risk groups - including intravenous drug users and MSM - has not been determined. Most importantly, the best strategy for use of antiretroviral agents to reduce the spread of HIV at either the individual level or the population level has not been developed, and remains the ultimate goal of this area of investigation.
Collapse
Affiliation(s)
- Myron S. Cohen
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
- Department of Microbiology and Immunology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kathryn E. Muessig
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - M. Kumi Smith
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kimberly A. Powers
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Angela D.M. Kashuba
- School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| |
Collapse
|
79
|
Small D. Canada's highest court unchains injection drug users; implications for harm reduction as standard of healthcare. Harm Reduct J 2012; 9:34. [PMID: 22817679 PMCID: PMC3492113 DOI: 10.1186/1477-7517-9-34] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 07/04/2012] [Indexed: 11/23/2022] Open
Abstract
North America’s only supervised injection facility, Insite, opened its doors in September of 2003 with a federal exemption as a three-year scientific study. The results of the study, evaluated by an independent research team, showed it to be successful in engaging the target group in healthcare, preventing overdose death and HIV infections while increasing uptake and retention in detox and treatment. The research, published in peer-reviewed medical and scientific journals, also showed that the program did not increase public disorder, crime or drug use. Despite the substantial evidence showing the effectiveness of the program, the future of Insite came under threat with the election of a conservative federal government in 2006. As a result, the PHS Community Services Society (PHS), the non-profit organization that operates Insite, launched a legal case to protect the program. On 30 September 2011, Supreme Court of Canada ruled in favour of Insite and underscored the rights of people with addictions to the security of their person under section 7 of the Charter of Rights and Freedoms (Charter of Rights). The decision clears the ground for other jurisdictions in Canada, and perhaps North America, to implement supervised injection and harm reduction where it is epidemiologically indicated. The legal case validates the personhood of people with addictions while metaphorically unchaining them from the criminal justice system.
Collapse
Affiliation(s)
- Dan Small
- PHS Community Services Society, 20 West Hastings Street, Vancouver, British Columbia, V6B 1G6, Canada.
| |
Collapse
|
80
|
Dietze P, Winter R, Pedrana A, Leicht A, Majó i Roca X, Brugal MT. Mobile safe injecting facilities in Barcelona and Berlin. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2012; 23:257-60. [DOI: 10.1016/j.drugpo.2012.02.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 02/19/2012] [Accepted: 02/21/2012] [Indexed: 11/25/2022]
|
81
|
Small W, Moore D, Shoveller J, Wood E, Kerr T. Perceptions of risk and safety within injection settings: Injection drug users' reasons for attending a supervised injecting facility in Vancouver, Canada. HEALTH RISK & SOCIETY 2012. [DOI: 10.1080/13698575.2012.680950] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
82
|
Klein MB, Rollet KC, Saeed S, Cox J, Potter M, Cohen J, Conway B, Cooper C, Côté P, Gill J, Haase D, Haider S, Hull M, Moodie E, Montaner J, Pick N, Rachlis A, Rouleau D, Sandre R, Tyndall M, Walmsley S. HIV and hepatitis C virus coinfection in Canada: challenges and opportunities for reducing preventable morbidity and mortality. HIV Med 2012; 14:10-20. [PMID: 22639840 DOI: 10.1111/j.1468-1293.2012.01028.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2012] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Hepatitis C virus (HCV) has emerged as an important health problem in the era of effective HIV treatment. However, very few data exist on the health status and disease burden of HIV/HCV-coinfected Canadians. METHODS HIV/HCV-coinfected patients were enrolled prospectively in a multicentre cohort from 16 centres across Canada between 2003 and 2010 and followed every 6 months. We determined rates of a first liver fibrosis or endstage liver disease (ESLD) event and all-cause mortality since cohort enrolment and calculated standardized mortality ratios compared with the general Canadian population. RESULTS A total of 955 participants were enrolled in the study and followed for a median of 1.4 (interquartile range 0.5-2.3) years. Most were male (73%) with a median age of 44.5 years; 13% self-identified as aboriginal. There were high levels of current injecting drug and alcohol use and poverty. Observed event rates [per 100 person-years; 95% confidence interval (CI)] were: significant fibrosis (10.21; 8.49, 12.19), ESLD (3.16; 2.32, 4.20) and death (3.72; 2.86, 4.77). The overall standardized mortality ratio was 17.08 (95% CI 12.83, 21.34); 12.80 (95% CI 9.10, 16.50) for male patients and 28.74 (95% CI 14.66, 42.83) for female patients. The primary causes of death were ESLD (29%) and overdose (24%). CONCLUSIONS We observed excessive morbidity and mortality in this HIV/HCV-coinfected population in care. Over 50% of observed deaths may have been preventable. Interventions aimed at improving social circumstances, reducing harm from drug and alcohol use and increasing the delivery of HCV treatment in particular will be necessary to reduce adverse health outcomes among HIV/HCV-coinfected persons.
Collapse
Affiliation(s)
- M B Klein
- Department of Medicine, Divisions of Infectious Diseases/Immunodeficiency, Royal Victoria Hospital, McGill University Health Centre, Montreal, QC, Canada.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
83
|
McNeil R, Guirguis-Younger M, Dilley LB, Aubry TD, Turnbull J, Hwang SW. Harm reduction services as a point-of-entry to and source of end-of-life care and support for homeless and marginally housed persons who use alcohol and/or illicit drugs: a qualitative analysis. BMC Public Health 2012; 12:312. [PMID: 22545586 PMCID: PMC3355019 DOI: 10.1186/1471-2458-12-312] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 04/30/2012] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Homeless and marginally housed persons who use alcohol and/or illicit drugs often have end-of-life care needs that go unmet due to barriers that they face to accessing end-of-life care services. Many homeless and marginally housed persons who use these substances must therefore rely upon alternate sources of end-of-life care and support. This article explores the role of harm reduction services in end-of-life care services delivery to homeless and marginally housed persons who use alcohol and/or illicit drugs. METHODS A qualitative case study design was used to explore end-of-life care services delivery to homeless and marginally housed persons in six Canadian cities. A key objective was to explore the role of harm reduction services. 54 health and social services professionals participated in semi-structured qualitative interviews. All participants reported that they provided care and support to this population at end-of-life. RESULTS Harm reduction services (e.g., syringe exchange programs, managed alcohol programs, etc.) were identified as a critical point-of-entry to and source of end-of-life care and support for homeless and marginally housed persons who use alcohol and/or illicit drugs. Where possible, harm reduction services facilitated referrals to end-of-life care services for this population. Harm reduction services also provided end-of-life care and support when members of this population were unable or unwilling to access end-of-life care services, thereby improving quality-of-life and increasing self-determination regarding place-of-death. CONCLUSIONS While partnerships between harm reduction programs and end-of-life care services are identified as one way to improve access, it is noted that more comprehensive harm reduction services might be needed in end-of-life care settings if they are to engage this underserved population.
Collapse
Affiliation(s)
- Ryan McNeil
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | | | - Laura B Dilley
- Faculty of Education, Simon Fraser University, Surrey, BC, Canada
| | - Tim D Aubry
- School of Psychology, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey Turnbull
- Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Inner City Health, Ottawa, ON, Canada
| | - Stephen W Hwang
- Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada
| |
Collapse
|
84
|
Potential role of safer injection facilities in reducing HIV and hepatitis C infections and overdose mortality in the United States. Drug Alcohol Depend 2011; 118:100-10. [PMID: 21515001 DOI: 10.1016/j.drugalcdep.2011.03.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Revised: 03/08/2011] [Accepted: 03/09/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Safer injection facilities (SIFs) reduce risks associated with injecting drugs, particularly public injection and overdose mortality. They exist in many countries, but do not exist in the United States. We assessed several ethical, operational, and public health considerations for establishing SIFs in the United States. METHOD We used the six-factor Kass framework (goals, effectiveness, concerns, minimization of concerns, fair implementation, and balancing of benefits and concerns), summarized needs of persons who inject drugs in the United States, and reviewed global evidence for SIFs. RESULTS SIFs offer a hygienic environment to inject drugs, provide sterile injection equipment at time of injection, and allow for safe disposal of used equipment. Injection of pre-obtained drugs, purchased by persons who inject drugs, happens in a facility where trained personnel provide on-site counseling and referral to addiction treatment and health care and intervene in overdose emergency situations. SIFs provide positive health benefits (reducing transmission of HIV and viral hepatitis, bacterial infections, and overdose mortality) without evidence for negative health or social consequences. SIFs serve most-at-risk persons, including those who inject in public or inject frequently, and those who do not use other public health programs. It is critical to address legal, ethical, and local concerns, develop and implement relevant policies and procedures, and assess individual- and community-level needs and benefits of SIFs given local epidemiologic data. CONCLUSIONS SIFs have the potential to reduce viral and bacterial infections and overdose mortality among those who engage in high-risk injection behaviors by offering unique public health services that are complementary to other interventions.
Collapse
|
85
|
Small W, Krusi A, Wood E, Montaner J, Kerr T. Street-level policing in the Downtown Eastside of Vancouver, Canada, during the 2010 Winter Olympics. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2011; 23:128-33. [PMID: 21885271 DOI: 10.1016/j.drugpo.2011.06.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 06/28/2011] [Accepted: 06/30/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND Police presence within street-based drug scenes has the potential to disrupt injection drug users' (IDUs) access to health services and prompt increased injection-related risk behaviour. We examined street-level policing in the Downtown Eastside (DTES) of Vancouver during the Olympic Winter games, to assess the potential impact on access to harm reduction services and injection-related risk behaviour. METHODS We analysed data from observational activities documenting police and drug user behaviour, unstructured interviews with drug users in street settings (n=15), expert interviews with legal and health professionals (n=6), as well as utilisation statistics from a local supervised injection facility (SIF). RESULTS Although police presence was elevated within the DTES during the Olympics, there was little evidence to suggest that police activities influenced IDUs' access to health services or injection-related risk behaviour. SIF attendance during the Olympics was consistent with regular monthly patterns. CONCLUSION Police presence during the Olympics did not reduce access to health services amongst local IDUs or prompt increased injection-related risk behaviour. Increased cooperation between local law enforcement and public health bodies likely offset the potential for negative health consequences resulting from police activity.
Collapse
Affiliation(s)
- Will Small
- British Columbia Centre for Excellence in HIV/AIDS, Canada.
| | | | | | | | | |
Collapse
|
86
|
DeBeck K, Kerr T, Lai C, Buxton J, Montaner J, Wood E. The validity of reporting willingness to use a supervised injecting facility on subsequent program use among people who use injection drugs. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2011; 38:55-62. [PMID: 21834612 DOI: 10.3109/00952990.2011.600389] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Innovative health programs for injection drug users (IDUs), such as supervised injecting facilities (SIFs), are often preceded by evaluations of IDUs' willingness to use the service. The validity of these surveys has not been fully evaluated. We sought to determine whether measures of willingness collected prior to the opening of a Canadian SIF accurately predicted subsequent use of the program. METHODS Data were derived from a prospective cohort of IDUs. The sample size for this study was 640 IDUs. Using multivariate logistic regression, it was assessed if a history of reporting willingness to use the program, were it available, was associated with subsequent use. In sub-analysis restricted to individuals who had a history of reported willingness, we used multivariate longitudinal analysis to identify factors associated with not attending the SIF. RESULTS Among 442 IDUs, 72% of those who reported initial willingness to use a SIF later attended the program, and a prior willingness to use a SIF significantly predicted later attendance (adjusted odds ratio = 1.67). In sub-analyses restricted to those who had a history of reporting willingness to use the SIF, not using the program was predicted by not frequenting the neighborhood where the SIF was located. CONCLUSION Our findings indicate that reported willingness measures collected from IDUs regarding potential SIF program participation prior to its opening independently predicted later attendance even when variables that were likely determinants of willingness were adjusted for. These data suggest that willingness measures are reasonably valid tools for planning the delivery of health services among IDU populations.
Collapse
Affiliation(s)
- Kora DeBeck
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | | | | | | | | | | |
Collapse
|
87
|
Smye V, Browne AJ, Varcoe C, Josewski V. Harm reduction, methadone maintenance treatment and the root causes of health and social inequities: An intersectional lens in the Canadian context. Harm Reduct J 2011; 8:17. [PMID: 21718531 PMCID: PMC3146821 DOI: 10.1186/1477-7517-8-17] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2011] [Accepted: 06/30/2011] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Using our research findings, we explore Harm Reduction and Methadone Maintenance Treatment (MMT) using an intersectional lens to provide a more complex understanding of Harm Reduction and MMT, particularly how Harm Reduction and MMT are experienced differently by people dependent on how they are positioned. Using the lens of intersectionality, we refine the notion of Harm Reduction by specifying the conditions in which both harm and benefit arise and how experiences of harm are continuous with wider experiences of domination and oppression; METHODS A qualitative design that uses ethnographic methods of in-depth individual and focus group interviews and naturalistic observation was conducted in a large city in Canada. Participants included Aboriginal clients accessing mainstream mental health and addictions care and primary health care settings and healthcare providers; RESULTS All client-participants had profound histories of abuse and violence, most often connected to the legacy of colonialism (e.g., residential schooling) and ongoing colonial practices (e.g., stigma & everyday racism). Participants lived with co-occurring illness (e.g., HIV/AIDS, Hepatitis C, PTSD, depression, diabetes and substance use) and most lived in poverty. Many participants expressed mistrust with the healthcare system due to everyday experiences both within and outside the system that further marginalize them. In this paper, we focus on three intersecting issues that impact access to MMT: stigma and prejudice, social and structural constraints influencing enactment of peoples' agency, and homelessness; CONCLUSIONS Harm reduction must move beyond a narrow concern with the harms directly related to drugs and drug use practices to address the harms associated with the determinants of drug use and drug and health policy. An intersectional lens elucidates the need for harm reduction approaches that reflect an understanding of and commitment to addressing the historical, socio-cultural and political forces that shape responses to mental illness/health, addictions, including harm reduction and methadone maintenance treatment.
Collapse
Affiliation(s)
- Victoria Smye
- University of British Columbia, School of Nursing. T201-2211 Wesbrook Mall, Vancouver, B.C. V6T 2B5, Canada
| | - Annette J Browne
- University of British Columbia, School of Nursing. T201-2211 Wesbrook Mall, Vancouver, B.C. V6T 2B5, Canada
| | - Colleen Varcoe
- University of British Columbia, School of Nursing. T201-2211 Wesbrook Mall, Vancouver, B.C. V6T 2B5, Canada
| | - Viviane Josewski
- University of British Columbia, School of Nursing. T201-2211 Wesbrook Mall, Vancouver, B.C. V6T 2B5, Canada
| |
Collapse
|
88
|
Gervasoni JP, Balthasar H, Huissoud T, Jeannin A, Dubois-Arber F. A high proportion of users of low-threshold facilities with needle exchange programmes in Switzerland are currently on methadone treatment: implications for new approaches in harm reduction and care. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2011; 23:33-6. [PMID: 21705205 DOI: 10.1016/j.drugpo.2011.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 04/14/2011] [Accepted: 05/23/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Increasingly, patients receiving methadone treatment are found in low threshold facilities (LTF), which provide needle exchange programmes in Switzerland. This paper identifies the characteristics of LTF attendees receiving methadone treatment (MT) compared with other LTF attendees (non-MT). METHODS A national cross-sectional survey was conducted in 2006 over five consecutive days in all LTF (n=25). Attendees were given an anonymous questionnaire, collecting information on socio-demographic indicators, drug consumption, injection, methadone treatment, and self-reported HIV and HCV status. Univariate analysis and logistic regression were performed to compare MT to non-MT. The response rate was 66% (n=1128). RESULTS MT comprised 57.6% of the sample. In multivariate analysis, factors associated with being on MT were older age (OR: 1.38), being female (OR: 1.60), having one's own accommodation (OR: 1.56), receiving public assistance (OR: 2.29), lifetime injecting (OR: 2.26), HIV-positive status (OR: 2.00), and having consumed cocaine during the past month (OR: 1.37); MT were less likely to have consumed heroin in the past month (OR: 0.76, not significant) and visited LTF less often on a daily basis (OR: 0.59). The number of injections during the past week was not associated with MT. CONCLUSIONS More LTF attendees were in the MT group, bringing to light an underappreciated LTF clientele with specific needs. The MT group consumption profile may reflect therapeutic failure or deficits in treatment quality and it is necessary to acknowledge this and to strengthen the awareness of LTF personnel about potential needs of MT attendees to meet their therapeutic goals.
Collapse
Affiliation(s)
- Jean-Pierre Gervasoni
- Institute of Social and Preventive Medicine (IUMSP), University Hospital Center and University of Lausanne, Bugnon 17, CH-1005 Lausanne, Switzerland.
| | | | | | | | | |
Collapse
|
89
|
How many HIV infections are prevented by Vancouver Canada's supervised injection facility? THE INTERNATIONAL JOURNAL OF DRUG POLICY 2011; 22:179-83. [DOI: 10.1016/j.drugpo.2011.03.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 02/14/2011] [Accepted: 03/01/2011] [Indexed: 11/19/2022]
|
90
|
Cutaneous diphtheria in the urban poor population of Vancouver, British Columbia, Canada: a 10-year review. J Clin Microbiol 2011; 49:2664-6. [PMID: 21525220 DOI: 10.1128/jcm.00362-11] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Between 1998 and 2007, records from 33 patients with cutaneous diphtheria from Vancouver's inner city were reviewed. Cases were associated with injection drug use and poverty. Coinfections with Staphylococcus aureus, Streptococcus pyogenes, and Arcanobacterium haemolyticum occurred. Corynebacterium diphtheriae is endemic in Vancouver's urban core, with strains of multilocus sequence type (MLST) 76 predominating.
Collapse
|
91
|
Marshall BDL, Milloy MJ, Wood E, Montaner JSG, Kerr T. Reduction in overdose mortality after the opening of North America's first medically supervised safer injecting facility: a retrospective population-based study. Lancet 2011; 377:1429-37. [PMID: 21497898 DOI: 10.1016/s0140-6736(10)62353-7] [Citation(s) in RCA: 312] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Overdose from illicit drugs is a leading cause of premature mortality in North America. Internationally, more than 65 supervised injecting facilities (SIFs), where drug users can inject pre-obtained illicit drugs, have been opened as part of various strategies to reduce the harms associated with drug use. We sought to determine whether the opening of an SIF in Vancouver, BC, Canada, was associated with a reduction in overdose mortality. METHODS We examined population-based overdose mortality rates for the period before (Jan 1, 2001, to Sept 20, 2003) and after (Sept 21, 2003, to Dec 31, 2005) the opening of the Vancouver SIF. The location of death was determined from provincial coroner records. We compared overdose fatality rates within an a priori specified 500 m radius of the SIF and for the rest of the city. FINDINGS Of 290 decedents, 229 (79·0%) were male, and the median age at death was 40 years (IQR 32-48 years). A third (89, 30·7%) of deaths occurred in city blocks within 500 m of the SIF. The fatal overdose rate in this area decreased by 35·0% after the opening of the SIF, from 253·8 to 165·1 deaths per 100,000 person-years (p=0·048). By contrast, during the same period, the fatal overdose rate in the rest of the city decreased by only 9·3%, from 7·6 to 6·9 deaths per 100,000 person-years (p=0·490). There was a significant interaction of rate differences across strata (p=0·049). INTERPRETATION SIFs should be considered where injection drug use is prevalent, particularly in areas with high densities of overdose. FUNDING Vancouver Coastal Health, Canadian Institutes of Health Research, and the Michael Smith Foundation for Health Research.
Collapse
|
92
|
Developing Canada's research base for harm reduction and health equity approaches to HIV prevention and treatment. Canadian Journal of Public Health 2011. [PMID: 21370777 DOI: 10.1007/bf03403960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In the area of infectious disease control, Canadian research efforts to address the HIV epidemic in Vancouver's Downtown East Side neighbourhood have fueled the development of harm reduction and health equity perspectives worldwide. These research efforts have, in turn, reshaped the field of public health approaches to HIV prevention and control. As a result of the intensive and sustained research initiatives led by Canadian scientists Drs. Thomas Kerr and Evan Wood, the 'HIV problem' and public health responses to it have been radically reconceptualized - shifting from an exclusive focus on individual choice towards asking fundamental questions about our society and the structural features that put people at risk for contracting HIV. Their research on harm reduction and health equity related to HIV vulnerability and outcomes has informed and shaped: (1) the establishment of North America's first supervised injection facility, Insite, located in Vancouver's Downtown East Side neighbourhood; (2) dramatic changes to Vancouver's needle exchange policies; (3) HIV treatment approaches among injection drug using populations (IDU). By drawing attention to the ways in which Canadian health care policies and programs can be restructured to better support the health of vulnerable populations, the work of Drs. Kerr and Wood represents a uniquely Canadian public health milestone.
Collapse
|
93
|
Small W, Ainsworth L, Wood E, Kerr T. IDU perspectives on the design and operation of North America's first medically supervised injection facility. Subst Use Misuse 2011; 46:561-8. [PMID: 20874006 DOI: 10.3109/10826084.2010.517714] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
While the public health benefits of supervised injection facilities (SIFs) have been well documented, there is a lack of research examining the views of injection drug users (IDU) regarding the operation of these facilities. This study used 50 semistructured qualitative interviews to explore IDU perspectives on the design and operation of an SIF in Vancouver, Canada. Although the environment and operation of the SIF are well accepted, long wait times and limited operating hours, as well as regulations that prohibit sharing drugs and assisted injections, pose barriers to using the SIF. Modifying operating procedures and expanding the capacity of the current facility could address these barriers.
Collapse
Affiliation(s)
- Will Small
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | | | | | | |
Collapse
|
94
|
Latkin C, Weeks MR, Glasman L, Galletly C, Albarracin D. A dynamic social systems model for considering structural factors in HIV prevention and detection. AIDS Behav 2010. [PMID: 20838871 DOI: 10.1007/s10461-010-9804-y.a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
We present a model for HIV-related behaviors that emphasizes the dynamic and social nature of the structural factors that influence HIV prevention and detection. Key structural dimensions of the model include resources, science and technology, formal social control, informal social influences and control, social interconnectedness, and settings. These six dimensions can be conceptualized on macro, meso, and micro levels. Given the inherent complexity of structural factors and their interrelatedness, HIV prevention interventions may focus on different levels and dimensions. We employ a systems perspective to describe the interconnected and dynamic processes of change among social systems and their components. The topics of HIV testing and safer injection facilities (SIFs) are analyzed using this structural framework. Finally, we discuss methodological issues in the development and evaluation of structural interventions for HIV prevention and detection.
Collapse
Affiliation(s)
- Carl Latkin
- Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA.
| | | | | | | | | |
Collapse
|
95
|
A dynamic social systems model for considering structural factors in HIV prevention and detection. AIDS Behav 2010; 14:222-38. [PMID: 20838871 DOI: 10.1007/s10461-010-9804-y] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We present a model for HIV-related behaviors that emphasizes the dynamic and social nature of the structural factors that influence HIV prevention and detection. Key structural dimensions of the model include resources, science and technology, formal social control, informal social influences and control, social interconnectedness, and settings. These six dimensions can be conceptualized on macro, meso, and micro levels. Given the inherent complexity of structural factors and their interrelatedness, HIV prevention interventions may focus on different levels and dimensions. We employ a systems perspective to describe the interconnected and dynamic processes of change among social systems and their components. The topics of HIV testing and safer injection facilities (SIFs) are analyzed using this structural framework. Finally, we discuss methodological issues in the development and evaluation of structural interventions for HIV prevention and detection.
Collapse
|
96
|
Small D. An appeal to humanity: legal victory in favour of North America's only supervised injection facility: Insite. Harm Reduct J 2010; 7:23. [PMID: 20932338 PMCID: PMC2959029 DOI: 10.1186/1477-7517-7-23] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Accepted: 10/09/2010] [Indexed: 11/23/2022] Open
Abstract
Canada's federal government has once again failed to shut North America's only authorized supervised injection facility: Insite. A majority ruling issued by the BC Court of Appeal on 15 January 2010 upheld an earlier British Columbia Supreme Court ruling in 2008 that protected the rights of injection drug users (IDUs) to access Insite as a health facility as per the Charter of Rights and Freedoms component of the Constitution of Canada. The majority decision from Honourable Madam Justices Rowles, Huddart and Smith also established a jurisdictional victory safeguarding Insite as most appropriately run under the authority of the province of British Columbia rather than the federal Government of Canada. The Federal Government has appealed the case to the Supreme Court of Canada. A hearing date has been set for 12 May 2011. The appeal will be a legal one but even more so, it will be an appeal to humanity.
Collapse
Affiliation(s)
- Dan Small
- Director PHS Community Services Society Vancouver, Canada.
| |
Collapse
|
97
|
DeBeck K, Kerr T. The use of knowledge translation and legal proceedings to support evidence-based drug policy in Canada: opportunities and ongoing challenges. OPEN MEDICINE : A PEER-REVIEWED, INDEPENDENT, OPEN-ACCESS JOURNAL 2010; 4:e167-70. [PMID: 21687336 PMCID: PMC3090104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Revised: 06/17/2010] [Accepted: 06/27/2010] [Indexed: 11/09/2022]
Abstract
There is growing recognition, particularly in the areas of illicit drug policy and HIV prevention, that policy-makers are in many instances implementing suboptimal programs and services because they are not basing their decisions on the best available scientific evidence. One notable example where a policy-making body has failed to use scientific evidence to inform policy is the Canadian federal government's opposition to Vancouver's supervised injection facility despite a large body of scientific evidence indicating that the program is associated with a range of health and social benefits. Two of the key strategies that have been used to try to shift drug policy toward an evidence-based approach and maintain the operation of this evidence-based health facility are knowledge translation and legal actions. We provide an overview of these two strategies and hope it will offer lessons for the implementation of evidence-based approaches in other controversial areas of public policy.
Collapse
|
98
|
Abstract
OBJECTIVE To determine whether Vancouver's Insite supervised injection facility and syringe exchange programs are cost-saving--that is, are the savings due to averted HIV-related medical care costs sufficient to offset Insite's operating costs? METHODS The analyses examined the impact of Insite's programs for a single year. Mathematical models were used to calculate the number of additional HIV infections that would be expected if Insite were closed. The life-time HIV-related medical costs associated with these additional infections were compared to the annual operating costs of the Insite facility. RESULTS If Insite were closed, the annual number of incident HIV infections among Vancouver IDU would be expected to increase from 179.3 to 262.8. These 83.5 preventable infections are associated with $17.6 million (Canadian) in life-time HIV-related medical care costs, greatly exceeding Insite's operating costs, which are approximately $3 million per year. CONCLUSIONS Insite's safe injection facility and syringe exchange program substantially reduce the incidence of HIV infection within Vancouver's IDU community. The associated savings in averted HIV-related medical care costs are more than sufficient to offset Insite's operating costs.
Collapse
Affiliation(s)
- Steven D Pinkerton
- Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, 2071 North Summit Avenue, Milwaukee, WI 53202, USA.
| |
Collapse
|
99
|
GIBSON ERINK, EXNER HEIDI, STONE RYAN, LINDQUIST JENNIFER, COWEN LAURA, ROTH ERICA. A mixed methods approach to delineating and understanding injection practices among clientele of a Victoria, British Columbia needle exchange program. Drug Alcohol Rev 2010; 30:360-5. [DOI: 10.1111/j.1465-3362.2010.00219.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
100
|
Williams CT, Metzger DS. Race and distance effects on regular syringe exchange program use and injection risks: a geobehavioral analysis. Am J Public Health 2010; 100:1068-74. [PMID: 20395589 PMCID: PMC2866590 DOI: 10.2105/ajph.2008.158337] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2009] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We conducted "geobehavioral" analyses by race to understand how distances among injection drug users' (IDUs') residences, drug purchase and use locations, and syringe exchange programs (SEPs) are associated with injection behaviors. METHODS Data were from the HIV Prevention Trial Network 037 (2002-2006) site in Philadelphia, Pennsylvania, a randomized study evaluating the efficacy of a network-oriented HIV prevention intervention for IDUs. At prescreening, participants were asked the nearest intersections to their residence, where they buy and use drugs, and about their injection behaviors. RESULTS Geographic distances had independent and interactive effects on injection risk behaviors and SEP use. Blacks, regardless of distance, were less likely than Whites to inject in public places (odds ratio [OR] = 0.62; 95% confidence interval [CI] = 0.43, 0.90), to use syringes after someone else (OR = 0.27; 95% CI = 0.19, 0.38), and to access syringes from SEPs (OR = 2.08; 95% CI = 1.48, 2.92). Latinos' injection behaviors were more distance-dependent than Blacks' or Whites'. CONCLUSIONS Distances among IDUs' homes, drug purchase and injecting sites, and prevention resources affected safe injection practices differentially by race. Understanding individuals' geographic relation to the risks and resources that surround them is an important aspect of understanding effects of the environment on health and behavior and the development of targeted interventions.
Collapse
Affiliation(s)
- Chyvette T Williams
- University of Illinois School of Public Health, 1603 West Taylor St, M/C 923, Chicago, IL 60612, USA.
| | | |
Collapse
|