The effect of exposures to policing on syringe sharing among people who inject drugs in Bangkok, Thailand

Factors associated with injury and blood-borne infection risk when providing assisted injection among people who inject drugs

OBJECTIVE

Prior research has associated assisted injection with risk behaviors, but other risks such as injury, missed veins, and incidental exposures to blood-borne infections during an injection episode have not been assessed. In the following, we present the frequency of these other risks and determine factors associated with missing a vein and incidental blood exposure among people who inject drugs (PWID).

METHODS

We conducted a cross-sectional analysis of data from PWID who were recruited using targeted sampling in Los Angeles and San Francisco, California, during 2016 and 2017. The analytic sample consist of 336 participants who reported providing injection assistance in the last 6 months. Multivariate logistic regression models were developed for reporting the following risks: missing a vein; getting the recipient's blood on the injection provider; and getting blood on clothes or surfaces.

RESULTS

In the last 6 months, the most common negative consequences were getting blood on clothes or surfaces (40%), getting the recipient's blood on the injection provider (23%), and missing a vein (17%). In multivariate logistic regression analysis, missing the vein was significantly associated with higher odds of assisting a leg injection while getting the injection recipient's blood on the provider or getting blood on clothes or nearby surfaces was associated with higher odds of assisting a groin injection injecting in the groin.

CONCLUSION

Providing injection assistance can result in incidental blood exposures and injury, particularly when injecting in sensitive locations on the body. Harm reduction interventions to reduce risks associated with this practice are essential to improving the well-being of PWID.

"I held on to the police's leg for mercy": Experiences of adversity, risk and harm among people who inject drugs during an anti-drug drive in Dhaka, Bangladesh

BACKGROUND

A number of countries across Asia have instituted "drug wars", aimed at eradicating drug supply and consumption. These wars often employ strategies like arbitrary arrest and detention, increased surveillance, harassment and sometimes extrajudicial killings. However, these measures have not been shown to effectively eliminate drug supply and consumption; rather they often predispose people who use drugs to increased risk and harm. Such a drug war was declared in the form of an anti-drug drive (ADD) in Bangladesh in 2018. This article examined the impact of the ADD on drug injecting activities and harm reduction service uptake among people who inject drugs (PWID).

METHODS

An ethnographic study was conducted in Dhaka, Bangladesh. Study participants included PWID, harm reduction service providers and other drug and alcohol experts. Data collection consisted of 2500 hours of observations, 25 in-depth interviews, five focus group discussions and 15 key informant interviews. Data were analysed using thematic analysis.

RESULTS

ADD operations and activities subjected PWID to multifaceted forms of violence and harassment including extrajudicial killings, which significantly affected drug procurement and drug using practices and led to increased needle and syringe sharing and a likely increase in HIV transmission. The gradual disappearance of established drug markets, alongside the emergence of new ones at alternate locations, resulted in the dislocation of PWID from outreach services and further increased risky injecting practices such as needle and syringe sharing between new and unfamiliar injecting partners. These harms were compounded by unpredictable drug supply and price increases stemming from the ADD, which in turn also increased needle and syringe sharing. Harm reduction outreach services were not able to adequately adapt to the volatile, dynamic and risky nature of the ADD.

CONCLUSION

The ADD not only precipitated risky injecting practices but also hindered the effective implementation of harm reduction outreach services and thus undermined public health. This warrants concerted efforts to nurture local evidence-based harm reduction approaches as opposed to punitive measures.

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

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

Enduring Consequences From the War on Drugs: How Policing Practices Impact HIV Risk Among People Who Inject Drugs in Baltimore City

BACKGROUND

Neighborhood-level characteristics, including police activity, are associated with HIV and Hepatitis C injection risk-behaviors among people who inject drugs (PWID). However, the pathways through which these neighborhood perceptions shape individual-level HIV risk behaviors are unclear. This study helps to explain perceived behaviors between perceived neighborhood police activity and HIV injection risk behavior (i.e., injection syringe/tool sharing in the previous 6 months).

METHODS

A sample of (n = 366) PWIDs who self-reported recent use were recruited using community-based outreach methods in Baltimore, Maryland. Neighborhood police perceptions were assessed by asking participants whether they would (1) be more likely to ask others to share injection tools in the context of heightened police activity and (2) be less likely to carry syringes with them due to fear of arrest. Poisson regression with robust variance was used to identify statistical relationships. Recent police encounters, frequency of heroin injection, and sociodemographic characteristics were controlled for in the model.

RESULTS

Neighborhood police perceptions shaped injection-risk behavior. Half of the sample (49%) reported an aversion of carrying personal syringes, due to fear of arrest. Those who agreed they would be more likely to ask others to share injection equipment in the context of heightened police activity were more likely to share syringes (21% vs. 3%, p <.01). Adjusted models showed that syringe sharing was independently associated with asking to borrow equipment in neighborhoods with perceived heightened police activity (aPR: 2.22, 95% confidence interval (CI): 1.7, 3.0).

CONCLUSION

This study sheds light on how police perceptions may influence injection risk behavior. While these relationships require further elucidation, this study suggests that public health interventions aiming to reduce HIV risk would benefit from improving community-police relationships.

Pre-incarceration police harassment, drug addiction and HIV risk behaviours among prisoners in Kyrgyzstan and Azerbaijan: results from a nationally representative cross-sectional study

Introduction

The expanding HIV epidemic in Azerbaijan and Kyrgyzstan is concentrated among people who inject drugs (PWID), who comprise a third of prisoners there. Detention of PWID is common but its impact on health has not been previously studied in the region. We aimed to understand the relationship between official and unofficial (police harassment) detention of PWID and HIV risk behaviours.

Methods

In a nationally representative cross-sectional study, soon-to-be released prisoners in Kyrgyzstan (N=368) and Azerbaijan (N=510) completed standardized health assessment surveys. After identifying correlated variables through bivariate testing, we built multi-group path models with pre-incarceration official and unofficial detention as exogenous variables and pre-incarceration composite HIV risk as an endogenous variable, controlling for potential confounders and estimating indirect effects.

Results

Overall, 463 (51%) prisoners reported at least one detention in the year before incarceration with an average of 1.3 detentions in that period. Unofficial detentions (13%) were less common than official detentions (41%). Optimal model fit was achieved (X²=5.83, p=0.44; Goodness of Fit Index (GFI) GFI=0.99; Comparative Fit Index (CFI) CFI=1.00; Root Mean Square Error of Approximation (RMSEA) RMSEA=0.00; PCLOSE=0.98) when unofficial detention had an indirect effect on HIV risk, mediated by drug addiction severity, with more detentions associated with higher addiction severity, which in turn correlated with increased HIV risk. The final model explained 35% of the variance in the outcome. The effect was maintained for both countries, but stronger for Kyrgyzstan. The model also holds for Kyrgyzstan using unique data on within-prison drug injection as the outcome, which was frequent in prisoners there.

Conclusions

Detention by police is a strong correlate of addiction severity, which mediates its effect on HIV risk behaviour. This pattern suggests that police may target drug users and that such harassment may result in an increase in HIV risk-taking behaviours, primarily because of the continued drug use within prisons. These findings highlight the important negative role that police play in the HIV epidemic response and point to the urgent need for interventions to reduce police harassment, in parallel with interventions to reduce HIV transmission within and outside of prison.

Declining trends in exposures to harmful policing among people who inject drugs in Vancouver, Canada

Introduction

In 2006, the Vancouver Police Department (VPD) developed an organization-wide drug policy approach, which included endorsing harm reduction strategies for people who inject drugs (PWID). We sought to examine rates of potentially harmful policing exposures and associated HIV risk behaviour among PWID in Vancouver, Canada before and after the VPD policy change.

Methods

Data were derived from two prospective cohort studies of PWID. Multivariable generalized estimating equation models were used to examine changes in the risk of confiscation of drug use paraphernalia and physical violence by the police, as well as changes in the relationship between exposures to the two policing practices and sharing of drug use paraphernalia, before and after the policy change.

Results

Among 2193 participants, including 757 (34.5%) women, the rates of experiencing police confiscation of drug use paraphernalia declined from 22.3% in 2002 to 2.8% in 2014, and the rates of reporting experiencing physical violence by the police also declined from 14.1% in 2004 to 2.9% in 2014. In multivariable analyses, the post-policy change period remained independently and negatively associated with reports of confiscation of drug use paraphernalia (adjusted odds ratio (AOR): 0.25; 95% confidence interval (CI): 0.21 to 0.31) and reported physical violence by the police (AOR: 0.76; 95% CI: 0.63 to 0.91). However, experiencing both confiscation of drug use paraphernalia and physical violence by the police (AOR: 1.92; 95% CI: 1.10 to 3.33) and experiencing only confiscation of drug use paraphernalia (AOR: 1.71; 95% CI: 1.34 to 2.19) remained independently and positively associated with sharing of drug use paraphernalia during the post-policy change period.

Conclusions

In our study, two policing practices known to increase HIV risk among PWID have declined significantly since the local police launched an evidence-based drug policy approach. However, these practices remained independently associated with elevated HIV risk after the post-policy change. Although there remains a continued need to ensure that policing activities do not undermine public health efforts, these findings demonstrate that a major shift towards a public health approach to policing is possible for a municipal police force.

Denial of pain medication by health care providers predicts in-hospital illicit drug use among individuals who use illicit drugs

BACKGROUND

Undertreated pain is common among people who use illicit drugs (PWUD), and can often reflect the reluctance of health care providers to provide pain medication to individuals with substance use disorders.

OBJECTIVE

To investigate the relationship between having ever been denied pain medication by a health care provider and having ever reported using illicit drugs in hospital.

METHODS

Data were derived from participants enrolled in two Canadian prospective cohort studies between December 2012 and May 2013. Using bivariable and multivariable logistic regression analyses, the relationship between having ever been denied pain medication by a health care provider and having ever reported using illicit drugs in hospital was examined.

RESULTS

Among 1053 PWUD who had experienced ≥ 1 hospitalization, 452 (44%) reported having ever used illicit drugs while in hospital and 491(48%) reported having ever been denied pain medication. In a multivariable model adjusted for confounders, having been denied pain medication was positively associated with having used illicit drugs in hospital (adjusted OR 1.46 [95% CI 1.14 to 1.88]).

CONCLUSIONS

The results of the present study suggest that the denial of pain medication is associated with the use of illicit drugs while hospitalized. These findings raise questions about how to appropriately manage addiction and pain among PWUD and indicate the potential role that harm reduction programs may play in hospital settings.

Experiences with policing among people who inject drugs in Bangkok, Thailand: a qualitative study

BACKGROUND

Despite Thailand's commitment to treating people who use drugs as "patients" not "criminals," Thai authorities continue to emphasize criminal law enforcement for drug control. In 2003, Thailand's drug war received international criticism due to extensive human rights violations. However, few studies have since investigated the impact of policing on drug-using populations. Therefore, we sought to examine experiences with policing among people who inject drugs (PWID) in Bangkok, Thailand, between 2008 and 2012.

METHODS AND FINDINGS

Between July 2011 and June 2012, semi-structured, in-depth interviews were conducted with 42 community-recruited PWID participating in the Mitsampan Community Research Project in Bangkok. Interviews explored PWID's encounters with police during the past three years. Audio-recorded interviews were transcribed verbatim, and a thematic analysis was conducted to document the character of PWID's experiences with police. Respondents indicated that policing activities had noticeably intensified since rapid urine toxicology screening became available to police. Respondents reported various forms of police misconduct, including false accusations, coercion of confessions, excessive use of force, and extortion of money. However, respondents were reluctant to report misconduct to the authorities in the face of social and structural barriers to seeking justice. Respondents' strategies to avoid police impeded access to health care and facilitated transitions towards the misuse of prescribed pharmaceuticals. The study's limitations relate to the transferability of the findings, including the potential biases associated with the small convenience sample.

CONCLUSIONS

This study suggests that policing in Bangkok has involved injustices, human rights abuses, and corruption, and policing practices in this setting appeared to have increased PWID's vulnerability to poor health through various pathways. Novel to this study are findings pertaining to the use of urine drug testing by police, which highlight the potential for widespread abuse of this emerging technology. These findings raise concern about ongoing policing practices in this setting.

Experiences with urine drug testing by police among people who inject drugs in Bangkok, Thailand

BACKGROUND

Thailand has relied on drug law enforcement in an effort to curb illicit drug use. While anecdotal reports suggest that Thai police frequently use urine toxicology to identify drug users, little is known about the prevalence or impacts of this practice among people who inject drugs (IDU). Therefore, we sought to examine experiences with urine drug testing by police among IDU in Bangkok.

METHODS

Data were derived from a community-recruited sample of IDU in Bangkok participating in the Mitsampan Community Research Project between July and October 2011. We assessed the prevalence and correlates of being subjected to urine toxicology testing by police using multivariate Poisson regression.

RESULTS

In total, 438 IDU participated in this study, with 293 (66.9%) participants reporting having been tested for illicit drugs by police. In multivariate analyses, reports of drug testing by police were independently and positively associated with younger age (adjusted prevalence ratio [APR]: 1.28), a history of methamphetamine injection (APR: 1.22), a history of incarceration (APR: 1.21), having been in compulsory drug detention (APR: 1.43), avoiding healthcare (APR: 1.15), and HIV seropositivity (APR: 1.19), and negatively associated with access to voluntary drug treatment (APR: 0.82) (all p<0.05).

CONCLUSION

A high proportion of IDU in Bangkok were subjected to drug testing by police. Young people and methamphetamine injectors were more likely to have been tested. The findings indicate that drug testing by police is associated with the compulsory drug detention system and may be interfering with IDU's access to healthcare and voluntary drug treatment. These findings raise concern about the widespread practice of drug testing by police and its associated impacts.

Reports of police beating and associated harms among people who inject drugs in Bangkok, Thailand: a serial cross-sectional study

Background

Thailand has for years attempted to address illicit drug use through aggressive drug law enforcement. Despite accounts of widespread violence by police against people who inject drugs (IDU), the impact of police violence has not been well investigated. In the wake of an intensified police crackdown in 2011, we sought to identify the prevalence and correlates of experiencing police beating among IDU in Bangkok.

Methods

Community-recruited samples of IDU in Bangkok were surveyed between June 2009 and October 2011. Multivariate log-binomial regression was used to identify factors associated with reporting police beating.

Results

In total, 639 unique IDU participated in this serial cross-sectional study, with 240 (37.6%) participants reporting that they had been beaten by police. In multivariate analyses, reports of police beating were associated with male gender (Adjusted Prevalence Ratio [APR] = 4.43), younger age (APR = 1.69), reporting barriers to accessing healthcare (APR = 1.23), and a history of incarceration (APR = 2.51), compulsory drug detention (APR = 1.22) and syringe sharing (APR = 1.44), and study enrolment in 2011 (APR = 1.27) (all p < 0.05). Participants most commonly reported police beating during the interrogation process.

Conclusions

A high proportion of IDU in Bangkok reported having been beaten by the police. Experiencing police beating was independently associated with various indicators of drug-related harm. These findings suggest that the over-reliance on enforcement-based approaches is contributing to police-perpetrated abuses and the perpetuation of the HIV risk behaviour among Thai IDU.