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Meyerson BE, Agley J, Crosby RA, Bentele KG, Vadiei N, Linde-Krieger LB, Russell DR, Fine K, Eldridge LA. ASAP: A pharmacy-level intervention to increase nonprescription syringe sales to reduce bloodborne illnesses. Res Social Adm Pharm 2024; 20:778-785. [PMID: 38734511 PMCID: PMC11180557 DOI: 10.1016/j.sapharm.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Pharmacy syringe sales are effective structural interventions to reduce bloodborne illnesses in populations, and are legal in all but two states. Yet evidence indicates reduced syringe sales in recent years. This study was designed as a feasibility test of an intervention to promote syringe sales by pharmacies in Arizona. METHODS A four-month pilot among three Arizona pharmacies measured feasibility and acceptability through monthly surveys to 18 enrolled pharmacy staff members. RESULTS Pharmacy staff reported increased ease of dispensing syringes across the study. Rankings of syringe dispensing as 'easiest' among 6 measured pharmacy practices increased from 38.9 % at baseline to 50.1 % post intervention module training, and to 83.3 % at pilot conclusion. The majority (72.2 %) of pharmacy staff agreed that intervention materials were easy to use. Over 70 % indicated that the intervention was influential in their "being more open to selling syringes without a prescription to someone who might use them for illicit drug use," and 61.1 % reported that in the future, they were highly likely to dispense syringes to customers who would use them to inject drugs. A vast majority (92 %) reported being likely to dispense subsidized naloxone if available to their pharmacy at no cost. CONCLUSIONS An education-based intervention was found to be feasible and acceptable to pharmacy staff and had an observed impact on perceptions of ease and likelihood of dispensing syringes without a prescription to people who may use them to inject drugs.
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Affiliation(s)
- B E Meyerson
- Harm Reduction Research Lab, Department of Family and Community Medicine, College of Medicine-Tucson, Tucson, University of Arizona, USA; Comprehensive Center for Pain and Addiction, University of Arizona Health Sciences, Tucson, AZ, USA.
| | - J Agley
- Harm Reduction Research Lab, Department of Family and Community Medicine, College of Medicine-Tucson, Tucson, University of Arizona, USA; Indiana University School of Public Health-Bloomington, Bloomington, IN, USA
| | - R A Crosby
- Harm Reduction Research Lab, Department of Family and Community Medicine, College of Medicine-Tucson, Tucson, University of Arizona, USA; College of Public Health, University of Kentucky, Lexington, KY, USA
| | - K G Bentele
- Harm Reduction Research Lab, Department of Family and Community Medicine, College of Medicine-Tucson, Tucson, University of Arizona, USA; Southwest Institute for Research on Women, College of Social and Behavioral Sciences, University of Arizona, Tucson, AZ, USA
| | - N Vadiei
- Harm Reduction Research Lab, Department of Family and Community Medicine, College of Medicine-Tucson, Tucson, University of Arizona, USA; Pharmacotherapy Division, University of Texas at Austin, Austin, TX, USA
| | - L B Linde-Krieger
- Harm Reduction Research Lab, Department of Family and Community Medicine, College of Medicine-Tucson, Tucson, University of Arizona, USA; Comprehensive Center for Pain and Addiction, University of Arizona Health Sciences, Tucson, AZ, USA
| | - D R Russell
- Harm Reduction Research Lab, Department of Family and Community Medicine, College of Medicine-Tucson, Tucson, University of Arizona, USA; Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - K Fine
- Arizona Pharmacy Association, Phoenix, AZ, USA
| | - L A Eldridge
- Harm Reduction Research Lab, Department of Family and Community Medicine, College of Medicine-Tucson, Tucson, University of Arizona, USA; Department of Health Education and Promotion, College of Health and Human Performance, East Carolina University, Greenville, NC, USA
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Aponte-Meléndez Y, Eckhardt B, Fong C, Padilla A, Trinidad-Martínez W, Maldonado-Rodríguez E, Agront N, Mateu-Gelabert P. Prevalence and associated risk factors of hepatitis C antibody and RNA among people who inject drugs in Puerto Rico. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 160:209308. [PMID: 38301921 PMCID: PMC11060894 DOI: 10.1016/j.josat.2024.209308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/08/2023] [Accepted: 01/24/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION As a public health crisis, hepatitis C viral infection (HCV) is highly prevalent among people who inject drugs (PWID). We aimed to assess factors associated with HCV antibody (Ab) and HCV ribonucleic acid (RNA) positivity among PWID in Puerto Rico. METHODS The study recruited a total of 150 persons in rural and peri-urban community settings through the respondent-driven sampling method and administered a structured questionnaire. We conducted HIV and HCV testing using dried blood spots (DBS). We examined correlates of HCV infection with sociodemographics, drug use patterns, and injection practices using regression in bivariate and multivariable analysis. RESULTS Of the 150 participants, 89 % were male; 11 % were female; 72 % identified as mixed race; and the median duration of drug injection was 17.8 years. The mean age was 43.1 years, with 64 % of the population being from 23 to 45 years old. Among study participants (n = 150), the prevalence of HCV Ab was 73 %, and HCV RNA was 53 %. Factors significantly associated with HCV Ab and RNA included older age, increasing years of injection, incarceration, injecting other people, and identifying as Black. The belief that syringe air blowing reduces HCV transmission was also independently associated with HCV Ab positivity. CONCLUSIONS Our findings regarding risk factors associated with HCV infection show the need to enhance prevention and control strategies for reducing transmission among PWID. Direct-acting antiviral treatment, sustained access to harm reduction, and culturally tailored services will be required to substantially reduce rates of HCV. Community-based treatment models and treatment in correctional settings are needed.
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Affiliation(s)
- Yesenia Aponte-Meléndez
- CUNY Graduate School of Public Health and Health Policy, Institute for Implementation Science in Population Health (ISPH), 55 West 125(th) street, New York, NY 10027, USA; NYU Rory Meyers College of Nursing, 433 1(st) Ave., New York, NY, 10010, USA.
| | - Benjamin Eckhardt
- New York University School of Medicine, 550 First Avenue, New York, NY 10016, USA.
| | - Chunki Fong
- CUNY Graduate School of Public Health and Health Policy, Institute for Implementation Science in Population Health (ISPH), 55 West 125(th) street, New York, NY 10027, USA.
| | - Adriana Padilla
- CUNY Graduate School of Public Health and Health Policy, Institute for Implementation Science in Population Health (ISPH), 55 West 125(th) street, New York, NY 10027, USA.
| | - Wanda Trinidad-Martínez
- CUNY Graduate School of Public Health and Health Policy, Institute for Implementation Science in Population Health (ISPH), 55 West 125(th) street, New York, NY 10027, USA.
| | - Eric Maldonado-Rodríguez
- CUNY Graduate School of Public Health and Health Policy, Institute for Implementation Science in Population Health (ISPH), 55 West 125(th) street, New York, NY 10027, USA.
| | - Nancy Agront
- AbbVie Corp., Paseo Caribe Building Suite 22415 Ave Munoz Rivera San Juan, 00901, Puerto Rico.
| | - Pedro Mateu-Gelabert
- CUNY Graduate School of Public Health and Health Policy, Institute for Implementation Science in Population Health (ISPH), 55 West 125(th) street, New York, NY 10027, USA.
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Libman H, Krakower D, Taylor JL, Burns RB. How Would You Manage HIV Pre-exposure Prophylaxis in This Patient With Medical Comorbidities? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2024; 177:518-526. [PMID: 38588544 DOI: 10.7326/m24-0217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2024] Open
Abstract
Despite advances in treatment, HIV infection remains an important cause of morbidity and mortality, with more than 30 000 new cases diagnosed in the United States each year. There are several interventions traditionally used to prevent HIV transmission, but these vary in effectiveness and there are challenges to their implementation. In 2014, the Centers for Disease Control and Prevention published initial guidance on the use of antiretroviral pre-exposure prophylaxis (PrEP) to prevent transmission of HIV infection in persons at risk based on multiple studies that showed it to be highly efficacious in various populations. It was updated in 2021 to reflect new drug options. The U.S. Preventive Services Task Force also recently updated its recommendations for PrEP, which strongly support its use in persons at risk. Despite its well-established effectiveness, the implementation of PrEP in clinical practice has been variable, especially among populations underserved by the medical system and marginalized by society. Fewer than one third of persons in the United States who are eligible for PrEP currently receive it. Here, 2 physicians experienced in HIV PrEP debate how best to identify patients who might benefit from PrEP, how to decide what regimen to use, and how to monitor therapy.
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Affiliation(s)
- Howard Libman
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (H.L., D.K., R.B.B.)
| | - Douglas Krakower
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (H.L., D.K., R.B.B.)
| | - Jessica L Taylor
- Boston University School of Medicine, Section of General Internal Medicine, Boston, Massachusetts (J.L.T.)
| | - Risa B Burns
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (H.L., D.K., R.B.B.)
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Hanson BL, Finley K, Otto J, Ward NJ, Banik S. Community Support for Harm Reduction and Treatment of Opioid Use Disorder. J Community Health 2024:10.1007/s10900-023-01278-6. [PMID: 38409628 DOI: 10.1007/s10900-023-01278-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 02/28/2024]
Abstract
As the opioid epidemic continues, availability of evidence-based strategies for harm reduction and treatment in communities is critical to reduce overdose and other consequences of opioid use disorder. Community members' support of harm reduction and treatment services is needed for new programs and to maintain existent programs. This study sought to understand beliefs and attitudes associated with support for three community-based strategies to address opioid misuse and addiction: naloxone, needle exchange, and medication-assisted treatment. We conducted a cross-sectional online survey with 545 adults. Results of the survey showed that participants supported all three strategies, with the strongest support for medication-assisted treatment. Multiple regression showed that stigma and perceived stigma were significant predictors for all three strategies, with inverse relationships. Stigmatizing beliefs predicted less support while perceiving stigma among others was associated with greater support for the strategies. Normative beliefs also significantly predicted support for all three strategies, such that stronger belief that others were supportive of each strategy was associated with greater support for that strategy. Other predictors varied across the three strategies. Support for harm reduction and treatment programs in communities affected by the opioid epidemic may be bolstered by reducing stigma and increasing normative beliefs. Stronger support for medication-assisted treatment may be leveraged and extended to harm reduction strategies. Results of our study contribute insights for bolstering community support for harm reduction and treatment, which is vital for adoption and maintenance of these important programs.
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Affiliation(s)
- Bridget L Hanson
- Center for Health and Safety Culture, Montana State University, P.O. Box 170548, Bozeman, MT, 59717, USA.
| | - Kari Finley
- Center for Health and Safety Culture, Montana State University, P.O. Box 170548, Bozeman, MT, 59717, USA
| | - Jay Otto
- Center for Health and Safety Culture, Montana State University, P.O. Box 170548, Bozeman, MT, 59717, USA
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Tonin FS, Alves da Costa F, Fernandez-Llimos F. Impact of harm minimization interventions on reducing blood-borne infection transmission and some injecting behaviors among people who inject drugs: an overview and evidence gap mapping. Addict Sci Clin Pract 2024; 19:9. [PMID: 38310293 PMCID: PMC10838443 DOI: 10.1186/s13722-024-00439-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 01/18/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND This study aimed to synthetize the evidence on the effectiveness of harm minimization interventions on reducing blood-borne infection transmission and injecting behaviors among people who inject drugs (PWID) through a comprehensive overview of systematic reviews and evidence gap mapping. METHODS A systematic review was conducted with searches in PubMed and Scopus to identify systematic reviews assessing the impact of interventions aimed at reducing the harms associated with injectable drug use. The overall characteristics of the studies were extracted and their methodological quality was assessed using AMSTAR-2. An evidence gap map was constructed, highlighting the most frequently reported outcomes by intervention (CRD42023387713). RESULTS Thirty-three systematic reviews were included. Of these, 14 (42.2%) assessed the impact of needle/syringe exchange programs (NSEP) and 11 (33.3%) examined opioid agonist therapy (OAT). These interventions are likely to be associated with reductions of HIV/HCV incidence (10-40% risk reduction for NSEP; 50-60% for OAT) and sharing injecting paraphernalia (50% for NSEP, 25-85% for OAT), particularly when combined (moderate evidence). Behavioral/educational interventions were assessed in 12 reviews (36.4%) with most authors in favor/partially in favor of the use of these approaches (moderate evidence). Take-home naloxone programs and supervised-injection facilities were each assessed in two studies (6.1%), which reported inconclusive results (limited/inconsistent evidence). Most authors reported high levels of heterogeneity and risk of bias. Other interventions and outcomes were inadequately reported. Most systematic reviews presented low or critically low quality. CONCLUSION The evidence is sufficient to support the effectiveness of OAT, NSEP and their combination in reducing blood-borne infection transmission and certain injecting behaviors among PWID. However, evidence of other harm minimizations interventions in different settings and for some outcomes remain insufficient.
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Affiliation(s)
- Fernanda S Tonin
- H&TRC - Health & Technology Research Center, ESTeSL - Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
| | - Filipa Alves da Costa
- Research Institute for Medicines (iMED.ULisboa), Faculty of Pharmacy, University of Lisbon, Av. Prof. Gama Pinto, Lisbon, Portugal.
| | - Fernando Fernandez-Llimos
- Applied Molecular Biosciences Unit, (UCIBIO-i4HB) Laboratory of Pharmacology, Faculty of Pharmacy, University of Porto, Porto, Portugal
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Abua J, Hagert Z, Baumann S, Batey S, Creasy S, Davis D, Kay E, Hawk M. Elucidating Harm Reduction Principles in a Client-Centered Representative Payee Program. Community Ment Health J 2024; 60:366-375. [PMID: 37682381 PMCID: PMC10861313 DOI: 10.1007/s10597-023-01180-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 08/15/2023] [Indexed: 09/09/2023]
Abstract
Harm Reduction seeks to mitigate harms associated with health behaviors without the expectation that these behaviors be extinguished completely. Client-Centered Representative Payee (CCRP) is an intervention that modifies the US Social Security Administration's (SSA) Representative Payee policy by incorporating relational harm reduction. We used Human-Centered Design (HCD) methods to elucidate ways that harm reduction principles are present in and integral to CCRP and to create a blueprint for replication. Thirteen individuals familiar with CCRP brainstormed 88 statements, which were parsed, consolidated, and then independently assigned by a subgroup of participants to six principles of harm reduction. After refining the data, 29 statements aligning with harm reduction principles remained. Delineating harm reduction within CCRP, which can empower and establish trust with clients, may help other providers identify how to offer representative payee services that are respectful, compassionate, rooted in harm reduction, and ultimately improve client outcomes.
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Affiliation(s)
- Joseph Abua
- Birmingham Aids Outreach, 205 32nd Street South, Birmingham, Al, 35233, USA.
| | | | | | | | | | - Dana Davis
- Youngstown State University, Youngstown, USA
| | - Emma Kay
- Birmingham Aids Outreach, 205 32nd Street South, Birmingham, Al, 35233, USA
| | - Mary Hawk
- University of Pittsburgh, Pittsburgh, USA
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Robinson K, Laing A, Choi J, Richardson L. Effect of modified income assistance payment schedules on substance use service access: Evidence from an experimental study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 124:104293. [PMID: 38183858 DOI: 10.1016/j.drugpo.2023.104293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/19/2023] [Accepted: 12/10/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Despite being critical to reducing the impacts of poverty internationally, synchronized monthly government income assistance payments are linked to intensified drug use and associated harms, including disrupted access to substance use-related services. This study evaluates whether alternative income assistance distribution schedules improve harm reduction (HR), pharmacotherapy and substance use service utilization. METHODS This exploratory, parallel group, unblinded, randomized controlled trial analyzed data from adults (n = 192) in Vancouver, Canada receiving income assistance, and reporting active, regular illicit drug use. Participants were randomly assigned on a 1:2:2 basis for six income assistance payment cycles to: (1) existing government schedules (control); (2) a "staggered" single monthly payment; or (3) "split & staggered" twice-monthly payments. Generalized linear mixed models analyzed secondary outcomes of HR, pharmacotherapy and substance use service utilization as well as barriers accessing these services. RESULTS Forty-five control, 71 staggered, and 76 split & staggered volunteers participated between 2015 and 2019. Multivariable modified per-protocol analyses demonstrate increased access to substance use services (Adjusted Odds Ratio [AOR] 1.64, 95% Confidence Interval [CI] 1.02-2.64) for split & staggered arm participants, and, conversely, increased barriers to HR for participants in the staggered (AOR 2.34, 95% CI 1.24-4.41) and split & staggered (AOR 2.16, 95% CI 1.08-4.35) arms. Results also showed decreased barriers to pharmacotherapy around government payments (AOR 0.23, 95% CI 0.06-0.90), pharmacotherapy around individual payments (AOR 0.12, 95% CI 0.02-0.58), and HR around individual payments (AOR 0.11, 95% CI 0.02-0.63) for staggered arm participants. CONCLUSION Modifying payments schedules demonstrate improved access to overall substance use services, and reduced barriers to HR and pharmacotherapy around income assistance payments. However, increased overall barriers to HR access were also shown. These complex, predominantly beneficial findings support the exploration of offering alternative payment schedules to support service access.
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Affiliation(s)
- Kaye Robinson
- Providence Health Care, 1081 Burrard St, Vancouver, BC V6Z1Y6, Canada; British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada
| | - Allison Laing
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Sociology, 6303 NW Marine Drive, Vancouver, BC V6T 1Z1, Canada
| | - JinCheol Choi
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada
| | - Lindsey Richardson
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Sociology, 6303 NW Marine Drive, Vancouver, BC V6T 1Z1, Canada.
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McCormick KA, Stanton MC, Ali SB. A Mixed Methods Analysis of Southern HIV Service Organizations' Implementation of Harm Reduction to Address the HIV and Opioid Syndemic. J Behav Health Serv Res 2024; 51:44-56. [PMID: 37697180 DOI: 10.1007/s11414-023-09859-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/13/2023]
Abstract
Southern HIV Service Organizations (SHSOs) are promising sites for the adoption and implementation of harm reduction as a means for addressing the HIV and opioid syndemic. However, little research to date has examined exactly how harm reduction is operationalized within and among SHSOs. Using program evaluation data (i.e., organizational assessment data and semi-structured qualitative group interview data with SHSO staff), this study aimed to characterize organizational implementation of harm reduction among SHSOs that sought harm reduction capacity-building assistance (i.e., training, coaching, funding) from the SUSTAIN Center. Authors utilized a convergent mixed methods design in which quantitative and qualitative approaches were employed in parallel to gain simultaneous insights into how harm reduction was operationalized in SHSOs and how the local context influenced implementation. Means and proportions of each organizational assessment domain were compared. Thematic analysis of group interview transcripts examined SHSO staff perceptions of harm reduction implementation in their respective communities. Quantitative results revealed that SHSOs most commonly operationalize harm reduction in the Outreach, Advocacy, and Principles domains but struggle to do so in terms of Services and Organizational Infrastructure. Qualitative results revealed that various factors in SHSOs' local context, such as the community's lack of knowledge and understanding of harm reduction, limited harm reduction services, and a challenging socio-political context, influence SHSOs implementation of harm reduction. Taken together, analyses reveal that (1) SHSOs expend significant effort conducting outreach activities because Southern communities are generally unaware of harm reduction, (2) SHSOs continually advocate for harm reduction in the midst of a challenging socio-political context, and (3) SHSOs offer fewer harm reduction services and integrate harm reduction into their organizational infrastructure to a lesser extent due to external, contextual factors. The combination of organizational-level data and SHSO staff insights provided by this mixed methods study have implications for policy advocacy, funding initiatives, and capacity-building efforts.
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Affiliation(s)
- Katie A McCormick
- Steve Hicks School of Social Work, University of Texas at Austin, 1925 San Jacinto Blvd, Austin, TX, 78712, USA.
| | - Megan C Stanton
- Department of Sociology, Anthropology, Criminology and Social Work, Eastern Connecticut State University, 83 Windham St, Willimantic, CT, 06226, USA
| | - Samira B Ali
- Graduate College of Social Work, University of Houston, 3511 Cullen Blvd, Houston, TX, 77204, USA
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Killion JA, Magana C, Cepeda JA, Vo A, Hernandez M, Cyr CL, Heskett KM, Wilson DP, Graff Zivin J, Zúñiga ML, Pines HA, Garfein RS, Vickerman P, Terris-Prestholt F, Wynn A, Martin NK. Unit costs of needle and syringe program provision: a global systematic review and cost extrapolation. AIDS 2023; 37:2389-2397. [PMID: 37773035 PMCID: PMC10653296 DOI: 10.1097/qad.0000000000003718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Needle and syringe programs (NSPs) are effective at preventing HIV and hepatitis C virus (HCV) among people who inject drugs (PWID), yet global coverage is low, partly because governments lack data on the cost and cost-effectiveness of NSP in their countries to plan and fund their responses. We conducted a global systematic review of unit costs of NSP provision to inform estimation of cost drivers and extrapolated costs to other countries. METHODS We conducted a systematic review to extract data on the cost per syringe distributed and its cost drivers. We estimated the impact of country-level and program-level variables on the cost per syringe distributed using linear mixed-effects models. These models were used to predict unit costs of NSP provision, with the best performing model used to extrapolate the cost per syringe distributed for 137 countries. The total cost for a comprehensive NSP (200 syringes per PWID/year) was also estimated for 68 countries with PWID population size estimates. RESULTS We identified 55 estimates of the unit cost per syringe distributed from 14 countries. Unit costs were extrapolated for 137 countries, ranging from $0.08 to $20.77 (2020 USD) per syringe distributed. The total estimated spend for a high-coverage, comprehensive NSP across 68 countries with PWID size estimates is $5 035 902 000 for 10 887 500 PWID, 2.1-times higher than current spend. CONCLUSION Our review identified cost estimates from high-income, upper-middle-income, and lower-middle-income countries. Regression models may be useful for estimating NSP costs in countries without data to inform HIV/HCV prevention programming and policy.
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Affiliation(s)
- Jordan A Killion
- University of California San Diego, La Jolla
- San Diego State University, San Diego, California
| | | | | | - Anh Vo
- Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Natasha K Martin
- University of California San Diego, La Jolla
- University of Bristol, Bristol, UK
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Levenson J, Textor L, Bluthenthal R, Darby A, Wahbi R, Clayton-Johnson MA. Abolition and harm reduction in the struggle for "Care, Not Cages". THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 121:104163. [PMID: 37722347 DOI: 10.1016/j.drugpo.2023.104163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/11/2023] [Accepted: 08/13/2023] [Indexed: 09/20/2023]
Abstract
Care that is organized around the principles of harm reduction and the movement for police and prison abolition has the potential to uproot and transform structural causes of harm and violence, in the interconnected crises of drug-related harm, policing, and punishment. The United States' crisis of overdose and drug-related harm and its system of policing and punishment are historically and empirically linked phenomena. The abandonment of people whose use of drugs leads to their premature death, in the form of an overdose, is directly and indirectly connected to wider systems of criminalization and incarceration that also produce premature suffering and death. Organizations advocating for harm reduction for people who use drugs (PWUD) and organizations seeking the abolition of police and prisons have developed in parallel albeit with different genealogies. We examine the historical origins, principles, and practical applications of the two movements to identify points of overlap and lessons to be learned for the public health goals of addressing and preventing premature suffering and death in the United States. A case study of Los Angeles (LA) County, where elected officials have promised a new paradigm of care, not punishment, frames our analysis. We show how the principles and strategies of harm reduction and abolition are both necessary to practically realizing a paradigm of care, not punishment, and achieving system transformation.
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Affiliation(s)
- Jeremy Levenson
- Department of Psychiatry, Yale University, United States; Department of Anthropology, UCLA, United States; Center for Social Medicine, University of California Los Angeles, United States
| | - Lauren Textor
- Department of Anthropology, UCLA, United States; Center for Social Medicine, University of California Los Angeles, United States; Department of Psychiatry, UCLA, United States.
| | - Ricky Bluthenthal
- Department of Preventive Medicine, Keck School of Medicine, USC, United States
| | - Anna Darby
- Emergency Medicine Program, LAC+USC Medical Center, Keck School of Medicine at USC, United States
| | - Rafik Wahbi
- Department of Community Health Sciences, UCLA Fielding School of Public Health, United States; Frontline Wellness Network, Los Angeles, United States
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11
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Krendl AC, Perry BL. Stigma Toward Substance Dependence: Causes, Consequences, and Potential Interventions. Psychol Sci Public Interest 2023; 24:90-126. [PMID: 37883667 DOI: 10.1177/15291006231198193] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Substance dependence is a prevalent and urgent public health problem. In 2021, 60 million Americans reported abusing alcohol within the month prior to being surveyed, and nearly 20 million Americans reported using illegal drugs (e.g., heroin) or prescription drugs (e.g., opioids) for nonmedical reasons in the year before. Drug-involved overdose rates have been steadily increasing over the past 20 years. This increase has been primarily driven by opioid and stimulant use. Despite its prevalence, drug dependence is one of the most stigmatized health conditions. Stigma has myriad negative consequences for its targets, including limiting their access to employment and housing, disrupting interpersonal relationships, harming physical and mental health, and reducing help-seeking. However, because research on stigma toward people with substance use disorders (SUDs) is relatively sparse compared with research on stigma toward other mental illnesses, the field lacks a comprehensive understanding of the causes and consequences of SUD stigma. Moreover, it remains unclear how, if at all, these factors differ from other types of mental illness stigma. The goal of this review is to take stock of the literature on SUD stigma, providing a clear set of foundational principles and a blueprint for future research and translational activity.
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Affiliation(s)
- Anne C Krendl
- Department of Psychological and Brain Sciences, Indiana University Bloomington
| | - Brea L Perry
- Department of Sociology, Indiana University Bloomington
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Marotta PL, Del Pozo B, Baker P, Abramovitz D, Artamonova I, Arredondo J, McCreedy K, Strathdee SA, Cepeda J, Beletsky L. Unlocking deflection: The role of supervisor support in police officer willingness to refer people who inject drugs to harm reduction services. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 121:104188. [PMID: 37826987 PMCID: PMC10842016 DOI: 10.1016/j.drugpo.2023.104188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 08/27/2023] [Accepted: 08/30/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Research is needed that investigates the relationship between police behaviors, attitudes, and perceived supervisor support as an implementation strategy of improving drug policy reforms. METHODS We hypothesized that officers with more positive attitudes and practices would be more likely to report the perceived support of their supervisors. Data includes a sample of 1227 police officers who completed Project ESCUDO, a police education training program in Tijuana, Mexico. A negative binomial distribution was used to estimate associations between police behaviors and attitudes and perceived supervisor support. RESULTS Officers who reported perceived supervisor support accounted for 29.2% (n=470) of the sample. Officers who referred people to social services were more likely and officers who broke syringes were less likely to report perceived supervisor support compared to officers who did not engage in these practices. Officers who believed: MOUD reduced criminal activity, "referring people who use drugs to social services is part of my job", and "laws that treat addiction as a public health problem make my job easier", were more likely to report perceived supervisor support. Beliefs that drug addiction is a disease, laws that treat addiction as a public health problem make their job easier, and talking to other law enforcement officers about infectious diseases were not significantly associated with perceived supervisor support. CONCLUSIONS Our research highlights the importance of incorporating police supervisors as key actors in assuring officers' practices reflect current drug law reforms as well as embrace patient-centered approaches to managing encounters people who use opioids and inject drugs.
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Affiliation(s)
| | | | - Pieter Baker
- Johns Hopkins University, Bloomberg School of Public Health, USA; University of South Carolina, Arnold School of Public Health, USA
| | - Daniela Abramovitz
- University of California San Diego School of Medicine, Division of Infectious Diseases and Global Public Health, USA
| | - Irina Artamonova
- University of California San Diego School of Medicine, Division of Infectious Diseases and Global Public Health, USA
| | - Jaime Arredondo
- University of California San Diego School of Medicine, Division of Infectious Diseases and Global Public Health, USA
| | - Katie McCreedy
- Center for Health Policy Research and Law, Northeastern University, USA
| | - Steffanie A Strathdee
- University of California San Diego School of Medicine, Division of Infectious Diseases and Global Public Health, USA
| | - Javier Cepeda
- Johns Hopkins University, Bloomberg School of Public Health, USA
| | - Leo Beletsky
- Brown School, Washington University in St. Louis, USA; The Warren Alpert Medical School of Brown University, USA; Johns Hopkins University, Bloomberg School of Public Health, USA; University of South Carolina, Arnold School of Public Health, USA; University of California San Diego School of Medicine, Division of Infectious Diseases and Global Public Health, USA; Center for Health Policy Research and Law, Northeastern University, USA
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Yeh PT, Yang X, Kennedy CE, Armstrong KA, Fonner VA, Sherryn, O'Reilly KR, Sweat MD. The Impact of Needle and Syringe Exchange Programs on HIV-Related Risk Behaviors in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis Examining Individual- Versus Community-Level Effects. AIDS Behav 2023; 27:3306-3331. [PMID: 37046029 PMCID: PMC10524190 DOI: 10.1007/s10461-023-04051-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 04/14/2023]
Abstract
We conducted a systematic review and meta-analysis of the impact of needle and syringe exchange programs (NSP) on both individual- and community-level needle-sharing behaviors and other HIV-related outcomes in low- and middle-income countries (LMIC). A search of five databases for peer-reviewed trial or quasi-experimental studies reported through July 2021 identified 42 interventions delivered in 35 studies, with a total of 56,751 participants meeting inclusion criteria. Random-effects meta-analysis showed a significant protective association between NSP exposure and needle-sharing behaviors at the individual-level (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.16-0.39, 8 trials, n = 3947) and community-level (OR 0.39, CI 0.22-0.69, 12 trials, n = 6850), although with significant heterogeneity. When stratified by needle-sharing directionality, NSP exposure remained associated with reduced receptive sharing, but not distributive sharing. NSP exposure was also associated with reduced HIV incidence and increased HIV testing but there were no consistent associations with prevalence of bloodborne infections. Current evidence suggests positive impacts of NSPs in LMICs.
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Affiliation(s)
- Ping Teresa Yeh
- Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA.
| | - Xuhao Yang
- Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Caitlin E Kennedy
- Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Kevin A Armstrong
- Division of Global and Community Health, Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA
| | - Virginia A Fonner
- Division of Global and Community Health, Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA
- FHI 360, Health Services Research Division, Durham, NC, 27701, USA
| | - Sherryn
- Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Kevin R O'Reilly
- Division of Global and Community Health, Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA
| | - Michael D Sweat
- Division of Global and Community Health, Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA
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14
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Mok J, Milloy MJ, Grant C, Lake S, DeBeck K, Hayashi K, Kerr T, Socías ME. Use of Cannabis as a Harm Reduction Strategy Among People Who Use Drugs: A Cohort Study. Cannabis Cannabinoid Res 2023; 8:670-678. [PMID: 35647886 PMCID: PMC10442679 DOI: 10.1089/can.2021.0229] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: While substance use contributes to a substantial burden of disease, access to evidence-based harm reduction interventions remains limited or inaccessible. Preliminary research suggests that some individuals use cannabis to reduce the harms associated with their use of other substances, including opioids and stimulants. This study examines factors associated with the self-reported use of cannabis for harm reduction among people who use drugs (PWUD). Methods: We drew data from three prospective, community-recruited cohorts of PWUD in Vancouver, Canada, between June 2016 and May 2018. Multivariable generalized linear mixed-effects modeling was used to examine factors associated with the primary outcome of "use of cannabis for harm reduction," defined as self-reported use of cannabis to substitute for other substances, treat withdrawal, or come down off other drugs. Results: One thousand nine hundred thirty-six participants contributed 5706 observations. In adjusted analyses, daily methamphetamine use (adjusted odds ratio [AOR]=1.43, 95% confidence interval [CI]: 1.09-1.89), experiencing barriers to accessing addiction treatment (AOR=1.92, 95% CI: 1.21-3.03), and enrollment in addiction treatment modalities other than opioid agonist therapy (AOR=1.64, 95% CI: 1.17-2.29) were positively associated with using cannabis for harm reduction. Older age was negatively associated (AOR=0.97, 95% CI: 0.95-0.98). Among 1281 (66.2%) participants who use cannabis, daily cannabis use and obtaining cannabis from unregulated dispensaries were also independent correlates of using cannabis for harm reduction. Discussion and Conclusions: Individuals who were more likely to use cannabis for harm reduction reported difficulty accessing addiction treatment or used substances, such as methamphetamines, where effective treatments are limited. These findings highlight the need to better understand the potential harm-reducing impacts of cannabis among PWUD in these scenarios.
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Affiliation(s)
- Janice Mok
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - M.-J. Milloy
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Cameron Grant
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Stephanie Lake
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- UCLA Cannabis Research Initiative, Jane and Terry Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, California, USA
| | - Kora DeBeck
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - M. Eugenia Socías
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Nchinda N, Elangovan R, Yun J, Dickson-Tetteh L, Kirtley S, Hemelaar J. Global associations of key populations with HIV-1 recombinants: a systematic review, global survey, and individual participant data meta-analysis. Front Public Health 2023; 11:1153638. [PMID: 37575094 PMCID: PMC10420084 DOI: 10.3389/fpubh.2023.1153638] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 06/28/2023] [Indexed: 08/15/2023] Open
Abstract
Introduction Global HIV infections due to HIV-1 recombinants are increasing and impede prevention and treatment efforts. Key populations suffer most new HIV infections, but their role in the spread of HIV-1 recombinants is unknown. We conducted a global analysis of the associations between key populations and HIV-1 recombinants. Methods We searched PubMed, EMBASE, CINAHL, and Global Health for HIV-1 subtyping studies published from 1/1/1990 to 31/12/2015. Unpublished data was collected through a global survey. We included studies with HIV-1 subtyping data of key populations collected during 1990-2015. Key populations assessed were heterosexual people (HET), men who have sex with men (MSM), people who inject drugs (PWID), vertical transmissions (VERT), commercial sex workers (CSW), and transfusion-associated infections (BLOOD). Logistic regression was used to determine associations of key populations with HIV-1 recombinants. Subgroup analyses were performed for circulating recombinant forms (CRFs), unique recombinant forms (URFs), regions, and time periods. Results Eight hundred and eighty five datasets including 77,284 participants from 83 countries were included. Globally, PWID were associated with the greatest odds of recombinants and CRFs (OR 2.6 [95% CI 2.46-2.74] and 2.99 [2.83-3.16]), compared to HET. CSW were associated with increased odds of recombinants and URFs (1.59 [1.44-1.75] and 3.61 [3.15-4.13]). VERT and BLOOD were associated with decreased odds of recombinants (0.58 [0.54-0.63] and 0.43 [0.33-0.56]). MSM were associated with increased odds of recombinants in 2010-2015 (1.43 [1.35-1.51]). Subgroup analyses supported our main findings. Discussion As PWID, CSW, and MSM are associated with HIV-1 recombinants, increased preventative measures and HIV-1 molecular surveillance are crucial within these key populations. Systematic review registration PROSPERO [CRD42017067164].
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Affiliation(s)
- Nkazi Nchinda
- Nuffield Department of Population Health, Infectious Disease Epidemiology Unit, National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom
| | - Ramyiadarsini Elangovan
- Nuffield Department of Population Health, Infectious Disease Epidemiology Unit, National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom
| | - Jason Yun
- Nuffield Department of Population Health, Infectious Disease Epidemiology Unit, National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom
| | - Leslie Dickson-Tetteh
- Nuffield Department of Population Health, Infectious Disease Epidemiology Unit, National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, United Kingdom
| | - Joris Hemelaar
- Nuffield Department of Population Health, Infectious Disease Epidemiology Unit, National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom
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16
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Claborn K, Samora J, McCormick K, Whittfield Q, Courtois F, Lozada K, Sledge D, Burwell A, Chavez S, Bailey J, Bailey C, Pederson CD, Zagorski C, Hill L, Conway FN, Steiker LH, Cance J, Potter J. "We do it ourselves": strengths and opportunities for improving the practice of harm reduction. Harm Reduct J 2023; 20:70. [PMID: 37296459 DOI: 10.1186/s12954-023-00809-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 06/06/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Unprecedented increases in substance-related overdose fatalities have been observed in Texas and the U.S. since the onset of the COVID-19 pandemic and have made clear there is considerable need to reduce harms associated with drug use. At the federal level, initiatives have called for widespread dissemination and implementation of evidence-based harm reduction practices to reduce overdose deaths. Implementation of harm reduction strategies is challenging in Texas. There is a paucity of literature on understanding current harm reduction practices in Texas. As such, this qualitative study aims to understand harm reduction practices among people who use drugs (PWUD), harm reductionists, and emergency responders across four counties in Texas. This work would inform future efforts to scale and spread harm reduction in Texas. METHODS Semi-structured qualitative interviews were conducted with N = 69 key stakeholders (25 harm reductionists; 24 PWUD; 20 emergency responders). Interviews were transcribed verbatim, coded for emergent themes, and analyzed using Applied Thematic Analysis with Nvivo 12. A community advisory board defined the research questions, reviewed the emergent themes, and assisted with interpretation of the data. RESULTS Emergent themes highlighted barriers to harm reduction at micro and macro levels, from the individual experience of PWUD and harm reductionists to systemic issues in healthcare and the emergency medical response system. Specifically, (1) Texas has existing strengths in overdose prevention and response efforts on which to build, (2) PWUD are fearful of interacting with healthcare and 911 systems, (3) harm reductionists are in increasing need of support for reaching all PWUD communities, and (4) state-level policies may hinder widespread implementation and adoption of evidence-based harm reduction practices. CONCLUSIONS Perspectives from harm reduction stakeholders highlighted existing strengths, avenues for improvement, and specific barriers that currently exist to harm reduction practices in Texas.
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Affiliation(s)
- Kasey Claborn
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA.
- Department of Psychiatry, Dell Medical School, The University of Texas at Austin, Austin, TX, USA.
- Addictions Research Institute, The University of Texas at Austin, Austin, TX, USA.
| | - Jake Samora
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
- Addictions Research Institute, The University of Texas at Austin, Austin, TX, USA
| | - Katie McCormick
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
- Addictions Research Institute, The University of Texas at Austin, Austin, TX, USA
| | - Quanisha Whittfield
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
- Addictions Research Institute, The University of Texas at Austin, Austin, TX, USA
| | | | - Kyle Lozada
- The Center for Healthcare Services, San Antonio, TX, USA
| | - Daniel Sledge
- Round Rock Fire Department Crisis Response Unit, Round Rock, TX, USA
| | - Annie Burwell
- Round Rock Fire Department Crisis Response Unit, Round Rock, TX, USA
| | | | | | | | - Chelsea Dalton Pederson
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
- Addictions Research Institute, The University of Texas at Austin, Austin, TX, USA
| | - Claire Zagorski
- College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Lucas Hill
- College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Fiona N Conway
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
- Addictions Research Institute, The University of Texas at Austin, Austin, TX, USA
| | - Lori Holleran Steiker
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
- Addictions Research Institute, The University of Texas at Austin, Austin, TX, USA
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The effects of COVID-19 on New York State's Drug User Health Hubs and syringe service programs: a qualitative study. Harm Reduct J 2023; 20:12. [PMID: 36732773 PMCID: PMC9893960 DOI: 10.1186/s12954-023-00742-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/19/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Syringe service programs (SSPs) deliver critical harm reduction services to people who inject drugs (PWID). Some SSPs in New York State received enhanced funding to provide additional services to combat opioid overdose fatalities. These SSPs, known as Drug User Health Hubs, provide buprenorphine for the treatment of opioid use disorder and other health-related services in addition to their syringe services. While the COVID-19 pandemic posed widespread challenges to the delivery of health services nationwide, the effect of the pandemic on SSPs uniquely impacts PWID. This study examines the impact of COVID-19 on service delivery of Drug User Health Hubs and stand-alone SSPs in New York State. METHODS Between July 2020 and September 2020, we performed eleven semi-structured virtual interviews with staff from three Health Hub SSPs and three stand-alone SSPs. The interviews explored the effect of the COVID-19 pandemic on SSPs and their clients as well as the changes implemented in response. Interviews were recorded and transcribed. We performed content analysis to identify emerging themes from the data. RESULTS Due to the COVID-19 pandemic, some SSPs temporarily shut down while others limited their hours of operation. SSPs modified their service delivery to maintain syringe services and naloxone distribution over other services such as STI and HCV testing. They virtualized components of their services, including telemedicine for the provision of buprenorphine. While SSPs found virtualization to be important for maintaining their services, it negatively impacted the intimate nature of client interactions. Participants also described the impact of the pandemic on the well-being of PWID, including isolation, worsened mental health challenges, and increased drug overdoses. CONCLUSIONS In response to the COVID-19 pandemic, SSPs demonstrated innovation, adaptability, and togetherness. Despite the challenges posed by the pandemic, SSPs continued to be key players in maintaining access to sterile supplies, buprenorphine, and other services for PWID. In addition to adapting to COVID-19 restrictions, they also responded to the dynamic needs of their clients. Sustainable funding and recognition of the critical role of SSPs in supporting PWID can help to improve outcomes for PWID.
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18
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Interventions to prevent HIV and Hepatitis C among people who inject drugs: Latest evidence of effectiveness from a systematic review (2011 to 2020). THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 109:103872. [PMID: 36202039 DOI: 10.1016/j.drugpo.2022.103872] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Hepatitis C virus (HCV) and HIV remain prevalent among people who inject drugs (PWID) and transmission is usually associated with injecting risk behaviour (IRB). We update a 2011 review of reviews (RoR) to assess the latest evidence on the effectiveness of harm reduction interventions - drug treatment (including opioid agonist therapy [OAT]), needle and syringe programmes (NSP) and other interventions - in the prevention of HCV and HIV transmission, and related measures of infection risk (IRB and injecting frequency [IF]), among PWID. METHODS We undertook an initial search for systematic reviews (i.e. an Overview of Reviews [OoR]) and subsequent systematic searches for primary studies where required. Where there was sufficient evidence based on synthesis of multiple robust studies for an intervention effect in the 2011 RoR, new evidence was not sought. Medline, CINAHL, The Cochrane Library, EMBASE, PsycINFO and Web of Science were searched (2011-2020). Two reviewers screened papers, extracted data, and graded reviews/studies. We classified evidence as 'sufficient', 'tentative', 'insufficient', or 'no evidence'. RESULTS We screened 8513 reviews and 7133 studies, with 27 and 61 identified as relevant, respectively. The level of evidence increased since the 2011 RoR and is now 'sufficient' for OAT (regarding all outcomes), NSP (for reducing HIV transmission and IRB), and combination OAT/NSP (for reducing HCV transmission). There is also now sufficient evidence for in-prison OAT, psychosocial interventions, pharmacy-based NSP and provision of sterile drug preparation equipment for reducing IRB. CONCLUSION There is now a strong body of empirical evidence for the effectiveness of OAT and NSP, alone and in combination, in reducing IRB, and HCV and HIV transmission. However, there is still a relative lack of evidence for other interventions, including heroin-assisted treatment, pharmacological treatment for stimulant dependence, contingency management, technology-based interventions, low dead space syringes and drug consumption rooms on HCV or HIV risk.
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Allen ST, Danforth S, Grieb SM, Glick JL, Harris SJ, Tomko C, Sherman SG. Law enforcement and syringe services program implementation in rural counties in Kentucky: a qualitative exploration. Harm Reduct J 2022; 19:109. [PMID: 36180853 PMCID: PMC9526275 DOI: 10.1186/s12954-022-00684-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/16/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Existing research in urban areas has documented a multitude of ways in which law enforcement may affect risks for bloodborne infectious disease acquisition among people who inject drugs (PWID), such as via syringe confiscation and engaging in practices that deter persons from accessing syringe services programs (SSPs). However, limited work has been conducted to explore how law enforcement may impact SSP implementation and operations in rural counties in the United States. This creates a significant gap in the HIV prevention literature given the volume of non-urban counties in the United States that are vulnerable to injection drug use-associated morbidity and mortality. OBJECTIVE This study explores the influence of law enforcement during processes to acquire approvals for SSP implementation and subsequent program operations in rural Kentucky counties. METHODS From August 2020 to October 2020, we conducted eighteen in-depth qualitative interviews among persons involved with SSP implementation in rural counties in Kentucky (USA). Interviews explored the factors that served as barriers and facilitators to SSP implementation and operations, including the role of law enforcement. RESULTS Participants described scenarios in which rural law enforcement advocated for SSP implementation; however, they also reported police opposing rural SSP implementation and engaging in adverse behaviors (e.g., targeting SSP clients) that may jeopardize the public health of PWID. Participants reported that efforts to educate rural law enforcement about SSPs were particularly impactful when they discussed how SSP implementation may prevent needlestick injuries. CONCLUSIONS The results of this study suggest that there are multiple ways in which rural SSP implementation and subsequent operations in rural Kentucky counties are affected by law enforcement. Future work is needed to explore how to expeditiously engage rural law enforcement, and communities more broadly, about SSPs, their benefits, and public health necessity.
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Affiliation(s)
- Sean T Allen
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway, Hampton House 184, Baltimore, MD, 21205, USA.
| | - Sarah Danforth
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway, Hampton House 184, Baltimore, MD, 21205, USA
| | - Suzanne M Grieb
- Department of Pediatrics, Center for Child and Community Health Research, Johns Hopkins School of Medicine, Baltimore, MD, 21224, USA
| | - Jennifer L Glick
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway, Hampton House 184, Baltimore, MD, 21205, USA
| | - Samantha J Harris
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Catherine Tomko
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway, Hampton House 184, Baltimore, MD, 21205, USA
| | - Susan G Sherman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway, Hampton House 184, Baltimore, MD, 21205, USA
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20
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Pro G, Hayes C, Montgomery BEE, Zaller N. Demographic and geographic shifts in the preferred route of methamphetamine administration among treatment cases in the US, 2010-2019. Drug Alcohol Depend 2022; 237:109535. [PMID: 35714531 DOI: 10.1016/j.drugalcdep.2022.109535] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/31/2022] [Accepted: 06/06/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Methamphetamine use disorder has increased rapidly in the past decade. Injecting is also increasing and has multifaceted implications for disease severity, overall health, and treatment outcomes, but less is known about where or among whom injecting has shifted the most. This national study assessed temporal changes in the preferred route of methamphetamine administration by race/ethnicity and within urban/rural geographies. METHODS We used the Treatment Episode Dataset-Discharges (2010-2019) to identify outpatient treatment cases who reported methamphetamine as their primary drug of choice at admission (N = 531,799; 2010 n = 33,744; 2019 n = 81,885). We created a combined variable indicating race/ethnicity and the rural/urban location of treatment, and used logistic regression to model the predicted probability of cases reporting injection, smoking, or snorting as their preferred route of administration. We included an interaction term to determine differences over time (race/ethnicity/rurality*year). RESULTS Across all years, smoking methamphetamine was the most common route of administration (66%), followed by injection (24%) and snorting (10%). Over time and among most sub-groups, the rates of injection increased while the rates of smoking decreased. Compared to 2010, the odds of injecting methamphetamine in 2019 were highest among Black cases in urban areas (aOR = 2.30, 95% CI = 1.76-3.00, p < 0.0001). CONCLUSION Increasing methamphetamine injection was most pronounced among Black treatment cases in more urban areas, which is in contrast to the longstanding narrative that methamphetamine is a White and rural drug. Methamphetamine prevention, treatment, and harm reduction should target populations with high injection prevalence and growing incidence.
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Affiliation(s)
- George Pro
- Health Behavior and Health Education, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301W. Markham, Little Rock, AR 72205, USA; Southern Public Health and Criminal Justice Research Center, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301W. Markham, Little Rock, AR 72205, USA.
| | - Corey Hayes
- Department of Biomedical Informatics, College of Medicine, University of Arkansas for Medical Sciences, 4301W. Markham, Little Rock, AR 72205, USA; Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114, USA.
| | - Brooke E E Montgomery
- Health Behavior and Health Education, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301W. Markham, Little Rock, AR 72205, USA; Southern Public Health and Criminal Justice Research Center, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301W. Markham, Little Rock, AR 72205, USA.
| | - Nickolas Zaller
- Health Behavior and Health Education, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301W. Markham, Little Rock, AR 72205, USA; Southern Public Health and Criminal Justice Research Center, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301W. Markham, Little Rock, AR 72205, USA.
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Stanton MC, Ali SB, McCormick K. Harm reduction implementation among HIV service organizations (HSOs) in the U.S. south: a policy context analysis and results from a survey of HSOs. BMC Health Serv Res 2022; 22:913. [PMID: 35831861 PMCID: PMC9281157 DOI: 10.1186/s12913-022-08277-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HIV service organizations are integral to serving communities disproportionately impacted by the HIV and opioid epidemics in the U.S. South. Addressing these intersecting epidemics requires implementation of evidence-based approaches, such as harm reduction. However, little is known about the extent to which Southern HIV service organizations implement harm reduction. This manuscript examines: 1) the implementation context of harm reduction in the South, 2) Southern HIV service organization implementation of harm reduction, and 3) the impact of different contexts within the South on HIV service organization implementation of harm reduction. METHODS To examine implementation context, authors analyzed nation-wide harm reduction policy and drug-related mortality data. To examine HIV service organization implementation of harm reduction, authors performed frequency distributions on survey data (n = 207 organizations). Authors then constructed logistic regressions, using state mortality data and policy context as predictors, to determine what contextual factors predicted HIV service organization implementation of harm reduction. RESULTS Drug-related mortality data revealed an increased need for harm reduction, and harm reduction policy data revealed an increased political openness to harm reduction. Frequency distributions revealed that approximately half of the HIV service organizations surveyed reported that their organizations reflect a harm reduction orientation, and only 26% reported providing harm reduction services. Despite low utilization rates, HIV service organizations indicated a strong interest in harm reduction. Logistic regressions revealed that while increased mortality rates do not predict HIV service organization implementation of harm reduction, a harm reduction-friendly policy context does. DISCUSSION This study highlights how regions within a high-income country can face unique barriers to healthcare and therefore require a unique understanding of implementation context. Study findings indicate a rapidly changing implementation context where increased need meets increased political opportunity to implement harm reduction, however there is a lag in HIV service organization adoption of harm reduction. Financial resources, capacity building, and continued policy advocacy are required for increased HIV service organization adoption of harm reduction.
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Affiliation(s)
- Megan C Stanton
- Department of Sociology, Anthropology, Criminology and Social Work, Eastern Connecticut State University, 83 Windham St, Willimantic, CT, 06226, USA.
| | - Samira B Ali
- Graduate College of Social Work, University of Houston, Houston, USA
| | - Katie McCormick
- Steve Hicks School of Social Work, University of Texas at Austin, Austin, USA
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22
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Song RS, Varshney K, Adalbert J, Reed M. Proximity analysis of hospitals and federally qualified health centers to syringe exchange programs in New York City. JOURNAL OF SUBSTANCE USE 2022. [DOI: 10.1080/14659891.2022.2087780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Rachel S. Song
- College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Karan Varshney
- College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Jenna Adalbert
- College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Megan Reed
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
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23
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Hall EW, Rosenberg ES, Jones CM, Asher A, Valverde E, Bradley H. Estimated number of injection-involved drug overdose deaths, United States, 2000 - 2018. Drug Alcohol Depend 2022; 234:109428. [PMID: 35364419 DOI: 10.1016/j.drugalcdep.2022.109428] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/10/2022] [Accepted: 03/22/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND In the United States, drug overdose mortality has increased. Death records categorize overdose deaths by type of drug involved, but do not include information about the route of drug administration. METHODS We utilized data from drug treatment admissions (Treatment Episodes Dataset, TEDS-A) and National Vital Statistics Systems to estimate the percentage of reported drug overdose deaths that were injection-involved from 2000 to 2018 in the U.S. Data on reported route of administration at admission were used to calculate the percent injecting each drug type, by demographic group (race/ethnicity, sex, age group) and year. Using the resulting probabilities, we estimated the number of overdose deaths that were injection-involved. Estimates were compared across drug types, demographic characteristics, and year. FINDINGS The number of overdose deaths among adults increased more than 3-fold from 2000 (n = 17,196) to 2018 (n = 67,021). During that timeframe, the number of estimated injection-involved overdose deaths increased more than 8-fold from 2000 (n = 3467, 95% CI: 3449-3485) to 2018 (n = 28,257, 95% CI: 28,192-28,322). From 2000-2007, the percent of overdose deaths that were injection-involved remained stable around 20%. From 2007-2018, the percent of overdose deaths that were injection-involved increased from 18.4% (95% CI: 18.3-18.6%) to 42.2% (95% CI: 42.1-42.3%). In 2018, most estimated injection-involved overdose deaths were due to injecting heroin/synthetic opioids (n = 24,860, 95% CI: 24,800-24,919), which accounted for 88.0% of all injection-involved deaths. CONCLUSIONS Much of the recent increase in overdose mortality is likely attributable to rising injection-involved overdose deaths.
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Affiliation(s)
- Eric W Hall
- School of Public Health, Oregon Health & Science University, Portland, OR, USA.
| | - Eli S Rosenberg
- Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, NY, USA
| | - Christopher M Jones
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alice Asher
- National Center for HIV/AIDS, Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Eduardo Valverde
- National Center for HIV/AIDS, Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Heather Bradley
- Department of Population Health Sciences, School of Public Health, Georgia State University, Atlanta, GA, USA
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24
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Puzhko S, Eisenberg MJ, Filion KB, Windle SB, Hébert-Losier A, Gore G, Paraskevopoulos E, Martel MO, Kudrina I. Effectiveness of Interventions for Prevention of Common Infections Among Opioid Users: A Systematic Review of Systematic Reviews. Front Public Health 2022; 10:749033. [PMID: 35273933 PMCID: PMC8901608 DOI: 10.3389/fpubh.2022.749033] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background The North American opioid crisis is marked by high opioid-related mortality and morbidity, including opioid use-associated infections (OUAIs). Users of pharmaceutical and non-pharmaceutical opioids are at an increased risk of acquiring hepatitis C (HCV), human immunodeficiency virus (HIV), and other infections. No high-level evidence, however, has been synthesized regarding effectiveness of interventions to prevent OUAIs in legal, and illegal/mixed opioid users. The aim of the study is to synthesize available systematic review (SR)-level evidence on the scope and effectiveness of interventions to prevent OUAIs among opioid users. Methods A SR of SRs approach was applied. We searched PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Epistemonikos and Google Scholar from inception to September 2020. Data selection and extraction were performed independently by three researchers. Risk of bias and quality of evidence were assessed using the AMSTAR2 tool. Results were narratively synthesized. Strength of evidence for each category was reported. Results Eleven of twelve identified SRs included interventions to prevent HCV/HIV transmission in persons who inject drugs (PWID), including opioids. One SR evaluated interventions to prevent recurrent infectious endocarditis. There was sufficient and tentative SR of SRs-level evidence for the effectiveness of opioid substitution therapy (OST) in preventing HIV and HCV, respectively. We found tentative evidence to support effectiveness of needle/syringe exchange programs (NSP) in HIV prevention, and sufficient evidence to support effectiveness of the combined OST and NSP in HCV prevention. There was insufficient SR-level evidence to support or discount effectiveness of other interventions to prevent OUAIs. No SR focused on non-PWID populations. Conclusion SR-level evidence supports the use of OST, NSP, and combined interventions for the reduction of HCV and HIV transmission in PWID. More research on prevention of other OUAIs and on prevention of OUAIs in non-PWID populations is urgently needed. Systematic Review Registration Registered in PROSPERO on July 30, 2020. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=195929, identifier: #195929.
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Affiliation(s)
- Svetlana Puzhko
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Mark J Eisenberg
- Jewish General Hospital, Lady Davis Institute for Medical Research, Montreal, QC, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada.,Division of Cardiology, Department of Medicine, Faculty of Medicine and Health Sciences, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Kristian B Filion
- Jewish General Hospital, Lady Davis Institute for Medical Research, Montreal, QC, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada.,Department of Medicine, Faculty of Medicine and Health Sciences, McGill University Health Center, McGill University, Montreal, QC, Canada
| | - Sarah B Windle
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Andréa Hébert-Losier
- Jewish General Hospital, Lady Davis Institute for Medical Research, Montreal, QC, Canada
| | - Genevieve Gore
- Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal, QC, Canada
| | | | - Marc O Martel
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada.,Faculty of Dentistry, McGill University, Montréal, QC, Canada
| | - Irina Kudrina
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada.,Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
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25
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Werb D, Scheim AI, Soipe A, Aeby S, Rammohan I, Fischer B, Hadland SE, Marshall BDL. Health harms of non-medical prescription opioid use: A systematic review. Drug Alcohol Rev 2022; 41:941-952. [PMID: 35437841 PMCID: PMC9064965 DOI: 10.1111/dar.13441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 01/06/2022] [Accepted: 01/08/2022] [Indexed: 11/30/2022]
Abstract
ISSUES Non-medical prescription opioid use (NMPOU) contributes substantially to the global burden of morbidity. However, no systematic assessment of the scientific literature on the associations between NMPOU and health outcomes has yet been undertaken. APPROACH We undertook a systematic review evaluating health outcomes related to NMPOU based on ICD-10 clinical domains. We searched 13 electronic databases for original research articles until 1 July 2021. We employed an adaptation of the Oxford Centre for Evidence-Based Medicine 'Levels of Evidence' scale to assess study quality. KEY FINDINGS Overall, 182 studies were included. The evidence base was largest on the association between NMPOU and mental and behavioural disorders; 71% (129) studies reported on these outcomes. Less evidence exists on the association of NMPOU with infectious disease outcomes (26; 14%), and on external causes of morbidity and mortality, with 13 (7%) studies assessing its association with intentional self-harm and 1 study assessing its association with assault (<1%). IMPLICATIONS A large body of evidence has identified associations between NMPOU and opioid use disorder as well as on fatal and non-fatal overdose. We found equivocal evidence on the association between NMPOU and the acquisition of HIV, hepatitis C and other infectious diseases. We identified weak evidence regarding the potential association between NMPOU and intentional self-harm, suicidal ideation and assault. DISCUSSION AND CONCLUSIONS Findings may inform the prevention of harms associated with NMPOU, although higher-quality research is needed to characterise the association between NMPOU and the full spectrum of physical and mental health disorders.
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Affiliation(s)
- Dan Werb
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, USA.,Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, Canada
| | - Ayden I Scheim
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, Canada.,Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, USA
| | - Ayorinde Soipe
- Department of Epidemiology, Brown University School of Public Health, Providence, USA.,Division of Nephrology, Department of Medicine, State University of New York, New York, USA
| | - Samantha Aeby
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada
| | - Indhu Rammohan
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, Canada
| | - Benedikt Fischer
- Schools of Population Health and Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.,Department of Psychiatry, University of Toronto, Toronto, Canada.,Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, Canada.,Department of Psychiatry, Federal University of Sao Paulo, São Paulo, Brazil
| | - Scott E Hadland
- Grayken Center for Addiction and Department of Pediatrics, Boston Medical Center, Boston, USA.,Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, Boston, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, USA
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26
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Merone L, Ashton S, Harris A, Edwards WS, Preston-Thomas A, Gair R, Russell DB. A complex increase in hepatitis C virus in a correctional facility: bumps in the road. Aust N Z J Public Health 2022; 46:377-381. [PMID: 35435996 DOI: 10.1111/1753-6405.13238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 10/01/2021] [Accepted: 02/01/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The prevalence of hepatitis C virus (HCV) in correctional facilities in Australia among people who inject drugs is 60%, with disproportionate effects observed in Aboriginal and Torres Strait Islander people. Following the micro-elimination of HCV in a Queensland correctional facility (QCF), newly acquired cases began to increase in mid-2019. Here we discuss the public health response to increasing HCV in a QCF. METHODS Enhanced surveillance was performed to obtain contextual outbreak data on risk factors including injecting drug use, sharing of personal hygiene equipment and do-it-yourself-tattooing. RESULTS In the sixteen months, there were 250 notifications of new and re-infected HCV infections in prisoners in the QCF. Qualitative data revealed the leading factor in transmission to be injecting drug use. CONCLUSIONS Drivers for increased HCV transmission in correctional facilities include boredom, waiting lists for opioid substitution programs, changes in injecting behaviours and sharing of injecting paraphernalia. Point-of-care testing combined with education and the development of a needle and syringe program may be promising ways forward for managing HCV in correctional facilities. IMPLICATIONS FOR PUBLIC HEALTH Correctional facilities are key locations to target sexually transmitted infection (STI) and blood-borne virus (BBV) testing and treatment as well as health promotion to improve the health of inmates and the communities they return to.
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Affiliation(s)
- Lea Merone
- Tropical Public Health Services, Cairns, Queensland
| | - Sian Ashton
- Tropical Public Health Services, Cairns, Queensland.,College of Health Care Sciences, James Cook University, Queensland
| | - Andy Harris
- Cairns and Hinterland Hospital and Health Service, Queensland
| | | | | | - Richard Gair
- Tropical Public Health Services, Cairns, Queensland
| | - Darren B Russell
- College of Health Care Sciences, James Cook University, Queensland.,Cairns Sexual Health Service, Queensland
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27
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Durable Viral Suppression Among People with HIV and Problem Substance Use in the Era of Universal Antiretroviral Treatment. AIDS Behav 2022; 26:385-396. [PMID: 34331177 PMCID: PMC8800950 DOI: 10.1007/s10461-021-03392-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2021] [Indexed: 02/03/2023]
Abstract
This study explored factors associated with durable viral suppression (DVS) among two groups of people living with HIV (PLWH) and problem substance use in the context of universal antiretroviral treatment initiation. Participants (N = 99) were recruited between 2014-2017 from public sexual health clinics [SHC] and a hospital detoxification unit [detox]). DVS (NYC HIV surveillance registry) was defined as two consecutive viral load tests ≤ 200 copies/mL, ≤ 90 days apart, with all other viral loads suppressed over 12 or 18 months. Detox participants were significantly older, with more unstable housing/employment, substance use severity, and longer-term HIV vs. SHC participants. Older age, opioid and stimulant use disorder were significantly associated with lower odds of DVS, while fulltime employment and stable housing were significantly associated with higher odds of DVS at 12-month follow-up. Patterns held at 18-month follow-up. Co-located substance use and HIV services, funding for supportive housing, and collaborative patient-provider relationships could improve DVS among populations with the syndemic of problem substance use, poverty, and long-term HIV.
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28
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Abstract
Opioid use disorder (OUD) is a treatable chronic disorder with episodes of remission and recurrence characterized by loss of control of opioid use, compulsive use, and continued use despite harms. If untreated, OUD is associated with significant morbidity and mortality. Buprenorphine and methadone reduce fatal and nonfatal opioid overdose and infectious complications of OUD and are the first-line treatment options. Physicians have an important role to play in diagnosing OUD and its comorbidities, offering evidence-based treatment, and delivering overdose prevention and other harm reduction services to people who continue to use opioids. Interdisciplinary office-based addiction treatment programs support high-quality OUD care.
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Affiliation(s)
- Jessica L Taylor
- Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, and Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts
| | - Jeffrey H Samet
- Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, and Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts
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29
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Community pharmacist engagement in HIV and HCV prevention: Current practices and potential for service uptake. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2021; 4:100088. [PMID: 35479840 PMCID: PMC9029914 DOI: 10.1016/j.rcsop.2021.100088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/10/2021] [Accepted: 10/25/2021] [Indexed: 11/20/2022] Open
Abstract
Background Objective Methods Results Conclusions Pharmacists are largely willing to help people who need HIV/HCV prevention services. Perception of HIV/HCV prevention fit with pharmacist professional identity varies. Cognitive HIV/HCV prevention services are preferred over hands-on clinical services. Pharmacists often engage in gatekeeping to limit sales of non-prescription syringes. Willingness to sell syringes potentially hinges on minimal contact with requestors.
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30
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Davy-Mendez T, Vittinghoff E, Dilworth SE, Suen LW, Braun C, Coffin PO, Satre DD, Riley ED. Non-fatal stimulant overdose among homeless and unstably housed women in San Francisco, California. Drug Alcohol Depend 2021; 228:109085. [PMID: 34600248 PMCID: PMC8595709 DOI: 10.1016/j.drugalcdep.2021.109085] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/14/2021] [Accepted: 09/14/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND US rates of overdose deaths involving stimulants (e.g., cocaine or methamphetamine) have increased, but little is known about non-fatal stimulant overdoses, particularly among vulnerable populations. We characterized rates of non-fatal stimulant overdose identified outside of health care settings among women at high risk. METHODS Homeless and unstably housed women in San Francisco, California using stimulants were administered questionnaires on drug use and outcomes (stimulant overdose, health care utilization) monthly for six months. Based on pilot interviews, stimulant overdose during follow-up was defined as acute toxicity from stimulant use ("over-amping") resulting in "feeling sick, really scared, or like one's life may be in danger". Poisson regression estimated unadjusted incidence rate ratio (IRR) comparing participant characteristics. RESULTS We included 160 women (41% Black, 26% White, 15% Latina, median age 54 years) using crack cocaine (81%), methamphetamine (48%), and powdered cocaine (36%). Participants reported 67 non-fatal stimulant overdoses over 685 person-months of observation, a rate of 117.4 per 100 person-years (95% CI 85.8-160.5). Rates were higher among participants who were Latina vs. White (IRR 4.18 [1.60-10.94]), used methamphetamine (IRR 1.80 [0.96-3.38]), or used any stimulant daily/almost daily (IRR 2.63 [1.41-4.91]). Among women reporting stimulant overdose, 4% received emergency and 3% inpatient care for overdose of any drug. CONCLUSIONS Women in this setting, particularly those who used stimulants frequently or used methamphetamine, experienced high non-fatal stimulant overdose and rarely received health care for these events. Efforts should be made to increase awareness and reduce harms of stimulant toxicity in vulnerable populations.
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Affiliation(s)
- Thibaut Davy-Mendez
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA,Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Samantha E. Dilworth
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Leslie W. Suen
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Carl Braun
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Phillip O. Coffin
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA,San Francisco Department of Public Health, San Francisco, CA, USA
| | - Derek D. Satre
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA,Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Elise D. Riley
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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31
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Handanagic S, Finlayson T, Burnett JC, Broz D, Wejnert C. HIV Infection and HIV-Associated Behaviors Among Persons Who Inject Drugs - 23 Metropolitan Statistical Areas, United States, 2018. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2021; 70:1459-1465. [PMID: 34673746 PMCID: PMC9361835 DOI: 10.15585/mmwr.mm7042a1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Senad Handanagic
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC
| | - Teresa Finlayson
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC
| | - Janet C Burnett
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC
| | - Dita Broz
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC
| | - Cyprian Wejnert
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC
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32
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Singer M, Bulled N, Ostrach B, Lerman Ginzburg S. Syndemics: A Cross-Disciplinary Approach to Complex Epidemic Events Like COVID-19. ANNUAL REVIEW OF ANTHROPOLOGY 2021. [DOI: 10.1146/annurev-anthro-100919-121009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In this review, we trace the origins and dissemination of syndemics, a concept developed within critical medical anthropology that rapidly diffused to other fields. The goal is to provide a review of the literature, with a focus on key debates. After a brief discussion of the nature and significance of syndemic theory and its applications, we trace the history and development of the syndemic framework within anthropology and the contributions of anthropologists who use it. We also look beyond anthropology to the adoption and use of syndemics in other health-related disciplines, including biomedicine, nursing, public health, and psychology, and discuss controversies in syndemics, particularly the perception that existing syndemics research focuses on methodologies at the individual level rather than at the population level and fails to provide evidence of synergistic interactions. Finally, we discuss emerging syndemics research on COVID-19 and provide an overview of the application of syndemics research.
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Affiliation(s)
- Merrill Singer
- Department of Anthropology, University of Connecticut, Storrs, Connecticut 06269-1248, USA
- Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut, Storrs, Connecticut 06269-1248, USA
| | - Nicola Bulled
- Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut, Storrs, Connecticut 06269-1248, USA
| | - Bayla Ostrach
- Family Medicine Department, Boston University School of Medicine, Boston, Massachusetts 02118, USA
| | - Shir Lerman Ginzburg
- Department of Public Health Sciences, The University of Connecticut Health Center, Manchester, Connecticut 06042, USA
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33
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Jones AA, Park JN, Allen ST, Schneider KE, Weir BW, Hunt D, Sherman SG. Racial differences in overdose training, naloxone possession, and naloxone administration among clients and nonclients of a syringe services program. J Subst Abuse Treat 2021; 129:108412. [PMID: 34080560 PMCID: PMC8565096 DOI: 10.1016/j.jsat.2021.108412] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 01/08/2021] [Accepted: 04/08/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate racial (Black/White) differences in overdose response training and take-home naloxone (THN) possession and administration among clients and nonclients of the Baltimore syringe service program (SSP). METHODS The study derived data from a cross-sectional survey of 263 (183 SSP clients, 80 nonclients) people who inject drugs (PWID). The study recruited SSP clients using targeted sampling and recruited nonclients through peer referral from April to November 2016. RESULTS In our sample, 61% of the participants were Black, 42% were between the ages of 18 and 44, and 70% were males. SSP clients, regardless of race, were more likely to have received overdose response training than Black nonclients (Black clients AOR: 3.85, 95% CI: 1.88, 7.92; White clients AOR: 2.73, 95% CI: 1.29, 5.75). The study found no significant differences in overdose response training between Black and White nonclients. SSP clients and White nonclients were more likely to possess THN than Black nonclients (Black clients: AOR: 4.21, 95% CI: 2.00, 8.87; White clients: AOR: 3.54, 95% CI: 1.56, 8.04; White nonclients AOR: 4.49, 95% CI: 1.50,13.47). CONCLUSION SSP clients were more likely to receive overdose response training than their nonclient peers who they referred to the study, illustrating the utility of SSPs in reaching PWID at high risk of overdose. We also observed that Black PWID, who did not access services at the SSP, were the least likely to possess THN, suggesting the need to employ outreach targeting Black PWID who do not access this central harm reduction intervention.
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Affiliation(s)
- A A Jones
- Department of Human Development and Family Studies, The Pennsylvania State University, 105 Health and Human Development Building, University Park, PA 16802, USA.
| | - J N Park
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, John Hopkins University, 624 N. Broadway, Baltimore, MD 21205, USA
| | - S T Allen
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, John Hopkins University, 624 N. Broadway, Baltimore, MD 21205, USA
| | - K E Schneider
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, John Hopkins University, 624 N. Broadway, Baltimore, MD 21205, USA
| | - B W Weir
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, John Hopkins University, 624 N. Broadway, Baltimore, MD 21205, USA
| | - D Hunt
- Baltimore City Health Department, 100 N. Holliday St, Baltimore, MD 21202, USA
| | - S G Sherman
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, John Hopkins University, 624 N. Broadway, Baltimore, MD 21205, USA
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Bouzanis K, Joshi S, Lokker C, Pavalagantharajah S, Qiu Y, Sidhu H, Mbuagbaw L, Qutob M, Henedi A, Levine MAH, Lennox R, Tarride JE, Kalina D, Alvarez E. Health programmes and services addressing the prevention and management of infectious diseases in people who inject drugs in Canada: a systematic integrative review. BMJ Open 2021; 11:e047511. [PMID: 34556508 PMCID: PMC8461723 DOI: 10.1136/bmjopen-2020-047511] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES People who inject drugs (PWID) experience a high burden of injection drug use-related infectious disease and challenges in accessing adequate care. This study sought to identify programmes and services in Canada addressing the prevention and management of infectious disease in PWID. DESIGN This study employed a systematic integrative review methodology. Electronic databases (PubMed, CINAHL and Web of Science Core Collection) and relevant websites were searched for literature published between 2008 and 2019 (last search date was 6 June 2019). Eligible articles and documents were required to address injection or intravenous drug use and health programmes or services relating to the prevention or management of infectious diseases in Canada. RESULTS This study identified 1607 unique articles and 97 were included in this study. The health programmes and services identified included testing and management of HIV and hepatitis C virus (n=27), supervised injection facilities (n=19), medication treatment for opioid use disorder (n=12), integrated infectious disease and addiction programmes (n=10), needle exchange programmes (n=9), harm reduction strategies broadly (n=6), mobile care initiatives (n=5), peer-delivered services (n=3), management of IDU-related bacterial infections (n=2) and others (n=4). Key implications for policy, practice and future research were identified based on the results of the included studies, which include addressing individual and systemic factors that impede care, furthering evaluation of programmes and the need to provide comprehensive care to PWID, involving medical care, social support and harm reduction. CONCLUSIONS These results demonstrate the need for expanded services across a variety of settings and populations. Our study emphasises the importance of addressing social and structural factors that impede infectious disease care for PWID. Further research is needed to improve evaluation of health programmes and services and contextual factors surrounding accessing services or returning to care. PROSPERO REGISTRATION NUMBER CRD42020142947.
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Affiliation(s)
- Katrina Bouzanis
- Department of Global Health, McMaster University, Hamilton, Ontario, Canada
| | - Siddharth Joshi
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Cynthia Lokker
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Yun Qiu
- School of Health Sciences, Jiangsu Institute of Commerce, Nanjing, Jiangsu, China
| | - Hargun Sidhu
- Department of Undergraduate Medical Education, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Majdi Qutob
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Alia Henedi
- Faculty of Pharmacy, Eastern Mediterranean University, Famagusta, North Cyprus, Cyprus
| | - Mitchell A H Levine
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Robin Lennox
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Center for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
| | - Dale Kalina
- Department of Infectious Diseases, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Elizabeth Alvarez
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Ontario, Canada
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Ginoza MEC, Tomita-Barber J, Onugha J, Bullock C, Bartholomew TS, Tookes HE, Serota DP. Student-Run Free Clinic at a Syringe Services Program, Miami, Florida, 2017-2019. Am J Public Health 2021; 110:988-990. [PMID: 34166061 DOI: 10.2105/ajph.2020.305705] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Margaret E C Ginoza
- Margaret E. C. Ginoza, Jasmine Tomita-Barber, Jason Onugha, and Corinne Bullock are with the Department of Medical Education, University of Miami Miller School of Medicine, Miami, FL. Tyler S. Bartholomew is with the Department of Public Health Sciences, University of Miami Miller School of Medicine. Hansel E. Tookes and David P. Serota are with the Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine
| | - Jasmine Tomita-Barber
- Margaret E. C. Ginoza, Jasmine Tomita-Barber, Jason Onugha, and Corinne Bullock are with the Department of Medical Education, University of Miami Miller School of Medicine, Miami, FL. Tyler S. Bartholomew is with the Department of Public Health Sciences, University of Miami Miller School of Medicine. Hansel E. Tookes and David P. Serota are with the Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine
| | - Jason Onugha
- Margaret E. C. Ginoza, Jasmine Tomita-Barber, Jason Onugha, and Corinne Bullock are with the Department of Medical Education, University of Miami Miller School of Medicine, Miami, FL. Tyler S. Bartholomew is with the Department of Public Health Sciences, University of Miami Miller School of Medicine. Hansel E. Tookes and David P. Serota are with the Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine
| | - Corinne Bullock
- Margaret E. C. Ginoza, Jasmine Tomita-Barber, Jason Onugha, and Corinne Bullock are with the Department of Medical Education, University of Miami Miller School of Medicine, Miami, FL. Tyler S. Bartholomew is with the Department of Public Health Sciences, University of Miami Miller School of Medicine. Hansel E. Tookes and David P. Serota are with the Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine
| | - Tyler S Bartholomew
- Margaret E. C. Ginoza, Jasmine Tomita-Barber, Jason Onugha, and Corinne Bullock are with the Department of Medical Education, University of Miami Miller School of Medicine, Miami, FL. Tyler S. Bartholomew is with the Department of Public Health Sciences, University of Miami Miller School of Medicine. Hansel E. Tookes and David P. Serota are with the Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine
| | - Hansel E Tookes
- Margaret E. C. Ginoza, Jasmine Tomita-Barber, Jason Onugha, and Corinne Bullock are with the Department of Medical Education, University of Miami Miller School of Medicine, Miami, FL. Tyler S. Bartholomew is with the Department of Public Health Sciences, University of Miami Miller School of Medicine. Hansel E. Tookes and David P. Serota are with the Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine
| | - David P Serota
- Margaret E. C. Ginoza, Jasmine Tomita-Barber, Jason Onugha, and Corinne Bullock are with the Department of Medical Education, University of Miami Miller School of Medicine, Miami, FL. Tyler S. Bartholomew is with the Department of Public Health Sciences, University of Miami Miller School of Medicine. Hansel E. Tookes and David P. Serota are with the Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine
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Ryan P, Valencia J, Cuevas G, Troya J, Torres-Macho J, Muñoz-Gómez MJ, Muñoz-Rivas N, Canorea I, Vázquez-Morón S, Resino S. HIV screening and retention in care in people who use drugs in Madrid, Spain: a prospective study. Infect Dis Poverty 2021; 10:111. [PMID: 34412695 PMCID: PMC8375145 DOI: 10.1186/s40249-021-00894-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/08/2021] [Indexed: 11/17/2022] Open
Abstract
Background The burden of human immunodeficiency virus (HIV) infection in people who use drugs (PWUD) is significant. We aimed to screen HIV infection among PWUD and describe their retention in HIV care. Besides, we also screen for hepatitis C virus (HCV) infection among HIV-seropositive PWUD and describe their linkage to care. Methods We conducted a prospective study in 529 PWUD who visited the “Cañada Real Galiana” (Madrid, Spain). The study period was from June 1, 2017, to May 31, 2018. HIV diagnosis was performed with a rapid antibody screening test at the point-of-care (POC) and HCV diagnosis with immunoassay and PCR tests on dried blood spot (DBS) in a central laboratory. Positive PWUD were referred to the hospital. We used the Chi-square or Fisher’s exact tests, as appropriate, to compare rates between groups. Results Thirty-five (6.6%) participants were positive HIV antibodies, but 34 reported previous HIV diagnoses, and 27 (76%) had prior antiretroviral therapy. Among patients with a positive HIV antibody test, we also found a higher prevalence of homeless (P < 0.001) and injection drug use (PWID) (P < 0.001), and more decades of drug use (P = 0.002). All participants received HIV test results at the POC. Of the 35 HIV positives, 28 (80%) were retained in HIV medical care at the end of the HIV screening study (2018), and only 22 (62.9%) at the end of 2020. Moreover, 12/35 (34.3%) were positive for the HCV RNA test. Of the latter, 10/12 (83.3%) were contacted to deliver the HCV results test (delivery time of 19 days), 5/12 (41.7%) had an appointment and were attended at the hospital and started HCV therapy, and only 4/12 (33.3%) cleared HCV. Conclusions We found almost no new HIV-infected PWUD, but their cascade of HIV care was low and remains a challenge in this population at risk. The high frequency of active hepatitis C in HIV-infected PWUD reflects the need for HCV screening and reinforcing the link to care. ![]()
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Affiliation(s)
- Pablo Ryan
- Hospital Universitario Infanta Leonor, Madrid, Spain.,Universidad Complutense de Madrid (UCM), Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Jorge Valencia
- Hospital Universitario Infanta Leonor, Madrid, Spain.,Unidad de Reducción de Daños "SMASD", Madrid, Spain
| | | | - Jesús Troya
- Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - María José Muñoz-Gómez
- Unidad de Infección Viral e Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Carretera Majadahonda- Pozuelo, Km 2.2, 28220, Majadahonda, Madrid, Spain
| | | | - Isabel Canorea
- Unidad de Infección Viral e Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Carretera Majadahonda- Pozuelo, Km 2.2, 28220, Majadahonda, Madrid, Spain
| | - Sonia Vázquez-Morón
- Unidad de Infección Viral e Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Carretera Majadahonda- Pozuelo, Km 2.2, 28220, Majadahonda, Madrid, Spain
| | - Salvador Resino
- Unidad de Infección Viral e Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Carretera Majadahonda- Pozuelo, Km 2.2, 28220, Majadahonda, Madrid, Spain.
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Bartholomew TS, Feaster DJ, Patel H, Forrest DW, Tookes HE. Reduction in injection risk behaviors after implementation of a syringe services program, Miami, Florida. J Subst Abuse Treat 2021; 127:108344. [PMID: 34134863 PMCID: PMC8221088 DOI: 10.1016/j.jsat.2021.108344] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 01/21/2021] [Accepted: 02/15/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Syringe services programs (SSPs) are evidence-based HIV prevention programs for people who inject drugs. However, not all SSPs operate evidence-based syringe distribution models, such as needs-based distribution. This study aims to provide preliminary evidence from the IDEA SSP on changes in injection risk behaviors over time, and to examine factors, including syringe coverage, associated with injection risk behavior trajectories over time under a one-for-one syringe distribution model. METHODS We used a prospective observational study design to generate a cohort of SSP clients who completed three behavioral assessments at SSP service visits between December 2016 and January 2020 (N = 115). The study used generalized estimating equations (GEE) to examine the relationship between covariate measures and the primary outcomes. The primary outcomes were 1) sharing of any injection equipment (e.g. syringes, needles, cookers, cottons) in the previous 30 days (yes/no) and 2) reusing of needles/syringes in the previous 30 days (yes/no). RESULTS Men were more likely to report reusing syringes (aRR = 1.15, 95% CI: 1.01-1.37) and those who reported injecting in public were less likely to report reusing syringes (aRR = 0.90, 95% CI: 0.82-0.99). HCV-positive clients had a 62% reduction in sharing injection equipment and those who reported public injection had a 62% increase in sharing injection equipment over time. Most importantly, increasing syringe coverage was associated with a decrease in both sharing injection equipment (aRR = 0.42, 95% CI: 0.25-0.72) and reusing syringes (aRR = 0.79, 95% CI: 0.66-0.95). CONCLUSION This study provides preliminary evidence of reductions in injection-related risk behaviors from the IDEA SSP and highlights potential high priority groups, such as people experiencing homelessness, that may need additional intervention. In addition, improving syringe coverage among SSP clients may be an important factor in reducing behaviors that place individuals at risk for contracting HIV and HCV.
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Affiliation(s)
- Tyler S Bartholomew
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA.
| | - Daniel J Feaster
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Hardik Patel
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - David W Forrest
- Department of Anthropology, College of Arts and Sciences, University of Miami, Miami, FL, USA
| | - Hansel E Tookes
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
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Wenger LD, Kral AH, Bluthenthal RN, Morris T, Ongais L, Lambdin BH. Ingenuity and resiliency of syringe service programs on the front lines of the opioid overdose and COVID-19 crises. Transl Res 2021; 234:159-173. [PMID: 33746108 PMCID: PMC8217165 DOI: 10.1016/j.trsl.2021.03.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/25/2021] [Accepted: 03/15/2021] [Indexed: 12/09/2022]
Abstract
As COVID-19 accelerated throughout 2020, syringe service programs (SSPs) faced challenges necessitating programmatic adaptations to prevent overdose deaths while simultaneously keeping workers and participants safe from COVID-19. We used qualitative methods to gain an understanding of the social context within which SSPs are operating during the COVID-19 pandemic. We conducted 36 in-depth interviews with program representatives from 18 programs and used the Exploration, Preparation, Implementation, Sustainment (EPIS) implementation framework to guide data analysis. We focused on 3 of the 4 EPIS constructs: Outer context, inner context, and innovation factors. Our data indicate that responding to the pandemic led to innovations in service delivery such as secondary and mail-based distribution, adoption of telemedicine for enrolling participants in medications for opioid use disorder (MOUD) and use of virtual training platforms for overdose prevention. We found high levels of staff and volunteer commitment, which was a cornerstone to the success of these innovations. We observed that many SSPs were short-staffed because of their commitment to safety, and some lost current funding as well as opportunities for future funding. Despite minimal staffing and diminished funding, SSPs innovated at an accelerated pace. To ensure the sustainability of these new approaches, a supportive external context (federal, state, and local policies and funding) is needed to support the development of SSPs' inner contexts (organizational characteristics, characteristics of individuals) and sustainment of the innovations achieved regarding delivery of naloxone and MOUD.
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Affiliation(s)
| | | | - Ricky N Bluthenthal
- University of Southern California, Keck School of Medicine, Los Angeles, California
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Wong CY, Zhu W, Aurigemma GP, Furukawa N, Teshale EH, Huang YLA, Peters PJ, Hoover KW. Infective Endocarditis Among Persons Aged 18-64 Years Living with Human Immunodeficiency Virus, Hepatitis C Infection, or Opioid Use Disorder, United States, 2007-2017. Clin Infect Dis 2021; 72:1767-1781. [PMID: 32270861 DOI: 10.1093/cid/ciaa372] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 04/08/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Infective endocarditis (IE) is a life-threatening bacterial infection of the heart valves, most often diagnosed in older persons and persons with prior cardiac surgery. It is also associated with injection drug use, a behavior that has increased in recent years along with the US opioid crisis. METHODS We conducted a retrospective cohort analysis of commercial and Medicaid health insurance databases to estimate incident cases of IE in the United States in 2017, stratified by persons living with human immunodeficiency virus (HIV), hepatitis C virus (HCV), and opioid use disorder (OUD). We also estimated annual percentage changes (EAPCs) in IE from 2007-2017 among persons with commercial insurance. RESULTS The weighted incidence rate of IE was 13.8 cases per 100 000 persons among persons with commercial insurance, and 78.7 among those with Medicaid. The incidence rate of IE among commercially insured persons increased slightly from 2007-2017 (EAPC, 1.0%). It decreased among commercially insured persons living with HIV, from 148.0 in 2007 to 112.1 in 2017 (EAPC, -4.3%), and increased among those with HCV infection, from 172.4 in 2007 to 238.6 in 2017 (EAPC, 3.2%). Among persons aged 18-29 years with HCV infection, IE increased from 322.3 in 2007 to 1007.1 in 2017 (EAPC, 16.3%), and among those with OUD it increased from 156.4 in 2007 to 642.9 in 2017 (EAPC, 14.8%). CONCLUSIONS The incidence rate of IE increased markedly among young persons with HCV infections or OUD. This increase appears to parallel the ongoing national opioid crisis. Harm reduction with syringe services programs, medications for opioid use disorder, and safe injection practices can prevent the spread of HIV, HCV, and IE.
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Affiliation(s)
- Cecillia Y Wong
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Weiming Zhu
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Gerard P Aurigemma
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Nathan Furukawa
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Eyasu H Teshale
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ya-Lin A Huang
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Philip J Peters
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Karen W Hoover
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Stein MD, Phillips KT, Herman DS, Keosaian J, Stewart C, Anderson BJ, Weinstein Z, Liebschutz J. Skin-cleaning among hospitalized people who inject drugs: a randomized controlled trial. Addiction 2021; 116:1122-1130. [PMID: 32830383 DOI: 10.1111/add.15236] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/31/2020] [Accepted: 08/17/2020] [Indexed: 01/29/2023]
Abstract
AIMS To test the hypothesis that among hospitalized people who inject drugs (PWID), a brief intervention in skin-cleaning would result in greater reductions in follow-up emergency department (ED) or hospitalization rates compared with a usual care condition. DESIGN Randomized, two-group (intervention, n = 128; usual care, n = 124), single-site clinical trial with12-month follow-up. SETTING Hospital inpatient services in Boston, Massachusetts, United States. PARTICIPANTS People who injected drugs on at least 3 days each week prior to hospital admission (n = 252). Participants averaged 37.9 (± 10.7) years of age; 58.5% were male, 59.3% were white and 61.1% had a diagnosis related to skin infection at enrollment. INTERVENTION AND COMPARATOR Intervention was a skin hygiene education and skills-training behavioral intervention [short-term efficacy data on a behavioral intervention (SKIN)] consisting of two education- and skills-based skin-cleaning sessions, one during hospitalization and another 4 weeks later. The comparator was treatment as usual: an informational brochure about substance use treatment options and needle exchange programs in the area and follow-up clinical appointments as arranged by the inpatient medical staff. MEASUREMENTS Electronic medical records were reviewed and discharge diagnoses for each ED visit and hospital admission were categorized into injection-related bacterial events (e.g. cellulitis) and non-injection-related events. Negative binomial regression was used to test the intervention effects for the primary outcome and total ED visits, as well as the secondary outcomes, total number of hospitalizations, injection drug use-related (IDU-related) ED visits and IDU-related hospitalizations. We also tested whether the outcomes were moderated by whether the initial hospitalization was IDU-related. FINDINGS Of people assigned to SKIN, 66 completed two sessions, 55 completed one session and seven completed zero sessions. Adjusting for baseline covariates, the mean rate of total ED visits in the next 12 months was non-significantly higher [incidence rate ratio (IRR) = 1.13, 95% confidence interval (CI) = 0.96, 1.33, P = 0.152] compared with usual treatment. The intervention did not significantly reduce total hospitalizations or IDU-related hospitalizations. Adjusting for baseline covariates, the mean rate of injection drug use-related ED visits in the next 12 months was lower (IRR = 0.57, 95% CI = 0.35, 0.91, P = 0.019) compared with treatment as usual. CONCLUSIONS A skin-cleaning intervention for people who inject drugs delivered during a hospitalization did not significantly reduce either overall emergency department use or hospitalization. There was some evidence that it may have reduced injection drug use-related emergency department visits.
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Affiliation(s)
- Michael D Stein
- Behavioral Medicine and Addictions Research, Butler Hospital, Providence, RI, USA.,Boston University School of Public Health, Boston, MA,, USA
| | - Kristina T Phillips
- Center for Integrated Health Care Research, Kaiser Permanente Hawaii, Honolulu, HI, USA
| | - Debra S Herman
- Behavioral Medicine and Addictions Research, Butler Hospital, Providence, RI, USA.,Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Julia Keosaian
- Boston University School of Public Health, Boston, MA,, USA
| | | | - Bradley J Anderson
- Behavioral Medicine and Addictions Research, Butler Hospital, Providence, RI, USA
| | - Zoe Weinstein
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jane Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
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Needling Policy Makers and Sharpening the Debate: Do Syringe Exchange Programs Improve Health at the Population Level? JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2021; 26:222-226. [PMID: 32235205 DOI: 10.1097/phh.0000000000001152] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
CONTEXT In the midst of the current opioid epidemic, states have selected differing legislative routes implementing pathways to ensure access to clean needles and syringes. OBJECTIVE To determine whether states that implemented laws supporting syringe exchange programs (SEPs) had reductions in transmission rates of hepatitis B, hepatitis C, and HIV infection compared with states without such laws. DESIGN AND SETTING Utilizing a longitudinal panel design, we determined the legal status of SEPs in each state for years 1983-2016. Disease transmission rates for this period were estimated via a simple Poisson regression, with transmitted cases as the dependent variable, law categories as the predictor variables, and the log of state population as the exposure. The mean number of incident cases per state-year was also calculated. PARTICIPANTS US states were utilized as the unit of analysis. RESULTS Hepatitis B and hepatitis C mean transmission rate per 100 000 population declined in states with local ordinances/decriminalized statutes and legalized SEPs (hepatitis B: 71% and 81%, respectively, differences P < .001; hepatitis C: 8% and 38%, respectively, differences P < .001). Reductions in mean incident cases per state-year mirrored these findings. HIV infection among injection drug users yielded inconsistent results. CONCLUSIONS Hepatitis B and hepatitis C transmission were reduced at the population level in states with SEP laws in a pattern reflecting the degree of legal intervention. HIV infection, based upon a smaller data set, showed a mixed impact. POLICY IMPLICATIONS The results show promise that SEPs have population-level effects on disease transmission. States lacking SEPs should reconsider current policies.
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Soria J, Johnson T, Collins J, Corby-Lee G, Thacker J, White C, Hoven A, Thornton A. Risk factors for loss to follow-up of persons who inject drugs enrolled at syringe services programs in Kentucky. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 95:103255. [PMID: 33853033 DOI: 10.1016/j.drugpo.2021.103255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 02/23/2021] [Accepted: 04/01/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Syringe services programs (SSP) are an effective strategy to reduce blood-borne infections of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) in persons who inject drugs (PWID). The objectives of this study were to determine the frequency and risk factors for loss to follow-up (LTFU) in PWID enrolled at SSPs in Kentucky. METHODS A retrospective cohort study was conducted which included data of PWID enrolled at 32 SSP. Demographics, use of drugs, HIV testing, HCV testing, and medical services were analyzed. A generalized linear model (GLM), family binomial was used to determine risk factors for LTFU. RESULTS The analysis included 5742 PWID. LTFU by year of enrollment was 287/770 (37.3%) in 2017, 796/1874 (42.5%) in 2018, and 1479/3,098 (47.7%) in 2019. LTFU was significantly associated with distance to SSP from home of more than five miles (RR 1.25; 95%CI 1.09-1.43; p = 0.002) and SSPs housed in rural counties (RR 1.22; 95%CI 1.06-1.40; p = 0.004), adjusted by age, sex, and race. The use of buprenorphine was associated with less risk of LTFU (RR 0.79, p = 0.034). CONCLUSION The distance to an SSP from home and SSPs in rural counties were identified as risk factors for LTFU. Initiatives that bring health services closer to PWID homes and offer opioid use disorder treatment may improve repeated participation in SSPs.
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Affiliation(s)
- Jaime Soria
- KADAP Income Reinvestment Program (KIRP), Division of Infectious Diseases, University of Kentucky, United States.
| | - Tisha Johnson
- Kentucky Department for Public Health, KY, United States
| | - Jana Collins
- KADAP Income Reinvestment Program (KIRP), Division of Infectious Diseases, University of Kentucky, United States
| | - Greg Corby-Lee
- KADAP Income Reinvestment Program (KIRP), Division of Infectious Diseases, University of Kentucky, United States
| | - James Thacker
- KADAP Income Reinvestment Program (KIRP), Division of Infectious Diseases, University of Kentucky, United States
| | - Connie White
- Kentucky Department for Public Health, KY, United States
| | - Ardis Hoven
- KADAP Income Reinvestment Program (KIRP), Division of Infectious Diseases, University of Kentucky, United States
| | - Alice Thornton
- KADAP Income Reinvestment Program (KIRP), Division of Infectious Diseases, University of Kentucky, United States
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Russell C, Ali F, Nafeh F, Rehm J, LeBlanc S, Elton-Marshall T. Identifying the impacts of the COVID-19 pandemic on service access for people who use drugs (PWUD): A national qualitative study. J Subst Abuse Treat 2021; 129:108374. [PMID: 34080545 DOI: 10.1016/j.jsat.2021.108374] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/12/2021] [Accepted: 03/14/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Closures and reductions in capacity of select health and social services in response to the COVID-19 pandemic may have placed people who use drugs (PWUD) at a disproportionately increased risk for experiencing harms, and resulted in critical treatment disruptions. We conducted the current national study among a cohort of PWUD to understand how COVID-19 has affected service access, including any significant impacts PWUD may have experienced. Results will contribute to the evidence base for informing future pandemic and public health policy planning for vulnerable populations. METHODS The project involved qualitative telephone-based interviews with 196 adult (aged 18+) PWUD from across Canada. Eligibility criteria included daily or weekly use of psychoactive substance(s), and/or current enrollment in opioid agonist treatment (OAT). Data collection took place between May and July 2020. Data underwent thematic analyses, and common themes informed the results. RESULTS Most participants experienced detrimental service access issues and treatment disruptions during COVID-19, including reduced access to harm reduction services, OAT, withdrawal management and treatment services, medical professionals (e.g., addictions and mental health counseling), shelters/housing, and food banks. Positive impacts included greater access to OAT take-home 'carries' and prescription deliveries. Decreases in service capacity resulted in increased health issues and risky substance use behaviors among PWUD, such as unaccompanied substance use, sharing/re-use of supplies, and overdose events. CONCLUSIONS Reductions in the accessibility of critical services PWUD rely on during COVID-19 has increased existent substance use and health issues among PWUD, while decreasing their ability to mitigate risks related to substance use. Thus, the expansion of the depth and breadth of support options is crucial. Services must remain open and flexible to the unique needs of PWUD during COVID-19, while novel and effective adaptations and interventions should remain available and accessible post-COVID-19.
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Affiliation(s)
- Cayley Russell
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada.
| | - Farihah Ali
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada.
| | - Frishta Nafeh
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada.
| | - Jürgen Rehm
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada; Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Ontario M5T 3M7, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), 250 College St., Toronto, Ontario M5T 1R8, Canada; Department of Psychiatry, University of Toronto, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada; Institute of Medical Science (IMS), University of Toronto, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada; Institut für Klinische Psychologie und Psychotherapie, Technische Universität Dresden, Chemnitzer Str. 46, 01187 Dresden, Germany; Department of International Health Projects, Institute for Leadership and Health Management, I.M. Sechenov First Moscow State Medical University, Bol'shaya Pirogovskaya Ulitsa, 19с1, Moscow 119146, Russia.
| | - Sean LeBlanc
- Drug Users Advocacy League, 216 Murray St, Ottawa, Ontario K1N 5S6, Canada; Canadian Association of People who Use Drugs (CAPUD), Canada.
| | - Tara Elton-Marshall
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada; Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Ontario M5T 3M7, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), 250 College St., Toronto, Ontario M5T 1R8, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St., London, Ontario M6A 5C1, Canada; Department of Health Sciences, Lakehead University, 955 Oliver Road, Thunder Bay, Ontario P7B 5E1, Canada.
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Pre-exposure prophylaxis awareness, acceptability and potential stigma among medical and non-medical clinic staff in methadone treatment settings in northern New Jersey: The key role of non-medical staff in enhancing HIV prevention. J Subst Abuse Treat 2021; 129:108371. [PMID: 34080542 DOI: 10.1016/j.jsat.2021.108371] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 01/06/2021] [Accepted: 03/11/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND HIV prevention is needed among people who use drugs (PWUD) due to mixing sex and drugs, selling/trading sex, and/or injecting drugs. Pre-exposure prophylaxis (PrEP) is an extremely effective biomedical HIV prevention strategy, but uptake remains low among communities most in need of HIV prevention, including PWUD. Previous studies have found that providers are less willing to prescribe PrEP to PWUD, yet PWUD express high levels of PrEP acceptance. More research is needed to understand how people who provide substance use treatment services think about PrEP to maximize this biomedical prevention strategy. METHODS The study conducted semistructured interviews with 29 staff members in two methadone clinic settings in urban northern New Jersey. Staff members included medical providers, methadone counselors, intake coordinators, front desk staff, lab technicians, security guards, and administrative/leadership personnel. RESULTS All staff recognized the need for HIV prevention among their patient populations, but most were either unaware of PrEP or unfamiliar with its purpose and how it works. Medical providers were more likely to have some PrEP knowledge in comparison to counselors and other staff, but the former largely did not have in-depth knowledge. Among those familiar with PrEP, many confused PrEP with HIV medication, as Truvada was the only FDA-approved PrEP at the time of the study. About half of participants expressed clear support for PrEP, while the other half expressed mixed or negative attitudes related to HIV, sexual behavior, and mistrust of the medication. Both the positive and negative perceptions entailed stigmatizing elements. RECOMMENDATIONS Due to patients' frequent interactions with non-medical staff (e.g., front desk staff, lab technicians, etc.), all staff, not only medical personnel, should be aware of PrEP and comfortable discussing it to foster well-informed, nonjudgmental conversations about HIV prevention with patients. PrEP education should specifically address HIV and sexual-related stigma, as even positive perceptions of PrEP may entail stigmatizing elements.
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Roth AM, Tran NK, Felsher MA, Gadegbeku AB, Piecara B, Fox R, Krakower DS, Bellamy SL, Amico KR, Benitez JA, Van Der Pol B. Integrating HIV Preexposure Prophylaxis With Community-Based Syringe Services for Women Who Inject Drugs: Results From the Project SHE Demonstration Study. J Acquir Immune Defic Syndr 2021; 86:e61-e70. [PMID: 33148998 PMCID: PMC7878321 DOI: 10.1097/qai.0000000000002558] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/14/2020] [Indexed: 01/07/2023]
Abstract
INTRODUCTION To guide future preexposure prophylaxis (PrEP) implementation for women who inject drugs (WWID), a population increasingly represented in new HIV cases in the United States, we present results from a demonstration project integrated within a syringe services program (SSP) in Philadelphia, PA. METHODS WWID ≥18 years were educated about and offered 24 weeks of daily PrEP. Participants completed surveys and clinical assessments at baseline and at weeks 1, 3, 12, and 24. We used descriptive statistics to estimate feasibility/acceptability, engagement in the care cascade, HIV/sexually transmitted diseases (STI) and pregnancy, issues of safety/tolerability, and preferences/satisfaction with PrEP services. Multivariable logistic regression with generalized estimating equations was used to identify factors associated with PrEP uptake and retention. RESULTS We recruited 136 WWID. Of those, 95 were included in the final sample, and 63 accepted a PrEP prescription at week 1. Uptake was associated with greater baseline frequency of SSP access [adjusted odds ratio (aOR) = 1.85; 95% confidence interval (CI): 1.24 to 2.77], inconsistent condom use (aOR = 3.38; 95% CI: 1.07 to 10.7), and experiencing sexual assault (aOR = 5.89; 95% CI: 1.02, 33.9). Of these 95, 42 (44.2%) were retained at week 24. Retention was higher among women who reported more frequent baseline SSP access (aOR = 1.46; 95% CI: 1.04 to 2.24). Self-reported adherence was high but discordant with urine-based quantification of tenofovir. Baseline STI prevalence was 17.9%; there were 2 HIV seroconversions and 1 pregnancy. Safety/tolerability issues were uncommon, and acceptability/satisfaction was high. CONCLUSIONS Integrating PrEP with SSP services is feasible and acceptable for WWID. This suggests that daily PrEP is a viable prevention tool for this vulnerable population.
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Affiliation(s)
- Alexis M. Roth
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Nguyen K. Tran
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Marisa A. Felsher
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Annette B. Gadegbeku
- Department of Family, Community, and Preventive Medicine, College of Medicine, Drexel University, Philadelphia, PA, USA
| | - Brogan Piecara
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Rachel Fox
- Partnership Comprehensive Care Practice, Drexel University, Philadelphia, PA, USA
| | - Douglas S. Krakower
- The Fenway Institute, Fenway Health, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Scarlett L. Bellamy
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - K. Rivet Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Barbara Van Der Pol
- Division of Infectious Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Earlywine JJ, Bazzi AR, Biello KB, Klevens RM. High Prevalence of Indications for Pre-exposure Prophylaxis Among People Who Inject Drugs in Boston, Massachusetts. Am J Prev Med 2021; 60:369-378. [PMID: 33229144 PMCID: PMC7902399 DOI: 10.1016/j.amepre.2020.09.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/20/2020] [Accepted: 09/15/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION In Massachusetts, recent outbreaks of HIV have been fueled by injection and sexual exposures among people who inject drugs. Understanding pre-exposure prophylaxis need, knowledge, and use among people who inject drugs will help inform and evaluate interventions. METHODS In 2019, investigators analyzed 2018 National HIV Behavioral Surveillance data from people who inject drugs in Boston, MA, who met eligibility criteria. Proportions of people who inject drugs with U.S. Preventive Services Task Force-based pre-exposure prophylaxis indication were estimated by types of HIV acquisition risk in the past year: injection exposure only, sexual exposure only, and overlapping injection and sexual exposures. Investigators then evaluated pre-exposure prophylaxis awareness, conversations with healthcare providers about pre-exposure prophylaxis, and self-reported pre-exposure prophylaxis use among those with and without pre-exposure prophylaxis indications. RESULTS The prevalence of pre-exposure prophylaxis indication was 92% overall (389/423), with 290 (69%) participants indicated for injection exposures only, 3 (<1%) indicated for sexual exposures only, and 96 (23%) indicated for both injection and sexual exposures. Among those indicated for pre-exposure prophylaxis (n=389), 152 (39%) reported being aware of pre-exposure prophylaxis, 41 (11%) had discussed pre-exposure prophylaxis with a healthcare provider, and 8 (2%) had used pre-exposure prophylaxis in the past year. There were no statistically significant differences between pre-exposure prophylaxis‒indicated and ‒nonindicated people who inject drugs with respect to pre-exposure prophylaxis awareness, discussion with a healthcare provider, and pre-exposure prophylaxis use. CONCLUSIONS Indication for pre-exposure prophylaxis was high, but awareness was low, conversations about pre-exposure prophylaxis with healthcare providers were uncommon, and pre-exposure prophylaxis use was extremely low. These findings highlight important areas for clinical and community-based interventions to improve pre-exposure prophylaxis uptake among and delivery to people who inject drugs.
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Affiliation(s)
- Joel J Earlywine
- From the Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts; Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Angela R Bazzi
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts.
| | - Katie B Biello
- Center for Health Promotion and Health Equity, Brown University, Providence, Rhode Island; Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island; Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island; The Fenway Institute, Fenway Health, Boston, Massachusetts
| | - R Monina Klevens
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, Massachusetts
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Macias-Konstantopoulos W, Heins A, Sachs CJ, Whiteman PJ, Wingkun NJG, Riviello RJ. Between Emergency Department Visits: The Role of Harm Reduction Programs in Mitigating the Harms Associated With Injection Drug Use. Ann Emerg Med 2021; 77:479-492. [PMID: 33579588 DOI: 10.1016/j.annemergmed.2020.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 10/05/2020] [Accepted: 11/12/2020] [Indexed: 01/29/2023]
Abstract
Injection drug use is a major public health problem in the United States. Cocaine, heroin, and methamphetamine are the most commonly injected illicit drugs, whereas opioids are responsible for the majority of overdose fatalities. Although recent emergency department (ED) efforts have focused on expanding capacity for buprenorphine induction for opioid use disorder treatment, the injection of illicit drugs carries specific health risks that require acknowledgment and management, particularly for patients who decline substance use treatment. Harm reduction is a public health approach that aims to reduce the harms associated with a health risk behavior, short of eliminating the behavior itself. Harm-reduction strategies fundamental to emergency medicine include naloxone distribution for opioid overdose. This clinical Review Article examines the specific health complications of injection drug use and reviews the evidence base for 2 interventions effective in reducing morbidity and mortality related to drug injection, irrespective of the specific drug used, that are less well known and infrequently leveraged by emergency medicine clinicians: syringe service programs and supervised injection facilities. In accordance with the recommendations of health authorities such as the Centers for Disease Control and Prevention, emergency clinicians can promote the use of harm-reduction programs in the community to reduce viral transmission and other risks of injection drug use by providing patients with information about and referrals to these programs after injection drug use-related ED visits.
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Affiliation(s)
| | - Alan Heins
- Department of Emergency Medicine, University of South Alabama College of Medicine, Mobile, AL
| | - Carolyn J Sachs
- David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA
| | - Paula J Whiteman
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Neil-Jeremy G Wingkun
- Department of Emergency Medicine, University of Texas MD Anderson Cancer Center and Houston Methodist Hospital, Houston, TX
| | - Ralph J Riviello
- Department of Emergency Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX
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White RH, O’Rourke A, Kilkenny ME, Schneider KE, Weir BW, Grieb SM, Sherman SG, Allen ST. Prevalence and correlates of receptive syringe-sharing among people who inject drugs in rural Appalachia. Addiction 2021; 116:328-336. [PMID: 32533612 PMCID: PMC7736103 DOI: 10.1111/add.15151] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/26/2020] [Accepted: 06/10/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIMS Syringe-sharing significantly increases the risk of HIV and viral hepatitis acquisition among people who inject drugs (PWID). Clearer understanding of the correlates of receptive syringe-sharing (RSS) is a critical step in preventing bloodborne infectious disease transmission among PWID in rural communities throughout the United States. This study aimed to measure the prevalence and correlates of RSS among PWID in a rural county in Appalachia. DESIGN Observational, cross-sectional sample from a capture-recapture parent study. SETTING Cabell County, West Virginia (WV), USA, June-July 2018. PARTICIPANTS The sample was restricted to people who reported injecting drugs in the past 6 months (n = 420). A total of 180 participants (43%) reported recent (past 6 months) RSS. Participants reported high levels of homelessness (56.0%), food insecurity (64.8%) and unemployment (66.0%). MEASUREMENTS The main outcome was recent re-use of syringes that participants knew someone else had used before them. Key explanatory variables of interest, selected from the risk environment framework, included: unemployment, arrest and receipt of sterile syringes from a syringe services program (SSP). Logistic regression was used to determine correlates of recent RSS. FINDINGS PWID reporting recent RSS also reported higher prevalence of homelessness, food insecurity and unemployment than their non-RSS-engaging counterparts. In adjusted analyses, correlates of RSS included: engagement in transactional sex work [adjusted odds ratio (aOR) = 2.27, 95% confidence interval (CI) = 1.26-4.09], unemployment (aOR = 1.67, 95% CI = 1.03-1.72), number of drug types injected (aOR = 1.33, 95% CI = 1.15-1.53) and injection in a public location (aOR = 2.59, 95% CI = 1.64-4.08). Having accessed sterile syringes at an SSP was protective against RSS (aOR = 0.57, 95% CI = 0.35-0.92). CONCLUSION The prevalence of receptive syringe-sharing among people who inject drugs in a rural US county appears to be high and comparable to urban-based populations. Receptive syringe-sharing among people who inject drugs in a rural setting appears to be associated with several structural and substance use factors, including unemployment and engaging in public injection drug use. Having recently acquired sterile syringes at a syringe services program appears to be protective against receptive syringe sharing.
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Affiliation(s)
- Rebecca Hamilton White
- Department of Health, Behavior, and Society; Bloomberg School of Public Health; Johns Hopkins University; Baltimore, MD, USA
| | - Allison O’Rourke
- Department of Psychology; DC Center for AIDS Research; George Washington University; Washington, DC, USA
| | | | - Kristin E. Schneider
- Department of Mental Health; Bloomberg School of Public Health; Johns Hopkins University; Baltimore, MD, USA
| | - Brian W. Weir
- Department of Health, Behavior, and Society; Bloomberg School of Public Health; Johns Hopkins University; Baltimore, MD, USA
| | - Suzanne M. Grieb
- Department of Health, Behavior, and Society; Bloomberg School of Public Health; Johns Hopkins University; Baltimore, MD, USA,School of Medicine; Johns Hopkins University, Baltimore, MD, USA
| | - Susan G. Sherman
- Department of Health, Behavior, and Society; Bloomberg School of Public Health; Johns Hopkins University; Baltimore, MD, USA
| | - Sean T. Allen
- Department of Health, Behavior, and Society; Bloomberg School of Public Health; Johns Hopkins University; Baltimore, MD, USA
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Baker LS, Smith W, Gulley T, Tomann MM. Community Perceptions of Comprehensive Harm Reduction Programs and Stigma Towards People Who Inject Drugs in Rural Virginia. J Community Health 2021; 45:239-244. [PMID: 31502098 DOI: 10.1007/s10900-019-00732-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The spread of infectious diseases, including Human Immunodeficiency virus and Hepatitis C virus, is a major risk of injection drug use. The Center for Disease Control's 2015 ranking of counties vulnerable to rapid dissemination of HIV/HCV infection among people who inject drugs (PWID) places Dickenson County, Virginia at 29th in the nation and 2nd in Virginia. Comprehensive Harm Reduction is an evidence-based intervention shown to reduce the negative impacts of drug use including the spread of infectious diseases, overdose and death among people who are unable or not ready to stop using drugs. The aim of this study was to assess community perceptions of comprehensive harm reduction programs and stigma towards PWID in a rural community. Data were collected through the use of an anonymous survey and interviews with community stakeholders. Surveys were distributed online through email and social media, as well as in person. Participants were included based on their zip code as an indicator of residence in Dickenson County. Statistical analysis of survey results was conducted using Sigma Plot. The survey was completed by 153 participants. The perception of PWID in rural Virginia is strikingly negative. Participants consider injection drug use a major problem in their community but have little to no knowledge of harm reduction programs and display high levels of stigma towards PWID. Additionally, higher levels of stigma towards PWID was associated with lower support for CHR programs. The results of this study show a definite and perceived need for harm reduction programs in rural Virginia. Challenges to implementing harm reduction programs include low levels of knowledge and high levels of stigma.
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Affiliation(s)
- Logan S Baker
- University of Virginia's College at Wise, 1 College Ave, Wise, VA, 24293, USA.
| | - Walter Smith
- University of Virginia's College at Wise, 1 College Ave, Wise, VA, 24293, USA
| | - Tauna Gulley
- University of Pikeville, Pikeville, KY, 41501, USA
| | - Margaret M Tomann
- University of Virginia's College at Wise, 1 College Ave, Wise, VA, 24293, USA
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Allen ST, Mazhnaya A, O'Rourke A, White RH, Wedlock P, Grieb SM, Kilkenny ME, Walls M, Sherman SG. Factors Associated with Sterile Syringe Acquisition among People Who Inject Drugs in West Virginia. Subst Use Misuse 2021; 56:1776-1784. [PMID: 34311667 DOI: 10.1080/10826084.2021.1954023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Syringe services programs (SSPs) are evidence-based interventions that provide essential overdose and infectious disease prevention resources to people who inject drugs (PWID). Little research has examined factors associated with sterile syringe acquisition at SSPs among rural PWID populations. OBJECTIVES We aim to identify factors associated with PWID in a rural county in West Virginia having recently acquired sterile syringes at an SSP. METHODS PWID (n = 420) completed a survey that included measures related to sociodemographics, structural vulnerabilities, and substance use. We used multivariable Poisson regression with robust variance estimation to examine independent associations with sterile syringe acquisition at an SSP. RESULTS Sixty-five percent of our sample reported having recently acquired sterile syringes at an SSP. Factors associated with recent sterile syringes acquisition at an SSP included: being older (aPR [adjusted prevalence ratio]: 1.011, 95% CI: 1.003-1.019), single (aPR: 0.862, 95% CI: 0.755-0.984), experiencing food insecurity (aPR: 1.233, 95% CI: 1.062-1.431), recently injecting fentanyl (aPR: 1.178, 95% CI: 1.010-1.375) and prescription opioid pain relievers (aPR: 0.681, 95% CI: 0.551-0.842), and recent naloxone acquisition (aPR: 1.360; 95% CI: 1.178-1.569). Receptive syringe sharing was inversely associated with acquiring sterile syringes at an SSP (aPR: 0.852; 95% CI: 0.741-0.979). CONCLUSION PWID accessing sterile syringes at an SSP was associated with several sociodemographic, structural, and substance use factors. Ensuring rural SSP operations are tailored to local PWID population-level needs is paramount to the prevention of infectious disease outbreaks and overdose fatalities.
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Affiliation(s)
- Sean T Allen
- Department of Health, Behavior, Society; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alyona Mazhnaya
- Department of Health, Behavior, Society; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Allison O'Rourke
- DC Center for AIDS Research, Department of Psychological and Brain Sciences, George Washington University, Washington, District of Columbia, USA
| | - Rebecca Hamilton White
- Department of Health, Behavior, Society; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Patrick Wedlock
- Department of Health, Behavior, Society; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Suzanne M Grieb
- Center for Child and Community Health Research, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Melissa Walls
- Department of International Health at the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Susan G Sherman
- Department of Health, Behavior, Society; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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