Gender differences in circumstances surrounding first injection experience of rural injection drug users in the United States

"I would do anything but that": Attitudes towards sex work among rural people who use drugs

BACKGROUND

Stigma towards people who use drugs and those who engage in sex work is well-documented, leading to consequences such as reduced access to health services and support, especially in rural milieus. Stigma reduction has been recognized as a priority in the opioid overdose crisis, but little attention has been paid to within-group attitudes and beliefs. This study aimed to explore how people who use drugs in rural counties across the United States appraise sex work by themselves or other community members.

METHODS

Qualitative interview data came from the Rural Opioid Initiative (ROI), a project coordinated by research teams across 65 rural counties in 10 states. Interviews were individual and conducted from 2018 to 2020. All participants reported past 30-day opioid use and/or any injection drug use. A working group coded the data, then used an iterative inductive-deductive approach to organize data into themes of stigma among people who use drugs, focusing on stigma towards sex work.

RESULTS

Across sites, 355 interviews were conducted. Mean participant age was 36, 55 % of participants were male, and 93 % were white. Participants expressed negative attitudes towards sex work as a function of its criminal-legal repercussions or framed sex work as morally transgressive. Many appraisals were gendered, with the behavior conveyed as being "easier" for women who were often described as "whores," with more neutral terms used to describe men. Some viewed sex work as an implicit "exchange" for drugs. Several participants noted a lack of agency as a feature leading to involvement in sex work, with partner power dynamics influencing an individual's behavior. Finally, a few participants acknowledged the circumstances under which they would newly engage in sex work.

CONCLUSION

We identified several patterns by which people who use drugs evaluate community members who sell sex. These included gendered and morally-charged forms of stigma, which may represent barriers to community acceptance and support among this subgroup.

Identifying and Treating Incarcerated Women Experiencing Substance Use Disorders: A Review

While research on substance use disorder (SUD) treatment among justice-involved populations has grown in recent years, the majority of corrections-based SUD studies have predominantly included incarcerated men or men on community supervision. This review 1) highlights special considerations for incarcerated women that may serve as facilitating factors or barriers to SUD treatment; 2) describes selected evidence-based practices for women along the cascade of care for SUD including screening and assessment, treatment and intervention strategies, and referral to services during community re-entry; and 3) discusses conclusions and implications for SUD treatment for incarcerated women.

Effects of a social network intervention on HIV seroconversion among people who inject drugs in Ukraine: moderation by network gender composition

BACKGROUND

Women who inject drugs in Ukraine are disproportionately burdened by HIV. To help address the needs of this population, a greater understanding of how interventions may uniquely benefit women who inject drugs is needed.

METHODS

Data come from a randomized controlled trial of a social network intervention targeting people who inject drugs in Ukraine (N = 1195). Indexes, plus two of their injection network members, received HIV testing and counseling (control arm) or HIV testing and counseling plus a social network intervention (intervention arm), in which indexes were trained to influence network members' risk behaviors. We used Cox regressions with interaction terms to assess differences in time to HIV seroconversion between arms by network gender composition and gender of the index. For significant interaction terms, we calculated simple effects, generated survival functions using Kaplan-Meier methods, and compared survival curves using log-rank tests.

RESULTS

At 12 months, there were 45 seroconversions among women (40.0 [28.3, 51.7] per 100 person years) and 111 among men (28.4 [23.1, 33.6] per 100 person years) in the control arm; there were 27 seroconversions among women (17.1 [10.7, 23.6] per 100 person years) and 77 among men (18.7 [14.5, 22.9] per 100 person years) in the intervention arm. Network gender composition (but not gender of the index) moderated the intervention effect on HIV incidence (p < 0.05). Specifically, the intervention appeared to be even more protective against HIV acquisition as female gender composition increased. In the intervention arm, the HIV seroconversion hazard rate was 44% lower with 1 network female; 61% lower with 2 network females; and 72% lower with 3 network females.

CONCLUSIONS

A greater number of women in an injection network, coupled with the provision of risk-reduction strategies, is associated with HIV risk-mitigation, though the mechanisms through which this occurs remain unclear. Findings can support new research and practice directions that prioritize women who inject drugs and more thoughtfully support their health and wellbeing.

Gender, sexual orientation identity, and initiation of amphetamine injecting among people who inject drugs: Examination of an expanding drug era in Montreal, Canada, 2011-19

BACKGROUND

Amphetamine injection is expanding in North America and has been associated with male homosexuality among people who inject drugs (PWID). Applying subcultural evolution theory, we examined overall and gender-stratified trends in amphetamine injection and assessed sexual orientation as a gender-specific predictor of initiation among PWID in Montreal, Canada.

METHODS

Data were from HEPCO, an open prospective cohort of PWID. Gender and sexual orientation were self-identified at enrolment. Interviewer-administered questionnaires at three-monthly (HCV RNA-negative participants) or yearly (RNA-positive) intervals captured past three-month amphetamine injection and covariates. Annual prevalence and linear trends in amphetamine injection were estimated using GEE. Incidence was computed among naïve individuals and hazard ratios for initiation estimated using gender-stratified, time-varying Cox regression models.

RESULTS

803 participants contributed 8096 observations between March 2011 and December 2019. Annual prevalence of amphetamine injecting increased from 3.25% [95%CI: 2.06-4.43%] to 12.7% [9.50-16.0] (trend p<0.001). Bivariate Cox regression models suggested similar and divergent predictors of initiation by gender. Incidence was 3.27 per 100 person-years [95%CI: 2.51-4.18] among heterosexual men, 7.18 [3.50-13.2] among gay/bisexual men, 1.93 [0.78-4.02] among heterosexual women and 5.30 [1.69-12.8] among gay/bisexual women. Among men, gay/bisexual identity doubled risk of initiation after adjusting for age, ethnicity, calendar year (aHR 2.16 [1.07-4.36]) and additional covariates (2.56 [1.24-5.30]). Among women, evidence for an association with gay/bisexual identity was inconclusive (aHR 2.63 [0.62-11.2]) and sample size precluded further adjustment CONCLUSIONS: Prevalence of amphetamine injection among PWID increased four-fold from 2011 to 2019, with elevated risk of initiation in gay and bisexual men.

Feasibility of using Facebook for HIV prevention: Implications for translational research among justice-involved women who use drugs in rural Appalachia

Background

Justice-involved women from rural Appalachia face significant barriers to the utilization of evidence-based HIV prevention interventions in spite of high rates of injection drug use and risky sexual practices. Adapting evidence-based practices to incorporate the cultural uniqueness of the target population is needed in order to advance translational and clinical science in this area. This study provides a descriptive overview of indicators of feasibility and acceptability of an adapted version of the National Institute on Drug Abuse Standard HIV prevention intervention for delivery using Facebook through a small randomized controlled pilot study with rural Appalachian women.

Method

Study methods include the random selection of rural Appalachian women from two local jails, screening for study eligibility, baseline data collection, random assignment to study interventions, and follow-up in the community three months post-release.

Results

Results indicate that the feasibility of the approach was supported through study enrollment of the target population who reported regular Facebook use and HIV risk behaviors including drug use and sex. Acceptability of the intervention was demonstrated through enrollment in the study intervention, engagement in the intervention through Facebook, and indicators of HIV/HCV knowledge.

Conclusions

Study findings contribute to the critical and unmet need to advance translational science on the delivery of evidence-based prevention interventions in real-world rural Appalachian settings to understudied, vulnerable individuals who are often overlooked in targeted prevention efforts.

Behavioural Risk for HIV, Hepatitis B, and Hepatitis C Infections among a Population of Drug Users and Injectors across Four Regions in Ghana

Background

Blood borne infections such as HIV, Hepatitis B (HBV), and Hepatitis C (HCV) are of great importance to governments and their implementing partners, especially among people who use drugs (PWUD) and people who inject drugs (PWID). Prevalence and determinants of HIV, HBV, and HCV among PWUD and PWID in Ghana are not well established, the significance of this study.

Method

This assessment was a cross-sectional study implemented via the respondent driven sampling approach. A team of community advisory boards that comprised former users, current users, and civil society organizations were constituted to help in the implementation of the study. The study was conducted in four regions in Ghana. The assessment was based on a representation of populations of PWID and PWUD from the four regions. Efforts were made by the team to ensure adequate representation of women where feasible. A quantitative questionnaire was developed and used to obtain information on the respondents' sociodemographics, sexual behavior, substance use, and biological characteristics. The prevalence of HIV, HBV, and HCV among PWID and PWUD was determined using blood samples. First response and oral quick test for confirmation of HIV positivity were carried out, while SD bioline was used to test for the presence of HBV and HBC. Data were analyzed using the Bayesian generalized linear model via the binomial family of distributions under the logit link function with weak Cauchy and Normal distribution as prior.

Results

A total of 323 PWUD and PWID participants were interviewed across four regions of Ghana. The overall median age of the respondents was 36 (28, 43) years. The prevalence of HIV, HBV, and HCV infection in the study was 2.5%, 4.6%, and 5.9%, respectively. The prevalence of HIV, HBV, and HCV among drug users was 2.5% (95% CI: 0.7%–4.2%), 4.1% (95% CI: 1.8%–6.2%), and 6.7% (95% CI: 3.9%–9.4%), respectively. Most drug injectors and users started using and injecting drugs at ages less than 20 years and between 20 and 29 years, respectively. Drug users who identified themselves as part of the general population were 66% less likely to be tested HIV positive (POR = 0.34, CrI: 0.12–0.81) compared to sex workers. Part time employment respondents had fivefold odds (POR = 5.50, CrI: 1.20–16.16) of being HBV positive as against full-time employment.

Conclusion

Most of the injectors and users started drugs at an early age. Drug users and injectors are at higher risk of these infections because of associated risky sexual behaviors and risky injection practices. Harm reduction programs to help addicts who are willing to quit the practice are recommended.

An Exploratory Examination of Social Media Use and Risky Sexual Practices: A Profile of Women in Rural Appalachia Who Use Drugs

HIV/HCV risk behavior among women who use drugs is often exacerbated within high risk networks. The use of social media platforms such as Facebook to identify sex partners within these high-risk networks has not been examined among rural Appalachian women who use drugs. This paper provides an exploratory examination of Facebook use to identify sex partners among rural Appalachian women who use drugs, as well as associated risky sexual practices. Rural Appalachian women were randomly selected from two rural jails, consented, screened for eligibility (including drug use), and interviewed prior to jail release. Findings indicated that using Facebook to meet sex partners was associated with exchanging sex for drugs or money and having a male casual partner during the same time frame. These study findings suggest that the use of social media for high-risk sexual practices may provide a valuable platform for intervention delivery, particularly in resource-deprived areas where formal prevention and treatment services are limited.

Associations between relationship quality and treatment-related stress among couples receiving methadone for opioid use disorder

BACKGROUND

Social relationships may buffer or exacerbate stress among patients receiving methadone treatment for opioid use disorder (OUD). Little is known, however, about how relationship quality is linked to treatment-related stress among couples in which both partners receive methadone. We considered the links between relationship quality and treatment-related stress among couples in methadone treatment for OUD.

METHODS

Participants for this cross-sectional observational study included 60 heterosexual married or cohabiting couples aged 18 and older drawn from two opioid treatment programs in Rhode Island and Massachusetts. Both partners completed a self-administered survey which assessed their sociodemographic information, relationship and treatment characteristics, and perceived treatment-related stress. We estimated actor-partner interdependence models to evaluate the links between each partner's perceptions of relationship quality (with their partner and their closest family member or friend) and treatment-related stress.

RESULTS

When their partners reported a more positive partner relationship, women had lower treatment-related stress. When women reported a more positive relationship with their own closest family member or friend, both women and their partners had lower treatment-related stress. When men perceived a more positive relationship with their closest family member or friend, their partners reported greater treatment-related stress. Negative relationship quality was not significantly linked to treatment-related stress.

CONCLUSIONS

This study highlights the importance of considering how social relationship quality might impact the experiences of couples receiving methadone for OUD. In particular, women's close relationships may help to mitigate treatment-related stress.

Shared injection experiences: Interpersonal involvement in injection drug practices among women

BACKGROUND

Many women who inject drugs are aware of the associated risks, however social influences play a part in their behavioral decisions. Incorporation of others in drug use behaviors may be common practice among women who use drugs. The aim of this study was to gain an in-depth understanding of women's injection drug use experiences with a focus on interpersonal involvement. Methods: Venue-based recruitment was conducted in collaboration with a harm reduction program. A group of 30 women, ages 18 and older, who reported injecting drugs within the past 30 days took part in a demographic survey and semi-structured interview to gain an understanding of their injection practices. In vivo coding and thematic analysis were conducted. Results: Three main themes that relate to incorporating others into injection drug behaviors surfaced, including: (1) injection practices described as we and not I, (2) partnered purchase and drug preparation, and (3) assisted injection. This group of women most often incorporated sexual and/or romantic partners (same and other-gender), friends, or family members into their injection drug use behaviors. Some women described a lack of ability to inject themselves and require assistance every time they use. Women also reported helping other women during drug use behaviors. Conclusions: Our primary themes indicate that a variety of relationship partners are important conceptual links in theoretical frameworks explaining drug use behaviors among women. Findings suggest same gender assistance during drug use behaviors, including injection, that may reduce harm. The interpersonal nature of injection drug use among women may indicate the expansion of treatment options designed for couples or other relationship partners, such as family, together.

Risks for acquiring hepatitis C virus among women in the United States

OBJECTIVE

To conduct a literature review about the breadth of risks for acquiring hepatitis C virus (HCV) among women who are living in the United States.

DESIGN

A mixed research synthesis of qualitative, quantitative, and mixed-methods studies guided by the Socioecological Model and Theory of Gender and Power.

SAMPLE AND ANALYTIC STRATEGY

The sample consisted of 29 studies: 10 qualitative, 18 quantitative, and one mixed-methods studies. Data were analyzed using a segregated approach and integrated into a narrative synthesis of themes by components of the Socioecological Model.

RESULTS

Individual risks themes were drug use as a coping strategy, transition to injection drug use, and lack of awareness about HCV. Interpersonal risks themes were social norms of drug use and drug use and sexual activities. Community risks themes were community re-entry, housing instability, and community HCV resources. Societal risks themes are policies affecting drug markets and social construct of "worthlessness."

CONCLUSIONS

Findings highlight the need for comprehensive gender-specific HCV prevention strategies built around harm reduction. In partnership with women with lived experience, public health nurses can apply findings to build harm reduction collaborations aimed at implementing HCV risk-reduction or risk-elimination strategies.

"I Know It Is Going to Ruin Their Life:" Fortune-Telling, Agency, and Harm Reduction in Narratives Concerning Injection Initiation Assistance

BACKGROUND

Considering most people who inject drugs (PWID) received help with the first injection, understanding the perspective of potential 'initiators' is a priority to inform harm reduction interventions. This paper examines how PWID narrate their experiences with injection initiation and assistance from the lens of their lived experience and perceptions of harm reduction.

METHODS

In-depth interviews were conducted with individuals who reported injection drug use and recent (past 30 days) opioid use in Baltimore (N = 19) and Anne Arundel County (N = 4), Maryland and analyzed using a narrative approach.

RESULTS

Respondents cast initiation events as meaningful transitions to a life characterized by predictable harms, including homelessness, infections, and social stigma. Respondents used examples from their personal experience to explain experiences with initiation and assistance by strategically attributing personal agency and predicting specific injection-related harms for initiates. In their narratives, respondents balanced notions of individual agency with harm reduction intentions by distinguishing between two forms of harm: perceived inevitable distal harm caused by long-term injection (e.g. socioeconomic decline) and potentially avoidable proximal harm caused by risky injection practices (e.g. overdose, HIV).

CONCLUSIONS

These findings highlight opportunities for interventions targeting injection initiation events and support the implementation of safer injection training in interventions. This identity of the 'responsible drug user' could be leveraged to support employing peers to help mitigate harm among inexperienced PWID either through peer outreach or formal venues, such as overdose prevention sites.

Dyadic associations between relationship quality and risk of opioid use among couples receiving methadone for opioid use disorder

BACKGROUND

Social relationships may serve as both protective factors and risk factors for opioid use (nonmedical prescription opioid or illicit opioid use) among patients receiving methadone for opioid use disorder (OUD). Yet little is known about how relationship quality is linked to outcomes among couples receiving methadone. We evaluated the links between relationship quality and risk of opioid use among couples in which both partners received methadone.

METHODS

Participants included 53 heterosexual married or cohabiting couples aged 18 and older who were drawn from two opioid treatment programs in Rhode Island and Massachusetts. Both members of the couple completed a self-administered survey assessing their sociodemographic information, relationship and treatment characteristics, and risk of opioid use.

RESULTS

Roughly half of women (47.2%) and men (52.8%) had a moderate to high risk of nonmedical prescription opioid use and almost two-thirds (64.2%) had a moderate to high risk of street opioid use. Risk of street opioid use was highly correlated within couples. Actor-partner interdependence models revealed that when women reported higher positive relationship quality, they had a lower risk of nonmedical prescription opioid use and their partners had a lower risk of street opioid use. Negative relationship quality was not significantly linked to risk of opioid use.

CONCLUSIONS

Couples in which both partners receive methadone for OUD may be at risk of return to use, and positive partner relationships may play a role in lowering this risk. Women's perceptions of relationship quality might be a particularly important target for clinical care and interventions.

Factors associated with phylogenetic clustering of hepatitis C among people who inject drugs in Baltimore

Background

The availability of effective, oral direct acting antivirals (DAAs) for hepatitis C virus (HCV) treatment has put elimination of HCV as a public health challenge within reach. However, little is known about the characteristics of transmission networks of people who inject drugs (PWID).

Methods

Sequencing of a segment of the HCV genome was performed on samples collected from a community-based cohort of PWID between August 2005 and December 2016. Phylogenetic trees were inferred, and clusters were identified (70% bootstrap threshold; 0.04 maximum genetic distance threshold). We describe sex, race, age difference, and HIV infection status of potential transmission partners. Logistic regression was used to assess factors associated with being in an HCV cluster.

Results

Of 508 HCV genotype 1 viremic PWID, 8% (n = 41) were grouped into 20 clusters, consisting of 19 pairs and 1 triad. In adjusted analyses, female sex (odds ratio [OR] 2.3 [95% confidence interval (CI) 1.2–4.5]) and HIV infection (OR 5.7 [CI 2.7–11.9]) remained independently associated with being in an HCV infection cluster.

Conclusions

Molecular epidemiological analysis reveals that, in this cohort of PWID in Baltimore, HIV infection and female sex were associated with HCV clustering. Combination HCV prevention interventions targeting HIV infected PWID and addressing HCV infection prevention needs of women have potential to advance HCV elimination efforts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-020-05546-x.

Prevalence and Correlates of Providing and Receiving Assistance With the Transition to Injection Drug Use

Preventing the transition to injection drug use is an important public health goal, as people who inject drugs (PWID) are at high risk for overdose and acquisition of infectious disease. Initiation into drug injection is primarily a social process, often involving PWID assistance. A better understanding of the epidemiology of this phenomenon would inform interventions to prevent injection initiation and to enhance safety when assistance is provided. We conducted a systematic review of the literature to 1) characterize the prevalence of receiving (among injection-naive persons) and providing (among PWID) help or guidance with the first drug injection and 2) identify correlates associated with these behaviors. Correlates were organized as substance use behaviors, health outcomes (e.g., human immunodeficiency virus infection), or factors describing an individual's social, economic, policy, or physical environment, defined by means of Rhodes' risk environments framework. After screening of 1,164 abstracts, 57 studies were included. The prevalence of receiving assistance with injection initiation (help or guidance at the first injection) ranged 74% to 100% (n = 13 estimates). The prevalence of ever providing assistance with injection initiation varied widely (range, 13%-69%; n = 13 estimates). Injecting norms, sex/gender, and other correlates classified within Rhodes' social risk environment were commonly associated with providing and receiving assistance. Nearly all PWID receive guidance about injecting for the first time, whereas fewer PWID report providing assistance. Substantial clinical and statistical heterogeneity between studies precluded meta-analysis, and thus local-level estimates may be necessary to guide the implementation of future psychosocial and sociostructural interventions. Further, estimates of providing assistance may be downwardly biased because of social desirability factors.

Injection Opioid and Injection Methamphetamine Use in the Rural United States: A Systematic Review and Network Analysis

The abuse of opioid and methamphetamine is a public health crisis in the United States, particularly in rural areas where injection drug use is common. This systematic review of rural injection drug use synthesized the research on injection of opioids and methamphetamine use and assessed the similarity of their research findings to the field of rural injection drug use in the United States. A citation network analysis was used to support the assessment of research similarity and provided a visualization of the field. This citation network analysis exposed a gap in the literature revealing that the state of research may not be fully applicable to the field in its entirety in the United States. In summary, this review provides a representative overview of the state of research in the field of injection drug use. Future research should conduct studies on rural drug use in areas of the country not represented in this review.

Initiating Persons into Injection Drug Use in Rural West Virginia, USA

Background: While prior research has explored factors associated with people who inject drugs (PWID) initiating others into drug injection in urban settings, very little work has been done to understand this behavior among rural PWID in Appalachia. Objectives: We aim to identify factors associated with PWID initiating injection-naïve individuals into drug injection in a rural community in West Virginia (WV). Methods: Data were derived from a cross-sectional survey of 420 rural PWID (163 women) in Cabell County, WV in June-July 2018 who indicated recent (past 6 months) injection drug use. Individuals completed a survey that included measures on socio-demographics and injection socialization behaviors. We used logistic regression to identify factors associated with PWID recently initiating someone for their first injection. Results: A minority (17%) reported recently initiating someone for their first injection. In multivariable regression, recent injection initiation was independently associated with number of injections per day (adjusted odds ratio [aOR] 1.16; 95% confidence interval [CI]:1.07,1.25), recent injection in front of an injection-naïve person (aOR 2.75; 95% CI: 1.25,6.04), recent describing how to inject drugs to an injection-naïve person (aOR 5.83; 95% CI: 2.71,12.57), and recent encouragement of an injection-naïve person to inject (aOR 7.13; 95% CI: 2.31,21.87). Conclusion: Injection initiation was independently associated with several injection socialization behaviors involving injection-naïve individuals. PWID who recently initiated injection-naïve individuals had higher odds of frequent injection. Educating rural PWID about how their behaviors can influence others and the importance of engaging in safe injection practices could carry significant public health utility.

Opioid use and misuse: health impact, prevalence, correlates and interventions

Objective: To provide a broad overview of the state of drug misuse research, particularly focusing on opioid drug use in the U.S.A. Design: An overview of published reviews of the literature. Results: Prescription opioid use has increased globally from 2008 to 2013, while use of opiates such as heroin and opium have remained stable in many countries, although, decreases have been observed in parts of Europe. Opioid misuse is highest in the United States; approximately 11.8 million Americans misused opioids in 2016. Demographic, genetic, psychosocial and structural/environmental factors all play a role in determining who will become an opioid misuser. Strategies such as increased prescribing of non-opioid derived pain relievers, expansion of medication treatment, distribution of naloxone for overdose reversal and supervised consumption sites are some of the solutions posed to reduce the spread and consequences of opioid misuse. Conclusion: Research focused on understanding of opioid neurobiology, as well as empirically based, effective alternatives to pain management and implementation studies on combined prevention and treatment approaches are needed. It will take the combined effort of community members, healthcare professionals, policymakers and researchers in order to prevent and treat opioid misuse.

The opioid and related drug epidemics in rural Appalachia: A systematic review of populations affected, risk factors, and infectious diseases

Background/aims: To examine trends in rural Appalachian opioid and related drug epidemics during the past 10 years, including at-risk populations, substance use shifts and correlates, and associated infections. Methods: We conducted this review in accordance with the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Seven databases were searched for quantitative studies, published between January 2006 and December 2017, of drug use, drug-related mortality, or associated infections in rural Appalachia. Results: Drug-related deaths increased in study states, and a high incidence of polydrug toxicity was noted. Rural substance use was most common among young, white males, with low education levels. A history of depression/anxiety was common among study populations. Prescription opioids were most commonly used, often in conjunction with sedatives. Women emerged as a distinct user subpopulation, with different routes of drug use initiation and drug sources. Injection drug use was accompanied by risky injection behaviors and was associated with hepatitis C. Conclusions: This review can help to inform substance use intervention development and implementation in rural Appalachian populations. Those at highest risk are young, white males who often engage in polysubstance use and have a history of mental health issues. Differences in risk factors among other groups and characteristics of drug use in rural Appalachian populations that are conducive to human immunodeficiency virus (HIV) spread also warrant consideration.

Network-Based Research on Rural Opioid Use: an Overview of Methods and Lessons Learned

PURPOSE OF REVIEW

The purpose of this paper is to provide a thorough overview of methods used for recruitment, network data collection, and network data management in a network-based study of rural people who use drugs (PWUD) and to offer methodological recommendations for future research on rural drug use.

RECENT FINDINGS

The Social Networks among Appalachian People (SNAP) study recruited a cohort of 503 rural PWUD via respondent-driven sampling (RDS) and has retained more than 80% of eligible participants over 7-9 years. SNAP has yielded important methodological insights, including that (1) RDS referral was non-random and disproportionately involved kin and (2) interviewer-administered questionnaires were successful in eliciting accurate name and age information about network members. The SNAP experience suggests that RDS was a successful recruitment strategy for rural PWUD and questionnaires administered by community-based interviewers in the context of a Certificate of Confidentiality could elicit detailed data on PWUD risk networks.

A latent class analysis of alcohol and drug use immediately before or during sex among women

BACKGROUND

Alcohol and drug use by women is related to high-risk sexual practices and protective behaviors.

OBJECTIVES

To determine sexual risk and protective behaviors using information about women's drug use immediately before or during sex.

METHODS

Latent class analysis using PROC LCA in SAS software was used to determine classes of women using both past 30-day drug use and before or during sex. Participants were recruited from a community-based research site located in a low socio-economic area of Los Angeles County and completed the Risk Behavior Assessment, which elicits information on drug and sex risk behaviors.

RESULTS

The Risk Behavior Assessment and HIV and sexually transmitted infections testing was obtained on 812 women. Five distinct groups were identified by PROC LCA: An Abstinent group comprised of 26% of participants; an Alcohol and Marijuana group (16%); an Amphetamine group (11%); a No Sex-with-Alcohol group (37%); and a Poly Drug group (11%). Multinomial logistic regression revealed that sexual behaviors and condom use were different across the five groups: The Alcohol and Marijuana group had a higher odds of vaginal intercourse, while the No Sex-with-Alcohol group was most likely to use condoms for vaginal intercourse. The Poly Drug group had the highest risk for anal intercourse while the Amphetamine and Poly Drug groups had high proportions of women with injection-drug using and men-who-have-sex-with-men sexual partners.

CONCLUSION

Identifying women based on drug use immediately before or during sex can help providers understand prevention and risk-reduction practices and interventions for drug-using women.

Drug Use and Incarceration among Rural Appalachian Women: Findings From a Jail Sample

BACKGROUND/OBJECTIVE

The purpose of this paper is to examine drug use and incarceration history among rural Appalachian women.

METHODS

This study involved random selection, screening, and interviews with rural women from local jails in Appalachia.

RESULTS

Of the women randomly selected and screened, 97% met criteria for substance use intervention. Significant factors associated with incarceration history included age, education, custody status, and mental health. A significant interaction was observed between male sex partners and drug use on incarceration history.

CONCLUSIONS

Study findings suggest that the drug/crime relationship among rural Appalachian women is associated with their high-risk home environment, partner relationships, and mental health. Specifically, in addition to drug use, factors such as family and child relationships, anxiety, victimization, and relationships with partners should also be considered in the trajectory of criminal careers among rural Appalachian women.

Partner Relationships and Injection Sharing Practices among Rural Appalachian Women

BACKGROUND

The role of relationships in initiating and maintaining women's risk behaviors has been established. However, understanding factors that may underlie partner relationships and women's risky drug use, particularly in rural contexts, is limited. This study is the first to examine the association between injecting partners and women's risky injection practices as a function of relationship power perception.

METHODS

Female participants were recruited from three rural jails in the Appalachian region. Women were selected randomly, provided informed consent, and screened for study eligibility criteria. This cross-sectional analysis focuses on women who inject drugs during the year before entering jail (n = 199).

MAIN FINDINGS

Approximately three-quarters (76%) reported having a recent main male sexual partner with a history of injection drug use. Although having a risky partner independently increased the likelihood of women reporting shared injection practices, perceptions of relationship power significantly moderated the effect on shared needle (adjusted odds ratio, 0.02; 95% CI, 0.003-0.23; p = .001) and shared works (adjusted odds ratio, 0.17; 95% CI, 0.03-0.95; p = .04) use.

CONCLUSIONS

This interaction indicated that, for women who inject drugs with a recent injecting male partner, greater perception of relationship power was associated with a decreased likelihood of shared injection practices. Implications for clinical assessment and intervention are discussed.

Correlates of Injection Drug Use Among Rural Appalachian Women

BACKGROUND

Limited research has focused on correlates of injection drug use (IDU) among high-risk subgroups of drug users, particularly women, who may be at increased risk for transmission of infectious diseases such as HIV and Hepatitis C. The purpose of this study is to better understand the contextual and health correlates of IDU among women living in rural Appalachia by examining (1) differences between injectors and noninjectors, and (2) the unique correlates of recent IDU and past IDU.

METHODS

This study involved random selection, screening, and face-to-face interviews with 400 rural Appalachian women from jails in one state. Analyses included descriptive statistics, multinomial logistic regression, and stepwise regression to identify significant correlates of recent IDU and past IDU compared to never injecting.

RESULTS

Findings indicated that 75.3% of this randomly selected sample reported lifetime injection of drugs. Contextual factors including drug use severity (RRR = 8.66, P < .001), more male sex partners (RRR = 1.01, P < .05), and having injecting partners (RRR = 7.60, P < .001) were robust correlates of recent injection practices.

CONCLUSIONS

This study makes an important contribution to understanding factors associated with IDU among rural Appalachian women drug users, which are strongly associated with both relational and health factors. Study findings on the specific factors associated with IDU risk have important implications for tailoring and targeting interventions that should include a focus on the relationship context reducing high-risk injection practices.

Rural, Pregnant, and Opioid Dependent: A Systematic Review

The nature, impact, and treatment of substance use during pregnancy are well described for women living in urban settings. Less is known about pregnant substance-using women living in rural communities. The objective of this review is to describe the existing evidence for the management of substance use in pregnant women living in rural areas. A systematic review of the literature was conducted using PubMed, Embase, and the Cochrane Database of Systematic Reviews, and the quality of the evidence was assessed using the GRADE system. Twenty-two articles that met the inclusion criteria were identified. Descriptive studies document high rates of smoking, marijuana, and polysubstance use among rural, substance-using pregnant women compared to their urban counterparts. Management of substance use disorders is limited by access to and acceptability of treatment modalities. Several innovative, integrated addiction and prenatal care programs have been developed, which may serve as models for management of substance use during pregnancy in rural settings.

Prevention knowledge, risk behaviours and seroprevalence among nonurban injectors of southwest Connecticut

INTRODUCTION AND AIMS

Little is known about injection-associated risk behaviours, knowledge and seroprevalence of viral infections among people who inject drugs (PWID) in nonurban locales in the US. Harm reduction services are more available in urban locales. The present study examined a cohort of active PWID residing in non urban areas of Connecticut to investigate how primarily injecting in urban or non urban areas was associated with injection-associated risk behaviours, knowledge and prevalence of blood-borne viruses.

DESIGN AND METHODS

We described the sample and performed bivariate and multivariable analyses on injection-associated risk behaviours, HIV/hepatitis/overdose knowledge and baseline serological data to identify differences between individuals who injected primarily in nonurban locales and those who did not.

RESULTS

Harm reduction knowledge and use of harm reduction services were poor in both groups. Those injecting most often in urban settings were 1.88 (1.19, 2.98 95% confidence interval) times more likely to engage in at least one injection-associated risk behaviour than their nonurban counterpart. Seroprevalence rates (23.6% for hepatitis B virus, 39.2% for hepatitis C virus, and 1.1% for HIV) were no different between the two groups.

DISCUSSION AND CONCLUSIONS

The data provided little evidence that the benefits of urban harm reduction programs, such as syringe exchange, risk reduction interventions and education programs have penetrated into this nonurban population, even among those who injected in urban locales where such programs exist. Harm reduction interventions for nonurban communities of PWID are needed to reduce HIV and hepatitis B and C transmission. [Grau LB, Zhan W, Heimer R. Prevention knowledge, risk behaviours and seroprevalence among nonurban injectors of southwest Connecticut. Drug Alcohol Rev 2016;35:628-636].

Risk Factors Associated with Unsafe Injection Practices at the First Injection Episode among Intravenous Drug Users in France: Results from PrimInject, an Internet Survey

Background. New drug use patterns may increase the risk of human immunodeficiency virus and hepatitis infections. In France, new injection patterns among youths with diverse social backgrounds have emerged, which may explain the persistently high rates of hepatitis C virus infection. This study explores factors associated with injection risk behaviours at first injection among users who began injecting in the post-2000 era. Methods. A cross-sectional study was conducted on the Internet from October 2010 to March 2011, through an online questionnaire. Multivariate logistic regression identified the independent correlates of needle sharing and equipment (cooker/cotton filter) sharing. Results. Among the 262 respondents (mean age 25 years), 65% were male. Both risk behaviours were positively associated with initiation before 18 years of age (aOR 3.7 CI 95% 1.3–10.6 and aOR 3.0 CI 95% 1.3–7.0) and being injected by another person (aOR 3.1 CI 95% 1.0–9.9 and aOR 3.0 CI 95% 1.3–7.1). Initiation at a party was an independent correlate of equipment sharing (aOR 2.6 95% CI 1.0–6.8). Conclusions. Results suggest a need for innovative harm reduction programmes targeting a variety of settings and populations, including youths and diverse party scenes. Education of current injectors to protect both themselves and those they might initiate into injection is critically important.

Global Epidemiology of HIV Among Women and Girls Who Use or Inject Drugs: Current Knowledge and Limitations of Existing Data

BACKGROUND

Women and girls who use and inject drugs are a critical population at risk of HIV. In this article, we review data on the epidemiology of drug use and injection among women globally and HIV prevalence among women and girls who use and inject drugs.

RESULTS

Women and girls comprise one-third of people who use and inject drugs globally. There is substantial variation in HIV prevalence in this population, between and within countries. There is a pronounced lack of data examining HIV risk among particularly vulnerable subpopulations of women who use and inject drugs, including women who have sex with women, transgender women, racial and ethnic minority women, and young women. Women who use and inject drugs experience stigma and discrimination that affect access to services, and high levels of sexual risk exposures.

CONCLUSIONS

There are significant gaps in our understanding of the epidemiology of drug use and injecting among women and girls and HIV risk and prevalence in this population. Women are frequently underrepresented in studies of drug use and HIV risk and prevalence among people who inject drugs, limiting our understanding of possible sex differences in this population. Most research originates from developed countries and may not be generalizable to other settings. A great deal of work is needed to improve understanding of HIV among particularly vulnerable subpopulations, such as transgender women who use drugs. Better data are critical to efforts to advocate for the needs of women and girls who use and inject drugs.

Factors associated with being asked to initiate someone into injection drug use

AIMS

Injection drug use initiation typically involves an established person who injects drugs (PWID) helping the injection-naïve person to inject. Prior to initiation, PWID may be involved in behaviors that elevate injection initiation risk for non-injectors such as describing how to inject and injecting in front of injection-naïve people. In this analysis, we examine whether PWID who engage in either of these behaviors are more likely to be asked to initiate someone into drug injection.

METHODS

Interviews with PWID (N = 602) were conducted in California between 2011 and 2013. Multivariate analysis was conducted to determine factors associated with being asked to initiate someone.

RESULTS

The sample was diverse in terms of age, race/ethnicity, and drug use patterns. Seventy-one percent of the sample had ever been asked to initiate someone. Being asked to initiate someone was associated with having injected in front of non-injectors (Adjusted Odds Ratio [AOR] = 1.80, 95% Confidence Interval [CI] = 1.12, 2.91), having described injection to non-injectors (AOR = 3.63; 95% CI = 2.07, 6.36), and doing both (AOR = 9.56; 95% CI = 4.43, 20.65) as compared to doing neither behavior (referent). Being female (AOR = 1.73; 95% CI = 1.10, 2.73) and non-injection prescription drug misuse in the last 30 days (AOR = 1.69; 95% CI = 1.12, 2.53) were also associated with having been asked to initiate someone.

CONCLUSION

Reducing initiation into injection drug use is an important public health goal. Intervention development to prevent injection initiation should include established PWID and focus on reducing behaviors associated with requests to initiate injection and reinforcing refusal skills and intentions among established PWID.

An exploratory study of mental health and HIV risk behavior among drug-using rural women in jail

OBJECTIVE

Rural women, particularly those in the criminal justice system, are at risk for HIV related to the increasing prevalence of injection drug use as well as limited services. Research on HIV risk correlates, including drug use and mental health, has primarily focused on urban women incarcerated in prisons. The purpose of this exploratory study is to examine dual HIV risk by 3 different mental health problems (depression, anxiety, and posttraumatic stress disorder [PTSD]) among drug-using women in rural jails.

METHOD

This study involved random selection, screening, and face-to-face interviews with 136 women in 1 Appalachian state. Analyses focused on the relationship between mental health and HIV risk.

RESULTS

Nearly 80% of women self-reported symptoms of depression, and more than 60% endorsed symptoms consistent with anxiety and PTSD symptoms. Mental health significantly correlated with severity of certain types of drug use, as well as risky sexual activity. In addition, for women experiencing anxiety and PTSD, injection drug use moderated the relationship between mental health and risky sexual activity.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Based on these rates of drug use, mental health problems, and the emergence of injection drug use in rural Appalachia, the need to explore the relationships between these issues among vulnerable and understudied populations, such as rural women, is critical. Because of service limitations in rural communities, criminal justice venues such as jails provide opportune settings for screening, assessment, and intervention for drug use, mental health, and HIV education and prevention. (PsycINFO Database Record

Differences in HIV risk behaviors among people who inject drugs by gender and sexual orientation, San Francisco, 2012

BACKGROUND

Sharing of drug injection equipment is a well-established risk factor for the transmission of viral infections, such as human immunodeficiency virus (HIV). However, there are multiple mechanisms through which people who inject drugs (PWID) can acquire and transmit HIV. Differences in drug using and sexual behaviors among heterosexual males, males who have sex with males (MSM), and females who inject drugs may explain health disparities.

METHODS

Data were collected in San Francisco by the National HIV Behavioral Surveillance (NHBS) System of PWID in 2012, and were analyzed to compare the sexual behaviors, drug use behaviors, and prevalence of viral infections among heterosexual males, MSM, and females.

RESULTS

Using a weighted analysis for the RDS sampling design, we estimate that 3.7% of heterosexual males who inject drugs, 24.0% of MSM, and 13.0% of females who inject drugs are living with HIV. Females and heterosexual males primarily injected heroin, while MSM primarily injected methamphetamine. MSM were most likely to have received goods or money for sex and have unprotected intercourse.

CONCLUSION

These data demonstrate differences in risk behaviors and prevalence of viral infections among heterosexual males, MSM, and females. The results also suggest that public health programs prioritizing the different populations of PWID are necessary.

Factors associated with initiating someone into illicit drug injection

AIMS

Most people who inject drugs (PWID) were first initiated into injection by a current PWID. Few studies have examined PWID who assist others into drug injection. Our goal is to describe the prevalence of and risk factors for initiating someone into injection in the last 12 months.

METHODS

We recruited a cross-sectional sample of PWID (N=605) in California from 2011 to 2013. We examined bivariate and multivariate risk factors for initiating someone into injection with a focus on behaviors that might encourage injection initiation such as injecting in front of non-PWID, describing how to inject to non-PWID, and willingness to initiate someone into drug injection.

RESULTS

Having initiated someone into injection was reported by 34% of PWID overall and 7% in the last 12 months. Forty-four PWID had assisted 431 people into injection in the past year. Factors independently associated with initiating someone into injection in the last 12 months were self-reported likelihood of initiating someone in the future (Adjusted Odds Ratio [AOR]=7.09; 95% Confidence Interval [CI]=3.40, 14.79), having injected another PWID in past month (AOR=4.05; 95% confidence interval [CI]=1.94, 8.47), having described how to inject to non-injectors (2.61; 95% CI=1.19, 5.71), and non-injection powder cocaine use in past month (AOR=4.97; 95% CI=2.08, 11.84) while controlling for study site.

CONCLUSION

Active PWID are important in facilitating the process of drug injection uptake. Interventions to reduce initiation should include efforts to change behaviors and intentions among PWID that are associated with injection uptake among others.