The role of social networks and geography on risky injection behaviors of young persons who inject drugs

Spatial inequities in access to medications for treatment of opioid use disorder highlight scarcity of methadone providers under counterfactual scenarios

Access to treatment and medication for opioid use disorder (MOUD) is essential in reducing opioid use and associated behavioral risks, such as syringe sharing among persons who inject drugs (PWID). Syringe sharing among PWID carries high risk of transmission of serious infections such as hepatitis C and HIV. MOUD resources, such as methadone provider clinics, however, are often unavailable to PWID due to barriers like long travel distance to the nearest methadone provider and the required frequency of clinic visits. The goal of this study is to examine the uncertainty in the effects of travel distance in initiating and continuing methadone treatment and how these interact with different spatial distributions of methadone providers to impact co-injection (syringe sharing) risks. A baseline scenario of spatial access was established using the existing locations of methadone providers in a geographical area of metropolitan Chicago, Illinois, USA. Next, different counterfactual scenarios redistributed the locations of methadone providers in this geographic area according to the densities of both the general adult population and according to the PWID population per zip code. We define different reasonable methadone access assumptions as the combinations of short, medium, and long travel distance preferences combined with three urban/suburban travel distance preference. Our modeling results show that when there is a low travel distance preference for accessing methadone providers, distributing providers near areas that have the greatest need (defined by density of PWID) is best at reducing syringe sharing behaviors. However, this strategy also decreases access across suburban locales, posing even greater difficulty in regions with fewer transit options and providers. As such, without an adequate number of providers to give equitable coverage across the region, spatial distribution cannot be optimized to provide equitable access to all PWID. Our study has important implications for increasing interest in methadone as a resurgent treatment for MOUD in the United States and for guiding policy toward improving access to MOUD among PWID.

Social-spatial network structures among young urban and suburban persons who inject drugs in a large metropolitan area

BACKGROUND

Recent studies underscore the significance of adopting a syndemics approach to study opioid misuse, overdose, hepatitis C (HCV) and HIV infections, within the broader context of social and environmental contexts in already marginalized communities. Social interactions and spatial contexts are crucial structural factors that remain relatively underexplored. This study examines the intersections of social interactions and spatial contexts around injection drug use. More specifically, we investigate the experiences of different residential groups among young (aged 18-30) people who inject drugs (PWID) regarding their social interactions, travel behaviors, and locations connected to their risk behaviors. By doing so, we aim to achieve a more comprehensive understanding of the multidimensional risk environment, thereby facilitating the development of informed policies.

METHODS

We collected and examined data regarding young PWID's egocentric injection network and geographic activity spaces (i.e., where they reside, inject drugs, purchase drugs, and meet sex partners). Participants were stratified based on the location of all place(s) of residence in the past year i.e., urban, suburban, and transient (both urban and suburban) to i) elucidate geospatial concentration of risk activities within multidimensional risk environments based on kernel density estimates; and ii) examine spatialized social networks for each residential group.

RESULTS

Participants were mostly non-Hispanic white (59%); 42% were urban residents, 28% suburban, and 30% transient. We identified a spatial area with concentrated risky activities for each residential group on the West side of Chicago in Illinois where a large outdoor drug market area is located. The urban group (80%) reported a smaller concentrated area (14 census tracts) compared to the transient (93%) and suburban (91%) with 30 and 51 tracts, respectively. Compared to other areas in Chicago, the identified area had significantly higher neighborhood disadvantages. Significant differences were observed in social network structures and travel behaviors: suburban participants had the most homogenous network in terms of age and residence, transient participants had the largest network (degree) and more non-redundant connections, while the urban group had the shortest travel distance for all types of risk activities.

CONCLUSION

Distinct residential groups exhibit varying patterns of network interaction, travel behaviors, and geographical contexts related to their risk behaviors. Nonetheless, these groups share common concentrated risk activity spaces in a large outdoor urban drug market area, underscoring the significance of accounting for risk spaces and social networks in addressing syndemics within PWID populations.

Spatial inequities in access to medications for treatment of opioid use disorder highlight scarcity of methadone providers under counterfactual scenarios

Access to treatment and medication for opioid use disorder (MOUD) is essential in reducing opioid use and associated behavioral risks, such as syringe sharing among persons who inject drugs (PWID). Syringe sharing among PWID carries high risk of transmission of serious infections such as hepatitis C and HIV. MOUD resources, such as methadone provider clinics, however, are often unavailable to PWID due to barriers like long travel distance to the nearest methadone provider and the required frequency of clinic visits. The goal of this study is to examine the uncertainty in the effects of travel distance in initiating and continuing methadone treatment and how these interact with different spatial distributions of methadone providers to impact co-injection (syringe sharing) risks. A baseline scenario of spatial access was established using the existing locations of methadone providers in a geographical area of metropolitan Chicago, Illinois, USA. Next, different counterfactual scenarios redistributed the locations of methadone providers in this geographic area according to the densities of both the general adult population and according to the PWID population per zip code. We define different reasonable methadone access assumptions as the combinations of short, medium, and long travel distance preferences combined with three urban/suburban travel distance preference. Our modeling results show that when there is a low travel distance preference for accessing methadone providers, distributing providers near areas that have the greatest need (defined by density of PWID) is best at reducing syringe sharing behaviors. However, this strategy also decreases access across suburban locales, posing even greater difficulty in regions with fewer transit options and providers. As such, without an adequate number of providers to give equitable coverage across the region, spatial distribution cannot be optimized to provide equitable access to all PWID. Our study has important implications for increasing interest in methadone as a resurgent treatment for MOUD in the United States and for guiding policy toward improving access to MOUD among PWID.

Injection partnership characteristics and HCV status associations with syringe and equipment sharing among people who inject drugs

BACKGROUND

Sharing of syringes is the leading transmission pathway for hepatitis C (HCV) infections. The extent to which HCV can spread among people who inject drugs (PWID) is largely dependent on syringe-sharing network factors. Our study aims to better understand partnership characteristics and syringe and equipment sharing with those partners, including measures of relationship closeness, sexual activity, and social support, as well as self and partner HCV status to better inform interventions for young urban and suburban PWID.

METHODS

Data are from baseline interviews of a longitudinal network-based study of young (aged 18-30) PWID (egos) and their injection network members (alters) in metropolitan Chicago (n = 276). All participants completed a computer-assisted interviewer-administered questionnaire and an egocentric network survey on injection, sexual, and support networks.

RESULTS

Correlates of syringe and ancillary equipment sharing were found to be similar. Sharing was more likely to occur in mixed-gender dyads. Participants were more likely to share syringes and equipment with injection partners who lived in the same household, who they saw every day, who they trusted, who they had an intimate relationship with that included condomless sex, and who provided personal support. PWID who had tested HCV negative within the past year were less likely to share syringes with an HCV positive partner compared to those who did not know their status.

CONCLUSION

PWID regulate their syringe and other injection equipment sharing to some extent by sharing preferentially with injection partners with whom they have a close personal or intimate relationship, and whose HCV status they are more likely to know. Our findings underscore the need for risk interventions and HCV treatment strategies to consider the social context of syringe and equipment sharing within partnerships.

Factors associated with sharing equipment among people who inject drugs: The role of community attachment in harm reduction and health promotion

INTRODUCTION

Sharing injecting equipment is a major route of transmission for blood borne viruses such as hepatitis C and HIV. Although needle and syringe programs are widely available throughout metropolitan Australia, rates of sharing equipment have not significantly changed in recent years. This study aimed to identify factors associated with recent equipment sharing among people who inject drugs in Australia.

METHODS

A paper-based survey was distributed via peer-based organisations between June and November 2018 and was completed by 603 participants. Survey questions addressed recent injecting experiences, equipment sharing, community attachment, stigma and wellbeing. Participants who had recently shared injecting equipment were compared with those who had not shared any equipment using multivariable logistic regression.

RESULTS

Recent equipment sharing was associated with recent heroin use, experiencing any past-year stigma related to injecting drug use, and higher levels of attachment to a community of people who inject drugs. An interaction effect showed increased community attachment was associated with increased odds of sharing equipment among young participants, but with decreased odds of sharing equipment among older participants.

DISCUSSION AND CONCLUSIONS

Community networks of people who inject drugs can play important roles in harm reduction initiatives. While being connected with a community of people who inject drugs increased the odds of sharing injecting equipment, this community connection also increases opportunities for social support, sharing information and mitigating the negative effects of stigma. Collaboratively and meaningfully engaging with communities of people who inject drugs has the potential to increase the reach and effectiveness of health promotion services.

Injection drug use in an affluent beachside community in Sydney: An exploratory qualitative study

INTRODUCTION

Social research on injection drug use has focussed on marginalised groups and communities, leaving a large gap in the field's understanding of how it is experienced in other settings, including in relatively affluent communities.

METHODS

This research is based on fieldwork and 18 in-depth qualitative interviews conducted in suburban beach-side communities in Sydney collectively known as the Northern Beaches.

RESULTS

Participants did not experience stigmatisation by local health services as the norm or as a deterrent to access. Drug acquisition on the Northern Beaches occurred among closed networks of friends and acquaintances, and injecting use rarely occurred in public settings. Police contact was minimal, resulting in lower levels of criminalisation.

DISCUSSION AND CONCLUSIONS

Unlike many of the participants featured in the literature, our study participants grew up in middle and upper middle-class households, typically experiencing comfortable childhoods with little to no exposure to injection drug use. In this setting injection drug use operates covertly within the normal rhythms of middle-class life, hidden in amongst the bustle of cafés and shopping centres, and through the friendliness of neighbourhood driveway and doorstep interactions. Drug use is described as common in the area, with injecting behaviours stigmatised in ways that set it against the 'good' families and neighbourhoods of this beach-side enclave. In contrast to much of the Australian qualitative literature which frames injection drug use as a means of psychological relief or a subcultural norm, our participants described injecting as motivated by the desire to enhance pleasure and social connection.

Network ethnic homophily and injection equipment sharing among Latinx and White non-Latinx people who inject drugs

Latinx people who inject drugs (PWID) are less likely to engage in injection equipment sharing, but are more vulnerable to injection drug use (IDU)-related morbidity and mortality than Whites. Identifying subgroups of Latinx PWID who do engage in equipment sharing and likely bear the brunt of this health burden is a priority. Ethnic disparities may reflect contextual drivers, including injection networks. Latinx PWID with low ethnic homophily (the proportion of individuals with the same ethnic background) may be more likely to share equipment due to forced distancing from health-protective ethnocultural resources and power imbalances within injection networks. The current study offers a framework and examines how associations between network ethnic homophily and injection equipment sharing differ among 74 Latinx and 170 non-Latinx White PWID in the Chicagoland area (N = 244). Latinx had less homophilous than non-Latinx Whites (p <.001). Ethnic homophily was protective for equipment sharing among Latinx (OR = 0.17, 95%CI [0.77, 0.04], p = .02), but not non-Latinx Whites (OR = 1.66, 95%CI [0.40, 6.93], p = .49). Our findings implicate the need for targeted cultured interventions that focus on Latinx PWID who are more vulnerable to morbidity and mortality, potentially due to less access to ethnic peers.

Social-spatial network structures among young urban and suburban persons who inject drugs in a large metropolitan area

Background

It is estimated that there are 1.5% US adult population who inject drugs in 2018, with young adults aged 18-39 showing the highest prevalence. PWID are at a high risk of many blood-borne infections. Recent studies have highlight the importance of employing the syndemic approach to study opioid misuse, overdose, HCV and HIV, along with the social and environmental contexts where these interrelated epidemics occur in already marginalized communities. Social interactions and spatial contexts are important structural factors that are understudied.

Methods

Egocentric injection network and geographic activity spaces for young (aged 18-30) PWID and their injection, sexual, and social support network members (i.e., where reside, inject drugs, purchase drugs, and meet sex partners) were examined using baseline data from an ongoing longitudinal study (n=258). Participants were stratified based on the location of all place(s) of residence in the past year i.e., urban, suburban, and transient (both urban and suburban) to i) elucidate geospatial concentration of risk activities within multi-dimensional risk environments based on kernel density estimates; and ii) examine spatialized social networks for each residential group.

Results

Participants were mostly non-Hispanic white (59%); 42% were urban residents, 28% suburban, and 30% transient. We identified a spatial area with concentrated risky activities for each residence group on the West side of Chicago where a large outdoor drug market area is located. The urban group (80%) reported a smaller concentrated area (14 census tracts) compared to the transient (93%) and suburban (91%) with 30 and 51 tracts, respectively. Compared to other areas in Chicago, the identified area had significantly higher neighborhood disadvantages (e.g., higher poverty rate, p <0.001). Significant ( p <0.01 for all) differences were observed in social network structures: suburban had the most homogenous network in terms of age and residence, transient participants had the largest network (degree) and more non-redundant connections.

Conclusion

We identified concentrated risk activity spaces among PWID from urban, suburban, and transient groups in a large outdoor urban drug market area, which highlights the need for considering the role of risk spaces and social networks in addressing the syndemics in PWID populations.

A qualitative exploration of daily path and daily routine among people in Ukraine who inject drugs to understand associated harms

Background

Patterns of movement, heterogeneity of context, and individual space-time patterns affect health, and individuals’ movement throughout the landscape is shaped by addiction, meeting basic needs, and maintaining relationships. Place and social context enable or constrain behavior and individuals use social networks and daily routines to accomplish individual goals and access resources.

Methods

This article explores drug use as part of daily routines and daily paths among people who inject drugs in Dnipro City, Ukraine. Between March and August 2018, we interviewed 30 people who inject drugs living in Dnipro City, Ukraine. Study participants completed a single interview that lasted between 1 and 2 hours. During the interview, participants described their daily routine and daily path using a printed map of Dnipro as a prompt. Participants were asked to draw important sites; give time estimates of arrival and departure; and annotate on the map the points, paths, and areas most prominent or important to them. Participants also described to what extent their daily routines were planned or spontaneous, how much their daily path varied over time, and how drug use shaped their daily routine.

Results

We identified 3 major types of daily routine: unpredictable, predictable, and somewhat predictable. Participants with unpredictable daily routines had unreliable sources of income, inconsistent drug suppliers and drug use site, and dynamic groups of people with whom they socialized and used drugs. Participants with predictable daily routines had reliable sources of income, a regular drug dealer or stash source, and a stable group of friends or acquaintances with whom they bought and/or used drugs. Participants with somewhat predictable daily routines had some stable aspects of their daily lives, such as a steady source of income or a small group of friends with whom they used drugs, but also experienced circumstances that undermined their ability to have a routinized daily life, such as changing drug use sites or inconsistent income sources.

Conclusions

Greater attention needs to be paid to the daily routines of people who use drugs to develop and tailor interventions that address the place-based and social contexts that contribute to drug-use related risks.

Egocentric network characteristics of people who inject drugs in the Chicago metro area and associations with hepatitis C virus and injection risk behavior

BACKGROUND

Hepatitis C (HCV) infection has been rising in the suburban and rural USA, mainly via injection-based transmission. Injection and sexual networks are recognized as an important element in fostering and preventing risky behavior; however, the role of social support networks has received somewhat less attention.

METHODS

Using baseline data from an ongoing longitudinal study, we examined the composition and structure of injection drug use (IDU), sex, and social support networks of young people who inject drugs (aged 18-30) and their injection network members. Lasso logistic regression was used to select a subset of network characteristics that were potentially important predictors of injection risk behaviors and HCV exposure.

RESULTS

Several measures of IDU, sexual, and support network structure and composition were found to be associated with HCV exposure, receptive syringe sharing (RSS), and ancillary equipment sharing. Gender and sexual relationships were important factors for all risk behaviors. Support network characteristics were also important, notably including a protective effect of majority Hispanic support networks for RSS and HCV exposure. Both IDU network residence heterogeneity and support network geography were associated with injection equipment sharing.

CONCLUSIONS

The associations of IDU and support network geography with equipment sharing highlight the need to extend harm reduction efforts beyond urban areas. Greater understanding of support network influences on risk behavior may provide important insights to strengthen the benefits of harm reduction. In considering the probability of HCV transmission, it is important to consider setting and network structures that promote propagation of risk.

Modeling hepatitis C micro-elimination among people who inject drugs with direct-acting antivirals in metropolitan Chicago

Hepatitis C virus (HCV) infection is a leading cause of chronic liver disease and mortality worldwide. Direct-acting antiviral (DAA) therapy leads to high cure rates. However, persons who inject drugs (PWID) are at risk for reinfection after cure and may require multiple DAA treatments to reach the World Health Organization's (WHO) goal of HCV elimination by 2030. Using an agent-based model (ABM) that accounts for the complex interplay of demographic factors, risk behaviors, social networks, and geographic location for HCV transmission among PWID, we examined the combination(s) of DAA enrollment (2.5%, 5%, 7.5%, 10%), adherence (60%, 70%, 80%, 90%) and frequency of DAA treatment courses needed to achieve the WHO's goal of reducing incident chronic infections by 90% by 2030 among a large population of PWID from Chicago, IL and surrounding suburbs. We also estimated the economic DAA costs associated with each scenario. Our results indicate that a DAA treatment rate of >7.5% per year with 90% adherence results in 75% of enrolled PWID requiring only a single DAA course; however 19% would require 2 courses, 5%, 3 courses and <2%, 4 courses, with an overall DAA cost of $325 million to achieve the WHO goal in metropolitan Chicago. We estimate a 28% increase in the overall DAA cost under low adherence (70%) compared to high adherence (90%). Our modeling results have important public health implications for HCV elimination among U.S. PWID. Using a range of feasible treatment enrollment and adherence rates, we report robust findings supporting the need to address re-exposure and reinfection among PWID to reduce HCV incidence.

People who inject drugs in metropolitan Chicago: A meta-analysis of data from 1997-2017 to inform interventions and computational modeling toward hepatitis C microelimination

Progress toward hepatitis C virus (HCV) elimination in the United States is not on track to meet targets set by the World Health Organization, as the opioid crisis continues to drive both injection drug use and increasing HCV incidence. A pragmatic approach to achieving this is using a microelimination approach of focusing on high-risk populations such as people who inject drugs (PWID). Computational models are useful in understanding the complex interplay of individual, social, and structural level factors that might alter HCV incidence, prevalence, transmission, and treatment uptake to achieve HCV microelimination. However, these models need to be informed with realistic sociodemographic, risk behavior and network estimates on PWID. We conducted a meta-analysis of research studies spanning 20 years of research and interventions with PWID in metropolitan Chicago to produce parameters for a synthetic population for realistic computational models (e.g., agent-based models). We then fit an exponential random graph model (ERGM) using the network estimates from the meta-analysis in order to develop the network component of the synthetic population.

Addressing injecting related risks among people who inject both opioids and stimulants: Findings from an Australian survey of people who inject drugs

Background

Opioids and stimulants are the most commonly injected illicit drugs worldwide and in Australia. While some people who inject drugs (PWID) prefer either opioids or stimulants, others regularly use both opioids and stimulants. Limited available research indicates that those who use opioids and stimulants together, either in combination or alternating between the two, may engage in injection-related practices which potentially place them at greater health risk and could lead to poorer health outcomes.

Methods

Participants were recruited nationally through member organizations of the Australian Injecting and Illicit Drug Users League (AIVL); these organizations represent PWID in each Australian state and territory. This study compared a sample of PWID (N = 535) who reported past-month injection of opioids only (N = 173), stimulants only (N = 208), or both (N = 154) on a range of health and wellbeing outcomes. PWID completed a survey assessing drugs injected, frequency of injecting, receptive equipment sharing, psychological distress, self-reported hepatitis C (HCV) status, experienced and internalized stigma, drug use salience, and community attachment.

Results

People who injected both opioids and stimulants reported more frequent injecting, more experiences of stigma, and greater reported HCV diagnosis than people who injected stimulants or opioids alone. They also showed greater attachment to a community of PWID and greater salience of drug use to their identity.

Conclusions

The findings of increased injecting and broader harms associated with injecting both stimulants and opioids are important for tailoring harm reduction and intervention designs for people who use both opioid and stimulant drugs, including prioritizing peer-based approaches.

Social support networks of users of crack cocaine and the role of a Brazilian health program for people living on the street: A qualitative study

This cross-sectional qualitative study analyzed characteristics of social support for users of crack cocaine and the role of "Consultório na Rua" (CR), or "Office in the Street," a Brazilian program for people living on the street. Data were collected using 1) ethnographic field observations during the delivery of services from this program, 2) in-depth interviews with 17 users of crack cocaine, and 3) a focus group with professionals from CR. To analyze data, we used content analysis and analytical categories based on Social Network Analysis (SNA) theoretical statements. Results showed that family, peers, community members, and professionals from CR were the main social support providers. Participants mentioned receiving material, informational, and emotional support from CR members. It was observed that CR had a welcoming and inclusive approach, but CR team members identified challenges related to stigma directed toward people who use substances and live on the street. CR assumed a central role in the health and social assistance of users of crack cocaine living on the street, providing an important link to healthcare and social services. However, initiatives related to motivation to receive mental health services, treatment, or social reintegration were not observed in conjunction with this program.

Trends in homelessness and injection practices among young urban and suburban people who inject drugs: 1997-2017

BACKGROUND

Among young people who inject drugs (PWID) homelessness is associated with numerous adverse psychosocial and health consequences, including risk of relapse and overdose, psychological distress and suicidality, limited treatment access, and injection practices that increase the risk of HIV and hepatitis C (HCV) transmission. Homeless PWID may also be less likely to access sterile syringes through pharmacies or syringe service programs.

METHODS

This study applied random-effects meta-regression to examine trends over time in injection risk behaviors and homelessness among young PWID in Chicago and surrounding suburban and rural areas using data from 11 studies collected between 1997 and 2017. In addition, subject-level data were pooled to evaluate the effect of homelessness on risk behaviors across all studies using mixed effects logistic and negative binomial regression with random study effects.

RESULTS

There was a significant increase in homelessness among young PWID over time, consistent with the general population trend of increasing youth homelessness. In mixed-effects regression, homelessness was associated with injection risk behaviors (receptive syringe sharing, syringe mediated sharing, equipment sharing) and exchange sex, though we detected no overall changes in risk behavior over time.

CONCLUSIONS

Increases over time in homelessness among young PWID highlight a need for research to understand factors contributing to youth homelessness to inform HIV/STI, HCV, and overdose prevention and intervention services for this population.

Positive effects of community attachment on internalised stigma and wellbeing among people who inject drugs

BACKGROUND

Internalised stigma experienced by people who inject drugs (PWID) is known to have negative health consequences. Research has explored factors that may protect or buffer individuals from the negative consequences of internalised stigma. Community attachment, or perceived connection to a community of like people, can have numerous health-related benefits. However, this relationship may be complex for PWID; being part of a social network of PWID may provide opportunity for more frequent drug use and equipment sharing. This study investigated the relationships between community attachment, internalised stigma, and wellbeing among PWID, while also addressing potential health risks associated with PWID community attachment.

METHODS

PWID (n=603) were recruited through nine peer-based drug user organisations across Australia with assistance from the peak consumer organisation. Participants completed a survey measuring community attachment, internalised stigma, personal wellbeing, injecting frequency, and equipment sharing.

RESULTS

Greater attachment to a PWID community was associated with lower internalised stigma, but also with sharing of injecting equipment and increased frequency of injecting behaviour. The relationship between community attachment and personal wellbeing was mediated by internalised stigma, however this was only the case for PWID who reported no sharing of injecting equipment.

CONCLUSIONS

This research highlights the significance of community attachment for PWID while also noting the complexity of this relationship and the potential negative consequences. It is important to view networks of PWID communities as sources of positive social capital, where norms about health behaviours and harm reduction can be promoted and which can buffer community members from the harms associated with stigma.

Drug use-related stigma, safer injection norms, and hepatitis C infection among a network-based sample of young people who inject drugs

BACKGROUND

Identifying risk for hepatitis C (HCV) infection is important for understanding recent increases in HCV incidence among young people who inject drugs (PWID) in suburban and rural areas; and for refining the targeting of effective HCV preventive interventions. Much of the extant research has focused on individual health behaviors (e.g., risky drug injection behaviors) as predictors of HCV infection. The present study examines two social factors (substance use-related stigma and injection-related social norms), and the interaction between these factors, as predictors of HCV infection.

METHODS

Baseline data were used from an ongoing longitudinal study of young PWID (N = 279; mean age = 30.4 years) from the Chicago suburbs and their injection risk network members. Adjusted logistic regression models were used to examine relationships among substance use-related stigma, safer injection norms, and HCV infection.

RESULTS

Despite a marginal bivariate association between less safe injection norms and HCV infection (OR = 0.74; 95 % CI[0.39, 1.02]; p = .071), a significant stigma X norms interaction (AOR = 0.68; 95 % CI[0.51, 0.90]) suggested that at high levels of stigma, probability of HCV infection was high regardless of injection norms.

CONCLUSIONS

Findings suggest that social factors - specifically, substance use-related stigma and injection norms - are important predictors of HCV infection risk. The interaction found between these social factors suggests that intervening only to change injection norms or behaviors is likely insufficient to reduce risk for HCV infection in high-stigma settings or among high-stigma populations. Future research should develop and evaluate stigma-reduction interventions in combination with safer-injection interventions in order to maximize HCV risk reduction.

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.

Geographically Focused Collocated Hepatitis C Screening and Treatment in Los Angeles's Skid Row

BACKGROUND

The inequitable prevalence of hepatitis C (HCV) in the homeless is a clinical and public health concern. Prior research estimates, at least one-quarter of homeless persons have been infected with HCV, yet linkage to care and treatment uptake remains marginal.

AIM

To evaluate the feasibility of treating HCV in a homeless population.

METHODS

Retrospective study of homeless individuals treated for HCV. Demographic information including risk factors was collected. Univariate analyses were performed. The proportion of patients linked to care and sustained viral response at 12 weeks post-treatment (SVR12) was measured.

RESULTS

During the study period, 6767 individuals were screened for HCV. A total of 769 (11.4%) were found to have detectable HCV antibodies. Of the individuals with detectable HCV antibodies, 443 (57.6%) were viremic. Of the 443 viremic patients, 375 (84.7%) were linked to care. Among them, 59 patients began antiviral treatment and 95% (56/59) completed the course of therapy. The ITT was 83.1% (49/59), and the per-protocol virologic cure rate was 100% (49/49).

CONCLUSION

The favorable linkage to care and cure outcomes in our study suggests that homeless persons may be more likely to engage in HCV screening and treatment when these services are located in the community for their use. Our study further lends support to the efficacy of care coordination programs to encourage movement through the HCV care continuum in vulnerable populations.

Negative affect, affect-related impulsivity, and receptive syringe sharing among people who inject drugs

Receptive syringe sharing (RSS) among people who inject drugs (PWID) is a risk factor for hepatitis C virus and HIV infections. PWID with borderline personality disorder (BPD) have increased risk of RSS, but it remains unclear what drives this association. This study used ecological momentary assessment (EMA) to study characteristics associated with BPD, and RSS among PWID. We recruited PWID, ages 18-35, through two Community Outreach Intervention Projects syringe service program sites in Chicago, Illinois. After a baseline interview, participants used a mobile phone app to respond to momentary surveys on mood, substance use, and injection risk behavior for two weeks. For each momentary assessment, ratings on negative mood descriptors were combined to create measures of total negative affect (NA), and NA components of dejection, shame, anger, irritability, and worry. RSS was defined by participant responses indicating that they had used a syringe that someone else had used. We estimated mixed effects logistic models, regressing RSS on baseline affect-related impulsivity, lagged momentary NA, and the interaction term. Out of 163 participants who completed at least two EMA assessments, 152 (93%) reported at least one injection event and had valid pre-injection mood assessments required to be included in the analysis. We found that affect-related impulsivity, combined with worried mood in the hours preceding the injection episode, predicted increased risk of RSS. PWID having difficulties with emotion regulation may be at increased risk of RSS during periods of anxiety or tension. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Characterizing latent classes of social support among persons who inject drugs

BACKGROUND

Social network members influence risk and health behaviors, yet little is known about the support that persons who inject drugs (PWID) receive from their closest ties.

METHODS

970 participants from the AIDS Linked to the IntraVenous Experience (ALIVE) study completed a social network survey between April 2016 and June 2017 about their five closest ties. Our analysis: 1) identified latent classes of support received by participants; 2) determined whether class membership differed by current (≤12 months) vs. former (>12 months) injection drug use; 3) compared classes of support by individual and network characteristics.

RESULTS

970 participants listed 3,388 network members. We identified three support classes: (1) Moderate (n = 249): probabilities of support <0.40; (2) High (n = 366): probabilities of support 0.58-0.82; (3) Very high (n = 355): probabilities of support 0.91-0.99. In adjusted analysis compared to moderate support, the odds of high and very high support increased as the mean age of network members increased (Adjusted Odds Ratio [AOR]:1.03; 95 % CI: 1.01, 1.05) and as the number of network members with whom they interacted daily increased (AOR-high: 1.33; 95 % CI:1.14, 1.56 and AOR-very high: 1.54; 95 % CI: 1.30, 1.83). While current injection drug use was associated with lower unadjusted odds of high and very high support, the associations were not statistically significant in adjusted analysis.

CONCLUSIONS

Support was higher among networks of older ties and more frequent interaction, but differences did not appear to be driven by injection drug use status. Findings point to the importance of the closest social ties.

Distributive Syringe Sharing and Use of Syringe Services Programs (SSPs) Among Persons Who Inject Drugs

Monitoring distributive syringe sharing (DSS) and syringe services program (SSP) use among persons who inject drugs (PWID) is important for HIV prevention. PWID aged ≥ 18 in 20 US cities were recruited for National HIV Behavioral Surveillance in 2015 using respondent-driven sampling, interviewed and offered HIV testing. Bivariate and multivariable analyses via log-linked Poisson regression with generalized estimating equations were conducted to examine associations between demographic and behavioral variables and DSS. Effect of SSP use on DSS by HIV sero-status was assessed by including an interaction between SSP and sero-status. Analyses were adjusted for sampling design. Among 10,402 PWID, 42% reported DSS. DSS was less likely to be reported among HIV-positive compared to HIV-negative PWID (aPR = 0.51, CI 0.45-0.60), and among those who primarily obtained syringes from SSPs versus those who did not (aPR = 0.82, 95% CI 0.77-0.88). After adjustment, those who primarily used SSPs were less likely to report DSS than those who did not among both HIV-negative PWID (aPR = 0.84, 95% CI 0.78-0.90) and HIV-positive PWID (aPR = 0.54, 95% CI 0.39-0.75). Findings support expansion of SSPs, and referrals to SSPs by providers working with PWID.

Latent Classes of Sexual Risk Behavior and Engagement in Outreach, Intervention and Prevention Services Among Women Who Inject Drugs Across 20 US Cities

BACKGROUND

Monitoring the effects of HIV prevention efforts among persons who inject drugs is key to informing prevention programs and policy.

METHODS

Data for this study came from the 2012 National HIV Behavioral Surveillance interviews with persons who inject drugs across 20 US cities. The present analyses include those who identified as female, ever had sex with a man, and were at risk of HIV infection (did not report a previous positive HIV test result) (n = 2624). We conducted latent class analysis to identify sexual risk classes, and modeled associations with engagement in HIV prevention services and HIV test results.

RESULTS

We identified 6 classes of sexual risk behavior: (1) low risk, (2) monogamous, (3) casual partner, (4) multiple partners, (5) exchange sex, and (6) exchange plus main partner. The class distribution was similar across the mainland regions. Bisexual orientation and homelessness were significant predictors of higher-risk class. HIV prevalence and participation in behavioral interventions did not vary significantly by risk class, while obtaining and using free condoms did. Independent of risk class, women in cities in the South were significantly less likely to use free condoms, and HIV prevalence was higher among non-Hispanic black women and women aged 40-49 years.

CONCLUSIONS

Bisexual orientation and homelessness were predictors of higher risk. Condom distribution programs reached fewer women in cities in the South. Race and age disparities in HIV-positive rates persisted after adjusting for sexual risk class.

HIV/HCV Co-infection: Burden of Disease and Care Strategies in Appalachia

PURPOSE OF REVIEW

The purpose of this review is to address infection with HIV and hepatitis C in the Appalachian region of the USA and the driving forces underlying this epidemic. We seek to discuss epidemiology of disease and the possible interventions to reduce incidence and burden of disease in this resource-limited area.

RECENT FINDINGS

The rise of the opioid crisis has fueled a rise in new hepatitis C infection, and a rise in new HIV infection is expected to follow. Injection drug use has directly contributed to the epidemic and continues to remain a risk factor. Men who have sex with men remains a significant risk factor for HIV acquisition as well. Progress has been made in the battle against HIV and, to a lesser extent, hepatitis C, but much more can be done. Limited data on co-infection with HIV/HCV are currently available for this at-risk region, but it is clear that Appalachia is highly vulnerable to co-infection outbreaks. A multipronged approach that includes advances in assessment of co-infection and education for both patients and clinicians can help to recognize, manage, and ideally prevent these illnesses.

Social Networks of Substance-Using Populations: Key Issues and Promising New Approaches for HIV

PURPOSE OF REVIEW

This paper presents recent literature on substance using networks and HIV, highlighting renewed and emerging themes in the field. The goal is to draw attention to research that holds considerable promise for advancing our understanding of the role of networks in shaping behaviors, while also providing critical information for the development of interventions, programs, and policies to reduce HIV and other drug-related harms.

RECENT FINDINGS

Recent research advances our understanding of networks and HIV, including among understudied populations, and provides new insight into how risk environments shape the networks and health of substance-using populations. In particular, the integration of network approaches with molecular epidemiology, research on space and place, and intervention methods provides exciting new avenues of investigation. Continued advances in network research are critical to supporting the health and rights of substance-using populations and ensuring the development of high-impact HIV programs and policies.

Factors associated with obtaining sterile syringes from pharmacies among persons who inject drugs in 20 US cities

BACKGROUND

Increased access to sterile syringes has been shown to reduce HIV risk among people who inject drugs (PWID). Where syringe services programs (SSPs) are limited, pharmacies are an important sterile syringe source. We assessed factors associated with using pharmacies as the primary source of syringes among PWID from 20 US cities.

METHODS

PWID ages ≥18 years were recruited for the 2015 National HIV Behavioral Surveillance using respondent-driven sampling. Using generalized estimating equation (GEE) models, we assessed demographic characteristics independently associated with participant-reported primary syringe source: pharmacies vs. SSPs. We calculated associations between primary syringe source and various behavioural outcomes, adjusted for participant characteristics.

RESULTS

PWID who were <30 years old, female, white, and less frequent injectors were more likely have used pharmacies as their primary syringe source. Accessing syringes primarily from pharmacies, as compared to SSPs, was associated with receptive syringe sharing and unsafe syringe disposal; using sterile syringes, recent HIV testing and participation in an HIV behavioural intervention were negatively associated with primary pharmacy use.

CONCLUSIONS

Pharmacies can play an important role in comprehensive HIV prevention among PWID. Linkage to HIV interventions and syringe disposal services at pharmacies could strengthen prevention efforts for PWID who cannot access or choose not to utilize SSPs.

Feasibility of ecological momentary assessment to study mood and risk behavior among young people who inject drugs

AIMS

To test the acceptability and feasibility of ecological momentary assessment (EMA) of mood and injection risk behavior among young people who inject drugs (PWID), using mobile phones.

METHODS

Participants were 185 PWID age 18-35 recruited from two sites of a large syringe service program in Chicago. After completing a baseline interview, participants used a mobile phone app to respond to momentary surveys on mood, substance use, and injection risk behavior for 15 days. Participants were assigned to receive surveys 4, 5, or 6 times per day.

RESULTS

Participants were 68% male, 61% non-Hispanic white, 24% Hispanic, and 5% non-Hispanic Black. Out of 185 participants, 8% (n = 15) failed to complete any EMA assessments. Among 170 EMA responders, the mean number of days reporting was 10 (SD 4.7), the mean proportion of assessments completed was 0.43 (SD 0.27), and 76% (n = 130) completed the follow-up interview. In analyses adjusted for age and race/ethnicity, women were more responsive than men to the EMA surveys in days reporting (IRR = 1.33, 95% CI 1.13-1.56), and total number of surveys completed (IRR = 1.51, 95% CI 1.18-1.93). Homeless participants responded on fewer days (IRR = 0.76, 95% CI 0.64-0.90) and completed fewer surveys (IRR = 0.70, 95% CI 0.54-0.91), and were less likely to return for follow-up (p = 0.016). EMA responsiveness was not significantly affected by the number of assigned daily assessments.

CONCLUSIONS

This study demonstrated high acceptability and feasibility of EMA among young PWID, with up to 6 survey prompts per day. However, homelessness significantly hampered successful participation.

High-Risk Geographic Mobility Patterns among Young Urban and Suburban Persons who Inject Drugs and their Injection Network Members

Young people in the USA who inject drugs, particularly those at a risk of residence instability, experience the highest incidence of hepatitis C (HCV) infections. This study examined associations between geographic mobility patterns and sociodemographic, behavioral, and social network characteristics of 164 young (ages 18-30) persons who inject drugs (PWID). We identified a potential bridge sub-population who reported residence in both urban and suburban areas in the past year (crossover transients) and higher-risk behaviors (receptive syringe sharing, multiple sex partners) compared to their residentially localized counterparts. Because they link suburban and urban networks, crossover transients may facilitate transmission of HIV and HCV between higher and lower prevalence areas. Interventions should address risk associated with residential instability, particularly among PWID who travel between urban and suburban areas.

Injection-Related Risk Behavior and Engagement in Outreach, Intervention and Prevention Services Across 20 US Cities

BACKGROUND

Monitoring the effects of HIV prevention efforts on risk behaviors among persons who inject drugs is a key to inform prevention programs and policy.

METHODS

Using data from the 2012 National HIV Behavioral Surveillance interviews with persons who inject drugs across 20 US cities (n = 10,171), we conducted latent class analysis to identify injection risk classes and assess the relationship between engagement in prevention services and injection-related risk behavior. We conducted stratified analyses to examine the consistency of these associations across different geographical regions.

RESULTS

The latent class analysis identified 6 distinct classes of injection-related risk behavior. The class structure was consistent across regions of the United States, but the distribution of risk classes varied significantly across regions. With covariate adjustment, the South had the most high-risk behavior (21%) and the Midwest had the least (6%). Participation in syringe access services and other prevention services was the lowest in the South. Syringe access was associated with a significantly lower likelihood of membership in the highest risk class in all regions except the Midwest. Participation in individual or group intervention with a practical skills component was associated with less risky injection behavior in all regions except the Northeast. Interventions that featured only safer injection information and discussion had no relationship with risk class.

CONCLUSIONS

Our findings support evidence of the effectiveness of syringe service programs and safer injection skills training in reducing high-risk injection behavior and underscore the need to improve access to these prevention interventions in the South of the United States.

Gender, Transience, Network Partnerships and Risky Sexual Practices Among Young Persons who Inject Drugs

Persons who inject drugs (PWID) may be at risk of acquiring HIV and sexually transmitted infections (STIs) from risky sexual practices and elevated disease prevalence within their drug injection and sexual networks. We conducted a personal (egocentric) network study of young PWID (aged 18-30) from the Chicago metropolitan area. Logistic regression with generalized estimating equations evaluated associations between individual and network factors and sexual behaviors. Of 162 participants, 116 (71.6 %) were non-Hispanic White and 135 reported on 314 sexual network members. Multiplexity-having network members with overlapping roles as injection and sexual partners-was associated with more condomless vaginal sex (aOR 5.55; 95 % CI 1.62-19.0) and anal sex (aOR 6.79; 95 % CI 2.49-18.5) and less exchange sex among women (aOR 0.12; 95 % CI 0.03-0.40), adjusting for sociodemographic and sexual network characteristics. The contribution of individual and sexual network factors to HIV/STI transmission among young PWID warrants further research.