Law enforcement influences on HIV prevention for injection drug users:

Evaluation of an Experimental Web-based Educational Module on Opioid-related Occupational Safety Among Police Officers: Protocol for a Randomized Pragmatic Trial to Minimize Barriers to Overdose Response

BACKGROUND

As drug-related morbidity and mortality continue to surge, police officers are on the front lines of the North American overdose (OD) crisis. Drug law enforcement shapes health risks among people who use drugs (PWUD), while also impacting the occupational health and wellness of officers. Effective interventions to align law enforcement practices with public health and occupational safety goals remain underresearched.

OBJECTIVE

The Opioids and Police Safety Study (OPS) aims to shift police practices relating to PWUD. It adapts and evaluates the relative effectiveness of a curriculum that bundles content on public health promotion with occupational risk reduction (ORR) to supplement a web-based OD response and naloxone training platform (GetNaloxoneNow.org, or GNN). This novel approach has the potential to improve public health and occupational safety practices, including using naloxone to reverse ODs, referring PWUD to treatment and other supportive services, and avoiding syringe confiscation.

METHODS

This longitudinal study uses a randomized pragmatic trial design. A sample of 300 active-duty police officers from select counties in Pennsylvania, Vermont, and New Hampshire with high OD fatality rates will be randomized (n=150 each) to either the experimental arm (GNN + OPS) or the control arm (GNN + COVID-19 ORR). A pre- and posttraining survey will be administered to all 300 officers, after which they will be administered quarterly surveys for 12 months. A subsample of police officers will also be qualitatively followed in a simultaneous embedded mixed-methods approach. Research ethics approval was obtained from the New York University Institutional Review Board.

RESULTS

Results will provide an understanding of the experiences, knowledge, and perceptions of this sample of law enforcement personnel. Generalized linear models will be used to analyze differences in key behavioral outcomes between the participants in each of the 2 study arms and across multiple time points (anticipated minimum effect size to be detected, d=0.50). Findings will be disseminated widely, and the training products will be available nationally once the study is completed.

CONCLUSIONS

The OPS is the first study to longitudinally assess the impact of a web-based opioid-related ORR intervention for law enforcement in the U.S. Our randomized pragmatic clinical trial aims to remove barriers to life-saving police engagement with PWUD/people who inject drugs by focusing both on the safety of law enforcement and evidence-based and best practices for working with persons at risk of an opioid OD. Our simultaneous embedded mixed-methods approach will provide empirical evaluation of the diffusion of the naloxone-based response among law enforcement.

TRIAL REGISTRATION

ClinicalTrail.gov NCT05008523; https://clinicaltrials.gov/show/NCT05008523.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/33451.

Working With Persons Who Inject Drugs and Live in Rural Areas: Implications From China/Vietnam for the USA

PURPOSE OF REVIEW

To describe a small city/rural area HIV prevention project (the Cross Border Project) implemented in Ning Ming County, Guangxi Province, China, and Lang Son province, Vietnam, and consider its implications for addressing the opioid/heroin epidemic in small cities/rural areas in the USA. The description and the outcomes of the Cross Border project were taken from published reports, project records, and recent data provided by local public health authorities. Evaluation included serial cross-sectional surveys of people who inject drugs to assess trends in risk behaviors and HIV prevalence. HIV incidence was estimated from prevalence among new injectors and through BED testing.

RECENT FINDINGS

The Cross Border project operated from 2002 to 2010. Key components of the project 2 included the use of peer outreach workers for HIV/AIDS education, distribution of sterile injection equipment and condoms, and collection of used injection equipment. The project had the strong support of local authorities, including law enforcement, and the general community. Significant reductions in risk behavior, HIV prevalence, and estimated HIV incidence were observed. Community support for the project was maintained. Activities have been continued and expanded since the project formally ended. The Cross Border project faced challenges similar to those occurring in the current opioid crisis in US small cities/rural areas: poor transportation, limited resources (particularly trained staff), poverty, and potential community opposition to helping people who use drugs. It should be possible to adapt the strategies used in the Cross Border project to small cities/rural areas in the US opioid epidemic.

Police attitudes towards pre-booking diversion in Baltimore, Maryland

BACKGROUND

In the context of high rates of drug-related incarceration that disproportionately affect urban communities of colour, advocates for drug policy criminal justice reform have called for alternatives to mass incarceration. The Law Enforcement Assisted Diversion (LEAD) program redirects low-level drug offenders to health and social services rather than immediately into the criminal justice system. In advance of piloting LEAD in Baltimore City, we assessed police perceptions towards harm reduction and specifically pre-booking diversion in effort to inform training and implementation activities in Baltimore City and elsewhere.

METHODS

We administered a survey to Baltimore City Police Officers (N = 83) in the planned implementation district using two scales: the first measured police attitudes toward people who use drugs (PWUD), current drug policies and public health measures, and the second measured police perceptions of pre-booking diversion programs. We calculated Cronbach's alpha (α) to assess internal consistency of both scales. Bivariate χ2 tests and multivariate logistic regression examined correlates of scale items stratified by new and seasoned officers.

RESULTS

Seasoned officers were significantly less likely to believe that drug treatment is easily available (51% vs. 81%, p = 0.005). The belief that current policies are effective and that PWUD should be arrested for small drug purchases decreased significantly per year on the force (aOR: 0.92; 95%CI 0.85,0.99; aOR: 0.94, 95% CI 0.88, 0.99, respectively), as did concerns about needle-stick injuries (aOR: 0.85, 95% CI 0.74, 0.98). Seasoned officers were significantly more comfortable referring PWUD to social services (100% vs. 83%, p = 0.006), and agree that such pre-booking diversion could be effective in improving public safety within (72% vs. 43%; p = 0.009) and beyond the intervention area (56% vs. 33%, p = 0.04).

CONCLUSIONS

The study indicates the value of intervening early and consistently throughout police career trajectories and engaging seasoned officers as allies to promote recognition and support of public health and harm reduction strategies within ongoing police reform efforts. LEAD provides important and broad opportunities for training police to enhance their understanding the intersection of public safety and public health.

Factors associated with extrajudicial arrest for syringe possession: results of a department-wide survey of municipal police in Tijuana, Mexico

Background

Mexican law permits syringe purchase and possession without prescription. Nonetheless, people who inject drugs (PWID) frequently report arrest for syringe possession. Extrajudicial arrests not only violate human rights, but also significantly increase the risk of blood-borne infection transmission and other health harms among PWID and police personnel. To better understand how police practices contribute to the PWID risk environment, prior research has primarily examined drug user perspectives and experiences. This study focuses on municipal police officers (MPOs) in Tijuana, Mexico to identify factors associated with self-reported arrests for syringe possession.

Methods

Participants were active police officers aged ≥18 years, who completed a self-administered questionnaire on knowledge, attitudes and behaviors related to occupational safety, drug laws, and harm reduction strategies. Univariable and multivariable logistic regression was used to identify correlates of recent syringe possession arrest.

Results

Among 1044 MPOs, nearly half (47.9%) reported always/sometimes making arrests for syringe possession (previous 6mo). Factors independently associated with more frequent arrest included being male (Adjusted Odds Ratio [AOR] = 1.62; 95% Confidence Interval [95% CI] =1.04–2.52; working in a district along Tijuana River Canal (where PWID congregate) (AOR = 2.85; 95%CI = 2.16–3.77); having recently experienced a physical altercation with PWID (AOR = 2.83; 95% CI = 2.15–3.74); and having recently referred PWID to social and health services (AOR = 1.97; 95% CI = 1.48–2.61). Conversely, odds were significantly lower among officers reporting knowing that syringe possession is legal (AOR = 0.61; 95% CI = 0.46–0.82).

Conclusions

Police and related criminal justice stakeholders (e.g., municipal judges, prosecutors) play a key role in shaping PWID risk environment. Findings highlight the urgent need for structural interventions to reduce extra-judicial syringe possession arrests. Police training, increasing gender and other forms of diversity, and policy reforms at various governmental and institutional levels are necessary to reduce police occupational risks, improve knowledge of drug laws, and facilitate harm reduction strategies that promote human rights and community health.

Characteristics of persons who inject drugs and who witness opioid overdoses in Vietnam: a cross-sectional analysis to inform future overdose prevention programs

BACKGROUND

Persons who use opioids have a high risk of overdose and associated mortality. In Vietnam, little is known about the characteristics of this population and the persons who are witness to those overdoses. One approach to combatting fatal overdose has been the use of peer interventions in which a friend or injecting partner administers overdose reversal medication, but availability in Vietnam of these medications is limited to pilot programs with aims to expand in the future (Le Minh and V.F. Go, Personal Communication, 2016). The primary objective of this paper is to explore the characteristics associated with witnessing three or more overdoses in a lifetime.

METHODS

This cross-sectional analysis used baseline data from a four-arm randomized control trial conducted in Thai Nguyen, Vietnam, known as the Prevention for Positives project. One thousand six hundred seventy-three PWID were included in the analysis. We conducted bivariable and multivariable logistic regression to identify characteristics associated with witnessing three or more overdoses in a lifetime. Characteristics explored included education, employment, marital status, risky drug use behaviors, locations for accessing syringes, recent overdose, history of incarceration, drug treatment, and having slept outside in the past 3 months.

RESULTS

Seventy-two percent (n = 1203) of participants had witnessed at least one overdose in their lifetime, and 46% had witnessed three or more overdoses (n = 765). In the multivariable model, having less than secondary education (AOR 0.70; 95% CI 0.57, 0.86), having slept outside in the past 3 months (AOR 1.77; 95% CI 1.31, 2.40), having a history of incarceration (AOR 1.33; 95% CI 1.07, 1.65), having a history of drug treatment (AOR 1.41; 95% CI 1.12, 1.77), experiencing a recent non-fatal overdose (AOR 3.84; 95% CI 2.36, 6.25), injecting drugs daily (AOR 1.79; 95% CI 1.45, 2.20), receptive needle sharing (AOR 1.30; 95% CI 1.04, 1.63), and number of years injecting (AOR 1.04; 95% CI 1.02, 1.07) were significantly associated with witnessing three or more overdoses.

CONCLUSIONS

Targeted interventions are needed to train persons witnessing an overdose to administer overdose-reversal medication. This includes targeting persons prior to release from prisons, drug treatment centers, and those accessing syringe exchange programs. Additional research should assess the burden of witnessing an overdose as well as locations for medication distribution. Assessments of the training capacity and needs for implementing these programs among drug using peers in Vietnam are of the utmost importance.

Police Encounters Among Needle Exchange Clients in Baltimore: Drug Law Enforcement as a Structural Determinant of Health

OBJECTIVES

We piloted a monitoring mechanism to document police encounters around programs targeting people who inject drugs (PWID), and assessed their demographic predictors at 2 Baltimore, Maryland, needle exchange program (NEP) sites.

METHODS

In a brief survey, 308 clients quantified, characterized, and sited recent police encounters. Multivariate linear regression determined encounter predictors, and we used geocoordinate maps to illustrate clusters.

RESULTS

Within the past 6 months, clients reported a median of 3 stops near NEP sites (interquartile range [IQR] = 0-7.5) and a median of 1 arrest in any location (IQR = 0-2). Three respondents reported police referral to the NEP. Being younger (P = .009), being male (P = .033), and making frequent NEP visits (P = .02) were associated with reported police stops. Among clients reporting arrest or citation for syringe possession, Whites were significantly less likely than non-Whites to report being en route to or from an NEP (P < .001). Reported encounters were clustered around NEPs.

CONCLUSIONS

Systematic surveillance of structural determinants of health for PWID proved feasible when integrated into service activities. Improved monitoring is critical to informing interventions to align policing with public health, especially among groups subject to disproportionate levels of drug law enforcement.

Syringe access, syringe sharing, and police encounters among people who inject drugs in New York City: a community-level perspective

BACKGROUND

Injection drug user (IDU) experience and perceptions of police practices may alter syringe exchange program (SEP) use or influence risky behaviour. Previously, no community-level data had been collected to identify the prevalence or correlates of police encounters reported by IDUs in the United States.

METHODS

New York City IDUs recruited through respondent-driven sampling were asked about past-year police encounters and risk behaviours, as part of the National HIV Behavioural Surveillance study. Data were analysed using multiple logistic regression.

RESULTS

A majority (52%) of respondents (n=514) reported being stopped by police officers; 10% reported syringe confiscation. In multivariate modelling, IDUs reporting police stops were less likely to use SEPs consistently (adjusted odds ratio [AOR]=0.59; 95% confidence interval [CI]=0.40-0.89), and IDUs who had syringes confiscated may have been more likely to share syringes (AOR=1.76; 95% CI=0.90-3.44), though the finding did not reach statistical significance.

CONCLUSIONS

Findings suggest that police encounters may influence consistent SEP use. The frequency of IDU-police encounters highlights the importance of including contextual and structural measures in infectious disease risk surveillance, and the need to develop approaches harmonizing structural policing and public health.

Drug users in Hanoi, Vietnam: factors associated with membership in community-based drug user groups

Background

A syndemic conjoins injection drug use, incarceration, and HIV in Vietnam, where there is a need for programs that empower people who use drugs to minimize the harms thereby produced. Here we present a post-hoc evaluation of the organizing efforts of the Centre for Supporting Community Development Initiatives (SCDI) with two community-based drug user groups (CBGs) in Hanoi.

Methods

Members (n = 188) of the CBGs were compared to non-member peers (n = 184) on demographic, psychosocial, behavioral and knowledge variables using a face-to-face structured interview that focused on issues of quality of life and harm reduction. Bivariate analyses were conducted, and variables significantly associated with membership at p < 0.10 were included in a multivariate model.

Results

Variables associated with membership in the CBGs in the multivariate model included increased self-efficacy to get drug-related health care (OR 1.59, 1.24-2.04), increased quality of life in the psychological (OR 2.04, 1.07-3.93) and environmental (OR 2.54, 1.31-4.93) domains, and greater history of interactions with police about drugs (OR 3.15, 1.79-5.52). There was little difference between members and non-members on injection-related harms except in the domain of knowledge about opioid overdose. Among the 114 current injectors (30.6% of the sample), low rates of unsafe injection practices were reported, and low statistical power limited the ability to conclusively assess association with membership.

Conclusions

Although the CBG members displayed higher levels of well-being and access to healthcare than non-members, further longitudinal study is required to determine if these are a result of membership. The CBGs should pay more attention towards meeting challenges in responding to specific health issues of those who continue to use drugs including HIV, hepatitis, and drug overdose.

Police education as a component of national HIV response: lessons from Kyrgyzstan

BACKGROUND

Recognition of the police's role in shaping HIV spread and prevention among people who inject drugs, sex workers, and other at-risk groups has generated interest in educational interventions targeting law enforcement. With input from civil society, trainings covering HIV prevention science, policy, and occupational safety were developed and delivered to cadets and active-duty police across Kyrgyzstan.

METHODS

We administered a multi-site cross-sectional survey of Kyrgyz police to assess whether having undergone HIV trainings was associated with improved legal and public health knowledge, positive attitudes toward public health programs and policies, occupational safety awareness, and intended practices .

RESULTS

In a 313-officer sample, 38% reported undergoing the training. In a multivariate analysis, training was associated with the officer being significantly more likely to support referring individuals to public health organizations (aOR 2.21; 95%CI 1.33-3.68), expressing no intent to extrajudicially confiscate syringes (aOR 1.92; 95%CI 1.09-3.39), and better understanding sex worker detention procedure (aOR 2.23; 95%CI 1.19-4.46), although trainee knowledge of policy on routine identification checks for sex workers was significantly lower (aOR 3.0; 95%CI 1.78-5.05). Training was also associated with improved occupational safety knowledge (aOR 3.85; 95%CI 1.66-8.95).

CONCLUSION

Kyrgyzstan's experience suggest that police trainings have the potential to improve the integration of policing and public health efforts targeting at-risk groups. Regardless of the legal environment, such structural approaches should be considered elsewhere in Central Asia and beyond. As these initiatives gain acceptance, further research is needed to inform their design and tailoring.

Social science research on HIV in Vietnam: a critical review and future directions

Social science research can enhance the response to Vietnam's growing HIV epidemic by capturing the country's rapidly changing social and political context. The present paper reviews the published, peer-reviewed and English-language social science literature on HIV in Vietnam in order to identify critical theoretical and substantive gaps, while laying the groundwork for future research. We found four broad foci for work on the social context of HIV and AIDS in Vietnam: the cultural meanings and social relationships that shape Vietnam's HIV epidemic; stigma and discrimination; social inequality and structural violence as contributors to HIV risk; and, finally, how broader global and social systems shape Vietnam's HIV epidemic. We signal the particular need for additional research on the effects of the media on attitudes towards HIV and AIDS, on social movements, and on health systems, as well as on a number of other key areas. Work along these lines, in addition to more effective communication of policy-relevant findings to those responsible for the development and implementation of policies and programmes, will strengthen Vietnam's response to HIV and AIDS.

Ability to access community-based needle-syringe programs and injecting behaviors among drug users: a cross-sectional study in Hunan Province, China

Background

Needle-syringe exchange programs (NSPs) have been substantially rolled-out in China since 2002. Limited studies reported effectiveness of NSPs in a Chinese setting. This study aimed to assess the association between accessibility to NSPs and drug-use risk behaviors of IDUs by investigating primary (self-reported) data of IDUs recruited from NSP sites, community settings and mandatory detoxification centers (MDCs) in Hunan province, China.

Methods

A cross-sectional survey was conducted in Hunan province in 2010. IDU recruits participated in a face-to-face interview to provide information related to their ability to access NSPs, demographic characteristics, and injecting behaviors in the past 30 days.

Results

Of the total 402 participants, 35%, 14% and 51% participants indicated low, medium and high ability to access NSPs in the past 30 days, respectively. A significantly higher proportion of IDUs (77.3%) from the high-access group reported ≤2 injecting episodes per day compared with medium- (46.3%) and low-access (58.8%) groups. Only 29.0% of high-access IDUs re-used syringes before disposal in the past 30 days, significantly lower than those in the medium- (43.1%) and low-access (41.3%) groups. Reported levels of needle/syringe sharing decreased significantly as the ability to access NSPs increased (16.3%, 12.7% and 2.5% in the low, medium and high access groups, respectively). Ninety percent of IDUs recruited from MDCs had low ability to access NSPs.

Conclusions

Increased NSP accessibility is associated with decreased levels of injecting frequency, repetitive use and sharing of injecting equipment among Chinese IDUs. Mandatory detention of IDUs remains as a major barrier for IDUs to access NSPs in China.

When grammars collide: Harm reduction, drug detention and the challenges of international policy reform efforts in Vietnam

Throughout the 1990s, a dramatic rise in HIV prevalence rates among drug users in Vietnam attracted the attention of international observers concerned about the prospect of a more generalised epidemic. Vietnam subsequently became the target of extensive funding and advocacy which sought to introduce needle exchange and methadone in a country where drug use was considered a 'social evil', and drug users were subjected to what international observers viewed as draconian incarceration measures. What were the goals of proponents of harm reduction when they came to Vietnam? How did they perceive the state of prevailing approaches to drug users in the context of the Vietnamese HIV epidemic? How did they understand the strategic challenges they faced and the dilemmas they had to confront? Based on in-depth interviews with international harm reduction proponents working in Vietnam, this paper explores the encounter of two grammars of harm reduction, one based on broadly accepted international approaches, the other rooted in Vietnam's own history and politics. From this encounter a set of policies and practices characterised by needle exchange and methadone maintenance emerged, as well as an extensive network of closed centres where tens of thousands of drug users are currently detained.

Harmonizing disease prevention and police practice in the implementation of HIV prevention programs: Up-stream strategies from Wilmington, Delaware

Introduction

Improving access to sterile injection equipment is a key component in community-based infectious disease prevention. Implementation of syringe access programs has sometimes been complicated by community opposition and police interference.

Case description

In 2006, the Delaware legislature authorized a pilot syringe exchange program (SEP). A program designed to prevent, monitor, and respond to possible policing and community barriers before they had a chance to effect program implementation and operation. A program designed to prevent, monitor, and respond to these barriers was planned and implemented by a multidisciplinary team of legal practitioners and public health professionals.

Discussion

We report on an integrated intervention to address structural barriers to syringe exchange program utilization. This intervention employs community, police and client education combined with systematic surveillance of and rapid response to police interference to preempt the kinds of structural barriers to implementation observed elsewhere. The intervention addresses community concerns and stresses the benefits of syringe exchange programs to officer occupational safety.

Conclusions

A cohesive effort combining collaboration with and educational outreach to police and community members based on the needs and concerns of these groups as well as SEP clients and potential clients helped establish a supportive street environment for the SEP. Police-driven structural barriers to implementation of public health programs targeting populations engaged in drug use and other illicit behavior can be addressed by up-stream planning, prevention, monitoring and intervention strategies. More research is needed to inform the tailoring of interventions to address police-driven barriers to HIV prevention services, especially among marginalized populations.

A harm reduction paradox: comparing China's policies on needle and syringe exchange and methadone maintenance

Background

China has launched methadone maintenance treatment (MMT) and needle and syringe exchange programmes (NSEP) as part of the country's HIV prevention strategy amongst injection drug users. MMT is expanding, with backing from multiple government ministries, however, NSEP have received less political support and funding.

Methods

Semi-structured, serial interviews were conducted with key informants, knowledgeable about China's harm reduction policies. Concurrent content analysis allowed for revision of the interview guide throughout the data collection process. This was combined with a systematic analysis of official government policy documents on NSEP and MMT, including white papers, legal documents, and policy statements.

Findings

Early consensus between public security and public health sectors regarding methadone's dual use in HIV prevention as well as method of drug control created broad institutional support for MMT programmes amongst policy makers. In contrast, NSEP were seen as satisfying only the HIV prevention goals of the public health sector, and were perceived as condoning illicit drug use. Furthermore, NSEP's roots in China, as an experimental collaboration with international groups, created suspicion regarding its role in China's drug control policy. NSEP and MMT's distinct paths to policy development are reflected in the complex and occasionally contradictory nature of China's harm reduction strategy.

Conclusions

These discrepancies highlight the need for a more politically sustainable and comprehensive integration of harm reduction projects. Recommendations include improved evaluation methods for NESP, NSEP-MMT cross-referral system, and stronger NSEP advocacy within the non-profit and public health sectors.

Prevalence, characteristics, and predictors of police training initiatives by US SEPs: building an evidence base for structural interventions

BACKGROUND

Community-based prevention initiatives such as syringe exchange programs (SEPs) are proven to curb injection-related HIV transmission. Policing targeting injection drug users (IDUs) can interfere with SEP functioning. Efforts to maximize the public health benefit of SEPs have included police trainings designed to reduce such interference.

METHODS

We surveyed US SEP managers to assess prevalence, content, and correlates of SEP police trainings. Multivariate analyses were utilized to identify predictors of training participation.

RESULTS

Of 107 SEPs (57% of all US programs), 20% reported participating in trainings during the previous year. Covered topics included the public health rationale behind SEPs (71%), police occupational health (67%), needle stick injury (62%), SEPs' legal status (57%), and harm reduction philosophy (67%). On average, trainings were seen as moderately effective, but only four programs reported conducting any formal evaluation. In multivariate modeling, training participation was independently associated with state law authorizing syringe possession by clients (aOR=3.71, 95%CI=1.04-13.23), higher frequency of client arrest (aOR=2.07, 95%CI=1.0-4.7), and systematic monitoring of adverse client-police encounters (aOR=4.02, 95%CI=1.14-14.17). Assistance with police trainings was identified by 72% of respondents as the key to improving police relations.

CONCLUSION

At a time when collaboration with police may become requisite for SEPs to receive federal funding, most program managers in the US perceive police trainings as a key to improved SEP-police relations. Robust evaluation is needed to better understand the impact of these trainings on law enforcement practices, SEP operations, and community health. Such research will inform technical assistance, policy design, and resource allocation.

Drug-related arrest rates and spatial access to syringe exchange programs in New York City health districts: combined effects on the risk of injection-related infections among injectors

Drug-related law enforcement activities may undermine the protective effects of syringe exchange programs (SEPs) on local injectors' risk of injection-related infections. We explored the spatial overlap of drug-related arrest rates and access to SEPs over time (1995-2006) in New York City health districts, and used multilevel models to investigate the relationship of these two district-level exposures to the odds of injecting with an unsterile syringe. Districts with better SEP access had higher arrest rates, and arrest rates undermined SEPs' protective relationship with unsterile injecting. Drug-related enforcement strategies targeting drug users should be de-emphasized in areas surrounding SEPs.

Exploring stakeholder perceptions of facilitators and barriers to accessing methadone maintenance clinics in Yunnan Province, China

Injection drug use is an ongoing public health crisis in China and one of the largest contributors to the transmission of HIV/AIDS. Though the government has rapidly scaled up methadone maintenance treatment clinics, they have not been extensively evaluated to analyze factors influencing rates of attendance. We explored the facilitators and barriers to accessing methadone maintenance clinics in Kunming City, Yunnan Province, China. Using in-depth qualitative interviews conducted from February 2008 to June 2008 with 35 informants - injection drug users (IDUs) and key stakeholders - we explored factors that determine whether drug users decide to present at methadone clinics. Interviews were digitally recorded with consent, transcribed verbatim, and translated. Content analysis was conducted to identify themes which included general attitudes toward methadone treatment, barriers and challenges to access, and suggestions for improvement. Within these, topics included responses to methadone, its side effects, and fear of discrimination, loss of privacy, and police interference. Respondents also listed numerous suggestions for improvement including raising awareness of harm reduction both among drug users and the community, providing additional support in the form of psychological counseling, job training and behavioral therapy, and increasing communication between police, government, and public health officials. High rates of HIV infection among IDUs in China have prompted public health responses including the scale up of methadone maintenance clinics. Our results may inform policy strategists in implementing social-structural changes to create enabling environments that facilitate an increase in access to methadone clinics among IDUs in Kunming.

Social and structural factors associated with HIV infection among female sex workers who inject drugs in the Mexico-US border region

Background

FSWs who inject drugs (FSW-IDUs) can acquire HIV through high risk sexual and injection behaviors. We studied correlates of HIV infection among FSW-IDUs in northern Mexico, where sex work is quasi-legal and syringes can be legally obtained without a prescription.

Methods

FSW-IDUs>18 years old who reported injecting drugs and recent unprotected sex with clients in Tijuana and Ciudad Juarez underwent surveys and HIV/STI testing. Logistic regression identified correlates of HIV infection.

Results

Of 620 FSW-IDUs, prevalence of HIV, gonorrhea, Chlamydia, trichomonas, syphilis titers ≥1∶8, or any of these infections was 5.3%, 4%, 13%, 35%, 10% and 72%, respectively. Compared to other FSW-IDUs, HIV-positive women were more likely to: have syphilis titers ≥1∶8 (36% vs. 9%, p<0.001), often/always inject drugs with clients (55% vs. 32%, p = 0.01), and experience confiscation of syringes by police (49% vs. 28%, p = 0.02). Factors independently associated with HIV infection were syphilis titers ≥1∶8, often/always injecting with clients and police confiscation of syringes. Women who obtained syringes from NEPs (needle exchange programs) within the last month had lower odds of HIV infection associated with active syphilis, but among non-NEP attenders, the odds of HIV infection associated with active syphilis was significantly elevated.

Conclusions

Factors operating in both the micro-social environment (i.e., injecting drugs with clients) and policy environment (i.e., having syringes confiscated by police, attending NEPs) predominated as factors associated with risk of HIV infection, rather than individual-level risk behaviors. Interventions should target unjustified policing practices, clients' risk behaviors and HIV/STI prevention through NEPs.

The roles of law, client race and program visibility in shaping police interference with the operation of US syringe exchange programs

AIMS

To determine the comparative levels of and associations between policing interference and characteristics of US syringe exchange programs (SEPs).

DESIGN

Cross-sectional.

SETTING

A national survey of US SEPs.

PARTICIPANTS

A total of 111 program managers (representing 59% of all US SEPs).

MEASUREMENTS

Program manager self-report.

FINDINGS

With overall interference profiles ranging from systematic to totally interference-free, 43% of respondents reported at least monthly client harassment, 31% at least monthly unauthorized confiscation of clients' syringes, 12% at least monthly client arrest en route to or from SEP and 26% uninvited police appearances at program sites at least every 6 months. In multivariate modeling, legal status of SEP, jurisdiction's syringe regulation environment and affiliation with health department were not associated with frequency of police interference. Programs serving predominantly injection drug users (IDUs) of color were 3.56 times more likely to report frequent client arrest en route to or from SEP and 3.92 times more likely to report unauthorized syringe confiscation. Those serving more than three sites were 3.96 times more likely to report client harassment, while stationary operation was protective against uninvited police appearances. The majority (56%) reported not documenting adverse police events; those who did were 2.92 times more likely to report unauthorized syringe confiscation from clients.

CONCLUSIONS

Findings highlight limitations of the impact of legal reforms on aligning police activities with SEP operations. Systematic adverse event surveillance and evidence-based structural interventions are needed to maximize the benefits of public health prevention targeting IDUs and other criminalized populations. SEPs that report no adverse events may represent programs already working in harmony with law enforcement agencies, a priority highlighted in US Centers for Disease Control's new SEP guidelines. The significance of mechanisms translating criminal justice disparities into health disparities is discussed.

Toward a comprehensive approach to HIV prevention for people who use drugs

Comprehensive HIV prevention interventions are increasingly recognized as critical in the global effort to reduce HIV transmission among people who use injection drugs. Scientific evidence clearly shows that a variety of biomedical, behavioral, and structural interventions can prevent and reduce injection drug user-driven HIV epidemics, yet social and structural barriers to their implementation remain. This review discusses the scientific evidence on the effectiveness of individual programs for reducing HIV incidence among people who use injection drugs and how, by integrating individual programs as complements within a comprehensive HIV prevention approach, it is possible to achieve, and to sustain, greater results than those of individual programs alone. The article concludes with a discussion of a critical research priority; namely, to improve the implementation of comprehensive HIV prevention interventions in settings of prevalent injection drug use and to overcome the often complex barriers that impede them. Such an effort will require more than research alone, however. It will also require the ongoing commitment of policymakers, public health officials, and the affected communities themselves to use comprehensive HIV treatment and prevention as the most effective strategy to reduce new HIV infections.

Incarcerated sex workers and HIV prevention in China: social suffering and social justice countermeasures

Sex workers in China are routinely coercively detained through administrative mechanisms outside of legal procedures, but very little is known about the anthropologic and public health context of these policies. This biosocial analysis of female Chinese sex worker detention uses ethnographic, legal, and public health data to describe social suffering and countervailing social justice responses among incarcerated sex workers (ISW) in China. Compared to sex workers not detained in China, ISW face substantive inequalities inscribed in physical and psychological suffering. Chinese sex worker detention camp practices may not only systematically increase HIV/syphilis risk among ISW, but also work to narrow women's social spheres of influence, a particularly cruel tragedy in a Chinese social system that highly values social and personal connections. A limited empiric analysis of Guangxi Province STI clinic data shows that cities detaining sex workers have higher mean HIV prevalence compared to cities that do not detain sex workers. While incipient medical and legal movements in China have generated momentum for expanding ISW services and resources, there is still substantial variation in the implementation of laws that ensure basic life-saving medical treatments. Post-incarceration social justice programs for sex workers linking women to essential STI/HIV resources, reconnecting broken social lives, and helping restore interpersonal relationships are urgently needed.

Assessing social risks prior to commencement of a clinical trial: due diligence or ethical inflation?

Assessing social risks has proven difficult for IRBs. We undertook a novel effort to empirically investigate social risks before an HIV prevention trial among drug users in Thailand and China. The assessment investigated whether law, policies and enforcement strategies would place research subjects at significantly elevated risk of arrest, incarceration, physical harm, breach of confidentiality, or loss of access to health care relative to drug users not participating in the research. The study validated the investigator's concern that drug users were subject to serious social risks in the site localities, but also suggested that participation in research posed little or no marginal increase in risk and might even have a protective effect. Our experience shows that it is feasible to inform IRB deliberations with actual data on social risks, but also raises the question of whether and when such research is an appropriate use of scare research resources.

Peer-Driven Interventions in Vietnam and China to Prevent HIV: A Pilot Study Targeting Injection Drug Users

The HIV epidemic in China and Vietnam is on the increase among injection drug users (IDUs). We report on the results of a pilot outreach study in northern Vietnam and southern China to test the feasibility of a peer-driven intervention (PDI) to prevent HIV among IDUs. In the PDI, recruitment relies on a “chain-referral” model in which IDUs carry-out the core outreach activities that salaried outreach-workers/peer-educators traditionally provide. A 6-month follow-up was built into the study design to measure possible changes in IDUs' risk behaviors. The impact results of the pilot study are reported bearing on several different measures, such as changes in IDUs' rates of lending or borrowing used syringes, willingness to enter into drug treatment, baseline and follow-up recruitment success, and effectiveness of serving as peer-educators in the community. The evidence suggests the PDI is highly feasible and deserving of greater research in both China and Vietnam.

Reducing HIV infection among new injecting drug users in the China-Vietnam Cross Border Project

OBJECTIVES

To assess an HIV prevention programme for injecting drug users (IDU) in the crossborder area between China and Vietnam.

DESIGN

Serial cross-sectional surveys (0, 6, 12, 18, 24 and 36 months) of community-recruited current IDU.

METHODS

The project included peer educator outreach and the large-scale distribution of sterile injection equipment. Serial cross-sectional surveys with HIV testing of community recruited IDU were conducted at baseline (before implementation) and 6, 12, 18, 24 and 36 months post-baseline. HIV prevalence and estimated HIV incidence among new injectors (individuals injecting drugs for < 3 years) in each survey wave were the primary outcome measures.

RESULTS

The percentages of new injectors among all subjects declined across each survey waves in both Ning Ming and Lang Son. HIV prevalence and estimated incidence fell by approximately half at the 24-month survey and by approximately three quarters at the 36-month survey in both areas (all P < 0.01).

CONCLUSION

The implementation of large-scale outreach and syringe access programmes was followed by substantial reductions in HIV infection among new injectors, with no evidence of any increase in individuals beginning to inject drugs. This project may serve as a model for large-scale HIV prevention programming for IDU in China, Vietnam, and other developing/transitional countries.

Paradoxes in antiretroviral treatment for injecting drug users: access, adherence and structural barriers in Asia and the former Soviet Union

Offered proper support, injection drug users (IDUs) can achieve the same levels of adherence to and clinical benefit from antiretroviral treatment (ARV) as other patients with HIV. Nonetheless, in countries of Asia and the former Soviet Union where IDUs represent the largest share of HIV cases, IDUs have been disproportionately less likely to receive ARV. While analysis of adherence amongst IDUs has focused on individual patient ability to adhere to medical regimens, HIV treatment systems themselves are in need of examination. Structural impediments to provision of ARV for IDUs include competing, vertical systems of care; compulsory drug treatment and rehabilitation services that often offer neither ARV nor effective treatment for chemical dependence; lack of opiate substitution treatments demonstrated to increase adherence to ARV; and policies that explicitly or implicitly discourage ARV delivery to active IDUs. Labeling active drug users as socially untrustworthy or unproductive, health systems can create a series of paradoxes that ensure confirmation of these stereotypes. Needed reforms include professional education and public campaigns that emphasize IDU capacity for health protection and responsible choice; recognition that the chronic nature of injecting drug use and its links to HIV infection require development of ARV treatment delivery that includes active drug users; and integrated treatment that strengthens links between health providers and builds on, rather than seeks to bypass, IDU social networks and organizations.

Street policing, injecting drug use and harm reduction in a Russian city: a qualitative study of police perspectives

We undertook a qualitative exploration of police perspectives on injecting drug use and needle and syringe access among injecting drug users (IDUs) in a Russian city which has witnessed explosive spread of HIV associated with drug injecting. Twenty-seven in-depth qualitative interviews were conducted in May 2002 with police officers of varying rank who reported having regular contact with IDUs. All interviews were tape-recorded, transcribed, translated and coded thematically. Accounts upheld an approach to policing which emphasised high street-based visibility and close surveillance of IDUs. IDUs were depicted as 'potential criminals' warranting a 'pre-emptive' approach to the prevention of drug-related crime. Street policing was described as a means of maintaining close surveillance leading to the official registration of persons suspected or proven to be users of illicit drugs. Such registration enabled further ongoing surveillance, including through stop and search procedures. While aware of drug users' reluctance to carry injecting equipment linked to their fears of detention or arrest, accounts suggested that the confiscation of previously used injecting equipment can constitute evidence in relation to drugs possession charges and that discovery of clean injecting equipment may be sufficient to raise suspicion and/or further investigation, including through stop and search or questioning. Our findings suggest an uneasy relationship between street policing and needle and syringe access, whereby policing strategies can undermine an HIV prevention ethos promoting needle and syringe accessibility among IDUs. We conclude that facilitating partnerships between policing agencies and HIV prevention initiatives are a critical feature of creating environments conducive for risk reduction.

Patterns of HIV prevalence and HIV risk behaviors among injection drug users prior to and 24 months following implementation of cross-border HIV prevention interventions in northern Vietnam and southern China

In 2002, we implemented a 4-year HIV prevention intervention for injection drug users (IDUs) in Lang Son Province, Vietnam, and Ning Ming County, Guangxi Province, China, a cross-border region seriously affected by inter-twined epidemics of heroin injection and HIV infection. The interventions involve peer education on HIV risk reduction and provision of new needles/syringes through direct distribution and pharmacy vouchers. We consider this to be a structural intervention in which risk reduction information and sterile injection equipment are diffused through the IDU populations and not limited to those who actually interact with peer educators. The evaluation of structural interventions poses complex methodological challenges. The evaluation of our interventions relies primarily on cross-sectional surveys (interviews and HIV testing) of samples of IDUs selected using a combination of targeted cluster and snowball methods. We consider this to be an appropriate, albeit imperfect, design given the study context. This paper presents analyses of data from the IDU surveys conducted just prior to implementation of the interventions and 24 months thereafter. The cross-border interventions have reached large proportions of the IDUs in the project sites, drug-related HIV risk behaviors have declined in frequency, and HIV prevalence among IDUs has been stable in China and declined in Vietnam over the 24 months since the interventions were implemented. Attribution of these positive trends to the interventions must be qualified in light of possible sampling biases and the absence of control groups. However, we believe that the structural interventions implemented by the cross-border project have played a role in stabilizing HIV prevalence among IDUs two years after they were initiated. Evidence of further diffusion of the interventions among IDUs and continued stability or decline of HIV prevalence would strengthen this case.