Retrospective accounts of injection initiation in intimate partnerships

Dual-substance use disorder couples: An integrative review and proposed theoretical model

Committed romantic relationships between two individuals with Substance Use Disorder (or dual-SUD couples) are prevalent. Dual-SUD couples have poor treatment engagement and outcomes. Research has established a reciprocal link between relationship dynamics (e.g., conflict, intimacy) and substance use. Thus, the couple's relationship presents a distinct social context for both partner's substance use. Dual-SUD couples face unique challenges due to substance use being a shared behavior that may serve as a rewarding source of compatibility, closeness, and short-term relationship satisfaction despite it being at the cost of other alternative sources of substance-free reinforcement. Yet, treatment options for these couples are scarce. Dual-maladaptive health behaviors (e.g., dual-substance use) are challenging to treat; however, theory and preliminary research suggests that transformation of couple's joint motivation toward adaptive health behavior change may result in a more satisfying relationship and improved treatment outcomes for both individuals. The current paper reviews the extant literature on dual-SUD couples from theoretical, empirical, and treatment research and proposes an expanded paradigm regarding how we understand dual-SUD couples with the aim of informing basic research and treatment development.

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

BACKGROUND

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

METHODS

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

RESULTS

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

Injection Drug Use and Sexual Risk Behaviors Among People who Inject Drugs in Ukraine: A Random-Intercept Latent Transition Analysis

HIV transmission in Ukraine is driven in part by unsafe injection drug use and sexual risk behaviors among people who inject drugs. We performed a random-intercept latent transition analysis on responses to 9 binary injection drug use and sexual behavior items from 1195 people who inject drugs with negative HIV status enrolled in a clustered randomized clinical trial of a social network intervention in Odessa, Donetsk, and Nikolayev, Ukraine. We identified 5 baseline classes: "Social injection/equipment-sharing" (11.7%), "Social injection" (25.9%), "High-risk collective preparation/splitting" (17.0%), "Collective preparation/splitting" (11.3%), and "Dealer-facilitated injection" (34.1%). After 12 months, intervention participants were more likely to transition to the "Collective preparation/splitting" class, which featured the fewest risk behaviors. Transitioning from the "Collective preparation/splitting" to the "Social injection/equipment-sharing" class was associated with HIV acquisition for control participants. Research to illuminate the stability of these patterns and how they may benefit from uniquely tailored programming to reduce unsafe behaviors is needed.

The association of gender with receptive and distributive needle sharing among individuals who inject drugs

Background

Injection drug use and needle sharing remains a public health concern due to the associated risk of HIV, HCV and skin and soft tissue infections. Studies have shown gendered differences in the risk environment of injection drug use, but data are currently limited to smaller urban cohorts.

Methods

To assess the relationship between gender and needle sharing, we analyzed publicly available data from the 2010–2019 National Survey on Drug Use and Health (NSDUH) datasets. Chi-square tests were conducted for descriptive analyses and multivariable logistic regression models were built adjusting for survey year, age, HIV status, and needle source.

Results

Among the entire sample, 19.8% reported receptive needle sharing, 18.8% reported distributive sharing of their last needle, and 37.0% reported reuse of their own needle during last injection. In comparison with men, women had 34% increased odds (OR 1.34, 95% CI 1.11–1.55) of receptive needle sharing and 67% increased odds (OR 1.67, 95% CI 1.41–1.98) of distributive needle sharing. Reuse of one's own needle did not differ by gender.

Conclusions

In this nationally representative sample, we found that women are more likely in comparison with men to share needles both through receptive and distributive means. Expansion of interventions, including syringe service programs, to increase access to sterile injection equipment is of great importance.

Gender and the first-time provision of injection initiation assistance among people who inject drugs across two distinct North American contexts: Tijuana, Mexico and Vancouver, Canada

INTRODUCTION

Injection drug use initiation is commonly facilitated by other people who inject drugs (PWID). We investigated how the gender of PWID influences their risk of providing initiation assistance to others across two distinct geo-cultural settings.

METHODS

Data were drawn from two prospective cohorts in Tijuana, Mexico and Vancouver, Canada which conducted semi-annual interviews within the PReventing Injecting by Modifying Existing Responses (PRIMER) study. Participants consisted of PWID who had reported never providing injection initiation assistance at baseline. We then conducted site-specific discrete-time survival analyses assessing the relationship between gender and other relevant covariates (e.g. age and past 6-month sex work) on the risk of the first reported instance of providing initiation assistance.

RESULTS

Of 1988 PWID (Tijuana: n = 596; Vancouver: n = 1392), 256 (43%) and 511 (36.7%) participants were women, and 42 (1.7%) and 78 (1.6%) reported recent injection initiation assistance across a median of three and two follow-up visits, respectively. Women had a lower risk of providing injection initiation assistance for the first time in Tijuana (adjusted hazard ratio = 0.52, 95% confidence interval 0.27-0.99), but not in Vancouver. Gendered pathways, like sex work, were associated with providing initiation assistance for the first time in Vancouver (adjusted hazard ratio = 1.97, 95% confidence interval 1.08-3.61).

DISCUSSION AND CONCLUSIONS

Women in Tijuana, but not Vancouver, were less likely to provide first-time initiation assistance among PWID. These results can inform gender- and site-specific prevention efforts aimed at reducing transitions into drug injecting across geographic contexts.

Factors Associated with Likelihood of Initiating Others into Injection Drug Use Among People Who Inject Drugs in West Virginia

People who inject drugs (PWID) play a critical role in injection-naïve individuals transitioning to injection drug use. We investigated factors associated with future likelihood of initiating injection-naïve individuals using multivariable logistic regression among 418 PWID in rural Appalachia (Cabell County, West Virginia). Less than 10% reported they were likely to initiate someone in the future. Acquiring syringes from a syringe services program was associated with decreased odds of being likely to initiate someone in the future (adjusted odds ratio [aOR] 0.46, 95% CI 0.23, 0.95), while having previously initiated someone into injection drug use was associated with increased odds (aOR 8.65, 95% CI 4.07, 18.41). Among our sample of PWID in Appalachia, a small proportion reported that they would be likely to initiate an injection-naïve individual in the future. Efforts to reduce injection initiation assistance should focus on this subpopulation of PWID who indicate a willingness to engage in this behavior.

Examining the gender composition of drug injecting initiation events: A mixed methods investigation of three North American contexts

BACKGROUND

Gender influences the health and social risks faced by individuals initiating drug injecting. Using mixed methods across three settings in North America, we investigated the gender composition of injection initiation events and the gendered risk environments in which they occurred.

METHODS

The PReventing Injecting by Modifying Existing Responses (PRIMER) study pooled data from three prospective community-recruited cohorts of people who inject drugs (PWID) in San Diego, USA, Vancouver, Canada, and Tijuana, Mexico. A qualitative subsample provided narrative data on their experiences of, and the contexts for, injection initiation events. Guided by Rhodes' risk environment framework, we examined the gender composition of initiation events stratified by city, and analyzed qualitative data using abductive thematic analyses.

RESULTS

Among 2,622 PWID (Tijuana: n = 531; San Diego: n = 352; Vancouver: n = 1,739), 112 (4.3%) reported providing initiation assistance to injection-naïve individuals in the previous six months. The proportion of gender concordant (e.g., male-male) initiation pairs varied, (χ2 = 10.32, p <0.001) with greater than expected concordance among pairs in Tijuana compared with those in Vancouver or San Diego. Sixty-one interviews provided context for the discrepancy across sites by highlighting the gendered injection initiation risk environments of prison/jail detention in Tijuana, intimate partnerships in San Diego, and overdose risk in Vancouver.

CONCLUSIONS

These results highlight how gender influences injection initiation events within spatial, social, and economic risk environments, and how this influence varies across settings. These findings can inform interventions to reduce the risk of injection initiation and related harms.

A prospective cohort study of risk behaviours, retention and loss to follow-up over 5 years among women and men in a needle exchange program in Stockholm, Sweden

BACKGROUND

Needle exchange programs (NEP) are important in reducing risk behaviours among people who inject drugs (PWID), also exposed to HIV and hepatitis C (HCV) through injecting drug use (IDU). Women (WWID) compared to men who inject drugs (MWID), are particularly vulnerable with complex needs, however less is known about their risk determinants and NEP outcomes.

METHODS

In an open prospective NEP cohort, 697 WWID and 2122 MWID were followed, 2013-2018. Self-reported socio/drug-related determinants for receptive injection (needle/syringe and paraphernalia) and sexual risk behaviours at enrolment, lost to follow-up (LTFU) and probability of retention, were assessed for both groups. Multivariable logistic regression (adjusted odds ratios, aOR) for enrolment and Poisson regression (adjusted incidence rate ratios, aIRR) for LTFU, were used. Cumulative NEP-retention probability was analysed using a six- and 12-month scenario.

RESULTS

At NEP enrolment, injection risk behaviours among WWID were associated with: younger age; homelessness; amphetamine-IDU; non-participation in opioid substitution therapy (OST); history of custody and among MWID: lower education level; cohabitation; homelessness, being a tenant; amphetamine-IDU; non-participation in OST; history of being sectioned, HIV-negative and HCV-positive. Condomless sex among WWID was associated with: younger age; lower education-level; cohabitation; having a partner; amphetamine-IDU; non-participation in OST; being HIV-negative and HCV-positive and among MWID: younger age; married; cohabitation; having a partner; amphetamine-IDU; non-participation in OST; history of custody, prison and being HIV-negative. WWID had higher NEP-retention levels compared to MWID over time. Being LTFU among WWID was associated with being HIV-negative and reporting injection risk behaviours and among MWID, younger age, non-participation in OST, being HIV-negative and having protected sex.

CONCLUSIONS

Despite better NEP compliance among WWID, high injection and sexual risk behaviours in both gender-subgroups, especially in intimate relationships, suggests ongoing HCV and HIV-infection risks. Subgroup-variation in the NEP continuum of care warrants more gender-disaggregated research and tailoring gender-sensitive services may improve prevention, health and retention outcomes.

Drugs as Soulmates: The Construction and Validation of a 12-Item Soulmate Scale to Measure Substance Addiction and Loneliness

Substance users use substances to tackle psychological stress, frustrations, poor social support and poor-quality relationships. Such experience resembles seeking a soulmate for receiving comfort, a sense of security and satisfaction to relieve feelings of loneliness. Against this backdrop, the study aims to develop a Soulmate Scale to measure substance use and loneliness. Data were collected from 507 drug abusers between 18-71 years of age who were receiving drug addiction treatment in Hong Kong. Both exploratory factor analysis and confirmatory factor analysis were conducted. Results show a valid and reliable scale with three factors: psychological release and shelter, staunch and supportive friendship, and spiritual solace and companionship. This study offers additional support for understanding the drug-taking experience of substance users from their perspective. The Scale provides a useful tool to assess the underlying reasons for substance users to persistently take drugs and formulate corresponding intervention plans to achieve drug abstinence.

The role of drug treatment and recovery services: an opportunity to address injection initiation assistance in Tijuana, Mexico

BACKGROUND

In the U.S. and Canada, people who inject drugs' (PWID) enrollment in medication-assisted treatment (MAT) has been associated with a reduced likelihood that they will assist others in injection initiation events. We aimed to qualitatively explore PWID's experiences with MAT and other drug treatment and related recovery services in Tijuana Mexico, a resource-limited setting disproportionately impacted by injection drug use.

METHODS

PReventing Injecting by Modifying Existing Responses (PRIMER) seeks to assess socio-structural factors associated with PWID provision of injection initiation assistance. This analysis drew on qualitative data from Proyecto El Cuete (ECIV), a Tijuana-based PRIMER-linked cohort study. In-depth qualitative interviews were conducted with a subset of study participants to further explore experiences with MAT and other drug treatment services. Qualitative thematic analyses examined experiences with these services, including MAT enrollment, and related experiences with injection initiation assistance provision.

RESULTS

At PRIMER baseline, 607(81.1%) out of 748 participants reported recent daily IDU, 41(5.5%) reported recent injection initiation assistance, 92(12.3%) reported any recent drug treatment or recovery service access, and 21(2.8%) reported recent MAT enrollment (i.e., methadone). Qualitative analysis (n = 21; female = 8) revealed that, overall, abstinence-based recovery services did not meet participants' recovery goals, with substance use-related social connections in these contexts potentially shaping injection initiation assistance. Themes also highlighted individual-level (i.e., ambivalence and MAT-related stigma) and structural-level (i.e., cost and availability) barriers to MAT enrollment.

CONCLUSION

Tijuana's abstinence-based drug treatment and recovery services were viewed as unable to meet participants' recovery-related goals, which could be limiting the potential benefits of these services. Drug treatment and recovery services, including MAT, need to be modified to improve accessibility and benefits, like preventing transitions into drug injecting, for PWID.

The role of gender and power dynamics in injection initiation events within intimate partnerships in the US-Mexico border region

Women's initiation into injection drug use often establishes a pattern of risk following first injection. This study explored sources of gendered power dynamics in injection initiation experiences for people who inject drugs. A qualitative subsample from two prospective community-recruited cohorts of people who inject drugs in San Diego and Tijuana provided data on the contexts surrounding injection initiation processes. Intimate partnerships were identified in initiation; sub-themes were identified drawing on three concepts within the theory of gender and power. With reference to sexual division of labour, men were often responsible for access to resources in partnerships across both contexts, although there were limited accounts of women obtaining those resources. Extending the structure of power, women in San Diego reported that initiation events involving an intimate partner occurred from a position of vulnerability but expressed greater agency when providing initiation assistance. With regard to structure of cathexis, social norms proscribing injection initiation among women exist, particularly in Tijuana. Gendered power dynamics are a multifaceted component of injection initiation events, especially for women in intimate partnerships. These results stress the need for nuance in understanding the intersection of risk, gender and harm reduction within injection initiation events across socio-cultural contexts.

Self-perception of assisting with future injection drug initiation: The influence of relationships in the process of drug injecting initiation

INTRODUCTION AND AIMS

People who inject drugs (PWID) play critical roles in assisting others into injection drug use (IDU) initiation. Understanding perceptions of PWID's risk of initiating others is needed to inform interventions for prevention. The objective was to examine factors associated with self-perception of assisting with future IDU initiation events. The primary variables of interest are the relationships of PWID with the person(s) they assisted and their reasons for previously providing initiation assistance.

DESIGN AND METHODS

Data from Preventing Injecting by Modifying Existing Responses, a multi-site prospective community-recruited cohort study, were analysed. Analyses were restricted to PWID who reported ever providing IDU initiation assistance. Site-specific (Vancouver, Canada [n = 746]; San Diego, USA [n = 95] and Tijuana, Mexico [n = 92]) multivariable logistic regression analyses were performed to determine factors associated with self-perception of assisting with future IDU initiation.

RESULTS

Having provided IDU initiation assistance to a family member or intimate partner decreased the odds of self-perception of assisting with future IDU initiation in Vancouver (AOR = 0.4; 95% CI 0.2-0.8); however, previous IDU initiation assistance to an 'other' increased the odds of self-perception of assisting with future IDU in Tijuana (AOR = 12.0; 95% CI 2.1-70.3). Daily IDU (Vancouver: AOR = 3.7; 95% CI 2.1-6.4) and less than daily IDU (San Diego: AOR = 5.9; 95% CI 1.3-27.1) (Vancouver: AOR = 2.6; 95% CI 1.4-2.9) were associated with increased self-perception of assisting with future IDU compared to current non-injectors.

DISCUSSION AND CONCLUSIONS

Relationship to past initiates and IDU frequency might increase PWID's self-perception of assisting with future IDU. Interventions focused on social support and reducing IDU frequency may decrease occurrences of IDU initiation assistance.

Preventing transitions into injection drug use: A call for gender-responsive upstream prevention

In 2017, there were large increases (260-500%) in overdose deaths among women in the United States across age groups (30-64 years and 55-64 years). In addition, U.S. women who inject drugs (WWID) are at increased risk for substance use-related disease transmission, bacterial infections, as well as sexual and physical violence compared to men who inject drugs. Relatedly, women face unique access barriers to substance use-related services, such as stigma and low coverage of gender-specific drug use-related services. Despite these heightened risks experienced by WWID, interventions specifically tailored to preventing women from transitioning into injection drug use have not been developed to date. As such, we advocate for the development of gender-responsive programs to prevent injection drug use initiation. This is critical to ensuring a comprehensive approach to preventing injection drug use initiation among those populations at highest risk of injection-related morbidity and mortality.

Risk factors of infective endocarditis in persons who inject drugs

BACKGROUND

The rising incidence of infective endocarditis (IE) among people who inject drugs (PWID) has been a major concern across North America. The coincident rise in IE and change of drug preference to hydromorphone controlled-release (CR) among our PWID population in London, Ontario intrigued us to study the details of injection practices leading to IE, which have not been well characterized in literature.

METHODS

A case-control study, using one-on-one interviews to understand risk factors and injection practices associated with IE among PWID was conducted. Eligible participants included those who had injected drugs within the last 3 months, were > 18  years old and either never had or were currently admitted for an IE episode. Cases were recruited from the tertiary care centers and controls without IE were recruited from outpatient clinics and addiction clinics in London, Ontario.

RESULTS

Thirty three cases (PWID IE+) and 102 controls (PWID but IE-) were interviewed. Multivariable logistic regressions showed that the odds of having IE were 4.65 times higher among females (95% CI 1.85, 12.28; p = 0.001) and 5.76 times higher among PWID who did not use clean injection equipment from the provincial distribution networks (95% CI 2.37, 14.91; p < 0.001). Injecting into multiple sites and heating hydromorphone-CR prior to injection were not found to be significantly associated with IE. Hydromorphone-CR was the most commonly injected drug in both groups (90.9% cases; 81.4% controls; p = 0.197).

DISCUSSION

Our study highlights the importance of distributing clean injection materials for IE prevention. Furthermore, our study showcases that females are at higher risk of IE, which is contrary to the reported literature. Gender differences in injection techniques, which may place women at higher risk of IE, require further study. We suspect that the very high prevalence of hydromorphone-CR use made our sample size too small to identify a significant association between its use and IE, which has been established in the literature.

Reasons for assisting with injection initiation: Results from a large survey of people who inject drugs in Los Angeles and San Francisco, California

Injection drug initiation usually requires assistance by someone who already injects drugs. To develop interventions that prevent people from starting to inject drugs, it is imperative to understand why people who inject drugs (PWID) assist with injection initiation.

METHODS

Injection initiation history and motives for initiating others were collected from 978 PWID in Los Angeles and San Francisco, CA, from 2016-17. This article documents motivations for providing injection initiation assistance and examines demographic, economic, and health-related factors associated with these motivations using multivariable logistic regression modeling.

RESULTS

Among the 405 PWID who ever facilitated injection initiation, motivations for initiating were: injury prevention (66%), skilled at injecting others (65%), to avoid being pestered (41%), in exchange for drugs/money (45%), and for food/shelter/transportation (15%). High frequency initiation (>5 lifetime injection initiations) was associated with all motivations except for being pestered. Initiation to prevent injury was associated with being female. Initiation due to pestering was associated with recycling income and sex work. Being skilled was associated with age and HIV status, while initiation for money or drugs was associated with age, race, education, social security income, and substance use treatment. Lastly, initiation for food, shelter, or transportation was associated with age, sexual orientation and education level.

CONCLUSION

Diverse factors were associated with reported motivations for assisting someone to initiate injection for the first time. Our analysis underscores the need for prevention strategies focused on improving economic and housing conditions along with implementing drug consumption rooms to disrupt the social processes of injection initiation.

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

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

Role of boyfriends and intimate sexual partners in the initiation and maintenance of injecting drug use among women in coastal Kenya

INTRODUCTION

Gender dynamics and interpersonal relations within intimate partnerships are known to determine health behaviors, including substance use, within couples. In addition, influence from intimate partners may occur in the context of wider social ecological determinants of health behavior. The aim of this study was to document the role of intimate partners in influencing injecting drug use among women in Kenya, where injecting drug use is on the rise.

METHODS

We performed secondary data analysis of an existing dataset from a 2015 qualitative study involving 45 women who inject drugs and 5 key stakeholders in coastal Kenya. Primary data had been collected via a combination of in-depth interviews and focus group discussions exploring sexual, reproductive, drug use, and other social contexts of women who inject drugs. The process by which intimate partners influenced women's initiation of drug use, transition to injecting practices, and maintenance of injecting drug use were identified using thematic analysis.

RESULTS

Boyfriends and intimate either facilitated or restrained women's drug-injecting. On the one hand, young women's entry into drug use was prompted by relationship problems, or a need to acquiesce with their drug-using boyfriends. Once women started injecting, intimate partners facilitated ongoing drug-injecting by financing the acquisition of drugs, peddling drugs to their women, or sharing their drugs with their women. The social capital that peddlers held insulated women from police arrests, and encouraged women to seek and sustain intimate relations with well-connected peddlers. Men's influences over women were driven by an underlying patriarchal drug acquisition and economic power. On the other hand, boyfriends and intimate partners who were non-injectors or non-drug users sought to moderate women's injecting drug use by encouraging them to inject less, to smoke or snort instead of injecting, or to enroll into rehabilitation. These moderating influences were most prominent when couples were pregnant. Despite men being a source of practical and emotional support, women were frequently unable limit or alter their injecting drug use, due to its addictive nature. Men's disagreement with women's ongoing injecting strained relationships, and occasionally led to separation.

CONCLUSIONS

Some boyfriends facilitated women's injecting drug use, while others moderated it, supporting assertions that intimate relationships can both be a site of injecting risks or protection. At the micro-level, these findings highlight an opportunity for couple-based interventions, leveraging on non-drug injecting males as a resource to support women adopt safer injecting practices. At a macro level, incorporating livelihood interventions into harm reduction programs is required in order to mitigate economic-based influence of male intimate partners on women's injecting drug use. At both levels, gender transformative approaches are essential. To gain a comprehensive understanding of women's injecting drug use, future studies drug use should explore women's contexts beyond micro influences and consider their wider macro-structural determinants.

Factors Associated with Frequency of Recent Initiation of Others into Injection Drug Use Among People Who Inject Drugs in Los Angeles and San Francisco, CA, USA, 2016-17

Objective: Drug injection initiation is often assisted by a person who injects drugs (PWID). How often PWID provide this assistance has not been examined. We examine frequency of injection initiation assistance and factors associated with high (4+) and low frequency (1-3) initiation assistance as compared to no initiation assistance among PWID. Methods: Participants were 979 Californian PWID. PWID were interviewed about providing injection initiation assistance in the last 6 months among other items. Multinomial regression analysis was used to examine factors associated with levels of frequency of injection initiation assistance. Results: Among participants, 132 (14%) had initiated 784 people into injection (mean = 5.94 [standard deviation = 20.13]; median = 2, interquartile range = 1,4) in the last 6 months. PWID engaged in high frequency initiation (26% of sample) assisted 662 new initiates (84% of total). Using multinomial regression analysis with no initiating as the referent group, we found that high frequency initiating was statistically associated with higher injection frequency, having a paying sex partner, taking someone to a shooting gallery, and providing injection assistance. Lower frequency initiation was statistically associated with having a paying sex partner, illegal income source, and providing injection assistance. Conclusion: Differences between high and low frequency initiators were not found. Sex work and assisting with drug injection were linked to initiating others. Individual-level interventions that reduce this behavior among PWID and structural interventions such as safe consumption sites and opioid medication treatments that interrupt the social process of injection initiation should be considered as ways to reduce injection initiations.

Navigating social norms of injection initiation assistance during an overdose crisis: A qualitative study of the perspectives of people who inject drugs (PWID) in Vancouver, Canada

Despite the proliferation of fentanyl and fentanyl-adulterated opioids in North America, the impacts of this drug market change on injection initiation processes have not been examined. With the aim of informing structural interventions to address injection initiation and related harms, we explore how people who inject drugs (PWID) in Vancouver, Canada understand and navigate social norms of initiating others into injecting within the context of an overdose crisis. In-depth qualitative interviews were conducted with 19 PWID who reported helping someone inject for the first time. Participants were recruited from two cohort studies of PWID. Participants articulated moral dilemmas about assisting others with injecting. While participants described a 'moral code' prohibiting assisting injection-naïve individuals, this code was not the sole consideration shaping social action around injection initiation. Rather, PWID exercised agency about whether and how to assist novice injectors within the context of constraining and enabling social norms around practicing interpersonal responsibility. Changes to the drug market heightened feelings of moral culpability and criminal liability among PWID who assisted others into injection, given that injecting heightened initiates' risk of overdose. These concerns operated in tension with the aim of protecting novice injectors from harms associated with an increasingly potent and unpredictable drug supply by providing them with injection assistance, education and supervision. Our analysis of how PWID practice interpersonal responsibility helps conceptualise how 'moral codes' prohibiting initiation assistance are managed and negotiated amidst structural vulnerability. Structural interventions reducing the vulnerability of novice injectors should be prioritized, including the implementation of supervised injection sites allowing for assisted injection, Good Samaritan laws, and policy changes conducive to a safer drug supply.

"Another Person Was Going to Do It": The Provision of Injection Drug Use Initiation Assistance in a High-Risk U.S.-Mexico Border Region

Background: Persons who inject drugs (PWID) play a key role in assisting others' initiation into injection drug use (IDU). We aimed to explore the pathways and socio-structural contexts for this phenomenon in Tijuana, Mexico, a border setting marked by a large PWID population with limited access to health and social services. Methods: Preventing Injecting by Modifying Existing Responses (PRIMER) is a multi-cohort study assessing socio-structural factors associated with PWID assisting others into initiating IDU. Semi-structured qualitative interviews in Tijuana included participants ≥18 years old, who reported IDU within the month prior to cohort enrollment and ever initiating others into IDU. Purposive sampling ensured a range of drug use experiences and behaviors related to injection initiation assistance. Thematic analysis was used to develop recurring and significant data categories. Results: Twenty-one participants were interviewed (8 women, 13 men). Broadly, participants considered public injection to increase curiosity about IDU. Many considered transitioning into IDU as inevitable. Emergent themes included providing assistance to mitigate overdose risk and to protect initiates from being taken advantage of by others. Participants described reluctance in engaging in this process. For some, access to resources (e.g., shared drugs or a monetary fee) was a motivator to initiate others. Conclusion: In Tijuana, public injection and a lack of harm reduction services are perceived to fuel the incidence of IDU initiation and to incentivize PWID to assist in injection initiation. IDU prevention efforts should address structural factors driving PWID participation in IDU initiation while including PWID in their development and implementation.

Change in injecting behaviour among people treated for hepatitis C virus: The role of intimate partnerships

Injecting behaviour in people who inject drugs is the main risk factor for hepatitis C virus (HCV) infection. Psychosocial factors such as having a partner who injects drugs and living with other drug users have been associated with increases in injecting risk behaviour. This study aimed to investigate changes in injecting behaviour during treatment for HCV infection whilst exploring the role of psychosocial factors on patients' injecting behaviour. Eradicate-C was a single-centred clinical trial (ISRCTN27564683) investigating the effectiveness of HCV treatment within the injecting drug-using population between 2012 and 2017. A total of 94 participants completed up to 24 weeks of treatment, with social and behavioural measures taken at different intervals throughout treatment. Data for 84 participants were analysed retrospectively to explore mechanisms of potential behavioural changes which had occurred during treatment. Injecting frequency reduced significantly between baseline (week 1) and every 4-weekly interval until week 26. Not being on opiate substitution therapy (OST) was associated with a statistically significant decrease in injecting frequency, χ² (1) = 10.412, P = 0.001, as was having a partner who also used drugs, in particular when that partner was also on treatment for HCV infection, Z = -2.312, P = 0.021. Treating a hard-to-reach population for HCV infection is not only possible, but also bears health benefits beyond treatment of HCV alone. Enrolling couples on HCV treatment when partners are sero-concordant has shown enhanced benefits for reduction in injecting behaviour. Implications for practice are discussed.

Gender differences in the provision of injection initiation assistance: a comparison of three North American settings

AIM

Individuals experience differential risks in their initiation into drug injecting based on their gender. Data suggest women are more likely to be injected after their initiator and to share injection equipment. Little is known, however, regarding how gender influences the risk that people who inject drugs (PWID) may assist others into injection initiation. We therefore sought to investigate the role of "initiator" gender in the provision of injection initiation assistance across multiple settings.

METHODS

We employed data from PReventing Injecting by Modifying Existing Responses (PRIMER), a multi-cohort study investigating factors influencing injection initiation assistance provision. Data were drawn from three cohort studies of PWID in San Diego, USA (STAHR II); Tijuana, Mexico (El Cuete IV); and Vancouver, Canada (VDUS). Site-specific logistic regression models were fit, with lifetime provision of injection initiation assistance as the outcome and gender as the independent variable.

RESULTS

Overall, 3.2% (24/746) of the women and 4.6% (63/1367) of the men reported providing injection initiation assistance. In Tijuana, men were more than twice as likely to have provided injection initiation assistance after controlling for potential confounders (adjusted odds ratio = 2.17, 95% confidence interval: 1.22-3.84). Gender was not significantly associated with providing injection initiation assistance in other sites.

CONCLUSION

We identified that being male in Tijuana, specifically, was associated with providing injection initiation assistance, which could inform targeted outreach aimed at reducing the influence of PWID populations on non-injectors in this site. This will likely require that existing interventions address gender- and site-specific factors for effectiveness.

Factors associated with time between using a drug and injection initiation among people who inject drugs in Kermanshah, Iran

Background The transition from non-injection to injection drug use dramatically increases the risk of transmitting HIV and other blood borne infections including hepatitis B virus (HBV) and hepatitis C virus (HCV). The aim of this study was to explore factors associated with the transition from first illicit drug use to first injection among drug users. Methods Using snowball sampling and convenience sampling through needle and syringe programmes (NSPs), we recruited 500 people who inject drugs (PWID) in Kermanshah, between September and December 2014. Trained interviewers collected data on socio-demographic characteristics, HIV testing and drug-related risk behaviors over the last month prior to interview using a structured questionnaire. Our main outcome variable was first illicit drug use to first injection (TIJ). TIJ was calculated by subtracting age at first drug injection from age of first illicit drug use. Results Overall, the average age at first drug use and injection were 21.4 [standard deviation (SD 5.6)] and 22.8 (SD 8.9), respectively. The average duration of injection was 6.0 (SD 4.6) years. Overall, the mean of TIJ for participants was 1.4 (IQR = 2, 4) years. Age of first injecting drug use negatively correlated with TIJ (R2 = 0.219, p = 0.001). Education level and socioeconomic status (SES), and negatively correlated with TIJ. Conclusion Some demographic factors and drug use characteristics including educational level, SES, knowledge of HIV status, age of initiating drug use, being a poly drug user and using methamphetamine were predictors of the time to transition.

A fragmented code: The moral and structural context for providing assistance with injection drug use initiation in San Diego, USA

BACKGROUND

Injection drug use initiation is shaped by social networks and structural contexts, with people who inject drugs often assisting in this process. We sought to explore the norms and contexts linked to assisting others to initiate injection drug use in San Diego, USA, to inform the development of structural interventions to prevent this phenomenon.

METHODS

We undertook qualitative interviews with a purposive sample of people who inject drugs and had reported assisting others to initiate injection (n = 17) and a sub-sample of people who inject drugs (n = 4) who had not reported initiating others to triangulate accounts. We analyzed data thematically and abductively.

RESULTS

Respondents' accounts of providing initiation assistance were consistent with themes and motives reported in other contexts: of seeking to reduce harm to the 'initiate', responding to requests for help, fostering pleasure, accessing resources, and claims that initiation assistance was unintentional. We developed analysis of these themes to explore initiation assistance as governed by a 'moral code'. We delineate a fragmented moral code which includes a range of meanings and social contexts that shape initiation assistance. We also show how assistance is happening within a structural context that limits discussion of injection drug use, reflecting a prevailing silence on drug use linked to stigma and criminalization.

CONCLUSIONS

In San Diego, the assistance of others to initiate injection drug use is governed by a fragmented moral code situated within particular social norms and contexts. Interventions that address the social and structural conditions shaped by and shaping this code may be beneficial, in tandem with efforts to support safe injection and the reduction of injection-related harms.

The experience of initiating injection drug use and its social context: a qualitative systematic review and thematic synthesis

BACKGROUND AND AIM

Understanding the experience of initiating injection drug use and its social contexts is crucial to inform efforts to prevent transitions into this mode of drug consumption and support harm reduction. We reviewed and synthesized existing qualitative scientific literature systematically to identify the socio-structural contexts for, and experiences of, the initiation of injection drug use.

METHODS

We searched six databases (Medline, Embase, PsychINFO, CINAHL, IBSS and SSCI) systematically, along with a manual search, including key journals and subject experts. Peer-reviewed studies were included if they qualitatively explored experiences of or socio-structural contexts for injection drug use initiation. A thematic synthesis approach was used to identify descriptive and analytical themes throughout studies.

RESULTS

From 1731 initial results, 41 studies reporting data from 1996 participants were included. We developed eight descriptive themes and two analytical (higher-order) themes. The first analytical theme focused on injecting initiation resulting from a social process enabled and constrained by socio-structural factors: social networks and individual interactions, socialization into drug-using identities and choices enabled and constrained by social context all combine to produce processes of injection initiation. The second analytical theme addressed pathways that explore varying meanings attached to injection initiation and how they link to social context: seeking pleasure, responses to increasing tolerance to drugs, securing belonging and identity and coping with pain and trauma.

CONCLUSIONS

Qualitative research shows that injection drug use initiation has varying and distinct meanings for individuals involved and is a dynamic process shaped by social and structural factors. Interventions should therefore respond to the socio-structural influences on injecting drug use initiation by seeking to modify the contexts for initiation, rather than solely prioritizing the reduction of individual harms through behavior change.

Correlates of Injection Drug Use Among Rural Appalachian Women

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

A qualitative analysis of transitions to heroin injection in Kenya: implications for HIV prevention and harm reduction

BACKGROUND

Heroin injection is emerging as a significant dimension of the HIV epidemic in Kenya. Preventing transitions to injecting drug use from less harmful forms of use, such as smoking, is a potentially important focus for HIV prevention. There is, however, little evidence to support comprehensive programming in this area, linked to a shortage of analysis of the social and structural context for transitions, particularly in low-income settings. We explore accounts of transitions from smoking to injecting in Kenya to understand the role of individual, social and structural processes.

METHODS

We combine data from two separate studies conducted in Kenya: an in-depth qualitative study of HIV care access for people who inject drugs (study 1) and an ethnographic study of the political economy of the heroin trade in Kenya (study 2). In-depth interviews with PWID and community observation from study 1 are triangulated with accounts from stakeholders involved in the heroin trade and documentary data from study 2.

RESULTS

People who inject drugs link transitions to injecting from smoking to a range of social and behavioural factors, as well as particular aspects of the local drug supply and economy. We present these results in the form of two narratives that account for factors shaping transitions. A dominant narrative of 'managing markets and maintaining a high' results from a process of trying to manage poverty and a shifting heroin supply, in the context of deepening addiction to heroin. A secondary narrative focuses on people's curiosity for the 'feeling' of injecting, and the potential pleasure from it, with less emphasis on structural circumstances.

CONCLUSIONS

The narratives we describe represent pathways through which structural and social factors interact with individual experiences of addiction to increase the risk of transitions to injecting. In response, HIV and harm reduction programmes need combinations of different strategies to respond to varied experiences of transitions. These strategies should include, alongside behaviour-oriented interventions, structural interventions to address economic vulnerability and the policing of the drug supply.

Transition to injecting drug use in Iran: A systematic review of qualitative and quantitative evidence

BACKGROUND

Injection drug use, a behavior associated with significant adverse health effects, has been increasing over the past decade in Iran. This study aims to systematically review the epidemiological and qualitative evidence on factors that facilitate or protect the transition to injection drug use in Iran.

METHODS

We conducted electronic searches in five international (Medline, Web of Science, EMBASE, CINAHL, PsycINFO), one regional (IMEMR) and three Iranian (Iranmedex, Iranpsych, IranDoc) databases, as well as contacting experts in the field. Two trained researchers screened documents to identify relevant studies and independently dual-extracted data following pre-specified protocol. We applied principles of thematic analysis for qualitative data and applied a random effect meta-analysis model for age of first injection.

RESULTS

A total of 38 documents from 31 studies met eligibility criteria, from which more than 50% were implemented from 2006 to 2008. The weighted mean age of first injection was 25.8 (95% Confidence Interval: 25.3-26.2). Between 1998 and 2011, the age of first injection was relatively stable. Overall, drug users had used drugs for 6-7 years before they started injection use. Heroin was the first drug of injection in the majority of the cases. We identified factors influencing the initiation of or transition to injection use at various levels, including: (1) individual (pleasure-seeking behavior, curiosity and development of drug dependency commonly reported), (2) social and environmental (role of peer drug users in the first injection use, the economic efficiency associated with injections and the wide availability of injectable form of drugs in the market).

CONCLUSION

Harm reduction policies in Iran have almost exclusively focused on drug injectors in Iran. However, given the extent of the non-injection drug use epidemic, evidence from this study can provide insight on points of interventions for the prevention of the transition to injection use.

Reorienting risk to resilience: street-involved youth perspectives on preventing the transition to injection drug use

BACKGROUND

The Youth Injection Prevention (YIP) project aimed to identify factors associated with the prevention of transitioning to injection drug use (IDU) among street-involved youth (youth who had spent at least 3 consecutive nights without a fixed address or without their parents/caregivers in the previous six months) aged 16-24 years in Metro Vancouver, British Columbia.

METHODS

Ten focus groups were conducted by youth collaborators (peer-researchers) with street-involved youth (n = 47) from November 2009-April 2010. Audio recordings and focus group observational notes were transcribed verbatim and emergent themes identified by open coding and categorizing.

RESULTS

Through ongoing data analysis we identified that youth produced risk and deficiency rather than resiliency-based answers. This enabled the questioning guide to be reframed into a strengths-based guide in a timely manner. Factors youth identified that prevented them from IDU initiation were grouped into three domains loosely derived from the risk environment framework: Individual (fear and self-worth), Social Environment (stigma and group norms - including street-entrenched adults who actively discouraged youth from IDU, support/inclusion, family/friend drug use and responsibilities), and Physical/Economic Environment (safe/engaging spaces). Engaging youth collaborators in the research ensured relevance and validity of the study.

CONCLUSION

Participants emphasized having personal goals and ties to social networks, supportive family and role models, and the need for safe and stable housing as key to resiliency. Gaining the perspectives of street-involved youth on factors that prevent IDU provides a complementary perspective to risk-based studies and encourages strength-based approaches for coaching and care of at-risk youth and upon which prevention programs should be built.

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

BACKGROUND

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

RESULTS

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

CONCLUSIONS

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

Women Who Use or Inject Drugs: An Action Agenda for Women-Specific, Multilevel, and Combination HIV Prevention and Research

Women account for more than half of all individuals living with HIV globally. Despite increasing drug and HIV epidemics among women, women who use drugs are rarely found in research, harm reduction programs, or drug and HIV treatment and care. Women who use drugs continue to face challenges that increase their vulnerability to HIV and other comorbidities because of high rates of gender-based violence, human rights violations, incarceration, and institutional and societal stigmatization. This special issue emphasizes how the burdens of HIV, drug use, and their co-occurring epidemics affect women in a global context. Articles included focus on the epidemiologies of HIV and hepatitis C virus and other comorbidities; HIV treatment, prevention, and care; and policies affecting the lives of women who use drugs. This issue also highlights the state of the science of biomedical and behavioral research related to women who use drugs. The final article highlights the major findings of articles covered and presents a call to action regarding needed research, treatment, and preventive services for women who use drugs. To address these needs, we advocate for women-specific thinking and approaches that consider the social, micro, and macro contexts of women's lives. We present a women-specific risk environment framework that reflects the unique lives and contexts of women who use drugs and provides a call to action for intervention, prevention, and policies.

The Risk Environment of Heroin Use Initiation: Young Women, Intimate Partners, and "Drug Relationships"

This paper examines young women's initiation to heroin use in the context of an intimate relationship based on data from a small-scale ethno-epidemiology of heroin use in Ireland, 2007-2009. The epidemiological sample included 120 young people, and life history interviews were conducted with a sub-sample of 40 youth aged 16-25 years. A detailed analysis of the "risk environment" of young women's heroin initiation highlights a complex interplay between women's agency and intimate partner influence. It is argued that dichotomous representations of women as victims or emancipated consumers do not adequately capture the complexity of women's initiation journeys. The study's limitations are noted and implications for drug use prevention and harm reduction strategies are discussed.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Women, drugs and HIV

BACKGROUND

Women who use drugs, irrespective of whether these are injected or not, are faced with multiple issues which enhance their vulnerability to HIV.

METHODS

In this commentary, we explore the HIV risks and vulnerabilities of women who use drugs as well as the interventions that have been shown to reduce their susceptibility to HIV infection.

RESULTS

Women who inject drugs are among the most vulnerable to HIV through both unsafe injections and unprotected sex. They are also among the most hidden affected populations, as they are more stigmatized than their male counterparts. Many sell sex to finance their own and their partner's drug habit and often their partner exerts a significant amount of control over their sex work, condom use and injection practices. Women who use drugs all over the world face many different barriers to HIV service access including police harassment, judgmental health personnel and a fear of losing their children.

CONCLUSION

In order to enable these women to access life-saving services including needle-syringe and condom programs, opioid substitution therapy and HIV testing and treatment, it is essential to create a conducive environment and provide tailor-made services that are adapted to their specific needs.

Factors associated with initiating someone into illicit drug injection

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

HIV risks among injecting and non-injecting female partners of men who inject drugs in Almaty, Kazakhstan: implications for HIV prevention, research, and policy

BACKGROUND

Kazakhstan and other countries in Central Asia are experiencing a rapidly growing HIV epidemic, which has historically been driven by injection drug use, but is more recently being fueled by heterosexual transmission.

METHODS

This paper examines HIV and HCV infection, as well as sexual and drug-related risks among female partners of men who inject drugs (MWID), comparing females who inject drugs (FWID) to non-injecting female partners on socio-demographic, relationship context, and structural characteristics.

RESULTS

The prevalence rate of HIV was 30.1% among FWID and 10.4% among non-IDU female partners of MWID. The prevalence rate of HCV was 89.8% among FWID and 14.8% among female non-IDUs. Less than one-fifth of all female participants had access to HIV education and services or harm reduction programs. Although high rates of non-injection drug use and sexual risk behaviors were found among both FWID and non-injecting female partners of MWID, we found that FWID were more likely to be HIV seropositive (aRR=3.03; 95% CI=1.78, 5.18) and HCV seropositive than non-IDU females (aRR=6.05; 95% CI=4.05, 9.04), were more likely to have used alcohol or drugs before sex (aRR=1.67; 95% CI=1.40, 2.00), and were more likely to have used sedatives, barbiturates, tranquilizers, sleeping pills, or painkillers that were not prescribed by a physician (aRR=17.45; 95% CI=8.01, 38.01).

CONCLUSION

Given the spread of the HIV epidemic to heterosexual partners in Kazakhstan, more attention is needed in research, prevention, and policies regarding female partners of male injection drug users.

People who inject drugs in intimate relationships: it takes two to combat HIV

We reviewed papers published during the past 18 months (2012-2013) focusing on micro-social contexts of gender and power inequalities as drivers of HIV risks among people who inject drugs (PWID) in intimate heterosexual relationships. Although there has been a proliferation of social and behavioral research on the micro-social contexts of drug injection in heterosexual intimate relationships, there is still a gap in knowledge of these issues, particularly in low- and middle-income countries. Research has identified couple-based approaches for PWID in intimate relationships as an effective HIV prevention strategy to address micro-social contexts driving HIV risks. While HIV incidence has declined in many countries, prevalence remains at troubling levels among PWID and transmission from PWID to their sex partners is increasing in many parts of the world. HIV prevention among drug-using couples must address the importance of the relationship dyad and micro-social contexts.

Factors associated with HCV risk practices in methadone-maintained patients: the importance of considering the couple in prevention interventions

BACKGROUND

One important public health issue associated with opioid use today is the risk of hepatitis C (HCV) infection. Although methadone maintenance may help to decrease HCV-related risk practices, HCV risk behaviors persist and are strongly associated with specific substance use patterns, mental status and social context. The ANRS-Methaville study gave us the opportunity to better disentangle the different relationships between these various factors and HCV risk practices.

METHODS

The ANRS-Methaville multisite randomized trial was designed to assess the feasibility of initiating methadone in primary care by comparing it with methadone initiation in specialized centers. This study recruited 195 participants initiating methadone maintenance and followed up for 12 months. Longitudinal data from this trial was used to acquire a greater understanding of HCV risk practices and their pattern of correlates in this population. We selected 176 patients who had data on HCV risk practices at M0 and M12, accounting for 312 visits. HCV risk practices were defined as follows: sharing needles or syringes, sharing drug paraphernalia, getting a tattoo or having a piercing in a non-professional context, sharing toiletry items. To identify factors associated with HCV risk practices, we performed a mixed logistic regression analysis.

RESULTS

HCV risk practices were reported by 19% and 15% of participants at baseline and M12, respectively. After adjustment for age, cocaine use and alcohol dependence as well as suicidal risk, living in a couple with a non-drug user and in a couple with a drug user were both independent predictors of HCV risk practices (OR[CI95%] = 4.16 [1.42-12.12]; OR[CI95%] = 9.85 [3.13-31.06], respectively).

CONCLUSIONS

Identifying individuals at risk of HCV transmission during methadone treatment such as stimulant users, alcohol dependent individuals, and those at suicidal risk is necessary to optimize response to treatment. Innovative prevention approaches tailored to couples are also urgently needed and could decrease HCV-risk in this population. The trial is registered with the French Agency of Pharmaceutical Products (ANSM) under the number 2008-A0277-48, the European Union Drug Regulating Authorities Clinical Trials. Number Eudract 2008-001338-28, the ClinicalTrials.gov Identifier: NCT00657397 and the International Standard Randomised Controlled Trial Number Register ISRCTN31125511.

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

BACKGROUND

Research has demonstrated that there can be substantial gender differences in circumstances surrounding initiation of injection drug use; however, little is known about the gendered dynamics of first injection in rural areas where syringe exchange is inaccessible or among those who predominantly inject prescription medications. The present study examines gender differences in first injection experience among rural residents who predominantly inject prescription opioids.

METHODS

Interview-administered questionnaires collected data from a sample of injection drug users (n=394) recruited from Appalachian Kentucky using respondent-driven sampling.

RESULTS

Women were more likely to have initiated injection due to social-pressure (p=0.001), received the drugs as a gift (p=0.011), initiated in their partner's home (p=0.004) and in their partner's presence (p<0.001), been injected by their partner (p<0.001), used an unclean syringe (p=0.026), and received the syringe from their partner (p<0.001). Women were also more likely to report having engaged in sexual intercourse before or after initiation (p<0.001). Men were more likely to have personally purchased the drugs (p=0.002), to have acquired the syringe from a pharmacy/clinic (p=0.004), and to have injected with a friend (p=0.001) or family member (p=0.020). Men were also more likely to have a friend administer the first injection (p=0.007).

CONCLUSIONS

In this population of rural drug users, notable gender differences in injection initiation were observed. Social pressure played a more substantial role in women's first injection experience, and male partners had an integral role in women's initiation.

Barriers to drug treatment for IDU couples: the need for couple-based approaches

This qualitative study examines the interpersonal and structural barriers to drug treatment program entry, retention, and outcomes experienced by injection drug-using couples, and the program policies regarding injection drug-using couples seeking treatment in New York, New York. Our findings reveal a mismatch between the substantial need for concurrent and coordinated treatment for partnered injection-drug users and programmatic policies that are antithetical to such treatment approaches. This discrepancy can be attributed to the lack of viable options for couple-focused treatment approaches that fit within the current drug treatment system. We provide a rationale and a roadmap for the development of innovative approaches for couple-based drug treatment.