The micro-social risk environment for injection drug use: An event specific analysis of dyadic, situational, and network predictors of injection risk behavior

A mixed methods exploration of injection drug use risk behaviors and place-based norms in Ukraine

INTRODUCTION

Despite global reductions in HIV incidence and significant investment in local harm reduction services, Ukraine continues to experience high HIV and HCV prevalence among people who inject drugs (PWID). Place-based factors and social norms affect drug use-related risk factors, but research has paid little attention to the relationship between drug use practices and place in Ukraine, including how these factors may contribute to or protect against HIV/HCV risk.

METHODS

This project used a sequential mixed methods design. Between March and August 2018, we interviewed 30 PWID in Dnipro, Ukraine. Participants completed a single in-depth interview in which they described where and with whom they lived; how they generated income; and where, when, how, and with whom they purchased and used drugs. Between May 2019 and March 2020, we recruited 150 PWID in Dnipro to complete a survey that was designed based on interview findings and consisted of three components: an activity space inventory, an egocentric social network inventory, and an HIV risk behavior assessment.

RESULTS

Both interview and survey respondents reported consistent use of pharmacies to acquire syringes and nearly universal use of new syringes when injecting. Interview participants reflected that while syringe sharing was previously considered a "common practice," PWID now viewed it as infrequent and unacceptable. However, interview respondents enumerated the contexts in which needle and syringe reuse occurred, including purchasing drugs directly from a dealer and chipping in with other PWID to prepare drugs bought through a stash.

CONCLUSION

Participants described relatively easy access to new needles and syringes through pharmacies and expressed strong social sanctioning against reusing needles or syringes. However, equipment sharing behaviors and norms persisted in certain contexts, creating an opportunity for further harm reduction campaigns that incorporate changing norms in these situations to "close the gap" and further reduce HIV and other infections among PWID.

Creation and Validation of a New Socio-built Environment Index Measure of Opioid Overdose Risk for Use in Both Non-urban and Urban Settings

A great deal of literature has examined features of the physical built environment as predictors of opioid overdose and other substance use-related outcomes. Other literature suggests that social characteristics of settings are important predictors of substance use outcomes. However, there is a dearth of literature simultaneously measuring both physical and social characteristics of settings in an effort to better predict opioid overdose. There is also a dearth of literature examining built environment as a predictor of overdose in non-urban settings. The present study presents a novel socio-built environment index measure of opioid overdose risk comprised of indicators measuring both social and physical characteristics of settings - and developed for use in both urban and non-urban settings - and assesses its validity among 565 urban, suburban, and rural New Jersey municipalities. We found that this novel measure had good convergent validity, based on significant positive associations with a social vulnerability index and crime rates, and significant negative associations with a municipal revitalization index and high school graduation rates. The index measure had good discriminant validity, based on lack of association with three different racial isolation indices. Finally, our index measure had good health outcome-based criterion validity, based on significant positive associations with recent overdose mortality. There were no major differences between rural, suburban, and urban municipalities in validity analysis findings. This promising new socio-built environment risk index measure could improve ability to target and allocate resources to settings with the greatest risk, in order to improve their impact on overdose outcomes.

Gender-specific associations between psychological distress and injecting risk behaviours among people who inject drugs in Montreal, Canada

BACKGROUND

Psychological distress is common among people who inject drugs (PWID) and may be associated with HCV-related risk behaviours. Previous studies have documented increased vulnerability to both psychological distress and HCV infection among female relative to male PWID. It is, however, unclear whether behavioural responses to distress differ by gender. This study estimated gender-specific associations between psychological distress and i) binge drug injection, and ii) sharing of injection materials.

METHODS

Data were drawn from HEPCO, a longitudinal cohort study involving three-monthly interviews with active PWID in Montreal, Canada. Past-month psychological distress was assessed with the Kessler (K10) scale, categorized for descriptive analyses as minimal (score 10-15), moderate (16-21), high (22-29), or severe (30-50). Binge was defined as injecting large quantities of drugs until participants could no longer continue (past 3 months). Sharing was defined as injection with previously-used needles or equipment (past 3 months). Generalized additive models were fit to estimate smooth, nonlinear associations between K10 scores and risk behaviours, by gender. Models were adjusted for known determinants of drug-related harms and included random intercepts to model within-subject correlation.

RESULTS

805 individuals (82% male) provided 8158 observations (2011-2020). High to severe levels of distress were common and more frequent among women (55% vs 37%). Among men, the odds of binge and sharing monotonically and non-linearly increased with increasing scores of psychological distress. Associations for binge among women were attenuated relative to men but nevertheless increased with distress, albeit in a linear fashion. Sharing was not associated with distress among women.

CONCLUSION

Psychological distress was differentially associated with injecting risk behaviours among men and women who inject drugs. Assessment of distress may provide novel prevention opportunities for select PWID. Further investigation into gender differences is warranted to inform development and tailoring of interventions.

Social network predictors of recent and sustained injection drug use cessation: findings from a longitudinal cohort study

BACKGROUND AND AIMS

The US opioid crisis has led to increases in overdose fatalities and the incidence of HIV, hepatitis C and other infections. This analysis examines social network predictors of recent (self-report injection followed by non-injection) and sustained (self-report non-injection at two consecutive visits among those who previously injected) injection cessation in Appalachian Kentucky.

DESIGN

Data were collected through bi-annual longitudinal assessments for Social Networks among Appalachian People (SNAP; 2008-17). Using logistic regression with generalized estimating equations that clustered on individuals, we regressed non-injection status on the number of social network members who (a) did not inject and (b) recently stopped injecting and tested for interactions between each social network exposure and prior non-injection status. Social network exposures were self-reported.

SETTING

Rural eastern Kentucky, USA.

PARTICIPANTS

Participants entered the analysis only after reporting recent injection and had to have had at least two consecutive study visits (n = 326).

MEASUREMENTS

Interviewer-administered surveys collected individual-level socio-demographics, recent (past 6 months) drug use behaviors and the names of recent social support, sex and drug-use partners.

FINDINGS

After adjusting for confounders, the number of non-injecting social network members was positively associated with recent/sustained injection cessation (adjusted odds ratio = 1.27; 95% confidence interval = 1.13-1.42) and having more social network members was associated with reduced odds of recent/sustained injection cessation. The number of previously injecting social network members who had recently stopped injecting was not statistically significantly associated with injection cessation. Neither of the interactions we tested for was statistically significant, suggesting that the relationships may be similar for those who recently stopped injecting versus had not injected for at least 1 year.

CONCLUSIONS

For each additional network member who did not inject drugs, there was an increased odds of recent and sustained injection cessation among people with a history of injection drug use in Appalachian Kentucky.

Injecting-related trust, cooperation, intimacy, and power as key factors influencing risk perception among drug injecting partnerships

Sharing of injection drug use paraphernalia is a dyadic process linked to the transmission of HIV and hepatitis C virus (HCV). Despite this, limited research exists identifying specific dyadic interpersonal factors driving injecting partners' engagement in needle/syringe and ancillary injecting equipment sharing among young adults. Using semi-structured in-depth interview data collected between 2014 and 2015 from twenty-seven people who inject drugs (PWID), we applied an inductive approach to identify key injection drug-related interpersonal factors and developed a conceptual model integrating the findings based on interdependence theory. Interactions between injecting partners resulted in varying levels of injecting-related trust, cooperation, intimacy, and power. These factors interacted to collectively influence the type and level of risk perceived and enacted by injecting partners. The relationship between these injecting-related interpersonal factors, on the one hand, and risk perception on the other was dynamic and fluctuated between actions that protect the self (person-centered) and those that protect the partnership (partnership-centered). These findings indicate that the interpersonal context exerts substantial influence that shapes risk perception in all types of injecting partnerships. Partnership-focused prevention strategies should consider the dynamics of trust, cooperation, intimacy, and power, in characterizing dyadic risk perceptions and in understanding risky injecting practices among PWID.

Rural risk environments for hepatitis c among young adults in appalachian kentucky

BACKGROUND

Rural Kentucky is an epicenter of hepatitis C(HCV), especially among young adults who inject drugs. While the Risk Environment Framework (REF) has been used widely to study and address socio-ecological determinants of infectious disease among people who inject drugs (PWID), it has been almost exclusively applied to urban environments. Applying REF to rural environments can enhance our understanding of the drivers of HCV epidemics in these hard-hit areas, and inform the creation and implementation of harm reduction interventions in this local context.

METHODS

Participants were recruited between March and August 2017 via community-based outreach methods (e.g., cookouts, flyers) and peer referral. Individuals who met eligibility criteria (aged 18-35, recently used prescription opioids and/or heroin to get high, lived in one of the 5 target counties) participated indepth, semi-structured interviews. The interview guide was informed by the REF, and covered HCV-related risk behaviors and environmental features that shaped vulnerability to engaging in these behaviors. Interviews were transcribed and analyzed using constructivist grounded-theory methods.

RESULTS

Participants (N=19) described multiple intersecting risk environment features that shaped vulnerability to HCV transmission. Economic decline generated intergenerational poverty, dwindling employment prospects, and diminished social enrichment opportunities that collectively contributed to substance misuse and risky injection practices. Geographic isolation, lack of collective knowledge about HCV transmission risks, scarce harm reduction services, familial poverty, and fear of law enforcement interacted to increase the odds of people injecting in "trap houses" (akin to shooting galleries) or secluded areas, spaces in which they rushed to inject and shared injection equipment. Pervasive stigma was a structural barrier to adopting, expanding, and using harm reduction services.

CONCLUSION

This exploratory study identified features of rural risk environments that may contribute to significant HCV burdens in Appalachian Kentucky. Findings signal the importance of expanding proven harm reduction strategies and anti-stigma interventions tailored to rural contexts.

Narratives of Young Men With Injecting Drug Use Histories Leaving Adult Prison

This research focuses on an under-examined aspect of the post-release prison trajectory for a seldom-researched cohort. Narratives of the immediate days/weeks surrounding release were gathered from young men with histories of injecting drug use (IDU). Twenty-eight participants (aged 19-24) released from adult prisons in Victoria, Australia, participated in face-to-face in-depth qualitative interviews after release. Analysis of findings through the lens of a "risk environment" framework reveals how their experiences were compromised by risk factors embedded in the physical spaces and social situations they inhabited, as well as the multi-sectoral policy environments under which they were governed. A complex interplay between these factors, young men's drug use and broader issues of structural vulnerability, including institutionalization and social disadvantage, combined to limit young men's chances of "success"¹ on the outside. Narratives provide evidence for interventions that transform risk environments into enabling environments, thereby promoting a more successful transition from prison to community for young men with IDU histories.

Association between injection in public places and HIV/HCV risk behavior among people who use drugs in Ukraine

BACKGROUND

In Eastern Europe and Central Asia new HIV infections occur at a high rate among people who inject drugs (PWID). Injection risk behavior may be associated with injecting in public places. However, there is a lack of studies exploring this association in Ukraine, which has an HIV prevalence 21-42% among PWID.

METHODS

Data came from a baseline survey of PWID recruited to participate in a behavioral HIV prevention intervention. The association between HIV/HCV injection risk behavior and place of injection (private vs. public) was assessed using multivariable Poisson regression with robust variance estimate.

RESULTS

Most of the sample was male (73%), > 30 years (56%), and reported opioids as their drug of choice (55%). One in six participants (15.8%, n = 57) reported using a syringe after somebody, and 70% (n = 253) reported injecting in public places within last 30-days. In the adjusted model, injection risk behavior was associated with injecting in public places (PrR: 4.24, 95% CI: 1.76-10.20), unstable housing situation (PrR: 2.46, 95% CI:1.26-4.83), higher than secondary education (PrR:1.82, 95%CI:1.04-3.16), injecting with a sex partner day (PrR:2.13, 95% CI:1.28-3.56), and injecting with a stranger (PrR: 1.47, 95% CI: 0.93-2.31).

CONCLUSIONS

Injecting in a public place is associated with increased prevalence of risky behavior. Therefore, understanding and addressing place-based context should be part of the national strategy to fight HIV and HCV in Ukraine. National programs would benefit from expanding models to include contextual and structural determinants of health.

Influence of social network on drug use among clients of methadone maintenance treatment centers in Kunming, China

AIMS

To examine drug use behavior of clients attending Methadone Maintenance Treatment (MMT) programs and its relationship with the clients' social network characteristics.

DESIGN

Cross-sectional study.

SETTING

Four MMT clinics in Kunming, Yunnan province, China.

PARTICIPANTS

324 consecutive MMT clients.

MEASUREMENTS

A structured, self-completed questionnaire on background characteristics and existing social network. Current drug use was assessed by urine test for opiate metabolites.

ANALYSIS

The association between client's social network characteristics and their own current drug use behavior is analysed using multiple logistic regression adjusting for socio-demographic characteristics. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) are obtained to give the strength of the associations.

FINDINGS

MMT clients were more likely to concurrently use heroin while attending MMT if their social network had any of the following characteristics: more than half of the members were older than them (AOR = 1.03, 95% CI = 1.00,1.06), any member had a high level of influence on them (AOR = 6.47, 95% CI = 2.86,14.65) and any member joined them in using drugs (AOR = 1.94, 95% CI = 1.04,3.63). Having a social network member who could provide emotional support (AOR = 0.11, 95% CI = 0.03,0.35), having a spouse and/or child in their social network (AOR = 0.44, 95% CI = 0.24,0.81) and having a social network member with a high level of closeness (AOR = 0.28, 95% CI = 0.09,0.90) were associated with a decreased odds of heroin use.

CONCLUSION

Social networks who could provide MMT clients with emotional support and a close relationship were significant factors for reducing the risk of concurrent drug use among clients attending MMT clinics in Kunming, China. Behavioral interventions should address the role of family and social network members in providing support to these clients.

Injecting drug use: Gendered risk

BACKGROUND

Research demonstrates gender related differences in drug-use practices and risk behaviours. Females' structural vulnerability stemming from traditional gender roles and gender-power relations may enhance their propensity to experience injecting related risk. In this paper we explore gender differences in injection practices at the initiation event, during the first year of injecting and in the most recent 12-month period, to inform more effective harm reduction strategies.

METHODS

Data used in this study were drawn from the Global Drug Survey 2015. The study employs chi-square and logistic regression to assess gender differences in injection behaviours in a sample of current injectors residing in six global regions: North-West Europe; Southern Eastern Europe; North America. South America and Oceania.

RESULTS

Females were more likely than males to report being injected by an intimate partner at initiation (OR = 4.4, 95%CI: 2.2-8.8), during the first year of injecting (OR = 4.8, 95% CI: 2.4-9.3) and in the most recent 12-month period (OR = 2.5, 95%CI: 1.0-6.2). Females reported greater difficulties accessing sterile equipment (X²(2,N = 453) = 8.2, p = 0.02) and were more likely to share injecting equipment than males (X²(1,N = 463) = 3.9, p = 0.05).

CONCLUSIONS

Our findings highlight females' continued dependence on their intimate partner to administer the injection into the first year of their injecting career. Females remained more likely than males to rely on intimate partners for injection during the most recent 12-month period. Females report greater difficulties in sourcing sterile equipment and are more likely to share injecting equipment. We suggest that these findings reflect the broader social structure in which females are disempowered through traditional gender roles and the lack of gender appropriate harm reduction services.

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.