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

Epidemiology of acute infections in people who inject drugs in Australia

ISSUES

People who inject drugs are at risk of acute infections, such as skin and soft tissue infections, infective endocarditis, bone and joint infections and bloodstream infections. There has been an increase in these infections in people who inject drugs internationally over the past 10 years. However, the local data regarding acute infections in Australia has not been well described.

APPROACH

We review the epidemiology of acute infections and associated morbidity and mortality amongst people who inject drugs in Australia. We summarise risk factors for these infections, including the concurrent social and psychological determinants of health.

KEY FINDINGS

The proportion of people who report having injected drugs in the prior 12 months in Australia has decreased over the past 18 years. However, there has been an increase in the burden of acute infections in this population. This increase is driven largely by skin and soft tissue infections. People who inject drugs often have multiple conflicting priorities that can delay engagement in care.

IMPLICATIONS

Acute infections in people who inject drugs are associated with significant morbidity and mortality. Acute infections contribute to significant bed days, surgical requirements and health-care costs in Australia. The increase in these infections is likely due to a complex interplay of microbiological, individual, social and environmental factors.

CONCLUSION

Acute infections in people who inject drugs in Australia represent a significant burden to both patients and health-care systems. Flexible health-care models, such as low-threshold wound clinics, would help directly target, and address early interventions, for these infections.

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.

Self-reported impacts of the COVID-19 pandemic among people who use drugs: a rapid assessment study in Montreal, Canada

BACKGROUND

People who use drugs (PWUD) are at high risk of experiencing indirect harms of measures implemented to curb the spread of COVID-19, given high reliance on services and social networks. This study aimed to document short-term changes in behaviours and health-related indicators among PWUD in Montreal, Canada following declaration of a provincial health emergency in Quebec.

METHODS

We administered a structured rapid assessment questionnaire to members of an existing cohort of PWUD and individuals reporting past-year illicit drug use recruited via community services. Telephone and in-person interviews were conducted in May-June and September-December 2020. Participants were asked to report on events and changes since the start of the health emergency (March 13, 2020). Descriptive analyses were performed.

RESULTS

A total of 227 participants were included (77% male, median age = 46, 81% Caucasian). 83% and 41% reported past six-month illicit drug use and injection drug use, respectively. 70% of unstably housed participants reported increased difficulty finding shelter since the start of the health emergency. 48% of opioid agonist treatment recipients had discussed strategies to avoid treatment disruptions with providers; 22% had missed at least one dose. Many participants perceived increased difficulty accessing non-addiction health care services. Adverse changes were also noted in indicators pertaining to income, drug markets, drug use frequency, and exposure to violence; however, many participants reported no changes in these areas. Among persons reporting past six-month injection drug use, 79% tried to access needle-syringe programmes during the health emergency; 93% of those obtained services. 45% tried to access supervised injection sites, of whom 71% gained entry.

CONCLUSIONS

This snapshot suggests mixed impacts of the COVID-19 pandemic on PWUD in Montreal in the months following declaration of a provincial health emergency. There were signals of increased exposure to high-risk environments as well as deteriorations in access to health services. Pandemic-related measures may have lasting impacts among vulnerable subgroups; continued monitoring is warranted.

Association of co-occurring mental health problems with hepatitis C status among young people who inject drugs in rural New Mexico, 2016-2018

BACKGROUND

Injection drug use (IDU) remains the strongest risk factor for hepatitis C virus (HCV) in the United States. HCV rates are increasing in rural areas among young adult people who inject drugs (PWID). People with HCV and PWID have disproportionate rates of mental health problems; however, it is unclear whether risky injection behaviors mediate the association between mental health problems and HCV. We examined the association between mental health problems and HCV in a rural cohort of young adult PWID, with the goal of informing rural service delivery.

METHODS

We conducted a secondary analysis of cross-sectional data from a convenience sample of young adult PWID in 2 rural counties in New Mexico. Participants were recruited from 2 community venues between September 2016 and May 2018. Associations between mental health problems and HCV were examined using bivariate (Fisher's exact) and multivariable modified Poisson regression analyses (with robust standard errors). Using structural equation modeling (SEM), we assessed duration of IDU and receptive syringe sharing (RSS) as mediators of this relationship.

RESULTS

A total of 263 patients were enrolled, with a median age of 26.1 years. The majority were male (66.3%) and Hispanic/Latino (a) (87.6%). The median age first injected was 19 years, and over half reported having ever engaged in RSS (53.4%). At least one mental health problem was reported by 60.1% of participants, with post-traumatic stress disorder (PTSD) being the most prevalent condition (42.2%). A majority (60.9%) tested positive for HCV antibody, and just under half (45.7%) of all participants tested positive for HCV ribonucleic acid. In SEM, PTSD had a significant total effect on HCV (τ = 0.230, P = 0.05), and this relationship was partially mediated by duration of IDU (αβ = 0.077, P = 0.03). The association between mental health problems and HCV was partially mediated by duration of IDU and the sequential mediation of duration of IDU and RSS (αβ + αββ = 0.091, P = 0.05).

CONCLUSIONS

High HCV rates among young adult PWID in rural New Mexico may be partly explained by mental health problems, duration of IDU and RSS. Mental health services for young adult PWID in rural areas may help decrease HCV transmission in rural areas. Trial Registration N/A.