Enduring Consequences From the War on Drugs: How Policing Practices Impact HIV Risk Among People Who Inject Drugs in Baltimore City

Epidemiology of drug arrests in the United States: Evidence from the national survey on drug use and health, 2015-2019

OBJECTIVE

Following changes to drug criminalization policies, we re-examine the epidemiology of drug arrests among people who use drugs (PWUD) in the U.S.

METHODS

Serial cross-sectional data from the National Survey on Drug Use and Health (2015-2019) were utilized. Past-year illicit drug use (excluding cannabis) and drug arrests were described by year, area of residence, drug use characteristics and participant demographics. Adjusted associations between race and drug arrest were estimated using multivariable logistic regression.

RESULTS

Past-year illicit drug use remained consistent over time and was highest among non-Hispanic (NH) white respondents. Of those reporting past-year illicit drug use (n = 25,429), prevalence of drug arrests remained stable over time overall and in metro areas while increasing in non-metro areas. Arrests were elevated among NH Black participants and those with lower income, unemployment, housing transience, non-metro area residence, polysubstance use, history of drug injection, substance use dependence and past-year drug selling. Adjusted odds of drug arrest remained significantly higher among NH Black individuals [aOR 1.92, 95% CI 1.30, 2.84].

CONCLUSION

Despite recent shifts away from punitive drug policies, we detected no reduction in drug arrests nationally and increasing prevalence in non-metro areas. Despite reporting the lowest level of illicit substance use and drug selling, NH Black individuals had significantly increased odds of arrest across years. Findings highlight the need for further examination of policy implementation and policing practices in different settings, with more research focused non-metro areas, to address enduring structural racism in drug enforcement and its consequences for health.

Emerging models of de facto drug policy reforms in the United States

BACKGROUND

Health and human rights organizations have endorsed drug decriminalization to promote public health-oriented approaches to substance use. In the US, policymakers have begun to pursue this via prosecutorial discretion-or the decision by a prosecutor to decline criminal charges for drug possession in their jurisdiction. This study characterizes drivers of adoption, policy design and implementation processes, and barriers to impact and sustainability of this approach to inform evolving policy efforts promoting the health of people who use drugs (PWUD).

METHODS

We conducted n=22 key informant interviews with policymakers and national policy experts representing 13 jurisdictions implementing de facto drug policy reforms. Analyses were informed by the Exploration, Preparation, Implementation and Sustainment (EPIS) framework and analyzed using a hybrid inductive-deductive approach.

RESULTS

Drivers of policy adoption included racial inequities, perceived failures of criminalization, and desires to prioritize violent crime given resource constraints. Three distinct policy typologies are described with varying conditions for eligibility, linkage to services, and policy transparency and dissemination. Public misinformation, police resistance and political opposition were seen as threats to sustainability.

CONCLUSIONS

Given evidence that criminalization amplifies drug-related harms, many policymakers are adopting de facto drug policy reforms in the absence of formal legislation. This is the first study to systematically describe relevant implementation processes and emerging policy models. Findings have implications for designing rigorous evaluations on health outcomes and informing sustainable evidence-based policies to promote health and racial equity of PWUD in the US.

Challenges to Providing Integrated HIV Prevention in Substance Use Treatment Settings: Frontline Staff Perspectives on HIV and Sex-Related, Education, Communication and Stigma

INTRODUCTION

Substance use treatment settings can play a critical role in ending the HIV epidemic. Community-based methadone clinics are potentially useful sites to offer biomedical HIV prevention, but little is known about how clinicians and other clinic staff communicate with patients about sexual behavior and HIV-related topics.

METHODS

Thirty semi-structured interviews were conducted at two methadone clinics in Northern New Jersey. Participants included medical providers (physicians, RNs, DNPs), methadone counselors, intake coordinators, lab technicians, and other auxiliary staff members. Results: Three major themes were identified: (1) HIV education is primarily provided by external organizations, (2) there is limited staff-patient communication around HIV and sexual behaviors, and (3) HIV stigma is prevalent among staff and patients.

CONCLUSION

To implement PrEP in methadone treatment settings, clinic staff must be able to engage in non-judgmental communication about HIV and sex with patients. Additionally, federal and state funding for HIV prevention in substance use treatment settings must be prioritized to enable clinics to access the necessary training and resources.

Racial Disparities in Drug Arrest Before and After De Facto Decriminalization in Baltimore

INTRODUCTION

To mitigate the harms of arrest and incarceration on health and racial equity, jurisdictions are increasingly enacting reforms to decriminalize drug possession through prosecutorial discretion (de facto). Impacts on health outcomes rely on whether this policy can reduce exposure to the carceral system among people who use drugs; however, data evaluating effects on arrest are lacking. This study explores the possible impacts of Baltimore City's enactment of de facto decriminalization on arrests by race.

METHODS

Police and court records were used to explore the possible impacts of Baltimore City's de facto decriminalization on street arrests and (processed) arrests advancing through the courts among people who use drugs. Interrupted time series models were used to compare pre-policy (January 2018-March 2020) trends with post-policy (April 2020-December 2021) trends in arrests for possession of drugs/paraphernalia and estimate racial disparities in street arrests (Black versus other races). Analyses were performed in February-May 2022.

RESULTS

The policy was associated with a significant and immediate decline in street and processed arrests for possession, which was not seen for other crime categories. Although declines were concentrated in the Black community, disparities in arresting persisted after the policy.

CONCLUSIONS

De facto decriminalization may be a promising strategy to reduce exposure to the carceral system, an established risk factor for overdose and other drug-related sequelae and a driver of racial disparities in the U.S. Further research is needed to elucidate the drivers of persisting racial disparities and disentangle policy effects from pandemic-related closures.

The impact of border crossing and imprisonment on injection practices and risk of HIV and hepatitis C infection among men who inject drugs in Nepal

BACKGROUND

In Nepal, personal drug use is criminalized and among people who inject drugs (PWID), the majority of whom are men, movement across the border with India for drug procurement and use is common. Using a risk environment approach, this study examined associations between border crossing and imprisonment with respect to HIV, HCV and injection risk behavior among men who inject drugs in Nepal.

METHODS

This cross-sectional study analyzed data from 1345 participants from 14 districts across Nepal. Explanatory variables were prior imprisonment and past-month border crossing to procure or use drugs. We used multivariable logistic regression to evaluate associations between these variables and HIV, HCV, HIV/HCV co-infection and past-month injection risk behavior among PWID.

RESULTS

Over half of participants reported prior imprisonment (34.6% prior to past year, 21.6% within past year) and Indo-Nepal border crossing in the past year to use or buy drugs (31.2% sometimes, 20.8% often); over one quarter of participants (29.6%) reported both. Imprisonment prior to the past year was associated with higher odds of all outcome variables: HIV (adjusted odds ratio (aOR) 2.44, 95% confidence interval (CI) 1.29-4.59), HCV (aOR 1.51, 95% CI 1.08-2.09), HIV/HCV co-infection (aOR 3.12, 95% CI 1.58-6.14) and injection risk behavior (aOR 1.64, 95% CI 1.20-2.25). Past-year border crossing to procure or use drugs was associated with HCV (aOR 2.06, 95% CI 1.42-2.98) and injection risk behavior (aOR 1.47, 95% CI 1.04-2.10), with larger effect sizes among PWID who reported both border crossing as well as history of imprisonment.

CONCLUSION

Imprisonment and border crossing were associated with injection risk behavior and disease outcomes. These findings indicate a need to implement cross-border disease surveillance and harm reduction initiatives in the Indo-Nepal border region and in Nepali prisons.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A national survey of law enforcement post-overdose response efforts

Background: Law enforcement agencies in the US have provided naloxone to officers and developed initiatives to follow-up after a non-fatal overdose. However, the prevalence and characteristics of these efforts have yet to be documented in research literature.Objectives: We sought to understand the national prevalence of naloxone provision among law enforcement and examine the implementation of post-overdose follow-up.Methods: We administered a survey on drug overdose response initiatives using a multimodal approach (online and mail) to a nationally representative sample of law enforcement agencies (N = 2,009; 50.1% response rate) drawn from the National Directory of Law Enforcement Administrators database. We further examine a subsample of agencies (N = 1,514) that equipped officers with naloxone who were also asked about post-overdose follow-up.Results: We found 81.7% of agencies reported officers were equipped with naloxone; among these, approximately one-third (30.3%) reported follow-up after an overdose. More than half (56.8%) of agencies indicated partnership in follow-up with emergency medical services as the most common partner (68.8%). There were 21.4% of agencies with a Quick Response Team, a popular national post-overdose model, and were more likely to indicate partnership with a substance use disorder treatment provider than when agencies were asked generally about partners in follow-up (74.5% and 26.2% respectively).Conclusion: Many law enforcement agencies across the US have equipped officers with naloxone, and about one-third of those are conducting follow-up to non-fatal overdose events. Post-overdose follow-up models and practices vary in ways that can influence treatment engagement and minimize harms against persons who use drugs.

"I want the doctors to know that I am as bright as a candle": : Experiences with and Hopes for Doctor Interactions Among Malaysian Key Populations and People Living with HIV

Stigma in healthcare settings is a pernicious barrier to HIV prevention and treatment in contexts with strong HIV-related structural stigma. Previous work has documented substantial stigma towards key populations and people living with HIV (PLWH) among Malaysian doctors. The perspectives of Malaysian key populations and PLWH, however, remain understudied. In 2021, 34 Malaysian participants representing key populations and PLWH engaged in a photovoice study designed to qualitatively explore their experiences with and hopes for doctor interactions. Many participants reported stigma from their doctors, perceiving that doctors view them as not normal, sinful, misguided, and incapable. Several emphasized that they wear figurative masks to conceal aspects of themselves from doctors. Yet, many also remain hopeful for constructive relationships with doctors. They want their doctors to know that they are bright, capable, kind, and valuable. Interventions are needed to address stigma among doctors working in contexts with strong structural stigma.

"They don't go by the law around here": law enforcement interactions after the legalization of syringe services programs in North Carolina

BACKGROUND

In 2016, the US state of North Carolina (NC) legalized syringe services programs (SSPs), providing limited immunity from misdemeanor syringe possession when law enforcement is presented documentation that syringes were obtained from an SSP. This study explores the law enforcement interactions experienced by SSP participants since the enactment of this law.

METHODS

This study used a convergent, mixed-methods design consisting of structured surveys and semi-structured interviews with SSP participants in seven NC counties. Survey and interview data were collected simultaneously between January and November 2019. This survey was designed to capture demographics, characteristics of drug use, SSP services used, and past-year negative experiences with law enforcement (officer did not recognize SSP card, did not believe SSP card belonged to participant, confiscated SSP card, confiscated syringes, or arrested participant for possessing syringes). Semi-structured interviews explored lived experiences with and perspectives on the same topics covered in the survey.

RESULTS

A total of 414 SSP participants completed the survey (45% male, 54% female, 1% transgender or non-binary; 65% White, 22% Black, 5% American Indian/Alaskan Native, 8% some other racial identity). 212 participants (51.2%) reported at least one past-year negative experience with law enforcement. Chi-square testing suggests that Black respondents were more likely to report having experienced law enforcement doubt their SSP card belonged to them. Interview data indicate that law enforcement practices vary greatly across counties, and that negative and/or coercive interactions reduce expectations among SSP participants that they will be afforded the protections granted by NC law.

CONCLUSION

Despite laws which protect SSP participants from charges, negative law enforcement responses to syringe possession are still widely reported. Evidence-based policy interventions to reduce fatal overdose are undermined by these experiences. Our findings suggest NC residents, and officers who enforce these laws, may benefit from clarification as to what is required of the documents which identify participants of registered SSPs where they may legally obtain syringes. Likewise, more thorough trainings on NC's syringe law for law enforcement officers may be merited. Further research is needed to assess geographic differences in SSP participants' law enforcement interactions across race and gender.

Hepatitis C antibody prevalence, correlates and barriers to care among people who inject drugs in Central California

Hepatitis C (HCV) infection among people who inject drugs (PWID) is a major public health concern. We examined correlates of HCV antibody (anti-HCV) seropositivity and characteristics of prior HCV testing and treatment among PWID in Fresno, California, which has among the highest prevalence of injection drug use (IDU) in the United States. We surveyed 494 peer-recruited PWID (≥18 years of age) in 2016 about their experiences with HCV testing and treatment, and conducted HCV and HIV antibody testing for all participants. Bivariate analyses and multivariable logistic regressions were used to identify correlates of anti-HCV seropositivity. A majority (65%) tested positive for anti-HCV, with 32% of those being unaware of their HCV status. Anti-HCV seroprevalence was independently and positively associated with older age (AOR = 1.11 per year, 95% CI = 1.06, 1.17), years injecting (AOR = 1.08 per year, 95% CI = 1.03, 1.13), distributive syringe sharing (AOR = 2.76, 95% CI = 1.29, 5.94), having syringes confiscated by police (AOR = 2.65, 95% CI = 1.22, 5.74), ever trading sex (AOR = 3.51, 95% CI = 1.40, 8.81) and negatively associated with being Black/African American (non-Hispanic) (AOR = 0.06, 95% CI = 0.01, 0.47). Prior HCV testing was associated with older age, ever getting syringes from a syringe services program, and having interactions with police. For those aware of their anti-HCV seropositivity, only 11% had initiated treatment; reasons for not seeing a physician regarding diagnosis included not feeling sick (23%), currently using drugs/alcohol (19%) and not knowing where to go for HCV medical care (19%). Our findings highlight the importance of expanding community-based access to sterile syringes alongside HCV testing and treatment services, particularly at syringe service programs where PWID may be more comfortable seeking testing and treatment.

Perceived vulnerability to overdose-related arrests among people who use drugs in Maryland

BACKGROUND

People who use drugs (PWUD) must weigh complex legal scenarios when seeking help during overdose events. Good Samaritan laws (GSL) offer limited immunity for certain low-level drug crimes to encourage PWUD to call 911. Drug-induced homicide laws (DHL) allow for criminal prosecution of people delivering drugs that result in overdose death and may exert opposing effects on the decision-making process. We examined whether perceptions of these laws were related to overall perceived vulnerability to overdose-related arrests, which can impact help-seeking and overdose mortality.

METHODS

We conducted a cross-sectional study of PWUD (N = 173) in Anne Arundel County, Maryland and measured sociodemographic characteristics, structural vulnerabilities, and knowledge of GSL and DHL. Perceived vulnerability to overdose-related arrest was defined as self-reported concern arising from calling 911, receiving medical help, or supplying drugs in the event of an overdose. Multivariable logistic regression was used to identify significant correlates of perceived vulnerability to overdose-related arrest.

RESULTS

Most participants were aware of DHL (87%) and half were aware of GSL (53%). Forty-seven percent of PWUD expressed concern about arrest during or due to an overdose. After adjustment, positive correlates of perceived vulnerability to arrest were non-white race (aOR 2.0, 95% CI 1.5-2.5) and hearing of somebody charged with DHL (aOR 3.1, 95%CI 1.9-5.0), and negative correlates were history of drug treatment (aOR 0.6, 95%CI 0.4-1.0), receiving naloxone (aOR 0.6, 95% CI 0.4-1.0), and having made, sold or traded drugs in the past 3 months (aOR 0.4, 95% CI 0.2-0.9).

CONCLUSIONS

We report persisting concern about arrest during overdose events among street-based PWUD facing a complicated landscape of legal protections and liabilities. Findings demonstrate clear racial disparities of concern outside an urban centre, where impacts of policing on health are less studied, and present evidence that DHL may compromise overdose prevention efforts. Changes to drug policy and enforcement including police nonattendance at overdose scenes may be necessary to promote help-seeking among PWUD and reduce overdose fatalities.

Disparities in risk perception and low harm reduction services awareness, access, and utilization among young people with newly reported hepatitis C infections in California, 2018

Background

Newly reported hepatitis C virus (HCV) infections in California increased 50% among people 15–29 years of age between 2014 and 2016. National estimates suggest this increase was due to the opioid epidemic and associated increases in injection drug use. However, most of California’s 61 local health jurisdictions (LHJs) do not routinely investigate newly reported HCV infections, so these individuals’ risk factors for infection are not well understood. We sought to describe the demographics, risk behaviors, and utilization of harm reduction services in California’s fastest-rising age group of people with newly reported hepatitis C infections to support targeted HCV prevention and treatment strategies.

Methods

California Department of Public Health invited LHJs to participate in enhanced surveillance if they met criteria indicating heightened population risk for HCV infection among people ages 15–29. From June–December 2018, eight LHJs contacted newly reported HCV cases by phone using a structured questionnaire.

Results

Among 472 total HCV cases who met the inclusion criteria, 114 (24%) completed an interview. Twenty-seven percent of respondents (n = 31) had ever been incarcerated, of whom 29% received a tattoo/piercing and 39% injected drugs while incarcerated. Among people who injected drugs (PWID)—36% (n = 41) of all respondents—68% shared injection equipment and many lacked access to harm reduction services: 37% knew of or ever used a needle exchange and 44% ever needed naloxone during an overdose but did not have it. Heroin was the most frequently reported injected drug (n = 30), followed by methamphetamine (n = 18). Pre-diagnosis HCV risk perception varied significantly by PWID status and race/ethnicity: 76% of PWID vs. 8% of non-PWID (p < 0.001), and 44% of non-Hispanic White respondents vs. 22% of people of color (POC) respondents (p = 0.011), reported thinking they were at risk for HCV before diagnosis. Eighty-nine percent of all respondents reported having health insurance, although only two had taken HCV antiviral medications.

Conclusions

Among young people with HCV, we found limited pre-diagnosis HCV risk perception and access to harm reduction services, with racial/ethnic disparities. Interventions to increase harm reduction services awareness, access, and utilization among young PWID, especially young PWID of color, may be warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11492-3.

"I held on to the police's leg for mercy": Experiences of adversity, risk and harm among people who inject drugs during an anti-drug drive in Dhaka, Bangladesh

BACKGROUND

A number of countries across Asia have instituted "drug wars", aimed at eradicating drug supply and consumption. These wars often employ strategies like arbitrary arrest and detention, increased surveillance, harassment and sometimes extrajudicial killings. However, these measures have not been shown to effectively eliminate drug supply and consumption; rather they often predispose people who use drugs to increased risk and harm. Such a drug war was declared in the form of an anti-drug drive (ADD) in Bangladesh in 2018. This article examined the impact of the ADD on drug injecting activities and harm reduction service uptake among people who inject drugs (PWID).

METHODS

An ethnographic study was conducted in Dhaka, Bangladesh. Study participants included PWID, harm reduction service providers and other drug and alcohol experts. Data collection consisted of 2500 hours of observations, 25 in-depth interviews, five focus group discussions and 15 key informant interviews. Data were analysed using thematic analysis.

RESULTS

ADD operations and activities subjected PWID to multifaceted forms of violence and harassment including extrajudicial killings, which significantly affected drug procurement and drug using practices and led to increased needle and syringe sharing and a likely increase in HIV transmission. The gradual disappearance of established drug markets, alongside the emergence of new ones at alternate locations, resulted in the dislocation of PWID from outreach services and further increased risky injecting practices such as needle and syringe sharing between new and unfamiliar injecting partners. These harms were compounded by unpredictable drug supply and price increases stemming from the ADD, which in turn also increased needle and syringe sharing. Harm reduction outreach services were not able to adequately adapt to the volatile, dynamic and risky nature of the ADD.

CONCLUSION

The ADD not only precipitated risky injecting practices but also hindered the effective implementation of harm reduction outreach services and thus undermined public health. This warrants concerted efforts to nurture local evidence-based harm reduction approaches as opposed to punitive measures.

Intersectional structural vulnerability to abusive policing among people who inject drugs: A mixed methods assessment in California's central valley

BACKGROUND

Abusive and violent policing is an important determinant of health for people who inject drugs (PWID), which has been linked to structural vulnerability. However, further exploration of the intersectional nature of this vulnerability is warranted. California's Central Valley is a largely rural/suburban and politically conservative area, with high rates of injection drug use and overdose mortality, where rates of abusive policing of PWID have not been characterized.

METHODS

We assessed self-reported experiences of abusive policing using a sequential mixed-methods approach, consisting of n = 54 in-depth qualitative interviews followed by a respondent driven survey of n = 494 PWID. Qualitative conclusions were used to guide the development a novel quantitative framework to explore intersectional structural vulnerability, drawing on UpSet visualization and multivariable logistic regression.

RESULTS

Qualitative analysis suggests that abusive policing is not random or isolated; instead it can be understood in the context of routinized police harassment of PWID, which can escalate into physical or other forms of violence. These cycles are mediated by various forms of social disadvantage-often articulated through the frame of "looking like a drug user"-with deep connections to markers of race, class, gender, occupation and other elements of personal identity. Quantitative results confirm high frequency of abusive encounters with police, including physical violence (42%), verbal abuse (62%), sexual violence (9%), and the confiscation of new/unused syringes (39%). Females report higher rates of sexual violence and exploitation (aOR= 4.2; 95% CI: 2.1-9.0) and males report higher rates of physical violence (aOR=3.6; 95% CI: 2.4-5.6) and all other outcomes. Experiencing homelessness, having traded sex, and living in a rural zip code, are independently associated with numerous forms of police abuse. Intersectional analysis reveals clusters of individuals with highly elevated vulnerability, and in general, having a greater number of vulnerability factors was associated with increased odds of police abuse.

CONCLUSIONS

We find that structural vulnerability is linked-in a highly intersectional manner-with experiencing abusive police encounters among PWID in California's Central Valley. Monitoring, prevention, and response to deleterious law enforcement practices must be integrated into structural interventions to protect vulnerable groups. Reform is especially urgent in rural/suburban areas that are increasingly important focal points to reduce social and health harms associated with injection drug use.

Preferences and acceptability of law enforcement initiated referrals for people who inject drugs: a mixed methods analysis

BACKGROUND

Law enforcement officers (LEOs) come into frequent contact with people who inject drugs (PWID). Through service referrals, LEOs may facilitate PWID engagement in harm reduction, substance use treatment, and other health and supportive services. Little is known about PWID and LEO attitudes and concerns about service referrals, however. The objective of this mixed-methods study was to examine the alignment of service referral preferences and acceptability among PWID and LEOs in Tijuana, Mexico.

METHODS

We assessed service referral preferences and perceived likelihood of participation in health and social services, integrating data from structured questionnaires with 280 PWID and 306 LEOs, contextualized by semi-structured interviews and focus groups with 15 PWID and 17 LEOs enrolled in two parallel longitudinal cohorts in Tijuana, Mexico.

RESULTS

Among potential service referral options, both PWID (78%) and LEOs (88%) most frequently cited assistance with drug- and alcohol-use disorders. Over half of PWID and LEOs supported including harm reduction services such as syringe service programs, overdose prevention, and HIV testing. The majority of PWID supported LEO referrals to programs that addressed basic structural needs (e.g. personal care [62%], food assistance [61%], housing assistance [58%]). However, the proportion of LEOs (30-45%) who endorsed these service referrals was significantly lower (p <  0.01). Regarding referral acceptability, 71% of PWID reported they would be very likely or somewhat likely to make use of a referral compared to 94% of LEOs reporting that they thought PWID would always or sometimes utilize them. These results were echoed in the qualitative analysis, although practical barriers to referrals emerged, whereby PWID were less optimistic that they would utilize referrals compared to LEOs.

CONCLUSIONS

We identified strong support for LEO service referrals among both LEO and PWID respondents, with the highest preference for substance use treatment. LEO referral programs offer opportunities to deflect PWID contact with carceral systems while facilitating access to health and social services. However, appropriate investments and political will are needed to develop an evidence-based (integrated) service infrastructure.

Hepatitis C treatment uptake among people who inject drugs in the oral direct-acting antiviral era

BACKGROUND

Increased uptake of hepatitis C virus (HCV) treatment among people who inject drugs (PWID) will be critical to achieve HCV elimination goals. There are limited data on HCV treatment uptake among PWID recruited from community-based settings in the HCV direct-acting antiviral (DAA) era.

METHODS

We analysed data from PWID with HCV newly recruited into the Baltimore, Maryland-based AIDS Linked to the IntraVenous Experience (ALIVE) cohort between 2015 and 2018. We characterized the HCV care continuum and evaluated factors associated with HCV treatment uptake.

RESULTS

Of the 418 PWID with HCV, the median age was 49 years and most (88%) reported recent injection drug use (IDU). Overall, 23% had ever been evaluated by a provider for HCV treatment, 17% ever initiated DAA treatment and 13% were cured of HCV infection. Treatment uptake approximately doubled between 2015 and 2018 (13% to 26%, P = .01). In multivariable analyses, HIV infection (adjusted Odds Ratio [aOR] 2.5 [95% Confidence Interval (CI) 1.3, 4.8]), current employment (aOR 4.1 [CI 1.2, 14.4]), having a primary care provider (aOR 4.3 [CI 1.2, 14.9) and longer duration of IDU (aOR 1.3 [CI 1.1, 1.6]) were positively associated with HCV treatment. PWID with a lower annual income (≤$5000) were less likely to have initiated HCV treatment (aOR 0.5 [CI 0.3, 0.98]).

CONCLUSIONS

Although HCV treatment uptake among PWID in this community-based setting in the DAA era remains suboptimal, it is encouraging that treatment uptake has increased in recent years. Innovative strategies are needed to reach all PWID infected with HCV.

"An ethnographic exploration of factors that drive policing of street-based female sex workers in a U.S. setting - identifying opportunities for intervention"

Background

Building on a broader sociological discourse around policing approaches towards vulnerable populations, increasing public health and human rights evidence points to policing practices as a key health determinant, particularly among street-based sex workers. Despite the importance of policing as a structural health determinant, few studies have sought to understand the factors that underlie and shape harmful policing practices towards sex workers. This study therefore aimed to explore the drivers for policing attitudes and practices towards street-based cisgender female sex workers.

Methods

Drawing on ethnographic methods, 280 h of observations with police patrol and 10 stakeholder interviews with senior police leadership in Baltimore City, USA were carried out to better understand the drivers for policing strategies towards cisgender female sex workers. Analysis was data- and theory-driven, drawing on the concepts of police culture and complementary criminological and sociological literature that aided exploration of the influence of the ecological and structural environment on policing practices.

Results

Ecological factors at the structural (e.g., criminalization), organizational (e.g., violent crime control), community and individual level (e.g., stigmatizing attitudes) emerged as key to shaping individual police practices and attitudes towards cisgender female sex workers in this setting. Findings indicate senior police support for increased alignment with public health and human rights goals. However, the study highlights that interventions need to move beyond individual officer training and address the broader structural and organizational setting in which harmful police practices towards sex work operate.

Conclusions

A more in-depth understanding of the circumstances that drive law enforcement approaches to street-based sex work is critical to the collaborative design of interventions with police in different settings. In considering public health-police partnerships to address the rights and health of sex worker populations in the U.S. and elsewhere, this study supports existing calls for decriminalization of sex work, supported by institutional and policy reforms, neighborhood-level dialogues that shift the cultural landscape around sex work within both the police and larger community, and innovative individual-level police trainings.

Policing Practices and Risk of HIV Infection Among People Who Inject Drugs

Drug-law enforcement constitutes a structural determinant of health among people who inject drugs (PWID). Street encounters between police and PWID (e.g., syringe confiscation, physical assault) have been associated with health harms, but these relationships have not been systematically assessed. We conducted a systematic literature review to evaluate the contribution of policing to risk of human immunodeficiency virus (HIV) infection among PWID. We screened MEDLINE, sociological databases, and gray literature for studies published from 1981 to November 2018 that included estimates of HIV infection/risk behaviors and street policing encounters. We extracted and summarized quantitative findings from all eligible studies. We screened 8,201 abstracts, reviewed 175 full-text articles, and included 27 eligible analyses from 9 countries (Canada, China, India, Malaysia, Mexico, Russia, Thailand, Ukraine, and the United States). Heterogeneity in variable and endpoint selection precluded meta-analyses. In 5 (19%) studies, HIV infection among PWID was significantly associated with syringe confiscation, reluctance to buy/carry syringes for fear of police, rushed injection due to a police presence, fear of arrest, being arrested for planted drugs, and physical abuse. Twenty-one (78%) studies identified policing practices to be associated with HIV risk behaviors related to injection drug use (e.g., syringe-sharing, using a "shooting gallery"). In 9 (33%) studies, policing was associated with PWID avoidance of harm reduction services, including syringe exchange, methadone maintenance, and safe consumption facilities. Evidence suggests that policing shapes HIV risk among PWID, but lower-income settings are underrepresented. Curbing injection-related HIV risk necessitates additional structural interventions. Methodological harmonization could facilitate knowledge generation on the role of police as a determinant of population health.

The development of the Police Practices Scale: Understanding policing approaches towards street-based female sex workers in a U.S. City

Policing is an important structural determinant of HIV and other health risks faced by vulnerable populations, including people who sell sex and use drugs, though the role of routine police encounters is not well understood. Given the influence of policing on the risk environment of these groups, methods of measuring the aggregate impact of routine policing practices are urgently required. We developed and validated a novel, brief scale to measure police patrol practices (Police Practices Scale, PPS) among 250 street-based female sex workers (FSW) in Baltimore, Maryland, an urban setting with high levels of illegal drug activity. PPS items were developed from existing theory and ethnography with police and their encounters with FSW, and measured frequency of recent (past 3 months) police encounters. The 6-item scale was developed using exploratory factor analysis after examining the properties of the original 11 items. Confirmatory factor analysis was used to model the factor structure. A 2-factor model emerged, with law enforcement PPS items and police assistance PPS items loading on separate factors. Linear regression models were used to explore the relative distribution of these police encounters among FSW by modeling association with key socio-demographic and behavioral characteristics of the sample. Higher exposure to policing was observed among FSW who were homeless (β = 0.71, p = 0.037), in daily sex work (β = 1.32, p = 0.026), arrested in the past 12 months (β = 1.44, p<0.001) or injecting drugs in the past 3 months (β = 1.04, p<0.001). The PPS provides an important and novel contribution in measuring aggregate exposure to routine policing, though further validation is required. This scale could be used to evaluate the impact of policing on vulnerable populations’ health outcomes, including HIV risk.

"One guy goes to jail, two people are ready to take his spot": Perspectives on drug-induced homicide laws among incarcerated individuals

BACKGROUND

As overdose deaths have increased in the United States, some lawmakers have explored punitive, "supply-side" interventions aimed at reducing the supply of fentanyl. While a rationale of seeking to protect people who use drugs is often given to justify harsh sentences for fentanyl distribution, there is no research to our knowledge on perceptions of the effect of drug-induced homicide laws among people who use drugs.

METHODS

We conducted semi-structured, qualitative interviews with 40 people with opioid use disorder (OUD) who were enrolled in a medication for addiction treatment (MAT) program in a unified jail and prison system in Rhode Island on attitudes surrounding increased sentences for distribution of fentanyl, including recently enacted drug-induced homicide laws. Codes were developed using a generalized, inductive method and interviews analyzed in NVivo 12 after being coded by two coders.

RESULTS

Most participants stated that drug-induced homicide laws would not be an effective strategy to stem the overdose crisis. We identified key themes, including discussions surrounding the autonomy of people who use drugs, widespread fentanyl prevalence as a barrier to implementation of drug-induced homicide laws, discussions of mass incarceration as ineffective for addressing substance use disorders, feelings that further criminalization could lead to violence, criminalization as a justification for interpersonal loss, and intention as meaningful to categorizing an act as homicide.

CONCLUSIONS

Findings highlight the importance of centering the experiences of people with OUD in creating policies surrounding the overdose epidemic, potential unintended health consequences of drug-induced homicides laws such as deterrence from calling 911 and increased violence, and how drug-induced homicide laws may undermine advances made in expanding access to OUD treatment for people who are criminal justice-involved.

Barriers to using new needles encountered by rural Appalachian people who inject drugs: implications for needle exchange

Background

Using a new needle for every injection can reduce the spread of infectious disease among people who inject drugs (PWID). No previous study has examined new needle use barriers among PWIDs residing in the rural Appalachian part of the United States, an area currently in the midst of a heroin epidemic.

Objective

Therefore, our primary aim was to explore self-reported barriers to using a new needle by PWID attending a needle exchange program (NEP).

Methods

We conducted a cross-sectional survey of PWID attending two NEPs in rural West Virginia located in the heart of Central Appalachia. A convenience sample of PWID (n = 100) completed the Barriers to Using New Needles Questionnaire.

Results

The median number of barriers reported was 5 (range 0–19). Fear of arrest by police (72% of PWID “agreed” or “strongly agreed”) and difficulty with purchasing needles from a pharmacy (64% “agreed” or “strongly agreed”) were the most frequently cited barriers.

Conclusions/Importance

Congruent with previous findings from urban locations, in rural West Virginia, the ability of PWID to use a new needle obtained from a needle exchange for every injection may be compromised by fear of arrest. In addition, pharmacy sales of new needles to PWID may be blunted by an absence of explicit laws mandating nonprescription sales. Future studies should explore interventions that align the public health goals of NEPs with the occupational safety of law enforcement and health outreach goals of pharmacists.

Electronic supplementary material

The online version of this article (10.1186/s12954-019-0295-5) contains supplementary material, which is available to authorized users.

Why are some people who have received overdose education and naloxone reticent to call Emergency Medical Services in the event of overdose?

BACKGROUND

Overdose Education and Naloxone Distribution (OEND) training for persons who inject drugs (PWID) underlines the importance of summoning emergency medical services (EMS). To encourage PWID to do so, Colorado enacted a Good Samaritan law providing limited immunity from prosecution for possession of a controlled substance and/or drug paraphernalia to the overdose victim and the witnesses who in good faith provide emergency assistance. This paper examines the law's influence by describing OEND trained PWIDs' experience reversing overdoses and their decision about calling for EMS support.

METHODS

Findings from two complementary studies, a qualitative study based on semi-structured interviews with OEND trained PWID who had reversed one or more overdoses, and an on-going fieldwork-based project examining PWIDs' self-identified health concerns were triangulated to describe and explain participants' decision to call for EMS.

RESULTS

In most overdose reversals described, no EMS call was made. Participants reported several reasons for not doing so. Most frequent was the fear that despite the Good Samaritan law, a police response would result in arrest of the victim and/or witness for outstanding warrants, or sentence violations. Fears were based on individual and collective experience, and reinforced by the city of Denver's aggressive approach to managing homelessness through increased enforcement of misdemeanors and the imposition of more recent ordinances, including a camping ban, to control space. The city's homeless crisis was reflected as well in the concern expressed by housed PWID that an EMS intervention would jeopardize their public housing.

CONCLUSION

Results suggest that the immunity provided by the Good Samaritan law does not address PWIDs' fear that their current legal status as well as the victim's will result in arrest and incarceration. As currently conceived, the Good Samaritan law does not provide immunity for PWIDs' already enmeshed in the criminal justice system, or PWID fearful of losing their housing.