Human Immunodeficiency Virus Testing Among People Who Inject Drugs in Rural West Virginia

BACKGROUND

Limited research exists on factors associated with human immunodeficiency virus (HIV) testing among people who inject drugs (PWID) in rural America. The purpose of this research is to identify factors associated with rural PWID in Appalachia having not been tested for HIV in the past year.

METHODS

Cross-sectional data (n = 408) from a 2018 PWID population estimation study in West Virginia were used to examine factors associated with PWID having not been tested for HIV in the past year.

RESULTS

Most participants identified as male (61%), white, non-Hispanic (84%), and reported having recently injected heroin (81%) and/or crystal methamphetamine (71%). Most (64%) reported having been tested for HIV in the past year, 17% reported having been tested but not in the past year, and 19% reported never having been tested. In multivariable analysis, not having been in a drug treatment program in the past year was associated with PWID not having been tested for HIV in the past year (adjusted prevalence ratio, 1.430; 95% confidence interval, 1.080-1.894).

CONCLUSIONS

Drug treatment programs may be important venues for rural PWID to access HIV testing; however, testing services should be offered at multiple venues as most PWID had not engaged in drug treatment in the past year.

Increased risk of HIV and other drug-related harms associated with injecting in public places: national bio-behavioural survey of people who inject drugs

BACKGROUND

Whilst injecting drugs in public places is considered a proxy for high risk behaviour among people who inject drugs (PWID), studies quantifying its relationship with multiple drug-related harms are lacking and none have examined this in the context of an ongoing HIV outbreak (located in Glasgow, Scotland). We aimed to: 1) estimate the prevalence of public injecting in Scotland and associated risk factors; and 2) estimate the association between public injecting and HIV, current HCV, overdose, and skin and soft tissue infections (SSTI).

METHODS

Cross-sectional, bio-behavioural survey (including dried blood spot testing to determine HIV and HCV infection) of 1469 current PWID (injected in last 6 months) recruited by independent interviewers from 139 harm reduction services across Scotland during 2017-18. Primary outcomes were: injecting in a public place (yes/no); HIV infection; current HCV infection; self-reported overdose in the last year (yes/no) and SSTI the last year (yes/no). Multi-variable logistic regression was used to determine factors associated with public injecting and to estimate the association between public injecting and drug-related harms (HIV, current HCV, overdose and SSTI).

RESULTS

Prevalence of public injecting was 16% overall in Scotland and 47% in Glasgow city centre. Factors associated with increased odds of public injecting were: recruitment in Glasgow city centre (aOR=5.45, 95% CI 3.48-8.54, p<0.001), homelessness (aOR=3.68, 95% CI 2.61-5.19, p<0.001), high alcohol consumption (aOR=2.42, 95% CI 1.69-3.44, p<0.001), high injection frequency (≥4 per day) (aOR=3.16, 95% CI 1.93-5.18, p<0.001) and cocaine injecting (aOR=1.46, 95% CI 1.00 to 2.13, p = 0.046). Odds were lower for those receiving opiate substitution therapy (OST) (aOR=0.37, 95% CI 0.24 to 0.56, p<0.001) and older age (per year increase) (aOR=0.97, 95% CI 0.95 to 0.99, p = 0.013). Public injecting was associated with an increased risk of HIV infection (aOR=2.11, 95% CI 1.13-3.92, p = 0.019), current HCV infection (aOR=1.49, 95% CI 1.01-2.19, p = 0.043), overdose (aOR=1.59, 95% CI 1.27-2.01, p<0.001) and SSTI (aOR=1.42, 95% CI 1.17-1.73, p<0.001).

CONCLUSIONS

These findings highlight the need to address the additional harms observed among people who inject in public places and provide evidence to inform proposals in the UK and elsewhere to introduce facilities that offer safer drug consumption environments.

Safe and unsafe spaces: Non-fatal overdose, arrest, and receptive syringe sharing among people who inject drugs in public and semi-public spaces in Baltimore City

The spaces in which drug use occurs constitutes a key aspect of the "risk environment" of people who inject drugs (PWID). We aimed to add nuance to the characterization of "safe" and "unsafe" spaces in PWID's environments to further understand how these spaces amplify the risk of morbidities associated with injection drug use. PWID were recruited through the Baltimore City syringe service program and through peer referral. Participants completed a socio-behavioral survey. Multivariable logistic regression was used to identify associations between utilization of public, semi-public and private spaces with arrest, non-fatal overdose, and receptive syringe sharing. The sample of PWID (N = 283) was mostly 45 years and older (54%), male (69%), Black (55%), and heroin users (96%). Compared to PWID who primarily used private settings, the adjusted odds of recent overdose were greater among PWID who mostly used semi-public and public locations to inject drugs. We also found independent associations between arrest and semi-public spaces, and between receptive syringe sharing and public spaces (all p < 0.05). This study highlights the need for safe spaces where PWID can reduce their risk of overdose, likelihood of arrest and blood-borne diseases, and the dual potential of the environment in promoting health and risk.

Predictors of HIV Risk Behavior in Iranian Women Who Inject Drugs

This study aimed to investigate predictors of drug-related HIV risk behaviors among women who inject drugs. A total of 163 women were recruited from harm-reduction-oriented drug-treatment centers in Tehran, Iran. Each completed a set of measures that included the Risk Behavior Assessment, Beck Depression Inventory–Second Edition, Revised Self-Efficacy Scale, and Peer Group Beliefs Regarding HIV-related Risk Behaviors Scale. The results indicated that past attempts to abstain from drugs, using methadone maintenance treatment programs, and acceptance of peers’ risky norms were significant predisposing, enabling, and reinforcing predictors of frequency of injection, respectively. Furthermore, predictors of frequency of sharing injection paraphernalia included purchasing drugs jointly with other drug users and peers’ norms conforming injecting drug use behaviors. Harm reduction services that take into consideration cultural and peer norms, as well as the development and implementation of HIV prevention programs, are likely to reduce drug-related HIV risk behaviors in women who inject drugs.

Drug use in business bathrooms: An exploratory study of manager encounters in New York City

BACKGROUND

Though public bathroom drug injection has been documented from the perspective of people who inject drugs, no research has explored the experiences of the business managers who oversee their business bathrooms and respond to drug use. These managers, by default, are first-responders in the event of a drug overdose and thus of intrinsic interest during the current epidemic of opioid-related overdoses in the United States. This exploratory study assists in elucidating the experiences that New York City business managers have with people who inject drugs, their paraphernalia, and their overdoses.

METHODS

A survey instrument was designed to collect data on manager encounters with drug use occurring in their business bathrooms. Recruitment was guided by convenience and purposive approaches.

RESULTS

More than half of managers interviewed (58%, n=50/86) encountered drug use in their business bathrooms, more than a third (34%) of these managers also found syringes, and the vast majority (90%) of managers had received no overdose recognition or naloxone training. Seven managers encountered unresponsive individuals who required emergency assistance.

CONCLUSION

The results from this study underscore the need for additional research on the experiences that community stakeholders have with public injection as well as educational outreach efforts among business managers. This research also suggests that there is need for a national dialogue about potential interventions, including expanded overdose recognition and naloxone training and supervised injection facilities (SIF)/drug consumption rooms (DCR), that could reduce public injection and its associated health risks.

Vulnerability, Social Networks, Sites, and Selling as Predictors of Drug use among Urban African American and Puerto Rican Emerging Adults

This paper reviews the results of research conducted with African American and Puerto Rican emerging adults between the ages of 18 and 25 whose life experiences increase vulnerability to drug use and pose some significant challenges in achieving milestones widely recognized as important in achieving adult status. Literature on drug use in adolescence suggests that personal vulnerability accounts for most experimental and problem drug use. Included in the vulnerability construct are religiosity, perceived risk, social influence, drug access, social norms, and social risk defined primarily as exposure to various forms of violence. This study shows that personal vulnerability explains only some of the variance in use and predicts variance differently with respect to different specific drugs and polydrug use. Further, it argues that additional contextual factors including social networks, party and club attendance, and drug selling activities, all typical of emerging adulthood and urban lifestyle, are also important factors in enhancing potential for accelerated drug use during this developmental period. Finally, it notes that the consequences of these activities have implications for further economic and social marginalization of urban, multiethnic low income emerging adults.

Crack Use Sites and HIV Risk in El Salvador

“The Social Context of Crack Use and Related Sexual Risk in El Salvador” study was designed to increase knowledge of the locations where drugs are consumed in urban San Salvador, the social dynamics within such sites, and their implications for HIV risk and prevention efforts. In-depth interviews with crack smokers reveal several different types of sites where drugs are consumed and risky sex may occur including trances (generally houses where crack is sold and consumed), brothels, motels, drug users' own homes, abandoned buildings, the street, parks, or cantinas. These range from private sites, where site “gatekeepers” strictly control access, to public sites where access is more open. However, even in more public sites there is considerable social interaction, rules regarding site usage, and in some cases gatekeeper control of the site. Social dynamics already normative at drug use sites may support a site-based, peer-led intervention approach.

The Risk Avoidance Partnership: Training Active Drug Users as Peer Health Advocates

Efforts have expanded to create AIDS prevention programs for drug users that consider the social context and interpersonal relationships within which risky practices take place. The Risk Avoidance Partnership (RAP) project is designed to train active drug users as peer/public health advocates (PHAs) to bring a structured, peer-led intervention into the sites where they and their drug-using social networks use illicit drugs. The RAP peer health advocacy training curriculum and peer-led intervention promote harm reduction among drug users and support drug-user organization to reduce infectious disease and other harm in the context of injection drug use, crack cocaine use, and sexual activity. Initial findings suggest that RAP PHAs perceive a significant positive role change in themselves while conducting health advocacy work and willingly and successfully carry the peer-led intervention into locations of high-risk drug activity to deliver it to their peers even in the absence of project staff support.

Reciprocity and Exploitation: Social Dynamics in Private Drug use Sites

The Study of High Risk Drug Use Settings for HIV Prevention was designed to increase knowledge of urban social contexts in which drugs are consumed. In this article, we use ethnographic methods to focus on one subtype of drug use setting in Hartford, Connecticut, private sites with gatekeepers. We analyze the social interactions of drug users who use these sites to explore the contradictory social processes that sometimes facilitate and at other times impede intervention efforts. Gatekeepers are often interested in attracting customers to their “business” and therefore may be willing to provide ongoing site-based HIV prevention education and materials. On the other hand, exploitative business exchanges contradict ideals of reciprocity and may undermine trust between gatekeepers and drug users impeding harm reduction efforts. Further, being the gatekeeper of a drug use site often accelerates gatekeepers' addictions, making it difficult for them to implement harm reduction strategies.

Exploration of a crack use setting and its impact on drug users' risky drug use and sexual behaviors: the case of piaules in a Montréal neighborhood

From July 2011, a one-year study based on ethnographic methodology was carried out in "crack houses" in the neighborhood of Hochelaga-Maisonneuve in Montréal, Canada. The study aimed to explore the operational style of a specific indoor drug use setting and its impact on users' risky sexual and drug use behaviors in a context of drug market change. A thematic analysis of observational and interview notes was conducted. This study stresses the importance to examine the role of environmental factors in relation to crack smoking's health-related risks and to complement individual-based interventions with structural strategies. The study's limitations are noted.

Capturing illicit drug use where and when it happens: an ecological momentary assessment of the social, physical and activity environment of using versus craving illicit drugs

AIMS

To understand the environmental and contextual influences of illicit cocaine and heroin use and craving using mobile health (mHealth) methods.

DESIGN

Interactive mHealth methods of ecological momentary assessment (EMA) were utilized in the Exposure Assessment in Current Time (EXACT) study to assess drug use and craving among urban drug users in real time. Participants were provided with mobile devices and asked to self-report every time they either craved (without using) or used heroin or cocaine for 30 days from November 2008 through May 2013.

SETTING

Baltimore, MD, USA.

PARTICIPANTS

A total of 109 participants from the AIDS Linked to the IntraVenous Experience (ALIVE) study.

MEASUREMENTS

For each drug use or craving event, participants answered questions concerning their drug use, current mood and their social, physical and activity environments. Odds ratios (OR) of drug use versus craving were obtained from logistic regression models with generalized estimating equations of all reported events.

FINDINGS

Participants were a median of 48.5 years old, 90% African American, 52% male and 59% HIV-infected. Participants were significantly more likely to report use rather than craving drugs if they were with someone who was using drugs [adjusted odds ratio (aOR) = 1.45, 95% confidence interval (CI) = 1.13, 1.86), in an abandoned space (aOR = 6.65, 95% CI = 1.78, 24.84) or walking/wandering (aOR = 1.68, 95% CI = 1.11, 2.54). Craving drugs was associated with being with a child (aOR = 0.26, 95% CI = 0.12, 0.59), eating (aOR = 0.54, 95% CI = 0.34, 0.85) or being at the doctor's office (aOR = 0.31, 95% CI = 0.12, 0.80).

CONCLUSIONS

There are distinct drug using and craving environments among urban drug users, which may provide a framework for developing real-time context-sensitive interventions.

A social network approach to demonstrate the diffusion and change process of intervention from peer health advocates to the drug using community

Project RAP (Risk Avoidance Partnership) trained 112 active drug users to become peer health advocates (PHAs). Six months after baseline survey (N(bl) = 522), 91.6% of PHAs and 56.6% of community drug users adopted the RAP innovation of giving peer intervention, and 59.5% of all participants (N(6m) = 367) were exposed to RAP innovation. Sociometric network analysis shows that adoption of and exposure to RAP innovation was associated with proximity to a PHA or a highly active interventionist (HAI), being directly linked to multiple PHAs/HAIs, and being located in a network sector where multiple PHAs/HAIs were clustered. RAP innovation has diffused into the Hartford drug-using community.

The relationship between community structural characteristics, the context of crack use, and HIV risk behaviors in San Salvador, El Salvador

This paper explores community structural factors in different low-income communities in the San Salvador, El Salvador, that account for differences in the social context in which crack is used and HIV risk behaviors among crack users. Results suggest that both more distal (type of low-income community, level of violent crime, and poverty) and proximate structural factors (type of site where drugs are used, and whether drugs are used within or outside of community of residence) influence HIV risk behaviors among drug users. Additionally, our results suggest that community structural factors influence the historical and geographic variation in drug use sites.

Drug use patterns in the presence of crack in downtown Montréal

INTRODUCTION AND AIMS

A study was undertaken to verify reports of an increasing presence of crack in downtown Montréal, and to investigate the influence of crack availability on current drug use patterns among street-based cocaine users.

DESIGN AND METHODS

The study combined both qualitative and quantitative methods. These included long-term intensive participant observation carried out by an ethnographer familiar with the field and a survey. The ethnographic component involved observations and unstructured interviews with 64 street-based cocaine users. Sampling was based on a combination of snowballing and purposeful recruitment methods. For the survey, structured interviews were conducted with a convenience sample of 387 cocaine users attending HIV/HCV prevention programs, downtown Montréal.

RESULTS

A gradual shift has occurred in the last 10 years, with the crack street market overtaking the powder cocaine street market. Although the data pointed to an increase in crack smoking, 54.5% of survey participants both smoked and injected cocaine. Drug market forces were major contributing factors to the observed modes of cocaine consumption. While the study focused primarily on cocaine users, it became apparent from the ethnographic fieldwork that prescription opioids (POs) were very present on the streets. According to the survey, 52.7% of participants consumed opioids, essentially POs, with 88% of them injecting these drugs.

DISCUSSION AND CONCLUSIONS

Despite the increased availability of crack, injection is still present among cocaine users due at least in part to the concurrent increasing popularity of POs.

Altruism and peer-led HIV prevention targeting heroin and cocaine users

Peer-delivered HIV prevention and intervention programs play an important role in halting the spread of HIV. Rigorous scientific analysis of the aforementioned programs has focused on the immediate reduction of risk-related behaviors among the target populations. In our longitudinal study of the Risk Avoidance Partnership Peer Intervention for HIV, we assessed the long-term behavioral effects of a peer-led HIV intervention project with active drug users. Initial analysis of the qualitative data highlights the role of altruism as a motivator in sustaining peer educators beyond the immediate goals of the project. We contend that altruism found in volunteers is an important factor in maintaining long-term participation in HIV intervention programs and initiatives using peer educators.

Structural factors influencing patterns of drug selling and use and HIV risk in the San Salvador metropolitan area

This article explores differences in the social context in which crack sales and use and HIV risk take place in seven low-income communities in San Salvador, and structural factors that may influence these differences. The organization of drug selling varied among the communities on a number of dimensions including: whether drug sales were open or closed systems; the type of drug-selling site; and the participation of drug users in drug-distribution roles. Drug-use sites also varied according to whether crack was used in private, semiprivate, or public spaces, and whether individuals used drugs alone or with other drug users. Three patterns of drug use and selling were identified based on the dimensions outlined above. Structural factors that influenced these patterns included the geographic location of the communities, their physical layout, gang involvement in drug sales, and police surveillance. Implications for HIV risk and prevention are explored for each pattern.

Changing drug users' risk environments: peer health advocates as multi-level community change agents

Peer delivered, social oriented HIV prevention intervention designs are increasingly popular for addressing broader contexts of health risk beyond a focus on individual factors. Such interventions have the potential to affect multiple social levels of risk and change, including at the individual, network, and community levels, and reflect social ecological principles of interaction across social levels over time. The iterative and feedback dynamic generated by this multi-level effect increases the likelihood for sustained health improvement initiated by those trained to deliver the peer intervention. The Risk Avoidance Partnership (RAP), conducted with heroin and cocaine/crack users in Hartford, Connecticut, exemplified this intervention design and illustrated the multi-level effect on drug users' risk and harm reduction at the individual level, the social network level, and the larger community level. Implications of the RAP program for designing effective prevention programs and for analyzing long-term change to reduce HIV transmission among high-risk groups are discussed from this ecological and multi-level intervention perspective.

The relationship between housing status and HIV risk among active drug users: a qualitative analysis

This paper examines the relationship between housing status and HIV risk using longitudinal, qualitative data collected in 2004-2005, from a purposeful sample of 65 active drug users in a variety of housed and homeless situations in Hartford, Connecticut. These data were supplemented with observations and in-depth interviews regarding drug use behavior collected in 2001-2005 to evaluate a peer-led HIV prevention intervention. Data reveal differences in social context within and among different housing statuses that affect HIV risk or protective behaviors including the ability to carry drug paraphernalia and HIV prevention materials, the amount of drugs in the immediate environment, access to subsidized and supportive housing, and relationships with those with whom drug users live. Policy implications of the findings, limitations to the data, and future research are discussed.

Outcomes of a peer HIV prevention program with injection drug and crack users: the Risk Avoidance Partnership

The Risk Avoidance Partnership (RAP) Project conducted in Hartford, Connecticut, tested a program to train active drug injectors and crack cocaine users as "Peer Health Advocates" (PHAs) to deliver a modular HIV, hepatitis, and STI prevention intervention to hard-to-reach drug users in their networks and others in the city. The intervention was designed to diffuse health promotion and risk-reduction interventions by supporting PHAs to model prevention practices and deliver risk- and harm-reduction materials and information. We compared change in behaviors and attitudes between baseline and 6-month follow-up of 112 primarily African-American and Latino PHAs, 223 of their drug-user network contact referrals, and 118 other study recruits (total n = 523). Results indicated significant HIV risk reduction among all study participants, associated with significant health advocacy action conducted by PHAs, and a relationship between exposure to the RAP peer-delivered intervention and risk reduction among all study groups. Findings suggest that active drug users' engagement in peer health advocacy can set in motion a feedback and diffusion process that supports both the continued work of the PHAs and the adoption of harm reduction and mimicking of health advocacy by their peers.

Accessing care for injection-related infections through a medically supervised injecting facility: a qualitative study

Injection drug users (IDU) experience complex barriers to accessing primary medical care which may result in over reliance on emergency health services. Supervised injecting facilities (SIF) aim to address HIV and overdose risks, as well as improve access to primary medical care among IDU. This study sought to investigate IDU perspectives regarding the impact of SIF on access to care and treatment of injection-related infections. Semi-structured qualitative interviews were conducted with 50 individuals recruited from a cohort of SIF users known as the Scientific Evaluation of Supervised Injecting (SEOSI). Audio-recorded interviews were transcribed verbatim and a thematic analysis was conducted. IDU narratives indicate the availability of on-site nursing attention at the SIF facilitated uptake of health services. IDU reported that the facility provided assessment and care of injection-related infections, as well as enhanced access to off-site medical services. The presence of professional nursing personnel within a sanctioned drug consumption setting serves to address social and structural barriers that often impede IDU access to health care. This study emphasizes that the facility enables contact with the healthcare system and thereby helps to facilitate the management of injection-related infections.

The perspectives of injection drug users regarding safer injecting education delivered through a supervised injecting facility

Background

Unsafe injection practices are prevalent among injection drug users (IDU) and have resulted in numerous forms of drug-related harm including HIV/HCV transmission and other bacterial and viral infections. North America's first supervised injection facility (SIF) was established in Vancouver in order to address injection-related harms among IDU. This study sought to examine injection drug users' experiences receiving safer injecting education in the context of a SIF.

Methods

Semi-structured qualitative interviews were conducted with 50 individuals recruited from a cohort of SIF users known as the Scientific Evaluation of Supervised Injection (SEOSI) cohort. Audio recorded interviews elicited IDU perspectives regarding the provision of safer injecting education within the context of a SIF. Interviews were transcribed verbatim and a thematic analysis was conducted.

Results

Participant narratives indicate that significant gaps in knowledge regarding safer injecting practices exist among local IDU, and that these knowledge deficits result in unsafe injecting practices and negative health outcomes. However, IDU perspectives reveal that the SIF allows clients to identify and address these gaps in knowledge through a number of mechanisms that are unique to this facility, including targeted educational messaging that occurs as a part of the drug use cycle and not outside of it, in situ demonstration of safer injecting techniques that takes place the moment a client is experiencing difficulties, and enhanced opportunities to seek help from 'expert' healthcare professionals. Importantly, study participants indicated that the overall environment of the SIF promotes the adoption of safer injecting practices over time, both within and outside of the facility.

Conclusion

We conclude that the SIF has been particularly effective in transmitting educational messages targeting unsafe and unhygienic injection practices to a population of active IDU. Consistent with previous work, results of this study indicate that SIFs represent a unique 'micro-environment' that can facilitate the reduction of numerous drug related harms.

Perceived risk, peer influences, and injection partner type predict receptive syringe sharing among young adult injection drug users in five U.S. cities

OBJECTIVES

This study examined risk factors for receptive syringe sharing (RSS) during illicit drug injection by persons 15-30 years old in five U.S. cities.

METHODS

Participants were recruited through street outreach and respondent-driven referrals in Baltimore, Chicago, Los Angeles, New York, and Seattle between May 2002 and January 2004. Surveys of drug use, sexual behaviors, and correlates were administered through audio computer-assisted self-interviews at baseline and, for the subset of participants who enrolled in an HIV/HCV prevention intervention trial, at 3-months and 6-months post-baseline. The proportions of injections involving RSS at baseline and at follow-up were used as outcomes in multivariate models that adjusted for intervention effects.

RESULTS

At baseline, 54% of 3128 participants reported RSS in the past 3 months. RSS decreased to 21% at 6-months post-baseline for the combined trial arms. Participants were more likely to report RSS if they perceived that their peers were not against RSS and if they injected with sex partners. Lower levels of perceived risk of infection with HIV (baseline, p<.001) or HCV (follow-up, p<.001) through RSS were also significant predictors of greater RSS.

CONCLUSIONS

Perceived risks, peer influences, and type of injection partner were robust predictors of RSS. Perceived risks and peer influences are particularly amenable to intervention efforts that may prevent RSS in this age group.

Unofficial policy: access to housing, housing information and social services among homeless drug users in Hartford, Connecticut

BACKGROUND

Much research has shown that the homeless have higher rates of substance abuse problems than housed populations and that substance abuse increases individuals' vulnerability to homelessness. However, the effects of housing policies on drug users' access to housing have been understudied to date. This paper will look at the "unofficial" housing policies that affect drug users' access to housing.

METHODS

Qualitative interviews were conducted with 65 active users of heroin and cocaine at baseline, 3 and 6 months. Participants were purposively sampled to reflect a variety of housing statuses including homeless on the streets, in shelters, "doubled-up" with family or friends, or permanently housed in subsidized, unsubsidized or supportive housing. Key informant interviews and two focus group interviews were conducted with 15 housing caseworkers. Data were analyzed to explore the processes by which drug users receive information about different housing subsidies and welfare benefits, and their experiences in applying for these.

RESULTS

A number of unofficial policy mechanisms limit drug users' access to housing, information and services, including limited outreach to non-shelter using homeless regarding housing programs, service provider priorities, and service provider discretion in processing applications and providing services.

CONCLUSION

Unofficial policy, i.e. the mechanisms used by caseworkers to ration scarce housing resources, is as important as official housing policies in limiting drug users' access to housing. Drug users' descriptions of their experiences working with caseworkers to obtain permanent, affordable housing, provide insights as to how access to supportive and subsidized housing can be improved for this population.

Public perceptions of public drug use in four UK urban sites

At the local level, proposals for regeneration are often put forwards as solutions to social and health problems associated with poverty, drug use and crime. Debates about establishing drug consumption rooms (DCRs) are also concerned with providing services to drug use-related environmental problems. However, conflicts may exist between interventions aiming to reduce drug-related harm to discriminated communities and wider regeneration aims to support corporate development. This commentary draws on data from a rapid assessment study which examined the experience of 100 people living and working in four British neighbourhoods where public drug use is common. Primary data were gathered in semi-structured interviews and during local walk-about tours. These were triangulated with secondary sources of information on local policies and indicators of public drug use. Public awareness of the impacts of environmental regeneration projects including loss of amenity, 'fortress mentality' and displacement effects were found at all study sites. However, comparative area analyses suggest that whether communities welcome these changes depends on how close-to-home they perceive the competitions for urban space. Cohesive communities may direct environmental regeneration in pursuit of general social improvement rather than the narrower aims of either DCRs or corporate developers.

Public injecting and the need for 'safer environment interventions' in the reduction of drug-related harm

BACKGROUND

One key structural dimension in the distribution of drug-related harm associated with injecting drug use is the injecting environment. Epidemiological evidence associates elevated blood-borne viral risk with injecting in 'public' and 'semipublic' environments. Yet the quality of evidence on public injecting and related viral risk is variable, and is lacking in many countries such as the United Kingdom.

AIM

This commentary considers the micro-injecting environment as a critical dimension of risk, exploring the need for 'safer injecting environment interventions'.

METHODS

We draw upon published research evidence and qualitative case examples.

RESULTS

We note the limits in epidemiological evidence on public injecting and emphasize the need for ethnographic research to determine the 'social relations' of how drug users and risk practices interact with injecting environments. We identify three main forms of 'safer environment intervention': purpose-built drug consumption rooms; interventions within existing spatial relations; and spatial programming and urban design. While drug consumption rooms find evidence-based support, they are not a panacea. We emphasize the potential of interventions embedded within existing spatial and social relations. These include low-cost pragmatic interventions enhancing facilities and safety at public and semipublic injecting sites and, primarily, peer-based interventions, including peer-supervised injecting sites. We caution against spatial programming and urban design interventions which can cause the displacement of socially marginalized populations and the redistribution of harm.

CONCLUSIONS

Public health interventions in the addictions field have in the past focused upon individual behavioural change at the cost of social interventions and environmental change. We wish to focus greater attention on reducing risks related to public injecting and encourage greater debate on 'safer environment interventions' in harm reduction.

Building interdisciplinary/intersectoral research partnerships for community-based mental health research with older minority adults

Community-based research often brings investigators from different disciplinary backgrounds together with community representatives to conduct research on topics of mutual concern. This paper describes a case example that illustrates an interdisciplinary/intersectoral study of depression and barriers to mental health care among older adults and illustrate the factors central to implementing a successful research partnership. It will address the following conditions that facilitate and challenge interdisciplinary/intersectoral research: (1) achieving commonality of purpose in study design and research and referral approaches; (2) ensuring the ability to develop, field-test and implement psychometrically rigorous and culturally and qualitatively appropriate instruments; (3) building effective management structures for interdisciplinary/intersectoral research partnerships; and (4) identifying, training and supporting qualified researchers to carry out a mental health study with older ethnically diverse adults. The paper concludes with strengths and limitations of the approach.

Place and space: the where and why of drug-use location among rural African American women

Increasing drug use among rural African American women and its effect on children warrants investigation. This article describes drug-use locations of rural African American women who use cocaine and construct their lives to conceal it from children. During 4 years, a 30-respondent ethnography was conducted. Data from in-depth interviews and field notes were analyzed for recurrent themes and patterns of drug-use location using NVivo. Most respondents with children used most often outside their households. One third (n = 10) used within their households when children were away or in designated spaces off limits to children. More respondents (n = 11) without children at home used in non-designated spaces; in contrast, few respondents (n = 2) with children at home used in non-designated spaces within the household. Most respondents thought they were successful at concealing their cocaine use. Implications for choice of space and place of drug use for themselves and their children are discussed.

Times and places: Process evaluation of a peer-led HIV prevention intervention

Here we present results from a process evaluation of a peer-led HIV prevention intervention. The Risk Avoidance Partnership, conducted from 2001 to 2005, trained active drug users to be peer health advocates (PHAs) to provide harm reduction materials and information to their peers. Results indicate that PHAs actively conducted harm reduction outreach both when partnered with staff and on their own time. Although PHAs conducted most of their outreach in public locations, they also provided drug users with harm reduction materials at critical moments in places where HIV risky behaviors were likely to occur. PHAs were credible and trusted sources of information to their drug-using peers who sought PHAs out for HIV prevention materials. Process evaluations of successful HIV prevention interventions are necessary to understand how and why such interventions work for further intervention refinement.

The social structural production of HIV risk among injecting drug users

There is increasing appreciation of the need to understand how social and structural factors shape HIV risk. Drawing on a review of recently published literature, we seek to describe the social structural production of HIV risk associated with injecting drug use. We adopt an inclusive definition of the HIV 'risk environment' as the space, whether social or physical, in which a variety of factors exogenous to the individual interact to increase vulnerability to HIV. We identify the following factors as critical in the social structural production of HIV risk associated with drug injecting: cross-border trade and transport links; population movement and mixing; urban or neighbourhood deprivation and disadvantage; specific injecting environments (including shooting galleries and prisons); the role of peer groups and social networks; the relevance of 'social capital' at the level of networks, communities and neighbourhoods; the role of macro-social change and political or economic transition; political, social and economic inequities in relation to ethnicity, gender and sexuality; the role of social stigma and discrimination in reproducing inequity and vulnerability; the role of policies, laws and policing; and the role of complex emergencies such as armed conflict and natural disasters. We argue that the HIV risk environment is a product of interplay in which social and structural factors intermingle but where political-economic factors may play a predominant role. We therefore emphasise that much of the most needed 'structural HIV prevention' is unavoidably political in that it calls for community actions and structural changes within a broad framework concerned to alleviate inequity in health, welfare and human rights.

Drug sharing among heroin networks: implications for HIV and hepatitis B and C prevention

Qualitative and quantitative findings from the baseline survey of a longitudinal, socially-focused blood-borne disease intervention study among 611 heroin IDU in Denver indicate that high risk injection practices-the sharing of contaminated drug solution in particular-often occur as a consequence of how heroin is obtained, the quantity obtained and the setting where it is injected. Contamination occurs if a contaminated syringe is used to liquefy and apportion the shared drug. In our cohort of 304 heroin injecting networks there was at least one member who, when asked to describe their last injection, reported dividing the drug as a liquid (82%), using a reservoir of water that syringes had been rinsed in to mix drugs (67%), using a common cooker (86%)-a proxy for drug sharing-and beating a shared cotton filter (58%). In contrast, only 22% reported syringe sharing. Variables associated with various injection practices included location of the last injection episode, quantity of drug injected, dope sickness, and years injecting. When compared to those who injected in a safe setting, those in an unsafe location had almost three times the odds (OR = 2.9; 95% CI: 1.9, 4.6) of being part of an injection episode where there was cooker sharing; and the smaller the quantity of heroin (< or =1/4 gram v. > 1/4 gram) present at the episode, the greater the odds that cooker sharing occurred (OR = 1.8; 95% CI: 1.2, 2.6). Use of a used, unbleached syringe to prepare shared drugs had twice the odds of occurring in "unsafe" v. safe settings (OR = 2.2; 95% CI: 1.3, 4.0) and in episodes in which a participant was dopesick (OR = 2.1; 95% CI: 1.2, 3.6). In summary, risky injection practices occur within an injection process that is, in part, a response to a structurally imposed risk environment. Lessening the blood-borne disease risks embedded within this process requires interventions designed to mitigate the environmental factors that influence it, including syringe accessibility, law enforcement strategies and the settings where IDU inject drugs.