Women's injection drug practices in their own words: a qualitative study

Overdose Experiences Among a Sample of Women in Jail with Opioid Use Disorder

Background:  Previous non-fatal overdose may increase risk of overdose fatality for women reentering the community following incarceration, but pre-incarceration overdose experiences are understudied. This study describes the prevalence and correlates of non-fatal overdose prior to jail among women with opioid use disorder (OUD). Methods: Women (N = 700) were randomly selected from eight Kentucky jails, screened for OUD, and interviewed as part of the NIDA-funded Kentucky Justice Community Opioid Innovation Network (JCOIN) trial. Descriptive statistics were used to examine women's prior overdose experiences, while bivariate analyses and logistic regression were used to identify correlates of overdose in the 90 days prior to jail. Results: Analyses found that 55.4% of women had overdosed in their lifetime, and 21.4% overdosed in the 90 days prior to jail. Of those who overdosed in the 90 days prior to jail, heroin (80.7%) was the most-commonly used drug prior to overdose, 35.2% received emergency, medically-attended services post-overdose, and 92.4% were administered naloxone - primarily by acquaintances. Overdosing in the 90 days prior to jail was positively correlated with identifying as a sexual minority, being from an urban community, childhood victimization, as well as recent heroin, fentanyl, and injection drug use. Conclusions: Findings indicate that prior overdose is common among jailed women with OUD, and although naloxone was often administered, few women received medically-attended services post-overdose. Results highlight the importance of distributing naloxone to community members and women reentering the community from jail, and suggest additional research is needed to understand factors inhibiting medical care following an overdose.

The Impact of Needle and Syringe Exchange Programs on HIV-Related Risk Behaviors in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis Examining Individual- Versus Community-Level Effects

We conducted a systematic review and meta-analysis of the impact of needle and syringe exchange programs (NSP) on both individual- and community-level needle-sharing behaviors and other HIV-related outcomes in low- and middle-income countries (LMIC). A search of five databases for peer-reviewed trial or quasi-experimental studies reported through July 2021 identified 42 interventions delivered in 35 studies, with a total of 56,751 participants meeting inclusion criteria. Random-effects meta-analysis showed a significant protective association between NSP exposure and needle-sharing behaviors at the individual-level (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.16-0.39, 8 trials, n = 3947) and community-level (OR 0.39, CI 0.22-0.69, 12 trials, n = 6850), although with significant heterogeneity. When stratified by needle-sharing directionality, NSP exposure remained associated with reduced receptive sharing, but not distributive sharing. NSP exposure was also associated with reduced HIV incidence and increased HIV testing but there were no consistent associations with prevalence of bloodborne infections. Current evidence suggests positive impacts of NSPs in LMICs.

Women who use drugs: engagement in practices of harm reduction care

BACKGROUND

Harm reduction services that employ or are operated by people who use drugs are an effective means of mitigating overdose risks and other drug-related harms. However, stereotypes portraying people who use criminalized drugs as incapable caregivers persist. This is especially true for women who use drugs, and to a greater extent racialized women, who are characterized as having diverged from traditional ideals of womanhood as a result of drug-user stigma and the intersections of gender- and class-based and racist stereotypes. In an effort to identify and understand how women who use drugs practise care through harm reduction, we explored the experiences of women accessing a low-threshold supervised consumption site exclusively for women (transgender and non-binary inclusive) in Vancouver, Canada.

METHODS

Data were drawn from research conducted from May 2017 to June 2018 exploring women's experiences accessing the supervised consumption site during an overdose crisis. Data included forty-five semistructured interviews with women recruited from the site, analysed thematically to explore practices of care through harm reduction.

FINDINGS

Participants reported engaging in both formal and informal care. Acts of care included interventions that both aligned with and deviated from conventional understandings of care practices, including overdose reversal and education, overdose supervision/care, and assisted injection.

CONCLUSION

The boundary between formal and informal harm reduction care is fluid. Women who use drugs engage in harm reduction across these borders with acts of care that align with or fill the gaps in current harm reduction services in order to meet the needs of drug-using communities, challenging negative stereotypes of women who use drugs. However, these caregiving practices can increase risks to care providers' physical, mental, and emotional health and wellness. Increased financial, social, and institutional supports, including safer supply, assisted injection, and community resources, are needed to better support women as they continue to engage in harm reduction care.

Medical Complications of Injection Drug Use - Part II

Medical Complications of Injection Drug Use - Part IIDuring the past 2 decades, the risk of death, as well as the prevalence of hospitalizations in the United States, has increased substantially among people who inject drugs, mainly because of the opioid epidemic. In Part Two of this two-part review, the authors review complications observed in people who inject drugs and strategies to reduce harm.

Factors associated with perceived ease of access to syringes in Appalachian North Carolina

PURPOSE

To examine associations between perceived ease of syringe access, syringe sources, injection behaviors, and law enforcement (LE) interactions among people who inject drugs (PWID) in rural Appalachian North Carolina (NC).

METHODS

Using respondent-driven sampling, a diverse sample of 309 self-reported PWID were recruited from rural Appalachian NC. Data were collected via audio computer-assisted self-interview technology from February 2019 through March 2020. Respondents reported demographics, sources of syringes, LE interactions, and injection behaviors. Univariate, bivariate, and linear regression analyses were performed.

FINDINGS

Respondents most often obtained syringes from pharmacies and syringe service programs (SSPs). Twenty-one percent disagreed that it was easy to obtain sterile syringes, with 28% reporting low or no access to an SSP. PWID who reported longer physical distances to an SSP had greater difficulty accessing syringes (P<.001). PWID who reported greater ease of access to syringes reported engaging in receptive syringe sharing less often (P<.01). PWID who were stopped and searched by LE more often reported injecting drugs somebody else prepared with nonsterile supplies more often (P<.01). Participants shared used injection supplies more than twice as often than they shared used syringes.

CONCLUSIONS

These results underscore the importance of SSPs to mitigate the spread of human immunodeficiency virus and viral hepatitis in rural areas. Supporting mobile SSP services in rural areas could increase access to sterile syringes and injection supplies. SSPs should educate PWID about the importance of not sharing injection supplies. Pharmacies could increase syringe access in areas where SSPs do not operate.

Contraception and Healthcare Utilization by Reproductive-Age Women Who Use Drugs in Rural Communities: a Cross-Sectional Survey

BACKGROUND

Women who use drugs (WWUD) have low rates of contraceptive use and high rates of unintended pregnancy. Drug use is common among women in rural U.S. communities, with limited data on how they utilize reproductive, substance use disorder (SUD), and healthcare services.

OBJECTIVE

We determined contraceptive use prevalence among WWUD in rural communities then compared estimates to women from similar rural areas. We investigated characteristics of those using contraceptives, and associations between contraceptive use and SUD treatment, healthcare utilization, and substance use.

DESIGN

Rural Opioids Initiative (ROI) - cross-sectional survey using respondent-driven sampling (RDS) involving eight rural U.S. regions (January 2018-March 2020); National Survey on Family Growth (NSFG) - nationally-representative U.S. household reproductive health survey (2017-2019).

PARTICIPANTS

Women aged 18-49 with prior 30-day non-prescribed opioid and/or non-opioid injection drug use; fecundity determined by self-reported survey responses.

MAIN MEASURES

Unweighted and RDS-weighted prevalence estimates of medical/procedural contraceptive use; chi-squared tests and multi-level linear regressions to test associations.

KEY RESULTS

Of 855 women in the ROI, 36.8% (95% CI 33.7-40.1, unweighted) and 38.6% (95% CI 30.7-47.2, weighted) reported contraceptive use, compared to 66% of rural women in the NSFG sample. Among the ROI women, 27% had received prior 30-day SUD treatment via outpatient counseling or inpatient program and these women had increased odds of contraceptive use (aOR 1.50 [95% CI 1.08-2.06]). There was a positive association between contraception use and recent medications for opioid use disorder (aOR 1.34 [95% CI 0.95-1.88]) and prior 6-month primary care utilization (aOR 1.32 [95% CI 0.96-1.82]) that did not meet the threshold for statistical significance.

CONCLUSION

WWUD in rural areas reported low contraceptive use; those who recently received SUD treatment had greater odds of contraceptive use. Improvements are needed in expanding reproductive and preventive health within SUD treatment and primary care services in rural communities.

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

Background

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

Methods

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

Results

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

Conclusions

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

COVID-19 and the opportunity for gender-responsive virtual and remote substance use treatment and harm reduction services

The COVID-19 pandemic has increased the uptake of virtual and remote service delivery in the substance use field, which was previously uncommon. This swift uptake of virtual services provides an opportunity to improve service design to meet the diverse needs of women and gender-diverse people. Such services have the potential to better meet the needs of women and gender-diverse people by allowing for increased choice, control, and autonomy, enabling empowerment, facilitating greater considerations of power relations, violence, childcare responsibilities, and fostering greater inclusion of trans and non-binary people. This commentary aims to identify how virtual and remote delivery of substance use treatment and harm reduction services can be gender-responsive. We highlight the role gender transformative services play in meeting the unique needs of women and gender-diverse people who use drugs both during and after the COVID-19 pandemic. By using the unique window of opportunity COVID-19 has created to develop and deliver gender-transformative programs, we can help address the detrimental gaps in service accessibility and effectiveness that have persistently been experienced by women and gender-diverse people who use drugs.

Prevalence and factors associated with hospitalisation for bacterial skin infections among people who inject drugs: The ETHOS Engage Study

BACKGROUND

Injecting-related skin and soft tissue infections (SSTIs) are a preventable cause of inpatient hospitalisation among people who inject drugs (PWID). This study aimed to determine the prevalence of hospitalisation for SSTIs among PWID, and identify similarities and differences in factors associated with hospitalisation for SSTIs versus non-bacterial harms related to injecting drug use.

METHODS

We performed cross-sectional analyses of baseline data from an observational cohort study of PWID attending drug treatment clinics and needle and syringe programs in Australia. Logistic regression models were used to identify factors associated with self-reported hospitalisation for (1) SSTIs (abscess and/or cellulitis), and (2) non-bacterial harms related to injecting drug use (e.g., non-fatal overdose; hereafter referred to as non-bacterial harms), both together and separately.

RESULTS

1851 participants who injected drugs in the previous six months were enrolled (67% male; 85% injected in the past month; 42% receiving opioid agonist treatment [OAT]). In the previous year, 40% (n = 737) had been hospitalised for drug-related causes: 20% (n = 377) and 29% (n = 528) of participants were admitted to hospital for an SSTI and non-bacterial harm, respectively. Participants who were female (adjusted odds ratio [aOR]: 1.53, 95% CI: 1.19-1.97) or homeless (aOR: 1.59, 95% CI: 1.16-2.19) were more likely to be hospitalised for an SSTI, but not a non-bacterial harm. Both types of hospitalisation were more likely among people recently released from prison.

CONCLUSIONS

Hospitalisation for SSTIs is common among PWID. Community-based interventions to prevent SSTIs and subsequent hospitalisation among PWID will require targeting of at-risk groups, including women, people experiencing homelessness, and incarcerated people upon prison release.

Factors associated with smoking and transitioning to nyaope injection amongst women in the City of Tshwane Municipality: A self-report by women

Background

Substance use disorder has emerged as a key health and social challenge in South Africa (SA). It is projected that about 15% of South African youth, especially young women are prone to engage in drug use and the prospects of coming into contact with nyaope, a highly addictive drug, are higher. Nyaope is mainly smoked, but the prevalence of injecting it is increasing in most regions.

Aim

This study aimed to explore and describe the perception of women, who use nyaope, about the factors contributing to nyaope smoking and transitioning to injecting nyaope amongst women in the City of Tshwane Municipality (CoT), Gauteng.

Setting

The research was conducted within Community Oriented Substance Use Programme sites across the CoT Municipality.

Methods

Qualitative research methods were utilised to explore and describe the perceptions of the participants on factors contributing to the use of nyaope amongst women residing in the CoT. Data were collected through face-to-face interviews and thematically analysed.

Results

Intimate partner influence (IPI), peer pressure, being misled by friends, weight loss, lack of effective coping mechanisms and counteracting other drugs contributed to women smoking nyaope. Additionally, a need for an intense high, IPI, influence by the social network, curiosity and cost-effectiveness contributed to women transitioning from smoking to injecting nyaope.

Conclusion

The study has established factors contributing to smoking and transition to injecting nyaope as viewed by women residing in the CoT.

Contribution

This research affirms that women are influenced by different factors to use and transition to injecting Nyaope.

Mothers Who Use Drugs: Closing the Gaps in Harm Reduction Response Amidst the Dual Epidemics of Overdose and Violence in a Canadian Urban Setting

Objectives. To identify key gaps in overdose prevention interventions for mothers who use drugs and the paradoxical impact of institutional practices that can increase overdose risk in the context of punitive drug policies and a toxic drug supply. Methods. Semistructured interviews were conducted with 40 women accessing 2 women-only, low-barrier supervised consumption sites in Greater Vancouver, British Columbia, Canada, between 2017 and 2019. Our analysis drew on intersectional understandings of structural, everyday, and symbolic violence. Results. Participants' substance use and overdose risk (e.g., injecting alone) was shaped by fear of institutional and partner scrutiny and loss (or feared loss) of child custody or reunification. Findings indicate that punitive policies and institutional practices that frame women who use drugs as unfit parents continue to negatively shape the lives of women, most significantly among Indigenous participants. Conclusions. Nonpunitive policies, including access to safe, nontoxic drug supplies, are critical first steps to decreasing women's overdose risk alongside gender-specific and culturally informed harm-reduction responses, including community-based, peer-led initiatives to maintain parent-child relationships. (Am J Public Health. 2022;112(S2):S191-S198. https://doi.org/10.2105/AJPH.2022.306776).

Under the Skin: The Relationship Between Subcutaneous Injection and Skin Infections Among People Who Inject Drugs

OBJECTIVES

People who inject drugs (PWID) are at increased risk for numerous negative health outcomes. Subcutaneous injections (aka skin popping) can result in greater risk of skin and soft tissue infections (SSTIs), but less is known about PWID who choose this route of administration. This study compares subcutaneous injectors to intravenous injectors, characterizes those who inject subcutaneously, and examines whether subcutaneous injection is associated with SSTIs in the past year.

METHODS

A cohort of hospitalized PWID (n = 252) were interviewed regarding injection-related behaviors, history of SSTI, and knowledge of subcutaneous injection risk. We examined differences between those who do and do not inject subcutaneously and used a negative binomial regression model to estimate adjusted odds associating subcutaneous injection and SSTI.

RESULTS

Participants averaged 38 years, with 58.3% male, 59.5% White, 20.6% Black, and 15.9% Latinx. PWID who performed subcutaneous injection were not demographically different from other PWID; however, the mean rate of past year SSTIs was higher for persons injecting subcutaneously than for those who did not (1.98 vs 0.96, P < 0.001). Persons injecting subcutaneously did not differ from those who injected intravenously in terms of their knowledge of subcutaneous injection risk (P = 0.112) and knowledge score was not associated with SSTIs (P = 0.457).

CONCLUSIONS

PWID who perform subcutaneous injections are demographically similar to other PWID but had higher rates of past year SSTIs. Knowledge of subcutaneous injection risk was not associated with SSTI risk.

Vulnerability, Risk and Harm for People Who Use Drugs and Are Engaged in Transactional Sex: Learning for Service Delivery

Against a backdrop of high levels of drug related harms in Scotland, this research aimed to inform training development to aid the upskilling of the workforce to support people who use drugs and are involved in transactional sex. Sixteen qualitative interviews were conducted with participants recruited across four health board areas and a range of services covering sexual health and/or harm reduction. Interviews explored initiation, frequency, and the nature of transactional sex; drug use, and experience of services. A thematic analysis was undertaken. Vulnerability was a key emerging theme when discussing drug use, sexual behavior, and service use. Vulnerability increased risk of a range of harms from sexual assault to injecting harms and overdose. Participants were often, but not always, introduced to drugs and transactional sex by someone who had power over them or was more experienced in drug use and/or sex. High risk drug use was evident in terms of polydrug use, consuming large quantities of drugs, sharing crack pipes/injecting equipment. There is a need for information and services to reduce the risk of harm from drugs, sexual violence, and unprotected sex as well as non-judgmental, trauma aware services. The workforce needs to be skilled to recognize and manage these potentially complex syndemics.

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

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

Sex Differences in Injection Drug Risk Behaviors Among Hospitalized Persons

OBJECTIVES

As opioid use increases, it remains important to assess factors that contribute to injection drug risk behaviors, as sharing needles and other drug use equipment contributes to the spread of human immunodeficiency virus and hepatitis C virus. Such risks may differ by sex and injecting with others. The current study examined factors that contribute to increased injection drug risk separately for men and women.

METHODS

People who inject drugs were recruited at an academic safety-net hospital that reported recent injection drug use. Two main injection outcomes were assessed: (1) human immunodeficiency virus drug risk behaviors as assessed by the Risk Assessment Battery and (2) the number of times participants injected drugs with a needle used by someone else. For each outcome, different models for women and men were conducted to detect differences by sex.

RESULTS

Both men and women were more likely to inject with a needle used by someone else if they used drugs within a sexual relationship (incidence rate ratio (IRR) = 14.61, P < 0.01; IRR = 7.17, P < 0.05). Being employed was associated with lower risk assessment battery scores among men, and lower mean rates of using a needle used by someone else among women (IRR = 0.22, P < 0.05). Women with post-traumatic stress disorder (PTSD) and men with higher depression scores had higher rates of injecting with a needle used by someone else.

CONCLUSIONS

People who inject drugs who are in intimate relationships report higher injection drug risk behaviors. We found benefits to employment among both men and women. Identifying factors associated with increased injection risk behaviors can be useful for creating interventions tailored by sex.

"I would rather do it myself": injection initiation and current injection patterns among women who inject drugs in Tijuana, Mexico

BACKGROUND

Women who inject drugs (WWID) experience unique risks and adverse health outcomes related to injection initiation and patterns of injection drug use. However, there is limited information on injection initiation experiences and injection patterns among women and the protective strategies employed to limit injection-related harms, especially in low- and middle-income settings. Therefore, this study sought to explore injection initiation and current injection patterns (e.g., relying on someone else to inject) among women who inject drugs and engage in sex work in Tijuana, Mexico.

METHODS

Semistructured in-depth interviews were conducted with 30 WWID on the following topics: injection initiation, current injection patterns, places where women inject, and protective strategies (i.e., risk reduction). All interviews were audio-recorded, transcribed, and de-identified. An inductive thematic analysis was conducted to identify and compare common themes and patterns across participants.

RESULTS

The interviews revealed that the vast majority of study participants were first initiated by another person who injects drugs (PWID), often a male sexual partner. However, the majority of the women transitioned to become self-injectors in order to avoid risks associated with relying on others for injection, including overdose, interpersonal violence, sexual abuse, and wounds. Those who relied on others indicated that they would prefer to inject themselves without assistance from others if they were able to.

CONCLUSIONS

The narratives uncovered in this study reveal the importance of multiple risk environments in shaping perceived risks associated with injection drug use among women in Tijuana, Mexico. Specifically, the interviews elucidate the connection between interpersonal relationships with other PWID and protective strategies used to minimize risk and harm. These findings highlight the need for women-centered harm reduction programs to facilitate the development of safer drug use environments among WWID in Tijuana, Mexico.

Rapid situational assessment of people who inject drugs (PWID) in Nairobi and coastal regions of Kenya: a respondent driven sampling survey

BACKGROUND

A Cross-sectional Rapid Situational Assessment of People Who Inject Drug (PWIDs) applying Respondent Driven sampling techniques (RDS) was used to recruit subjects/participants in a study aimed at assessing HIV prevalence and risk behaviors among injecting drug users in Nairobi and Coastal regions of Kenya. There is paucity of data and information on injecting drug use in sub-Saharan Africa and there is sufficient evidence of existence of the environment for development and growth of injecting drug use. Past studies on PWID and its association to HIV and AIDS that have been conducted in Kenya do not provide sufficient information to support effective planning and comprehensive national response to the HIV and AIDS epidemic.

METHODS

A cross-sectional study design was adopted in which a set of initial subjects referred to as 'seeds' were first identified from which an expanding chain of referrals were obtained, with subjects from each wave referring subjects of subsequent waves. The seeds were drawn randomly from the population and interviewed to pick the one with the largest network and other unique characteristics. A maximum of twelve seeds were recruited. The second stage involved conducting assessment visits to the sites to identify potential collaborators that included non-governmental organizations (NGOs), drug treatment centres, health facilities, community based organizations (CBO's) among others. Three NGOs located in the coast region and one in Nairobi region were identified to assist in identifying drug injection locations and potential participants. Key informant interviews (KIIs) and Focus Group Discussions (FGDs) were also conducted using interview guides.

RESULTS

A total of 646 individuals (344 in Nairobi and 302 at the coast) were recruited for the study between January and March 2010. Of these 590 (91%) were male and 56 (9%) were female. Findings showed that most PWIDs initiated injecting drug use between the ages of 20-29 years, with the youngest age of initiation being 11 years and oldest age being 53 years. Most commonly injected drug was heroin (98%), with a small (2%) percentage injecting cocaine. Other non-injecting methods such as smoking or combining these two drugs with other drugs such as cannabis or Rohypnol were also common. Most PWIDs used other substances (cigarettes, alcohol, and cannabis) before initiating injecting drug use. The adjusted national HIV prevalence of PWIDs was 18.3% (19.62% unadjusted) with PWIDs in Nairobi region registering 18.33% (20.58% unadjusted) compared PWIDs for Coastal region indicating 18.27% (18.59% - unadjusted). The gender based HIV prevalence showed that women were more at risk of acquiring HIV (44.51%-adjusted) compared to men (15.97%-adjusted). The age specific HIV prevalence showed that PWIDs who initiated injecting at 11-19 years (44.7% adjusted) were most at risk in Nairobi compared to those who initiated injecting at age 20-24 years (23.2% - adjusted) in the coastal region. While all PWIDs continue to be at risk in the two regions, those from the Western parts of Nairobi, Kenya were at a relatively higher risk given their increased propensity for sharing injecting equipment and solutions.

CONCLUSIONS

Compared to the national HIV prevalence of (4.9%), the results show that People Who Inject Drugs (PWIDs) are at particularly high risk of infection in Kenya and there is urgent need for intervention (KenPHIA, 2018). This study also showed clear evidence that 70% of PWIDs are primary school educated, engage in high risk injecting and sexual behaviors comprising sharing of injecting equipment, unprotected heterosexual and homosexual sex. Given that initiation of injecting drug use begins early and peaks after formal school years (20-29 years), prevention programmes should be targeted at primary and secondary school students, college and out of school youth. Further, to protect People who inject drugs (PWIDs) from HIV infection, the country should introduce free Needle Syringe Programs (NSP) with provision of condoms and Methadone Assisted Therapy (MAT) as a substitute for drug use.

Shared injection experiences: Interpersonal involvement in injection drug practices among women

BACKGROUND

Many women who inject drugs are aware of the associated risks, however social influences play a part in their behavioral decisions. Incorporation of others in drug use behaviors may be common practice among women who use drugs. The aim of this study was to gain an in-depth understanding of women's injection drug use experiences with a focus on interpersonal involvement. Methods: Venue-based recruitment was conducted in collaboration with a harm reduction program. A group of 30 women, ages 18 and older, who reported injecting drugs within the past 30 days took part in a demographic survey and semi-structured interview to gain an understanding of their injection practices. In vivo coding and thematic analysis were conducted. Results: Three main themes that relate to incorporating others into injection drug behaviors surfaced, including: (1) injection practices described as we and not I, (2) partnered purchase and drug preparation, and (3) assisted injection. This group of women most often incorporated sexual and/or romantic partners (same and other-gender), friends, or family members into their injection drug use behaviors. Some women described a lack of ability to inject themselves and require assistance every time they use. Women also reported helping other women during drug use behaviors. Conclusions: Our primary themes indicate that a variety of relationship partners are important conceptual links in theoretical frameworks explaining drug use behaviors among women. Findings suggest same gender assistance during drug use behaviors, including injection, that may reduce harm. The interpersonal nature of injection drug use among women may indicate the expansion of treatment options designed for couples or other relationship partners, such as family, together.

Tales of gender-based oppression and violence: Risks and vulnerabilities of women who inject drugs (WWID) in Dhaka, Bangladesh

BACKGROUND

Women who inject drugs (WWID) experience various complexities, risks and vulnerabilities attributed to unequal gendered power differentials. This article has aimed to explore the unequal gendered power dynamics that influence HIV risks and vulnerabilities among WWID in Dhaka, Bangladesh.

METHODS

This paper is based on an ethnographic study conducted from April 2018 to December 2019 in Dhaka, Bangladesh. This component of the study constituted 2500 h of extensive field observations, 15 in-depth interviews and five focus groups exclusively with WWID. We also interviewed 15 key-informants including programme managers, an academician and harm reduction service providers. Data were thematically analysed in relation to the four bases of gendered power theorised by gender scholars Pratto and Walker which include force, resource control, asymmetrical obligations and consensual ideologies.

RESULTS

The first base, "force", highlighted situations where WWID were compelled into risky injecting and sexual behaviours to avoid violent ramifications or losing their safety nets with intimate partners. The second base, "resource control", depicted unequal access to commodities where men exercised their dominance over money and drugs. The third base, "social obligations", depicted the propensity of WWID to obey their partners and clients, thus precipitating their risky behaviours. The fourth base, consensual ideologies, were linked to weakened negotiation powers of WWID, thus increasing their propensity to risky injecting and sexual behaviours alongside poly-drug use. Despite several instances of gender-based violence and oppression, WWID have fallen victim to gender-blind interventions, as demonstrated by study observations and anecdotes.

CONCLUSION

Gender-based violence and oppression were depicted as prominent driving forces exacerbating WWID's HIV risks and vulnerabilities. If these issues are overlooked, the HIV burden will continue permeating among WWID. Thus, stakeholders need to look beyond the lens of conventional harm reduction modalities and synergize evidence-based gendered dynamics to formulate a gender-responsive comprehensive service package for WWID.

Predictors of skin and soft tissue infections among sample of rural residents who inject drugs

Introduction

Skin and soft tissue infections (SSTIs) are among the leading causes of morbidity and mortality for people who inject drugs (PWID). Studies demonstrate that certain injection practices correlate with SSTI incidence among PWID. The opioid epidemic in the USA has particularly affected rural communities, where access to prevention and treatment presents unique challenges. This study aims to estimate unsafe injection practices among rural-dwelling PWID; assess treatments utilized for injection related SSTIs; and gather data to help reduce the overall risk of injection-related SSTIs.

Methods

Thirteen questions specific to SSTIs and injection practices were added to a larger study assessing unmet health care needs among PWID and were administered at six syringe exchange programs in rural Wisconsin between May and July 2019. SSTI history prevalence was estimated based on infections reported within one-year prior of response and was compared to self-reported demographics and injection practices.

Results

Eighty responses were collected and analyzed. Respondents were white (77.5%), males (60%), between the ages 30 and 39 (42.5%), and have a high school diploma or GED (38.75%). The majority of respondents (77.5%) reported no history of SSTI within the year prior to survey response. Females were over three times more likely to report SSTI history (OR = 3.07, p = 0.038) compared to males. Water sources for drug dilution (p = 0.093) and frequency of injecting on first attempt (p = 0.037), but not proper skin cleaning method (p = 0.378), were significantly associated with a history of SSTI. Injecting into skin (p = 0.038) or muscle (p = 0.001) was significantly associated with a history of SSTI. Injection into veins was not significantly associated with SSTI (p = 0.333).

Conclusion

Higher-risk injection practices were common among participants reporting a history of SSTIs in this rural sample. Studies exploring socio-demographic factors influencing risky injection practices and general barriers to safer injection practices to prevent SSTIs are warranted. Dissemination of education materials targeting SSTI prevention and intervention among PWID not in treatment is warranted.

A qualitative study of facilitators and barriers to participate in a needle exchange program for women who inject drugs

BACKGROUND

Women who inject drugs (WWID) show higher levels of injecting risk behaviour compared to men, putting them at risk of contracting HIV and hepatitis C (HCV). Compared to men, WWID are also less present in harm reduction programs such as needle exchange programs (NEP). The aim of this study is to investigate reasons for, and barriers to, participation in NEP among WWID in Sweden, and to identify measures that could be taken to strengthen the program and increase participation among WWID.

METHOD

In-depth interviews (IDIs) were conducted with 20 WWID who had participated in the Stockholm NEP for at least six months and was over 18 years old. IDIs were audio recorded and transcribed et verbatim. Qualitative content analysis was used to identify themes.

RESULTS

The need for sterile injection equipment was identified as the main driver to join and remain in the NEP program. Continuous participation in the NEP was further driven by easy access to a multitude of health-related services. The most valued service was the sexual and reproductive health services (SRHR), allowing participants to access contraceptives, cervical cancer screening and sexually transmitted infections testing (STI-testing). NEP staffs' respectful treatment of participants further contributed to program participation. However, participants also expressed a number of concerns around NEP participation, which created barriers to joining. These included losing custody or visitation rights to children, male partner jealousy and violence, unwillingness to spend time in the waiting area and fear of receiving positive HIV/HCV test results. Practical barriers included limited opening hours and travel distance to the NEP. To strengthen the program, most participants requested additional SRHR services. Most participants also proposed some form of "women only" access to the NEP, to strengthen the feeling of the NEP as a safe space.

CONCLUSION

This study identified factors that may increase uptake of NEP among WWID. Additional SRHR services and "women only" access are recommended to be implemented and evaluated as part of NEP. These findings may inform and improve the current scale-up of NEPs in Sweden to ensure equal access to services.

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

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

Effects of low-dose contraceptive pills on the risk factors of cardiovascular diseases among 15-35-year-old women: A retrospective cohort

Background

Cardiovascular diseases could be preventable; as a result, understanding the risk factors was regarded as the major priority for healthcare providers.

Objective

The main objective of this research was to achieve a deeper insight into the effect of long-term use of low-dose oral contraceptive pills (OCP) on the risk factors of cardiovascular diseases.

Materials and Methods

This research was a retrospective cohort conducted (historical and prospectively) conducted on 100 women with normal menstrual cycles aged 15 to 35 yr, who were referred to the healthcare centers in Yazd, Iran. The participants were categorized into two groups: The OCP group was consuming the pills for 0-3, 4-23, and 24-36 months, and the non-OCP group. Participants were followed up for a minimum of 3 months and a maximum of six months.

Results

The highest level of low-density lipoprotein (LDL), homocysteine, cholesterol, triglyceride levels, and systolic blood pressure was observed in the OCP group in the duration of 24 to 36 months. The Tukey's test demonstrated that there were comprehensible differences in the LDL (p = 0.01), cholesterol (p = 0.01), triglyceride (p < 0.001), and homocysteine levels (p < 0.001), also systolic blood pressure (p = 0.04).

Conclusion

It was realized that the long-term consumption of low-dose OCP can augment the incidence of some risk factors (systolic blood pressure, homocysteine levels, cholesterol, LDL-c, and triglyceride) and lead to developing cardiovascular diseases amongst the healthy women.

When and how do individuals transition from regular drug use to injection drug use in Uganda? Findings from a rapid assessment

BACKGROUND

In Uganda, injection drug use is a growing but less studied problem. Preventing the transition to injection drug use may help prevent blood-borne viral transmission, but little is known about when and how people transition to injection drug use. A greater understanding of this transition process may aid in the country's efforts to prevent the continued growth of injection drug use, HIV, and hepatitis C Virus (HCV) infection among people who inject drugs (PWID).

METHODS

Using a rapid situation assessment framework, we conducted semi-structured interviews among 125 PWID (102 males and 23 females)-recruited through outreach and snow-ball sampling. Participants were interviewed about their experiences on when and how they transitioned into injection drug use and these issues were also discussed in 12 focus groups held with the participants.

RESULTS

All the study participants started their drug use career with non-injecting forms including chewing, smoking, and sniffing before transitioning to injecting. Transitioning was generally described as a peer-driven and socially learnt behavior. The participants' social networks and accessibility to injectable drugs on the market and among close friends influenced the time lag between first regular drug use and first injecting-which took an average of 4.5 years. By the age of 24, at least 81.6% (95.7% for females and 78.4% for males) had transitioned into injecting. Over 84.8% shared injecting equipment during their first injection, 47.2% started injecting because a close friend was already injecting, 26.4% desired to achieve a greater "high" (26.4%) which could reflect drug-tolerance, and 12% out of curiosity.

CONCLUSIONS

Over 81% non-injecting drug users in Kampala and Mbale districts transitioned into injecting by the age of 24; a process that reproduces a population of PWID but also puts them at increased risk of HIV and HCV infection. As Uganda makes efforts to introduce and/or strengthen harm reduction services, interventions targeting non-injecting drug users before they transition into injecting should be considered as a key component for HIV/HCV epidemic control efforts, and their evaluation considered in future researches.

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

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The intersection of women's sexual pleasure and injection drug use

Background: There is a dearth of literature concerning the sexual behaviors of women who inject drugs. The existing literature emphasizes the violence, trauma, and social disadvantage experienced by these women and obscures any sense of agency or sexual pleasure. This omission imperils our ability to develop effective interventions for women, ignores the true context of their sexual and injection practices, and presumes women to be free of agency and thus at the will of external social, environmental, and economic factors. This qualitative study strives to extend the boundaries of conventional risk-focused research to understand the complex and multidimensional sexual practices of women who inject drugs. Methods: Purposive sampling was used to select women who inject drugs from a syringe exchange program in New York City. The principal investigator and trained study staff conducted interviews with 26 women. The interview transcripts were thematically coded in Atlas.ti with a grounded theory approach to understand the concerns, actions, and practices to further explain patterns. Results: Four themes emerged with respect to women's descriptions of their sexual and injection experiences: (a) linguistic parallels of sexual and injection experiences, (b) substituting sex with injection drug use, (c) pleasure, and (d) injection drug use as intimacy. Our findings indicated that there was much positive discourse about sexual experiences and injection drug practices, with some women describing injecting as a substitute for negative sexual experiences and others noting that injection drug use served as a foundation for intimacy and eroticism in a relationship. Conclusions: In contrast to the literature, women who inject drugs demonstrated power and agency and discussed pleasurable sexual experiences. Ultimately, interventions should recognize the realities of women's experiences to help empower them to practice safer sexual and injection practices.

A latent class analysis of alcohol and drug use immediately before or during sex among women

BACKGROUND

Alcohol and drug use by women is related to high-risk sexual practices and protective behaviors.

OBJECTIVES

To determine sexual risk and protective behaviors using information about women's drug use immediately before or during sex.

METHODS

Latent class analysis using PROC LCA in SAS software was used to determine classes of women using both past 30-day drug use and before or during sex. Participants were recruited from a community-based research site located in a low socio-economic area of Los Angeles County and completed the Risk Behavior Assessment, which elicits information on drug and sex risk behaviors.

RESULTS

The Risk Behavior Assessment and HIV and sexually transmitted infections testing was obtained on 812 women. Five distinct groups were identified by PROC LCA: An Abstinent group comprised of 26% of participants; an Alcohol and Marijuana group (16%); an Amphetamine group (11%); a No Sex-with-Alcohol group (37%); and a Poly Drug group (11%). Multinomial logistic regression revealed that sexual behaviors and condom use were different across the five groups: The Alcohol and Marijuana group had a higher odds of vaginal intercourse, while the No Sex-with-Alcohol group was most likely to use condoms for vaginal intercourse. The Poly Drug group had the highest risk for anal intercourse while the Amphetamine and Poly Drug groups had high proportions of women with injection-drug using and men-who-have-sex-with-men sexual partners.

CONCLUSION

Identifying women based on drug use immediately before or during sex can help providers understand prevention and risk-reduction practices and interventions for drug-using women.

A Study of Sexual Relationship Power among Young Women Who Inject Drugs and Their Sexual Partners

BACKGROUND

To date, research applying the Sexual Relationship Power Scale (SRPS) has been limited to sexual risk behaviors.

OBJECTIVE

We measured levels of sexual relationship power and examined associations between sexual relationship power and injecting and sexual behaviors that place women at increased risk for blood borne infections.

METHODS

Using data from a cross-sectional study of young women who inject drugs (WWID) in San Francisco, USA, logistic regression analysis identified independent associations between SRPS and subscale scores (relationship control [RC] and decision making dominance [DMD]) and injecting and sexual behaviors.

RESULTS

Of the 68 young WWID, 24 (34%) reported receptive syringe sharing, 38 (56%) reused/shared a cooker to prepare drugs, and 25 (37%) injected someone else's drug residue during the three-months prior to enrollment. Most (60, 88%) reported condomless sex with main sex-partner, 8 (12%) reported transactional sex, and 36 (53%) had two or more recent sex partners. The median SRPS score was 2.98 (IQR: 2.65, 3.18), 3.23 (IQR: 3.23, 3.57) for RC and 2.40 (IQR: 2.20, 2.60) for DMD. No significant associations were detected between SRPS or DMD and injecting or sexual risk behaviors. After adjusting for gender and years injecting, for every one-point increase in RC, women had a 6.70 lower odds of recent condomless sex (95%CI: 0.92, 50.00, p = 0.06), and a 3.90 lower odds of recent transactional sex (95%CI: 1.22, 12.50, p = 0.02).

CONCLUSION

Our study findings suggest that some components of sexual relationship power may play a role in sexual risk, but not in injecting risk.

Risk Factors Associated With Skin and Soft Tissue Infections Among Hospitalized People Who Inject Drugs

OBJECTIVES

Skin and soft tissue infections (SSTIs) are common among people who inject drugs (PWID), and can lead to serious morbidity and costly emergency room and hospital utilization. A range of high-risk injection practices may contribute to these infections. The goal of the current study was to examine risk practices that were associated with SSTIs in a sample of hospitalized PWID.

METHODS

PWID (N = 143; 40.6% female) were recruited from inpatient medical units at a large urban hospital and completed a baseline interview that focused on infection risk. Measures included demographics, substances used/injected, and self-report of SSTIs (ie, abscesses, ulcers, or cellulitis) within the past year. The Bacterial Infections Risk Scale for Injectors-a 7-item index-assessed specific behaviors expected to increase the risk of acquiring SSTIs (eg, injection without skin cleaning, intramuscular injection).

RESULTS

The sample was 58% Caucasian and averaged 38.7 (SD = 10.7) years of age. Ninety-three participants (65%) reported at least 1 SSTI within the past year. Using a logistic regression model, the Bacterial Infections Risk Scale for Injectors (odds ratio 1.87, P = 0.004) and total number of injections over the past 3 months (odds ratio 2.21, P = 0.002) were associated with past year SSTIs.

CONCLUSIONS

In conclusion, rates of past-year SSTIs were high in this sample of hospitalized PWID. Results suggest that interventions should target specific injection practices to reduce infection risk.

Sex work, injection drug use, and abscesses: Associations in women, but not men

BACKGROUND

Abscesses commonly occur among people who inject drugs (PWID). However, whether the risks are comparable between males and females, and the impact of sex work on abscess risk is unclear. The goal of this study was to examine the contemporary associations of gender and sex work with the risk of abscesses in PWID.

METHODS

Combining data from two cross-sectional studies conducted in the Greater Boston Area with people at risk for HIV and hepatitis C virus (HCV), we used the following inclusion criteria: age 18-45 years and report of illicit or non-prescription drug injection within the 30 days prior to the survey. Information on demographics, injection-mediated risks, and sexual behaviors was collected using Audio Computer-Assisted Self-Interview Software. Multivariable logistic regressions were used to model associations.

RESULTS

The study sample included 298 people including 30% were female. Females were more likely than men to report sex work (28% vs. 16%, p = .012) and abscess during their lifetime (55% vs. 37% p = .004). Among the females, engaging in sex work increased by >5-fold the odds of reporting abscesses [Adjusted odds ratio 5.42; 95% CI: 1.27, 23.10]. There was no association between sex work and abscesses among men.

DISCUSSION

We found a female-specific association between sex work, injection drug use, and abscesses among PWID. Although the cross-sectional designs precluded causal inferences, longitudinal studies could enhance understanding of gender-associated risks for abscesses and inform the development of harm reduction interventions.

Socio-demographic and sexual practices associated with HIV infection in Kenyan injection and non-injection drug users

Background

Substance use is increasingly becoming prevalent on the African continent, fueling the spread of HIV infection. Although socio-demographic factors influence substance consumption and risk of HIV infection, the association of these factors with HIV infection is poorly understood among substance users on the African continent. The objective of the study was to assess socio-demographic and sexual practices that are associated with HIV infection among injection drug users (IDUs), non-IDUs, and non-drug users (DUs) at an urban setting of coastal Kenya.

Methods

A cross-sectional descriptive study was conducted among 451 adults comprising HIV-infected and -uninfected IDUs (n = 157 and 39); non-IDUs (n = 17 and 48); and non-DUs (n = 55 and 135); respectively at coastal, Kenya. Respondent driven sampling, snowball and makeshift methods were used to enroll IDUs and non-IDUs. Convenience and purposive sampling were used to enroll non-DUs from the hospital’s voluntary HIV testing unit. Participant assisted questionnaire was used in collecting socio-demographic data and sexual practices.

Results

Binary logistic regression analysis indicated that higher likelihood of HIV infection was associated with sex for police protection (OR, 9.526; 95% CI, 1.156-78.528; P = 0.036) and history of sexually transmitted infection (OR, 5.117; 95% CI, 1.924-13.485; P = 0.001) in IDUs; divorced, separated or widowed marital status (OR, 6.315; 95% CI, 1.334-29.898; P = 0.020) in non-IDUs; and unemployment (OR, 2.724; 95% CI, 1.049-7.070; P = 0.040) in non-drug users. However, never married (single) marital status (OR, 0.140; 95% CI, 0.030-0.649; P = 0.012) was associated with lower odds for HIV infection in non-drug users.

Conclusion

Altogether, these results suggest that socio-demographic and sexual risk factors for HIV transmission differ with drug use status, suggesting targeted preventive measures for drug users.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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