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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Practices of care among people who buy, use, and sell drugs in community settings

BACKGROUND

Popular perception of people who sell drugs is negative, with drug selling framed as predatory and morally reprehensible. In contrast, people who use drugs (PWUD) often describe positive perceptions of the people who sell them drugs. The "Satellite Sites" program in Toronto, Canada, provides harm reduction services in the community spaces where people gather to buy, use, and sell drugs. This program hires PWUD-who may move into and out of drug selling-as harm reduction workers. In this paper, we examine the integration of people who sell drugs directly into harm reduction service provision, and their practices of care with other PWUD in their community.

METHODS

Data collection included participant observation within the Satellite Sites over a 7-month period in 2016-2017, complemented by 20 semi-structured interviews with Satellite Site workers, clients, and program supervisors. Thematic analysis was used to examine practices of care emerging from the activities of Satellite Site workers, including those circulating around drug selling and sharing behaviors.

RESULTS

Satellite Site workers engage in a variety of practices of care with PWUD accessing their sites. Distribution of harm reduction equipment is more easily visible as a practice of care because it conforms to normative framings of care. Criminalization, coupled with negative framings of drug selling as predatory, contributes to the difficultly in examining acts of mutual aid and care that surround drug selling as practices of care. By taking seriously the importance for PWUD of procuring good quality drugs, a wider variety of practices of care are made visible. These additional practices of care include assistance in buying drugs, information on drug potency, and refusal to sell drugs that are perceived to be too strong.

CONCLUSION

Our results suggest a potential for harm reduction programs to incorporate some people who sell drugs into programming. Taking practices of care seriously may remove some barriers to integration of people who sell drugs into harm reduction programming, and assist in the development of more pertinent interventions that understand the key role of drug buying and selling within the lives of PWUD.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Guide for the classification of clinical research articles for the International Journal of Andrology]

The classification of knowledge is essential for understanding between researchers and the advancement of science. In this article a brief classification of clinical research methods is presented. The advantages that researchers use the same nomenclature are recalled, which enables improved communication among researchers, facilitates replication of studies and searches in databases, and helps to establish the aspects that can affect the different research models. They are grouped into four broad categories: epidemiological articles, articles of qualitative methodology, mixed methodology articles and review articles.

Examining the link between cocaine binging and individual, social and behavioral factors among street-based cocaine users

AIMS

To estimate the prevalence of cocaine binging and examine associated factors, to characterize binge episodes and to study the relationship between cocaine binging and HIV and HCV risk behaviors among street-based cocaine users.

METHODS

A prospective cohort study was conducted in Montréal, Canada. Interviewer-administered questionnaire were carried out at 3-month intervals. Cocaine binging was defined as using large quantities of cocaine, without stopping, over a limited period of time, until resources run out or until being physically incapable of consuming. Generalized Estimation Equations (GEE) analyses were used. Covariates considered included demographic, behavioral, mental health and social risk factors.

FINDINGS

In total, 605 participants were recruited. Prevalence of cocaine binging over the month prior to recruitment was 24.5%. Correlates of cocaine binging were older age (AOR 1.46), homelessness (AOR 1.44), criminal/marginal income strategies (AOR 1.61), high psychological distress (AOR 1.31), high cocaine dependence (AOR 3.71), drug overdoses (AOR 1.56) and smoking as the main route of cocaine administration (AOR 1.38). Additional GEE analyses showed that cocaine binging was significantly associated with the sharing of drug paraphernalia (AOR 1.35) and sexual relations under the influence of cocaine (AOR 1.21).

CONCLUSION

Cocaine binging is frequent among street-based cocaine users and is associated with markers of vulnerability. It is also associated with increased odds of both sexual and drug use risk behaviors. Interventions need to be tailored in order to help cocaine bingers develop personal strategies that could prevent binging. Harm reduction programs should help cocaine bingers adequately assess their drug equipment needs.

Outbreak of tuberculosis among substance users and homeless people in Greater Montréal, Canada, 2003-2016

Background

In Canada, active tuberculosis (TB) is found mainly among migrants from endemic countries and Indigenous populations. However, cases of active tuberculosis in substance users and homeless persons have been reported in Greater Montréal since 2003.

Objective

To describe the Montréal TB outbreak in terms of the sociodemographic characteristics, risk factors and clinical characteristics of cases, as well as the intensity of public health interventions, the follow-up and identification of locations of potential transmission.

Methods

All cases of active tuberculosis with the same genotype of interest residing in Quebec and epidemiologically linked cases were included in the analysis. Data were retrospectively extracted from routine public health investigations. Characteristics of cases were summarized using Excel. Spatial analysis of locations frequented during cases' infectiousness periods was performed.

Results

Between January 2003 and February 2016 a total of 35 cases were identified. Most (86%) were non-Indigenous people born in Canada. Of these, 28 had several risk factors, including substance use (93%), alcohol abuse (64%), homelessness (46%), comorbidities such as HIV coinfection (36%) and advanced stage of the disease. Seven cases without risk factors were all close contacts of cases. Intensity of case management by public health authorities was high. Locations frequented by cases with risk factors included crack houses, shelters and rehabilitation centers in Montréal's downtown core and a residential setting in a suburban area.

Conclusion

TB outbreaks can occur in marginalized Canadian-born urban populations, especially those with substance use. Tailored interventions in this population may be needed for screening, and earlier identification of both latent and active TB and better linkage to care.