Declining trends in exposures to harmful policing among people who inject drugs in Vancouver, Canada

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Challenges, Skepticism, and Recommendations from Police about Working in Collaboration with Supervised Consumption Services

The operation of supervised consumption services (SCS), programs that offer supervised locations for the consumption of drugs such as heroin, other opioids, cocaine, other stimulants, and other drugs, is contingent on cooperative relationships with police. In this manuscript, we focus on an under studied topic: how active duty police officers understand their role with respect to SCS, and their recommendations for improving relationships with these programs. Methods: During 2018, we audio-recorded and transcribed focus group discussions conducted in four police divisions with 26 police constables and 3 officers of other ranks in Toronto, Canada. Officers were asked about their roles relative to SCS, perceived training needs, and how to build cooperative relationships with SCS. We followed an iterative thematic approach to analyze the data. Results: Participants in three divisions were unclear about their roles, duties, and policy governing policing of SCS. Participants in the fourth division had received instructions from the division commander to observe a "distance and discretion policy". However, these participants believed that developing familiarity with the new SCS, instead of keeping a distance, would be a more effective approach to building working relationships with staff, clients, and the local community. There was nearly unanimous skepticism about the willingness of SCS workers to work cooperatively with the police. These perceptions were commonly linked to previous negative experiences with harm reduction workers and, in some cases, staff at the new SCS. Several participants also linked problems in communication to fundamental differences between the philosophies or worldviews of SCS staff versus those of police. Conclusions: Building collaborative SIS-police relationships can be assisted by demystifying the operation of SCS for police, articulating policies, and working toward mutual respect.

A scoping review of harm reduction training for police officers

ISSUES

Preventable overdose deaths, especially due to opioids, have increasingly been reported worldwide. Expansion of life-saving harm reduction services is underway with increasing public support in some jurisdictions. However, such services often fall short of reaching people who use drugs (PWUD), in part, due to law enforcement practices that are aligned with punitive drug laws and incongruent with harm reduction principles. One suggested strategy to facilitate police understanding and uptake of practices that are more congruent with harm reduction is to provide police with relevant training.

APPROACH

This scoping review synthesises English-language peer-reviewed and grey literature on harm reduction training programs for police.

KEY FINDINGS

We reviewed 31 sources and found that most trainings covered topics related to harm reduction objectives, overdose recognition and response, occupational safety and policing practices. Information was often presented via single-session, 1-hour long, slide-assisted presentations that were integrated into in-service trainings. Inconsistent throughout the literature was the career stage or position/rank of training audience (e.g. cadets, senior officers, street-level officers), when and how much training should be provided, and the occupational background of the training facilitator.

IMPLICATIONS

The available literature contains significant gaps pertaining to descriptions of training development, design and content specific to facilitating positive police-PWUD interactions, and formal evaluations. These gaps limit our understanding of what well-designed trainings may look like, if and how training alters policing practices, and to what extent training completion may lead to improved outcomes.

CONCLUSION

Greater research and formal evaluations of harm reduction training for police is recommended.

Police violence among people who inject drugs in Baltimore, Maryland

BACKGROUND

Police violence is a deleterious public health and criminal justice issue that disproportionately affects people who inject drugs (PWID). Studies documenting the prevalence and correlates of physical police violence in this population are rare. The aim of this study was to examine the correlates of past year physical police violence among an urban sample of PWID.

METHODS

PWID participating in the 2015 wave of the National HIV Behavioral Surveillance (NHBS) system in Baltimore City, Maryland, completed a socio-behavioral survey. Multivariable logistic regression was used to detect the socio-demographic, place-based, law-enforcement and health behavior correlates of exposure to police violence as well as knowledge of violence directed towards other PWID.

RESULTS

Enrolled PWID (N = 570) were mostly male (72%), non-Hispanic Black (77%) and daily heroin injectors (86%). Seven percent had experienced past year physical police violence (Respondent-Driven Sampling [RDS] weighted estimate: 4%), and a quarter (24%) knew someone who had experienced physical police violence in the past year (RDS-weighted estimate: 17%). Male gender, homelessness, arrest, drug paraphernalia confiscation, and receptive syringe sharing were independently associated with police violence. Knowing someone who had experienced police violence was independently correlated with selling drugs, arrest, and attending a syringe services program.

CONCLUSION

Population differences in the extent of police violence exposure indicate that experiences of police violence are not uniform among PWID. Violent encounters with police were associated with disruptions in harm reduction strategies that can prevent HIV and HCV transmission. This study adds to the small body of public health literature on police violence and highlights the importance of monitoring and addressing this critical issue.

Elimination of HIV transmission through novel and established prevention strategies among people who inject drugs

Despite the effectiveness of existing HIV prevention strategies for people who inject drugs (PWID), uncontrolled outbreaks of HIV among this group are common and occur around the world. In this Review, we summarise recent evidence for novel and established HIV prevention approaches to eliminate HIV transmission among PWID. Effective HIV prevention strategies include mobile needle and syringe programmes, pre-exposure prophylaxis, supervised injection facilities, and, to a lesser extent, some behavioural interventions. Studies have also shown the cost-effectiveness of long-standing HIV prevention strategies including needle and syringe programmes, opioid agonist therapy, and antiretroviral therapy for prevention. Although each individual intervention can reduce the risk of HIV acquisition among PWID, there is a consensus that a combination of approaches is required to achieve substantial and durable reductions in HIV transmission. Unfortunately, in many settings, the implementation of these interventions is often limited by public and political opposition that manifests as structural barriers to HIV prevention, such as the criminalisation of drug use. Given that there is ample evidence showing the effectiveness of several HIV prevention methods, social and political advocacy will be needed to overcome these barriers and integrate innovative HIV prevention approaches with addiction science to create effective drug policies.

Creating and sustaining cooperative relationships between supervised injection services and police: A qualitative interview study of international stakeholders

BACKGROUND

Supervised injection services (SIS) operate with special exemptions from drug law enforcement. Given the expansion of SIS and the opioid overdose crisis in numerous jurisdictions, now is a critical time to examine factors that contribute to cooperative SIS-police relationships. We sought to learn about SIS-police relationships from international jurisdictions with well-established as well as newer SIS.

METHODS

We conducted 16 semi-structured telephone interviews with SIS managers (n = 10) and police liaisons (n = 6) from 10 cities in seven different countries (Australia, Canada, Denmark, France, Germany, Netherlands, and Spain). All participants provided informed consent. We focused our coding and analysis on themes that emerged from the data.

RESULTS

Five key contributors to cooperative SIS-police relationships emerged from the data: early engagement and dialogues; supportive police chiefs; dedicated police liaisons; negotiated boundary agreements; and regular face-to-face contact. Most participants perceived the less formalised, on-the-ground approach to relationship-building between police and SIS adopted in their city to be working well in general. SIS managers and police participants reported a lack of formal police training on harm reduction, and some thought that training was unnecessary given the relatively positive local SIS-police relationships they reported.

CONCLUSION

Our qualitative study provides new, in-depth empirical examples of how police in varied international jurisdictions can come to accept and work cooperatively with, not against, SIS staff and clients. Investing ongoing effort in SIS-police relationships, in a manner that best suits local needs, may hold greater and more sustainable public health value than delivering specific curricula to police.

Using a programmatic mapping approach to plan for HIV prevention and harm reduction interventions for people who inject drugs in three South African cities

BACKGROUND

Stigma, criminalisation and a lack of data on drug use contribute to the "invisibility" of people who inject drugs (PWID) and make HIV prevention and treatment service delivery challenging. We aimed to confirm locations where PWID congregate in Cape Town, eThekwini and Tshwane (South Africa) and to estimate PWID population sizes within selected electoral wards in these areas to inform South Africa's first multi-site HIV prevention project for PWID.

METHODS

Field workers (including PWID peers) interviewed community informants to identify suspected injecting locations in selected electoral wards in each city and then visited these locations and interviewed PWID. Interviews were used to gather information about the accessibility of sterile injecting equipment, location coordinates and movement patterns. We used the Delphi method to obtain final population size estimates for the mapped wards based on estimates from wisdom of the crowd methods, the literature and programmatic data.

RESULTS

Between January and April 2015, we mapped 45 wards. Tshwane teams interviewed 39 PWID in 12 wards, resulting in an estimated number of accessible PWID ranging from 568 to 1431. In eThekwini, teams interviewed 40 PWID in 15 wards with an estimated number of accessible PWID ranging from 184 to 350. The Cape Town team interviewed 61 PWID in 18 wards with an estimated number of accessible PWID ranging between 398 and 503. Sterile needles were only available at one location. Almost all needles were bought from pharmacies. Between 80 and 86% of PWID frequented more than one location per day. PWID who reported movement visited a median of three locations a day.

CONCLUSIONS

Programmatic mapping led by PWID peers can be used effectively to identify and reach PWID and build relationships where access to HIV prevention commodities for PWID is limited. PWID reported limited access to sterile injecting equipment, highlighting an important HIV prevention need. Programmatic mapping data show that outreach programmes should be flexible and account for the mobile nature of PWID populations. The PWID population size estimates can be used to develop service delivery targets and as baseline measures.

Police must join the fast track to end AIDS by 2030

World leaders have committed to ending AIDS by 2030, but stigma and discrimination remain significant obstacles. In particular, police are critical, front-line determinants of risk for many people living with HIV (PLHIV) and members of other key affected populations (KAPs). The negative impact of adverse police behaviours and practices on HIV risk is well documented, and these risks undermine global efforts to end AIDS. Far less well documented, and less common, are attempts to ameliorate this impact by working to change police behaviours. This Special Issue seeks to help redress this imbalance by presenting a selection of original, provocative and important interventions from academics, police officers and other stakeholders concerned with documenting the potential for constructive, progressive and evidence-based approaches to the reduction of HIV risk. We recommend urgent boosting of efforts and funding to engage police in the HIV response. Among other strategies, this needs sustainable funding of programmes and their evaluation, and increased and continuing advocacy and education at all levels to match policy and law reform.