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1.  Increased hepatitis C virus vaccine clinical trial literacy following a brief intervention among people who inject drugs 
Drug and alcohol review  2012;32(4):419-425.
Background and Aims
While people who inject drugs are at high risk of hepatitis C virus (HCV) infection and will be the target population for future HCV vaccine trials, little is known about clinical trial literacy (CTL) in this group. We assessed the impact of a brief intervention (BI) designed to improve HCV vaccine CTL among people who inject drugs in Sydney, Australia.
Design and Methods
People who inject drugs enrolled in a community-based prospective observational study between November 2008 and September 2010 (n = 102) completed a CTL assessment followed immediately by the BI. Post-test assessment was conducted at 24 weeks.
The median age of the sample was 27 years, 73% were male and 60% had 10 or less years of schooling. The median time since first injection was five years and 20% reported daily or more frequent injecting. The mean number of correct responses increased from 5.3 to 6.3/10 (t = −.4.2; 101df, P < 0.001) 24 weeks post-intervention. Statistically significant differences were observed for three knowledge items with higher proportions of participants correctly answering questions related to randomisation (P = 0.002), blinding (P = 0.005) and vaccine-induced seropositivity (P = 0.003) post-intervention.
Discussion and Conclusions
A significant increase in HCV vaccine CTL was observed, suggesting that new and relatively novel concepts can be learned and recalled in this group. These findings support the feasibility of future trials among this population.
PMCID: PMC3567229  PMID: 23113829
hepatitis C virus; injecting drug use; clinical trial literacy; brief intervention; vaccine preparedness study
2.  ‘It’s more about the heroin’: Injection drug users’ response to an overdose warning campaign in a Canadian setting 
Addiction (Abingdon, England)  2013;108(7):1270-1276.
To assess heroin injectors’ perceptions of and responses to a warning issued by public health officials regarding high-potency heroin and increases in fatal overdoses.
Semi-structured qualitative interviews
Vancouver, Canada.
Eighteen active heroin injectors
Semi-structured interview guide focussing on heroin injectors’ perceptions of and responses to the overdose warning, including reasons for failing to adhere to risk reduction recommendations.
Although nearly all participants were aware of the warning, their recollections of the message and the timing of its release were obscured by on-going social interactions within the drug scene focussed on heroin quality. Many injection drug users reported seeking the high potency heroin and nearly all reported no change in overdose risk behaviours. Responses to the warning were shaped by various social, economic and structural forces that interacted with individual behaviour and undermined efforts to promote behavioural change, including sales tactics employed by dealers, poverty, the high cost and shifting quality of available heroin, and risks associated with income-generating activities. Individual-level factors, including emotional suffering, withdrawal, entrenched injecting routines, perceived invincibility and the desire for intense intoxication also undermined risk reduction messages.
Among heroin injectors in British Columbia, a 2011 overdose warning campaign appeared to be of limited effectiveness and also produced unintended negative consequences that exacerbated overdose risk.
PMCID: PMC3913056  PMID: 23551565
heroin; injection drug use; overdose; public health warning
3.  Did Somebody Say Community? Young People’s Critiques of Conventional Community Narratives in the Context of a Local Drug Scene 
Human organization  2013;72(2):98-110.
The language of community is ubiquitous in academic, public health, and policy discourse about drug using populations. Yet, it has been argued that in some settings, the parameters of “the drug user community” are far from self-evident. We undertook this ethnographic investigation to explore experiences and understandings of a “drug user community” (sometimes referred to more specifically as a “street youth community”) among young people entrenched in Vancouver’s inner city drug scene. Our findings revealed that in this context, conventional notions of community—that is, a social network characterized by commonality, mutual responsibility, solidarity, and/or stability—resonated with some youth. However, most questioned the value of membership within this community, in which what they had in common with other youth were ongoing experiences of poverty, marginalization, and social exclusion. Many felt membership in the drug user community precluded their ability to be responsible and productive citizens within the wider community of “mainstream society.” Experiences of resource deprivation and everyday violence on the streets led many participants to emphasize the limited possibilities for community among their peers. We argue that it is important to critically examine heretofore essentializing assumptions about the nature of inner city drug user or street youth communities in order to better understand young people’s needs and desires in these settings.
PMCID: PMC3947898  PMID: 24634540
drug scene; drug use; street youth; community; violence
4.  Declining Incidence of Hepatitis C Virus Infection among People Who Inject Drugs in a Canadian Setting, 1996-2012 
PLoS ONE  2014;9(6):e97726.
People who inject drugs (PWID) are at high risk of hepatitis C virus (HCV) infection. Trends in HCV incidence and associated risk factors among PWID recruited between 1996 and 2012 in Vancouver, Canada were evaluated.
Data were derived from a long-term cohort of PWID in Vancouver. Trends in HCV incidence were evaluated. Factors associated with time to HCV infection were assessed using Cox proportional hazards regression.
Among 2,589, 82% (n = 2,121) were HCV antibody-positive at enrollment. Among 364 HCV antibody-negative participants with recent (last 30 days) injecting at enrollment, 126 HCV seroconversions were observed [Overall HCV incidence density: 8.6 cases/100 person-years (py); 95% confidence interval (95% CI): 7.2, 10.1; HCV incidence density among those with injecting during follow-up: 11.5 cases/100 py; 95% CI 9.7, 13.6]. The overall HCV incidence density declined significantly from 25.0/100 py (95% CI: 20.2, 30.3) in 1996–99, as compared to 6.0/100 py (95% CI: 4.1, 8.5) in 2000–2005, and 3.1/100 py (95% CI: 2.0, 4.8) in 2006–2012. Among those with injecting during follow-up, the overall HCV incidence density declined significantly from 27.9/100 py (95% CI: 22.6, 33.6) in 1996–99, as compared to 7.5/100 py (95% CI: 5.1, 10.6) in 2000–2005, and 4.9/100 py (95% CI: 3.1, 7.4) in 2006–2012. Unstable housing, HIV infection, and injecting of cocaine, heroin and methamphetamine were independently associated with HCV seroconversion.
HCV incidence has dramatically declined among PWID in this setting. However, improved public health strategies to prevent and treat HCV are urgently required to reduce HCV-associated morbidity and mortality.
PMCID: PMC4045728  PMID: 24897109
5.  A Mixed Methods Approach to Exploring the Relationship between Norway Rat (Rattus norvegicus) Abundance and Features of the Urban Environment in an Inner-City Neighborhood of Vancouver, Canada 
PLoS ONE  2014;9(5):e97776.
Urban rats (Rattus spp.) are among the most ubiquitous pest species in the world. Previous research has shown that rat abundance is largely determined by features of the environment; however, the specific urban environmental factors that influence rat population density within cities have yet to be clearly identified. Additionally, there are no well described tools or methodologies for conducting an in-depth evaluation of the relationship between urban rat abundance and the environment. In this study, we developed a systematic environmental observation tool using methods borrowed from the field of systematic social observation. This tool, which employed a combination of quantitative and qualitative methodologies, was then used to identify environmental factors associated with the relative abundance of Norway rats (Rattus norvegicus) in an inner-city neighborhood of Vancouver, Canada. Using a multivariate zero-inflated negative binomial model, we found that a variety of factors, including specific land use, building condition, and amount of refuse, were related to rat presence and abundance. Qualitative data largely supported and further clarified observed statistical relationships, but also identified conflicting and unique situations not easily captured through quantitative methods. Overall, the tool helped us to better understand the relationship between features of the urban environment and relative rat abundance within our study area and may useful for studying environmental determinants of zoonotic disease prevalence/distribution among urban rat populations in the future.
PMCID: PMC4022650  PMID: 24830847
6.  Loss of Nuclear Receptor SHP Impairs but Does Not Eliminate Negative Feedback Regulation of Bile Acid Synthesis 
Developmental cell  2002;2(6):713-720.
The in vivo role of the nuclear receptor SHP in feedback regulation of bile acid synthesis was examined. Loss of SHP in mice caused abnormal accumulation and increased synthesis of bile acids due to derepression of rate-limiting CYP7A1 and CYP8B1 hydroxylase enzymes in the biosynthetic pathway. Dietary bile acids induced liver damage and restored feedback regulation. A synthetic agonist of the nuclear receptor FXR was not hepatotoxic and had no regulatory effects. Reduction of the bile acid pool with cholestyramine enhanced CYP7A1 and CYP8B1 expression. We conclude that input from three negative regulatory pathways controls bile acid synthesis. One is mediated by SHP, and two are SHP independent and invoked by liver damage and changes in bile acid pool size.
PMCID: PMC4010195  PMID: 12062084
7.  Increases and decreases in drug use attributed to housing status among street-involved youth in a Canadian setting 
Among a cohort of drug-using street-involved youth, we sought to identify the prevalence of reporting increases and decreases in illicit drug use due to their current housing status and to identify factors associated with reporting these changes.
This longitudinal study was based on data collected between June 2008 and May 2012 from a prospective cohort of street-involved youth aged 14–26 in Vancouver, Canada. At semi-annual study follow-up visits, youth were asked if their drug use was affected by their housing status. Using generalized estimating equations, we identified factors associated with perceived increases and decreases in drug use attributed to housing status. Among our sample of 536 participants at baseline, 164 (31%) youth reported increasing their drug use due to their housing situation and 71 (13%) reported decreasing their drug use. In multivariate analysis, factors that were positively associated with perceived increases in drug use attributed to housing status included the following: being homeless, engaging in sex work and drug dealing. Regular employment was negatively associated with increasing drug use due to housing status. Among those who reported decreasing their drug use, only homelessness was significant in bivariate analysis.
Perceived changes in drug use due to housing status were relatively common in this setting and were associated with being homeless and, among those who increased their drug use, engaging in risky income generation activities. These findings suggest that structural factors, particularly housing and economic opportunities, may be crucial interventions for reducing or limiting drug use among street-involved youth.
PMCID: PMC3999483  PMID: 24721725
Homelessness; Drug use; Street-involved youth; Stable housing; Risk behaviour; Employment
8.  Homelessness Independently Predicts Injection Drug Use Initiation among Street-involved Youth in a Canadian setting 
This longitudinal study examines the association between homelessness and injection drug use initiation among a cohort of street-involved youth in a setting of high prevalence crystal methamphetamine use.
Data were derived from the At-Risk Youth Study, a prospective cohort of street-involved youth aged 14 to 26 recruited between September 2005 and November 2011. Cox proportional hazards regression was used to identify factors independently associated with time to injection initiation.
Among 422 street-youth who had never injected at baseline, 77 injection initiation events were observed during follow-up. Homelessness was independently associated with injection initiation in multivariate Cox regression (Relative Hazard: 1.80 [95% CI: 1.13–2.87]) after adjusting for crystal methamphetamine use and other potential confounders.
These findings highlight that homelessness is a key risk factor for injection initiation among street-involved youth. Supportive housing interventions for street-youth may help prevent injection drug use initiation among this high-risk population.
PMCID: PMC3608753  PMID: 23299006
Youth; injection drug use; initiation; homelessness
9.  HIV pre-exposure prophylaxis for people who inject drugs: a review of current results and an agenda for future research 
Studies examining the use of pre-exposure prophylaxis (PrEP) to prevent HIV transmission among people who inject drugs (PWIDs) have not been adequately summarized. Recently, the Bangkok Tenofovir Study has shown that PrEP may be effective at reducing new HIV infections among this high-risk group. This randomized controlled trial was the first study to specifically examine the efficacy of PrEP among PWIDs. In this review, we present the current state of evidence regarding the use of PrEP to prevent HIV infection in PWID populations, and set an agenda for future research to inform the most effective implementation of PrEP in the context of existing evidence-based HIV prevention strategies.
Despite positive trial results confirming that PrEP may prevent HIV transmission among PWIDs, there remain many questions regarding the interpretation of these results, as well as obstacles to the implementation of PrEP regimens within highly diverse drug-using communities. Aside from the Bangkok Tenofovir Study, we identified only one other published study that has collected empirical data to inform the use of PrEP among PWIDs. The large gap in research regarding the use and implementation of PrEP for PWIDs signals the need for further research and attention.
We recommend that future research efforts focus on elucidating the generalizability of the Bangkok Tenofovir Study results in other injection drug–using populations, examining the willingness of PWIDs to use PrEP in diverse contexts, identifying barriers to adherence to PrEP regimens and determining the most effective ways to implement PrEP programmes within the context of existing evidence-based prevention strategies, including opioid substitution therapy and needle and syringe distribution programmes.
PMCID: PMC3969508  PMID: 24679634
HIV; pre-exposure prophylaxis; injection drug use; people who inject drugs
10.  Severe food insecurity is associated with elevated unprotected sex among HIV-seropositive injection drug users independent of HAART use 
AIDS (London, England)  2011;25(16):2037-2042.
Despite emerging evidence of a significant adverse relationship between food insecurity and sexual risk-taking, data have been primarily derived from resource-constrained settings and HIV-negative populations. To our knowledge, this study is the first to longitudinally evaluate the relationship between food insecurity and unprotected sex among HIV-seropositive people who inject drugs [injection drug users (IDUs)] both on and not on HAART.
Longitudinal analyses were restricted to HIV-positive IDUs who completed baseline and at least one follow-up visit in a prospective cohort (AIDS Care Cohort to evaluate Exposure to Survival Services, 2005–2009).
We constructed a multivariate logistic model using generalized estimating equations (GEEs) to assess an independent relationship between severe food insecurity (e.g., hunger due to lack of access or means to acquire food) and unprotected vaginal/anal sex.
Among 470 HIV-positive IDUs, the median age was 42 years (interquartile range 36–47) with 61% men and 39% women. The prevalence of severe food insecurity was 71%, with no differences by HAART use. Severe food insecure IDUs were marginally less likely to have a suppressed HIV-1 RNA viral load (31 vs. 39%, p=0.099). In multivariate GEE analyses, severe food insecurity [adjusted odds ratio=2.68, 95% confidence interval 1.49–4.82] remained independently correlated with unprotected sex among HIV-positive IDUs, controlling for age, sex/gender, married/cohabitating partner, binge drug use, homelessness, and HAART use.
These findings highlight a crucial need for structural HIV interventions that incorporate targeted food assistance strategies for IDUs. Given recent evidence of poor virological response among food insecure individuals on HAART, innovative HIV care models should integrate targeted food security programs and early access to HAART.
PMCID: PMC3956106  PMID: 21811140
food insecurity; HAART; HIV/AIDS; injection drug use; sexual risk
11.  Social and structural factors associated with HIV disease progression among illicit drug users: A systematic review 
AIDS (London, England)  2012;26(9):1049-1063.
To systematically review factors associated with HIV disease progression among illicit drug users, focusing on exposures exogenous to individuals that likely shape access and adherence to HIV treatment.
A systematic review of peer-reviewed English-language studies among HIV-seropositive illicit drug users with at least one of these endpoint of interest: a diagnosis of AIDS; death; changes/differences in CD4 cell counts; or changes/differences in plasma HIV-1 RNA levels.
Articles were included if they reported factors associated with an outcome of interest among a group of illicit drug users. Studies were identified, screened and selected using systematic methods.
Of 2,668 studies matching the search criteria, 58 (2%) met the inclusion criteria, all but one from North America or Western Europe. Overall, 41 (71%) studies contained significant individual-level clinical characteristics or behaviours (e.g., illicit drug use) associated with disease progression. Fifteen studies (26%) identified significant social, physical, economic or policy-level exposures, including incarceration, housing status or lack of legal income.
While past studies demonstrate important environmental exposures that appear to shape access to care and subsequent disease progression, the limited literature to examine these factors demonstrates the need for future research to consider risk environment characteristics and the role they may play in shaping health outcomes from HIV infection among drug users through determining access and adherence to evidence-based care. (198 words)
PMCID: PMC3955099  PMID: 22333747
Antiretroviral therapy; CD4; drug users; pathogenesis; progression; risk factors; viral load
12.  Demographics, Health-Care Utilization, and Substance Use Profiles of Older Adults in Canada’s Lowest Income Neighbourhood 
Canadian Geriatrics Journal  2013;17(1):5-11.
This study aimed to determine the baseline demographics, health status, and drug use profiles of current and former substance-using older adults in Vancouver’s Downtown Eastside.
Data were derived from two U.S. National Institutes of Health-funded cohort studies of current and former illegal drug users in Vancouver’s Downtown Eastside. We used logistic regression of cross-sectional data obtained between June and November 2008 to calculate odds ratios and identify factors that were more commonly associated with cohort members being older adults (greater than or equal to age 50).
214 subjects (25%) were greater than or equal to age 50 upon study enrollment. Females (Adjusted Odds Ratio [AOR]: 0.50; 95% CI: 0.34–0.75) and individuals who reported Aboriginal ancestry (AOR: 0.49; 95% CI: 0.33–0.72) were less likely to be in the older cohort. Individuals with higher income (AOR: 2.07; 95% CI: 1.16–3.68 per $1,000), and those with a regular place to stay were more likely to be in older cohort (AOR: 3.39; 95% CI: 1.90–6.06). Older participants accessed family physicians more frequently (OR: 1.47; 95% CI: 1.01 – 2.16) and were more likely to be actively taking (OR: 3.34; 95% CI 1.71–6.55) or have taken (OR 3.21; 95% CI 1.58–6.53) HIV antiretroviral therapy. There were no differences between groups in regard to injection drug use status or daily alcohol intake.
Older current and former illegal drug users in a major inner city Canadian centre have different demographic, health-care, and drug utilization profiles. Further studies in this population are warranted.
PMCID: PMC3940477  PMID: 24596588
injection drug use; initiation; homeless; older adults
13.  High prevalence of exposure to the child welfare system among street-involved youth in a Canadian setting: implications for policy and practice 
BMC Public Health  2014;14:197.
Street-involved youth are more likely to experience trauma and adverse events in childhood; however, little is known about exposure to the child welfare system among this vulnerable population. This study sought to examine the prevalence and correlates of being in government care among street-involved youth in Vancouver, Canada.
From September 2005 to November 2012, data were collected from the At-Risk Youth Study, a prospective cohort of street-involved youth aged 14–26 who use illicit drugs. Logistic regression analysis was employed to identify factors associated with a history of being in government care.
Among our sample of 937 street-involved youth, 455 (49%) reported being in government care at some point in their childhood. In a multivariate analysis, Aboriginal ancestry (adjusted odds ratio [AOR] = 2.07; 95% confidence interval [CI]: 1.50 – 2.85), younger age at first “hard” substance use (AOR = 1.10; 95% CI: 1.05 – 1.16), high school incompletion (AOR = 1.40; 95% CI: 1.00 – 1.95), having a parent that drank heavily or used illicit drugs (AOR = 1.48; 95% CI: 1.09 – 2.01), and experiencing physical abuse (AOR = 1.90; 95% CI: 1.22 – 2.96) were independently associated with exposure to the child welfare system.
Youth with a history of being in government care appear to be at high-risk of adverse illicit substance-related behaviours. Evidence-based interventions are required to better support vulnerable children and youth with histories of being in the child welfare system, and prevent problematic substance use and street-involvement among this population.
PMCID: PMC3936938  PMID: 24564822
Child welfare system; Foster care; Government care; Street-involved youth; Youth substance use
14.  The impact of harm reduction on HIV and illicit drug use 
There has been widespread support for harm reduction programs as an essential component for responding to the HIV and illicit drug use epidemics. However, despite the growing international acceptance of harm reduction, there continues to be strong opposition to this approach, with critics alleging that harm reduction programs enable drug use. Vancouver, Canada provides a compelling case study that demonstrates that many positive impacts of harm reduction can be attained while addiction treatment-related goals are simultaneously supported. While the evidence for harm reduction is clearly mounting, it is unfortunate that ideological and political barriers to implementing harm reduction programs in Canada remain. As evidenced by Vancouver and elsewhere, harm reduction programs do not exacerbate drug use and undermine treatment efforts and should thereby occupy a well-deserved space within the continuum of programs and services offered to people who inject drugs.
PMCID: PMC3936850  PMID: 24559062
Harm reduction; Illicit drug use; Canada
15.  Expansion of HAART Coverage Is Associated with Sustained Decreases in HIV/AIDS Morbidity, Mortality and HIV Transmission: The “HIV Treatment as Prevention” Experience in a Canadian Setting 
PLoS ONE  2014;9(2):e87872.
There has been renewed call for the global expansion of highly active antiretroviral therapy (HAART) under the framework of HIV treatment as prevention (TasP). However, population-level sustainability of this strategy has not been characterized.
We used population-level longitudinal data from province-wide registries including plasma viral load, CD4 count, drug resistance, HAART use, HIV diagnoses, AIDS incidence, and HIV-related mortality. We fitted two Poisson regression models over the study period, to relate estimated HIV incidence and the number of individuals on HAART and the percentage of virologically suppressed individuals.
HAART coverage, median pre-HAART CD4 count, and HAART adherence increased over time and were associated with increasing virological suppression and decreasing drug resistance. AIDS incidence decreased from 6.9 to 1.4 per 100,000 population (80% decrease, p = 0.0330) and HIV-related mortality decreased from 6.5 to 1.3 per 100,000 population (80% decrease, p = 0.0115). New HIV diagnoses declined from 702 to 238 cases (66% decrease; p = 0.0004) with a consequent estimated decline in HIV incident cases from 632 to 368 cases per year (42% decrease; p = 0.0003). Finally, our models suggested that for each increase of 100 individuals on HAART, the estimated HIV incidence decreased 1.2% and for every 1% increase in the number of individuals suppressed on HAART, the estimated HIV incidence also decreased by 1%.
Our results show that HAART expansion between 1996 and 2012 in BC was associated with a sustained and profound population-level decrease in morbidity, mortality and HIV transmission. Our findings support the long-term effectiveness and sustainability of HIV treatment as prevention within an adequately resourced environment with no financial barriers to diagnosis, medical care or antiretroviral drugs. The 2013 Consolidated World Health Organization Antiretroviral Therapy Guidelines offer a unique opportunity to further evaluate TasP in other settings, particularly within generalized epidemics, and resource-limited setting, as advocated by UNAIDS.
PMCID: PMC3922718  PMID: 24533061
16.  Carriage of Methicillin-Resistant Staphylococcus aureus by Wild Urban Norway Rats (Rattus norvegicus) 
PLoS ONE  2014;9(2):e87983.
Methicillin-resistant Staphylococcus aureus (MRSA) is an important cause of multi-drug-resistant infections in people, particularly indigent populations. MRSA can be transmitted between people and domestic animals, but the potential for transmission between people and commensal pests, particularly rodents, had not been investigated. The objective of this study was to identify the presence and characterize the ecology of MRSA in rats (Rattus spp.) from in an impoverished, inner-city neighborhood. Oropharyngeal swabs were collected from rats trapped in 33 city blocks and one location within the adjacent port. Bacterial culture was performed and MRSA isolates were characterized using a variety of methods, including whole-genome sequencing (WGS). The ecology of MRSA in rats was described using phylogenetic analysis, geospatial analysis, and generalized linear mixed models. MRSA was identified 22 of 637 (3.5%) rats tested, although prevalence varied from 0 – 50% among blocks. Isolates belonged to 4 clusters according to WGS, with the largest cluster (n = 10) containing isolates that were genetically indistinguishable from community-acquired USA300 MRSA strains isolated from people within the study area. MRSA strains demonstrated both geographic clustering and dispersion. The odds of an individual rat carrying MRSA increased with increased body fat (OR = 2.53, 95% CI = 1.33 – 4.82), and in the winter (OR = 5.29, 95% CI = 1.04 – 26.85) and spring (OR = 5.50, 95% CI = 1.10 – 27.58) compared to the fall. The results show that urban rats carried the same MRSA lineages occurring in local human and/or animal populations, supporting recent transmission from external sources. MRSA carriage was influenced by season, most likely as a result of temporal variation in rat behavior and rat-human interactions.
PMCID: PMC3912160  PMID: 24498421
17.  Groin injecting among a community-recruited sample of people who inject drugs in Thailand 
Use of the femoral vein for the injection of illicit drugs (i.e. groin injecting) has been linked to various health-related harms, including deep vein thrombosis. However, little is known about the prevalence of groin injecting and factors that predict this practice among people who inject drugs (PWID) in Thailand. We sought to investigate the prevalence and factors associated with groin injecting in Bangkok, Thailand.
Data were derived from the Mitsampan Community Research Project in Bangkok between July and October 2011. Multivariate logistic regression was used to identify factors associated with groin injecting in the last six months.
Among 437 participants, 34.3% reported groin injecting in the last six months. In multivariate analyses, factors positively associated with groin injecting included: having higher than secondary education (adjusted odds ratio [AOR] = 1.59; 95% confidence interval [CI]: 1.00 – 2.56), weekly midazolam injection (AOR = 8.26; 95% CI: 5.04 – 14.06), and reports of having had drugs planted on oneself by police (AOR = 2.14; 95% CI: 1.37 – 3.36).
Over one-third of our sample of Thai PWID reported recent groin injecting. Frequent midazolam injection and higher education were found to be associated with groin injecting. That high intensity PWID were more likely to inject in the groin is concerning given the known negative consequences associated with the groin as a site of injection. Additionally, PWID who reported drug planting by police were more likely to inject in the groin, suggesting that reliance on law enforcement approaches may undermine safe injection practices in this setting. These findings highlight the need for evidence-based interventions to address the harms associated with groin injecting, including efforts to alert PWID to risks of groin injecting, the distribution of appropriate injecting equipment, and efforts to encourage use of other injecting sites.
PMCID: PMC3904698  PMID: 24433435
Groin injection; People who inject drugs; Midazolam; Police; Thailand
18.  Police confrontations among street-involved youth in a Canadian setting 
Street-level policing has been recognized as a driver of health-related harms among people who inject drugs (IDU). However, the extent of interaction between police and street-involved youth has not been well characterized. We examined the incidence and risk factors for police confrontations among street-involved youth in a Canadian setting.
Using data derived from participants enrolled in the At-Risk Youth Study (ARYS) between 2005 and 2011, we assessed factors associated with being stopped, searched, or detained by police without arrest in the previous six months using generalized estimating equations (GEE) with logit link for binary outcomes.
Among 991 participants followed during the study period, 440 (44.4%) reported being stopped, searched, or detained by police for an incidence density of 49.20 (95% confidence interval [CI]: 36.42–65.01) per 100 person years. In multivariate GEE analyses, factors associated with police confrontations included: male gender (adjusted odds ratio [AOR] = 1.35), homelessness (AOR = 2.05), recent incarceration (AOR = 1.78), daily cannabis use (AOR = 1.31), daily heroin injecting (AOR = 1.36), crack pipe/syringe sharing (AOR = 1.61), injection drug use (AOR = 1.37), public drug use (AOR = 2.19), sex work involvement (AOR = 1.67), and drug dealing (AOR = 1.49) (all p<0.05). In total, 19.0% of participants reported that police confiscated their drug paraphernalia without arresting them. Additionally, 16.9% individuals reported experiencing violence at the hands of police.
We found that various factors, such as homelessness and markers of more severe addiction, increased the likelihood of being confronted by police, and police confrontations were associated with markers of health-related harm among street youth. These findings highlight the need for social and structural interventions that best enable police to fulfill public safety and public order objectives without negatively influencing health behaviours of street youth.
PMCID: PMC3498516  PMID: 22883543
street-involved youth; policing; Vancouver; illicit drug use
19.  The impact of social, structural and physical environmental factors on transitions into employment among people who inject drugs 
Social science & medicine (1982)  2012;76(1):126-133.
Despite growing awareness of the importance of context for the health of people who use drugs, studies examining labour market outcomes have rarely considered the role that physical, social and structural factors play in shaping labour market participation among drug users. Using discrete time event history analyses, we assessed associations between high-intensity substance use, individual drug use-related risk and features of inner-city drug use scenes with transitions into regular employment. Data were derived from a community-recruited cohort of people who inject drugs in Vancouver, Canada (n=1579) spanning the period of May 1996 to May 2005. Results demonstrate that systematic socio-demographic differences in labour market outcomes in this context generally correspond to dimensions of demographic disadvantage. Additionally, in initial analyses, high-intensity substance use is negatively associated with transitions into employment. However, this negative association loses significance when indicators measuring exposure to physical, social and structural features of the broader risk environment are considered. These findings indicate that interventions designed to improve employment outcomes among drug users should address these social, structural and physical components of the risk environment as well as promote the cessation of drug use.
PMCID: PMC3525755  PMID: 23157930
Canada; drug use; employment; risk environment; Vancouver
20.  Experiences with Policing among People Who Inject Drugs in Bangkok, Thailand: A Qualitative Study 
PLoS Medicine  2013;10(12):e1001570.
Using thematic analysis, Kerr and colleagues document the experiences of policing among people who inject drugs in Bangkok and examine how interactions with police can affect drug-using behaviors and health care access.
Please see later in the article for the Editors' Summary
Despite Thailand's commitment to treating people who use drugs as “patients” not “criminals,” Thai authorities continue to emphasize criminal law enforcement for drug control. In 2003, Thailand's drug war received international criticism due to extensive human rights violations. However, few studies have since investigated the impact of policing on drug-using populations. Therefore, we sought to examine experiences with policing among people who inject drugs (PWID) in Bangkok, Thailand, between 2008 and 2012.
Methods and Findings
Between July 2011 and June 2012, semi-structured, in-depth interviews were conducted with 42 community-recruited PWID participating in the Mitsampan Community Research Project in Bangkok. Interviews explored PWID's encounters with police during the past three years. Audio-recorded interviews were transcribed verbatim, and a thematic analysis was conducted to document the character of PWID's experiences with police. Respondents indicated that policing activities had noticeably intensified since rapid urine toxicology screening became available to police. Respondents reported various forms of police misconduct, including false accusations, coercion of confessions, excessive use of force, and extortion of money. However, respondents were reluctant to report misconduct to the authorities in the face of social and structural barriers to seeking justice. Respondents' strategies to avoid police impeded access to health care and facilitated transitions towards the misuse of prescribed pharmaceuticals. The study's limitations relate to the transferability of the findings, including the potential biases associated with the small convenience sample.
This study suggests that policing in Bangkok has involved injustices, human rights abuses, and corruption, and policing practices in this setting appeared to have increased PWID's vulnerability to poor health through various pathways. Novel to this study are findings pertaining to the use of urine drug testing by police, which highlight the potential for widespread abuse of this emerging technology. These findings raise concern about ongoing policing practices in this setting.
Please see later in the article for the Editors' Summary
Editors' Summary
In many countries, the dominant strategy used to control illegal drugs such as heroin and methamphetamine is criminal law enforcement, a strategy that sometimes results in human rights abuses such as ill-treatment by police, extrajudicial killings, and arbitrary detention. Moreover, growing evidence suggests that aggressive policing of illicit drug use can have adverse public-health consequences. For example, the fear engendered by intensive policing may cause people who inject drugs (PWID) to avoid services such as needle exchanges, thereby contributing to the HIV/AIDS epidemic. One country with major epidemics of illicit drug use and of HIV/AIDS among PWID is Thailand. Although Thailand reclassified drug users as “patients” instead of “criminals” in 2002, possession and consumption of illicit drugs remain criminal offenses. The 2002 legislation also created a system of compulsory drug detention centers, most of which lack evidence-based addiction treatment services. In 2003, the Thai government launched a campaign to suppress drug trafficking and to enrol 300,000 people who use drugs into treatment. This campaign received international criticism because it involved extensive human rights violations, including more than 2,800 extrajudicial killings of suspected drug users and dealers.
Why Was This Study Done?
Drug-related arrests and compulsory detention of drug users are increasing in Thailand but what is the impact of current policing practices on drug users and on public health? In this qualitative study (a study that aims for an in-depth understanding of human behavior), the researchers use thematic analysis informed by the Rhodes' Risk Environment Framework to document the social and structural factors that led to encounters with the police among PWID in Bangkok between 2008 and 2012, the policing tactics employed during these encounters, and the associated health consequences of these encounters. The Risk Environment Framework posits that a range of social, political, economic, and physical environmental factors interact with each other and shape the production of drug-related harm.
What Did the Researchers Do and Find?
Between July 2011 and June 2012, the researchers conducted in-depth interviews with a convenience sample (a non-random sample from a nearby population) of 42 participants in the Mitsampan Community Research Project, an investigation of drug-using behavior, health care access, and drug-related harms among PWID in Bangkok. Respondents reported that policing activities had intensified since rapid urine toxicology screening became widely available and since the initiation of a crackdown on drug users in 2011. They described various forms of violence and misconduct that they had experienced during confrontations with police, including false accusations, degrading stop and search procedures, and excessive use of force. Urine drug testing was identified as a key tool used by the police, with some respondents describing how police caused unnecessary humiliation by requesting urine samples in public places. It was also reported that the police used positive test results as a means of extortion. Finally, some respondents reported feeling powerless in relation to the police and cited fear of retaliation as an important barrier to obtaining redress for police corruption. Others reported that they had adopted strategies to avoid the police such as staying indoors, a strategy likely to impede access to health care, or changing their drug-using behavior by, for example, injecting midazolam rather than methamphetamine, a practice associated with an increased risk of injection-related complications.
What Do These Findings Mean?
These findings suggest that the policing of PWID in Bangkok between 2008 and 2012 involved injustices, human rights abuses, and corruption and highlight the potential for widespread misuse of urine drug testing. Moreover, they suggest that policing practices in this setting may have increased the vulnerability of PWID to poor health by impeding their access to health care and by increasing the occurrence of risky drug-using behaviors. Because this study involved a small convenience sample of PWID, these findings may not be generalizable to other areas of Bangkok or Thailand and do not indicate whether police misconduct and corruption is highly prevalent across the all police departments in Bangkok. Nevertheless, these findings suggest that multilevel structural changes and interventions are needed to mitigate the harm associated with policing of illicit drug use in Bangkok. These changes will need to ensure full accountability for police misconduct and access to legal services for victims of this misconduct. They will also need to include ethical guidelines for urine drug testing and the reform of policies that promote repressive policing and compulsory detention.
Additional Information
Please access these websites via the online version of this summary at
This study is further discussed in a PLOS Medicine Perspective by Burris and Koester
Human Rights Watch, a global organization dedicated to defending and protecting human rights, has information about drug policy and human rights, which includes information on Thailand
The Global Commission on Drug Policy published a report in June 2012 entitled “The War on Drugs and HIV/AIDS: How the Criminalization of Drug Use Fuels the Global Pandemic” (available in several languages)
The Global Commission on HIV and the Law published a report in July 2012 entitled “HIV and the Law: Risk, Rights and Health” (available in several languages), the Open Society Foundations have prepared a briefing on this report
More information about the Mitsampan Community Research Project is available
PMCID: PMC3858231  PMID: 24339753
21.  Crystal methamphetamine and initiation of injection drug use among street-involved youth in a Canadian setting 
Although injection drug use is known to result in a range of health-related harms, including transmission of HIV and fatal overdose, little is known about the possible role of synthetic drugs in injection initiation. We sought to determine the effect of crystal methamphetamine use on risk of injection initiation among street-involved youth in a Canadian setting.
We used Cox regression analyses to identify predictors of injection initiation among injection-naive street-involved youth enrolled in the At-Risk Youth Study, a prospective cohort study of street-involved youth in Vancouver, British Columbia. Data on circumstances of first injection were also obtained.
Between October 2005 and November 2010, a total of 395 drug injection–naive, street-involved youth provided 1434 observations, with 64 (16.2%) participants initiating injection drug use during the follow-up period, for a cumulative incidence of 21.7 (95% confidence interval [CI] 1.7–41.7) per 100 person-years. In multivariable analysis, recent noninjection use of crystal methamphetamine was positively associated with subsequent injection initiation (adjusted hazard ratio 1.93, 95% CI 1.31–2.85). The drug of first injection was most commonly reported as crystal methamphetamine (14/31 [45%]).
Noninjection use of crystal methamphetamine predicted subsequent injection initiation, and crystal methamphetamine was the most commonly used drug at the time of first injection. Evidence-based strategies to prevent transition to injection drug use among crystal methamphetamine users are urgently needed.
PMCID: PMC3855114  PMID: 24130244
Cutaneous injection-related infections (CIRI) are a primary reason injection drug users (IDU) access the emergency department (ED).
Using Cox proportional hazard regression, we examined predictors of ED use for CIRI, stratified by sex, among 1083 supervised injection facility (SIF) users.
Over a four-year period, 289 (27%) visited the ED for CIRI, yielding an incidence density for females of 23.8 (95% confidence interval (CI): 19.3 – 29.0) and males of 19.2 per 100 person-years (95% CI: 16.7 – 22.1). Factors associated with ED use for CIRI among females included residing in the Downtown Eastside (DTES) (adjusted hazard ratio [AHR] = 2.06 [1.13 – 3.78]) and being referred to hospital by SIF nurses (AHR = 4.48 [2.76 – 7.30]). Among males, requiring assistance with injection (AHR = 1.38 [1.01 – 1.90]), being HIV-positive (AHR = 1.85 [1.34 – 2.55]), and being referred to hospital by SIF nurses (AHR = 2.97 [1.93 – 4.57]) were associated with an increased likelihood of an ED visit for CIRI.
These results suggest SIF nurses have facilitated referral of hospital treatment for CIRI, highlighting the need for continued development of efficient and collaborative efforts to reduce the burden of CIRI.
PMCID: PMC3856908  PMID: 24339842
abscesses; cellulitis; emergency department; epidemiology; gender; health services; injection drug use
23.  Incarceration is associated with used syringe lending among active injection drug users with detectable plasma HIV-1 RNA: a longitudinal analysis 
BMC Infectious Diseases  2013;13:565.
Informed by recent studies demonstrating the central role of plasma HIV-1 RNA viral load (VL) on HIV transmission, interventions to employ HIV antiretroviral treatment as prevention (TasP) are underway. To optimize these efforts, evidence is needed to identify factors associated with both non-suppressed VL and HIV risk behaviours. Thus, we sought to assess the possible role played by exposure to correctional facilities on VL non-suppression and used syringe lending among HIV-seropositive people who use injection drugs (PWID).
We used data from the ACCESS study, a community-recruited prospective cohort. We used longitudinal multivariate mixed-effects analyses to estimate the relationship between incarceration and plasma HIV-1 RNA > 500 copies/mL among antiretroviral therapy (ART)-exposed active PWID and, during periods of non-suppression, the relationship between incarceration and used syringe lending.
Between May 1996 and March 2012, 657 ART-exposed PWID were recruited. Incarceration was independently associated with higher odds of VL non-suppression (Adjusted Odds Ratio [AOR] = 1.54, 95% Confidence Interval [95% CI]: 1.10, 2.16). In a separate multivariate model restricted to periods of VL non-suppression, incarceration was independently associated with lending used syringes (AOR = 1.81, 95% CI: 1.03, 3.18).
The current findings demonstrate that incarceration is associated with used syringe lending among active PWID with detectable plasma HIV-1 RNA. Our results provide a possible pathway for the commonly observed association between incarceration and increased risk of HIV transmission. Our results suggest that alternatives to incarceration of non-violent PWID and evidence-based combination HIV prevention interventions for PWID within correctional facilities are urgently needed.
PMCID: PMC3924231  PMID: 24289651
24.  Sex-for-Crack exchanges: associations with risky sexual and drug use niches in an urban Canadian city 
While crack cocaine has been associated with elevated sexual risks and transmission of HIV/STIs, particularly in the context of street-based sex work, few empirical studies have examined correlates of direct sex-for-crack exchanges. This study longitudinally examined the correlates of sex-for-crack exchanges and associated effects on sexual risk outcomes among street-based female sex workers (SW) who use drugs in Vancouver, Canada.
Data were drawn from a prospective cohort of street-based SWs (2006–2008), restricted to those who smoke crack cocaine. Multivariable generalized estimating equations (GEE) were employed to examine the correlates of exchanging sex for crack. A confounding model using GEE quasi-Poisson regression modeled the independent effect of exchanging sex for crack on number of clients/week.
Of 206 SWs, 101 (49%) reported sex-for-crack exchanges over 18 months of follow-up. In multivariable GEE analyses, sharing a crack pipe with a client (aOR = 1.98; 95%CI: 1.27-3.08) and smoking crack in a group of strangers (e.g., in an alley or crackhouse) (aOR = 1.70; 95% CI: 1.13-2.58) were independently correlated with sex-for-crack exchanges. In our confounding model, exchanging sex for crack (aIRR = 1.34; 95% CI: 1.07-1.69) remained significantly associated with servicing a greater number (>10) of clients/week.
These findings reveal elevated sexual- and drug- risk patterns among those who exchange sex for crack. The physical and social environment featured prominently in our results as a driver of sex-for-crack exchanges, highlighting the need for gender-sensitive multilevel approaches to harm reduction, STI and HIV prevention that address SWs’ environment, individual level factors, and the interplay between them.
PMCID: PMC3833173  PMID: 24238367
Crack cocaine; Sex work; Sexual risk; HIV; STI
25.  Factors Associated With Intention to Use Internet-Based Testing for Sexually Transmitted Infections Among Men Who Have Sex With Men 
Internet-based testing programs are being increasingly used to reduce testing barriers for individuals at higher risk of infection, yet the population impact and potential for exacerbation of existing health inequities of these programs are not well understood.
We used a large online sample of men who have sex with men (MSM) in Canada to measure acceptability of Internet-based testing and perceived advantages and disadvantages of this testing approach.
We asked participants of the 2011/2012 Sex Now Survey (a serial online survey of gay and bisexual men in Canada) whether they intended to use Internet-based testing and their perceived benefits and disadvantages of use. We examined whether intention to use was associated with explanatory variables spanning (A) sociodemographics, (B) Internet and technology usage, (C) sexually transmitted infections (STI)/ human immunodeficiency virus (HIV) and risk, and (D) health care access and testing, using multivariable logistic regression (variable selection using Bayesian information criterion).
Overall, intention to use was high (5678/7938, 71.53%) among participants with little variation by participant characteristics. In our final model, we retained the variables related to (B) Internet and technology usage: use of Internet to cruise for sex partners (adjusted odds ratio [AOR] 1.46, 95% CI 1.25-1.70), use of Internet to search for sexual health information (AOR 1.36, 95% CI 1.23-1.51), and mobile phone usage (AOR 1.19, 95% 1.13-1.24). We also retained the variables for (D) health care access and testing: not “out” to primary care provider (AOR 1.24, 95% CI 1.10-1.41), delayed/avoided testing due to privacy concerns (AOR 1.77, 95% CI 1.49-2.11), and delayed/avoided testing due to access issues (AOR 1.65, 95% CI 1.40-1.95). Finally, we retained the variable being HIV positive (AOR 0.56, 95% CI 0.46-0.68) or HIV status unknown (AOR 0.89, 95% CI 0.77-1.01), age <30 years (AOR 1.41, 95% CI 1.22-1.62), and identifying as bisexual (AOR 1.18, 95% CI 1.04-1.34) or straight/other (AOR 0.67, 95% CI 0.50-0.90). The greatest perceived benefits of Internet-based testing were privacy (2249/8388, 26.81%), general convenience (1701/8388, 20.28%), and being able to test at any time (1048/8388, 12.49%). The greatest perceived drawbacks were the inability to see a doctor or nurse (1507/8388, 17.97%), wanting to talk to someone about results (1430/8388, 17.97%), not wanting online results (1084/8388, 12.92%), and low trust (973/8388, 11.60%).
The high and wide-ranging intention to use that we observed suggests Internet-based testing has the potential to reach into all subgroups of MSM and may be particularly appealing to those facing current barriers to accessing STI/HIV testing and who are more comfortable with technology. These findings will be used to inform the promotion and further evaluation of an Internet-based testing program currently under development in British Columbia, Canada.
PMCID: PMC3841365  PMID: 24240644
homosexuality; male; Internet; testing; human immunodeficiency virus; sexually transmitted infection; health equity; patient acceptance of health care

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