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.
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.
Groin injection; People who inject drugs; Midazolam; Police; Thailand
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.
street-involved youth; policing; Vancouver; illicit drug use
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.
Canada; drug use; employment; risk environment; Vancouver
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.
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.
abscesses; cellulitis; emergency department; epidemiology; gender; health services; injection drug use
Individuals who are homeless or living in marginal conditions have an elevated burden of infection with HIV. Existing research suggests the HIV/AIDS pandemic in resource-rich settings is increasingly concentrated among members of vulnerable and marginalized populations, including homeless/marginally-housed individuals, who have yet to benefit fully from recent advances in highly-active antiretroviral therapy (HAART). We reviewed the scientific evidence investigating the relationships between inferior housing and the health status, HAART access and adherence and HIV treatment outcomes of people living with HIV/AIDS (PLWHA.) Studies indicate being homeless/marginally-housed is common among PLWHA and associated with poorer levels of HAART access and sub-optimal treatment outcomes. Among homeless/marginally-housed PLWHA, determinants of poorer HAART access/adherence or treatment outcomes include depression, illicit drug use and medication insurance status. Future research should consider possible social- and structural-level determinants of HAART access and HV treatment outcomes that have been shown to increase vulnerability to HIV infection among homeless/marginally-housed individuals. As evidence indicates homeless/marginally-housed PLWHA with adequate levels of adherence can benefit from HAART at similar rates to housed PLWHA, and given the individual and community benefits of expanding HAART use, interventions to identify HIV-seropositive homeless/marginally-housed individuals and engage them in HIV care including comprehensive support for HAART adherence are urgently needed.
HIV/AIDS; antiretroviral therapy; homelessness; People Living with HIV/AIDS (PLWHA); adherence; CD4+; plasma; HIV-1; RNA; viral load; highly-active antiretroviral therapy (HAART); behavior aspects of HIV/AIDS
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.
Crack cocaine pipe sharing is associated with various health-related harms, including hepatitis C transmission. Although difficulty accessing crack pipes has been found to predict pipe sharing, little is known about the factors that limit pipe access in settings where pipes are provided at no cost, albeit in limited capacity. Therefore, we investigated crack pipe access among people who use drugs in Vancouver, Canada.
Data was collected through two Canadian prospective cohort studies. Generalized estimating equations (GEE) with logit link for binary outcomes was used to identify factors associated with difficulty accessing crack pipes.
Among 914 participants who reported using crack cocaine, 33% reported difficulty accessing crack pipes. In multivariate analyses, factors independently associated with difficulty accessing crack pipes included: sex work involvement (adjusted odds ratio [AOR] = 1.57; 95% confidence interval [CI]: 1.03 – 2.39), having shared a crack pipe (AOR = 1.69; 95%CI: 1.32 – 2.16), police presence where one buys/uses drugs (AOR = 1.47; 95%CI: 1.10 – 1.95), difficulty accessing services (AOR = 1.74; 95%CI: 1.31 – 2.32), and health problems associated with crack use (AOR = 1.37; 95%CI: 1.04 – 1.79). Reasons given for difficulty accessing pipes included sources being closed (48.2%) and no one around selling pipes (18.1%).
A substantial proportion of people who smoke crack cocaine report difficulty accessing crack pipes in a setting where pipes are available at no cost but in limited quantity. These findings indicate the need for enhanced efforts to distribute crack pipes and address barriers to pipe access.
harm reduction; crack smoking; crack pipe access; Vancouver
Adherence to antiretroviral therapy (ART) among injection drug users (IDU) is often sub-optimal, yet little is known about changes in patterns of adherence since the advent of highly active antiretroviral therapy in 1996. We sought to assess levels of optimal adherence to ART among IDU in a setting of free and universal HIV care.
Data was collected through a prospective cohort study of HIV-positive IDU in Vancouver, British Columbia. We calculated the proportion of individuals achieving at least 95% adherence in the year following initiation of ART from 1996 to 2009.
Among 682 individuals who initiated ART, the median age was 37 (31–44) years with 248 (36.4%) female participants. The proportion achieving at least 95% adherence increased over time from 19.3% in 1996 to 65.9% in 2009 (Cochrane-Armitage test for trend: p < 0.001). In a logistic regression model examining factors associated with 95% adherence, initiation year was statistically significant (Odds Ratio = 1.08, 95% Confidence Interval: 1.03–1.13, p < 0.001 per year after 1996) after adjustment for a range of drug use variables and other potential confounders.
The proportion of IDU achieving at least 95% adherence during the first year of ART has consistently increased over a 13-year period. Although improved tolerability and convenience of modern ART regimens likely explain these positive trends, by the end of the study period a substantial proportion of IDU still had sub-optimal adherence demonstrating the need for additional adherence support strategies.
This study examined whether childhood sexual abuse predicts initiation of injection drug use in a prospective cohort of youth.
From October 2005 to November 2010, data were collected from the At Risk Youth Study (ARYS), a prospective cohort study of street-involved youth in Vancouver, Canada. Inclusion criteria were age 14-26 years, no lifetime drug injection, and non-injection drug use in the month preceding enrollment. Participants were interviewed at baseline and semiannually thereafter. Cox regression was employed to identify risk factors for initiating injection.
Among 395 injection-naïve youth, 81 (20.5%) reported childhood sexual abuse. During a median follow-up of 15.9 months (total follow-up 606.6 person-years), 45 (11.4%) youth initiated injection drug use, resulting in an incidence density of 7.4 per 100 person-years. In univariate analyses, childhood sexual abuse was associated with increased risk of initiating injection (unadjusted hazard ratio [HR], 2.38; 95% confidence interval [CI], 1.29–4.38; p=0.006), an effect that persisted in multivariate analysis despite adjustment for gender, age, Aboriginal ancestry and recent non-injection drug use (adjusted HR, 2.71; 95% CI, 1.42–5.20; p=0.003).
Childhood sexual abuse places drug users at risk for initiating injection. Addiction treatment programs should incorporate services for survivors of childhood maltreatment.
child abuse; sexual; drug abuse; adolescent; cohort studies
Among 559 street youth recruited between 2005 and 2007 in Vancouver, Canada, young drug users (<21years of age) were compared with older drug users (≥21 years) with regard to recent drug use and sexual practices using multiple logistic regression. Older youth were more likely to be male and of Aboriginal ancestry, to have more significant depressive symptoms, to have recently engaged in crack smoking, and to have had a recent history of injection drug use. Young drug users, by contrast, were more likely to have engaged in recent binge alcohol use. Efforts to reduce drug use-related harm among street youth may be improved by considering the highly prevalent use of “harder” drugs and risk for depression among older youth.
street youth; adolescents; injection; drug use; sex; HIV/AIDS
The objective of this study was to examine supervised injecting facility (SIF) use among a cohort of 395 HIV-positive injection drug users (IDUs) in Vancouver, Canada. The correlates of SIF use were identified using generalized estimating equation analyses. In multivariate analyses, frequent SIF use was associated with homelessness (adjusted odds ratio [AOR] = 1.90), daily heroin injection (AOR = 1.56), and daily cocaine injection (AOR = 1.59). The reasons given for not using the SIF included a preference for injecting at home and already having a safe place to inject. The SIF services most commonly used were needle exchange and nursing services. The SIF appears to have attracted a high-risk subpopulation of HIV-positive IDUs; this coverage perhaps could be extended with the addition of HIV- specific services such as disease monitoring and the provision of antiretroviral therapy.
For decades, Thailand has experienced high rates of illicit drug use and related harms. In response, the Thai government has relied on drug law enforcement to address this problem. Despite these efforts, high rates of drug use persist, and Thailand has been contending with an enduring epidemic of human immunodeficiency virus (HIV) among people who inject drugs (IDU).
In response to concerns regarding drug-related harm in Thailand and a lack of research focused on the experiences and needs of Thai IDU, the Mitsampan Community Research Project was launched in 2008. The project involved administering surveys capturing a range of behavioral and other data to community-recruited IDU in Bangkok in 2008 and 2009.
In total, 468 IDU in Bangkok were enrolled in the project. Results revealed high rates of midazolam injection, non-fatal overdose and incarceration. Syringe sharing remained widespread among this population, driven primarily by problems with access to syringes and methamphetamine injection. As well, reports of police abuse were common and found to be associated with high-risk behavior. Problems with access to evidence-based drug treatment and HIV prevention programs were also documented. Although compulsory drug detention centers are widely used in Thailand, data suggested that these centers have little impact on drug use behaviors among IDU in Bangkok.
The findings from this project highlight many ongoing health and social problems related to illicit drug use and drug policies in Bangkok. They also suggest that the emphasis on criminal justice approaches has resulted in human rights violations at the hands of police, and harms associated with compulsory drug detention and incarceration. Collectively, the findings indicate the urgent need for the implementation of evidence-based policies and programs in this setting.
Injection drug use; Drug law enforcement; Harm reduction; Community-based participatory research; Thailand
Employment is commonly upheld as an important outcome of addiction treatment. To explore this attribution we assessed whether treatment enrolment predicts employment initiation among participants enrolled in a community-recruited Canadian cohort of people who inject drugs (IDU) (n=1579). Survival analysis initially found no association between addiction treatment enrolment and employment initiation. However, when methadone maintenance therapy (MMT) was separated from other treatment modalities, non-MMT treatment positively predicted employment transitions, while MMT was negatively associated with employment initiation. Sub-analyses examining transitions into temporary, informal and under-the-table income generation echo these results. Findings suggest that individual factors impacting employment transitions may systematically apply to MMT clients, and that, in this setting, the impact of treatment on employment outcomes is contingent on treatment type and design. Treatment-specific differences underscore the need to expand low-threshold MMT, explore MMT alternatives and evaluate the impact of treatment design on the social and economic activity of IDU.
employment; addiction treatment; methadone maintenance therapy; Vancouver; injection drug use
We sought to identify factors associated with harmful microinjecting practices in a longitudinal cohort of IDU.
Using data from the Vancouver Injection Drug Users Study (VIDUS) between January 2004 and December 2005, generalized estimating equations (GEE) logistic regression was performed to examine sociodemographic and behavioral factors associated with four harmful microinjecting practices (frequent rushed injecting, frequent syringe borrowing, frequently injecting with a used water capsule, frequently injecting alone).
In total, 620 participants were included in the present analysis. Our study included 251 (40.5%) women and 203 (32.7%) self-identified Aboriginal participants. The median age was 31.9 (interquartile range: 23.4–39.3). GEE analyses found that each harmful microinjecting practice was associated with a unique profile of sociodemographic and behavioral factors.
We observed high rates of harmful microinjecting practices among IDU. The present study describes the epidemiology of harmful microinjecting practices and points to the need for strategies that target higher risk individuals including the use of peer-driven programs and drug-specific approaches in an effort to promote safer injecting practices.
injection drug use; harmful; Vancouver; microinjecting practices
Assisted injection is common among people who inject drugs (IDU), and has been associated with elevated risk for HIV infection and overdose. However, this practice has not been explored in the Asian context, including in Thailand, where HIV prevalence among IDU remains high.
Using multivariate logistic regression, we examined the prevalence and correlates of assisted injecting among IDU participating in the Mitsampan Community Research Project in Bangkok. We also sought to identify reasons for engaging in assisted injecting and those who provide this form of assistance.
In total, 430 IDU participated in this study, including 376 (87.5%) who reported having ever required assistance injecting, and 81 (18.8%) who reported assisted injecting in the previous six months. In multivariate analyses, assisted injecting in the previous six months was independently and positively associated with being female (adjusted odds ratio [AOR] = 2.42; 95% confidence interval [CI]: 1.40 – 4.18), being a weekly heroin injector (AOR = 1.78; 95% CI: 0.99 – 3.20), syringe sharing (AOR = 2.08; 95% CI: 1.18 – 3.68) and soft-tissue infection (AOR = 3.51; 95% CI: 1.43 – 2.53). Having a longer injecting career (AOR = 0.96; 95% CI: 0.94 – 0.99) was negatively associated with assisted injecting. Primary reasons given for engaging in assisted injecting included being new to injecting and lacking knowledge on how to inject. The most common providers of assistance with injecting were close friends.
We found a high prevalence of assisted injecting among IDU in Bangkok, with females, frequent heroin injectors, those with shorter injecting careers being more likely to engage in this practice. Those who require help with the injecting process are more likely to share syringes, and have skin infections. These findings indicate the need for interventions focused on promoting safer and self-administered injections.
Injection drug use; Thailand; Assisted injection
Current drug-control strategies in Canada focus funding and resources predominantly on drug law enforcement, often at the expense of preventive, treatment, and harm reduction efforts. This study aimed to examine the availability of the most commonly used substances in Vancouver, Canada after the implementation of such strategies.
Using data from two large cohorts of drug-using youth and adults in Vancouver from the calendar year 2007, we assessed perceived availability of heroin, crack, cocaine, crystal methamphetamine, and marijuana.
Compared to youth (n = 330), a greater proportion of adults (n = 1160) reported immediate access (i.e., within ten minutes) to heroin (81.0% vs. 55.9%, p < 0.001), crack (90.4% vs. 69.3%, p < 0.001) and cocaine (83.7% vs. 61.1%, p < 0.001). Conversely, larger proportions of youth reported immediate access to crystal methamphetamine (62.8% vs. 39.4%, p < 0.001) and marijuana (88.4% vs. 73.2%, p < 0.001) compared to adult users.
Regardless of differences in illicit drug availability by age, all drugs are readily accessed in Vancouver despite drug law enforcement efforts. This includes drugs that are frequently injected and place users at risk of human immunodeficiency virus (HIV) infection and transmission of other blood-borne disease.
Exchanging sex for money, drugs, or other commodities for survival is associated with an array of HIV risks. We sought to determine if street-involved drug-using sexual minority youth are at greater risk for survival sex work and are more likely to engage in risk behaviors with clients.
We examined factors associated with survival sex work among participants enrolled in the At Risk Youth Study using logistic regression. Self-reported risk behaviors with clients were also examined.
Of 558 participants eligible for this analysis, 75 (13.4%) identified as a sexual minority and 63 (11.3%) reported survival sex work in the past 6 months. Sexual minority males (adjusted odds ratio = 16.1, P < .001) and sexual minority females (adjusted odds ratio = 6.87, P < 0.001) were at significantly greater risk for survival sex work. Sexual minority youth were more likely to report inconsistent condom use with clients (odds ratio = 4.30, P = 0.049) and reported a greater number of clients in the past 6 months (median = 14 vs. 3, P = 0.008).
Sexual minority street youth are not only more likely to engage in survival sex work but also demonstrate elevated HIV risk behavior. These findings suggest that harm reduction and HIV prevention programs for sexual minority youth who exchange sex are urgently required.
adolescent; HIV; LGBT; sex work; sexual minority; street youth
Illegal drug use continues to be a major threat to community health and safety. We used international drug surveillance databases to assess the relationship between multiple long-term estimates of illegal drug price and purity.
We systematically searched for longitudinal measures of illegal drug supply indicators to assess the long-term impact of enforcement-based supply reduction interventions.
Data from identified illegal drug surveillance systems were analysed using an a priori defined protocol in which we sought to present annual estimates beginning in 1990. Data were then subjected to trend analyses.
Main outcome measures
Data were obtained from government surveillance systems assessing price, purity and/or seizure quantities of illegal drugs; systems with at least 10 years of longitudinal data assessing price, purity/potency or seizures were included.
We identified seven regional/international metasurveillance systems with longitudinal measures of price or purity/potency that met eligibility criteria. In the USA, the average inflation-adjusted and purity-adjusted prices of heroin, cocaine and cannabis decreased by 81%, 80% and 86%, respectively, between 1990 and 2007, whereas average purity increased by 60%, 11% and 161%, respectively. Similar trends were observed in Europe, where during the same period the average inflation-adjusted price of opiates and cocaine decreased by 74% and 51%, respectively. In Australia, the average inflation-adjusted price of cocaine decreased 14%, while the inflation-adjusted price of heroin and cannabis both decreased 49% between 2000 and 2010. During this time, seizures of these drugs in major production regions and major domestic markets generally increased.
With few exceptions and despite increasing investments in enforcement-based supply reduction efforts aimed at disrupting global drug supply, illegal drug prices have generally decreased while drug purity has generally increased since 1990. These findings suggest that expanding efforts at controlling the global illegal drug market through law enforcement are failing.
AUDIT; PUBLIC HEALTH
Thailand has for years attempted to address illicit drug use through aggressive drug law enforcement. Despite accounts of widespread violence by police against people who inject drugs (IDU), the impact of police violence has not been well investigated. In the wake of an intensified police crackdown in 2011, we sought to identify the prevalence and correlates of experiencing police beating among IDU in Bangkok.
Community-recruited samples of IDU in Bangkok were surveyed between June 2009 and October 2011. Multivariate log-binomial regression was used to identify factors associated with reporting police beating.
In total, 639 unique IDU participated in this serial cross-sectional study, with 240 (37.6%) participants reporting that they had been beaten by police. In multivariate analyses, reports of police beating were associated with male gender (Adjusted Prevalence Ratio [APR] = 4.43), younger age (APR = 1.69), reporting barriers to accessing healthcare (APR = 1.23), and a history of incarceration (APR = 2.51), compulsory drug detention (APR = 1.22) and syringe sharing (APR = 1.44), and study enrolment in 2011 (APR = 1.27) (all p < 0.05). Participants most commonly reported police beating during the interrogation process.
A high proportion of IDU in Bangkok reported having been beaten by the police. Experiencing police beating was independently associated with various indicators of drug-related harm. These findings suggest that the over-reliance on enforcement-based approaches is contributing to police-perpetrated abuses and the perpetuation of the HIV risk behaviour among Thai IDU.
HIV/AIDS; Drug law enforcement; Injection drug use; Harm reduction; Thailand
Drug law enforcement remains the dominant response to drug-related harm. However, the impact of incarceration on deterring drug use remains under-evaluated. We sought to explore the relationship between incarceration and patterns of drug use among people who inject drugs (IDU).
Using generalized estimating equations (GEE), we examined the prevalence and correlates of injection cessation among participants in the Vancouver Injection Drug User Study followed over 9 years. In subanalyses, we used McNemar's tests and linear growth curve analyses to assess changes in drug use patterns before and after a period of incarceration among participants reporting incarceration and those not incarcerated.
Among 1603 IDU, 842 (53%) reported injection cessation for at least 6 months at some point during follow-up. In multivariate GEE analyses, recent incarceration was associated negatively with injection cessation [adjusted odds ratio (AOR) = 0.43, 95% confidence interval (CI) 0.37–0.50], whereas the use of methadone was associated positively with cessation (AOR = 1.38, 95% CI 1.22–1.56). In subanalyses assessing longitudinal patterns of drug use among incarcerated individuals and those not incarcerated over the study period, linear growth curve analyses indicated that there were no statistically significant differences in patterns of drug use between the two groups (all P > 0.05).
These observational data suggest that incarceration does not reduce drug use among IDU. Incarceration may inhibit access to mechanisms that promote injection cessation among IDU. In contrast, results indicate that methadone use is associated positively with injection cessation, independent of previous frequency of drug use.
Addiction treatment; deterrence; drug law enforcement; drug policy; drug use patterns; incarceration; injection cessation; injection drug use
HIV-positive injection drug users (IDU) are known to be at risk for multiple medical problems that may necessitate emergency department (ED) use, however, the relative contribution of HIV disease versus injection-related complications have not been well described.
We examined factors associated with ED use among a prospective cohort of HIV-positive IDU in a Canadian setting.
We enrolled HIV-positive IDU into a community-recruited prospective cohort study. We modeled factors associated with the time to first ED visit using Cox regression to determine factors independently associated with ED use. In sub-analyses, we examined ED diagnoses and subsequent hospital admission rates.
Between December 5, 2005, and April 30, 2008, 428 HIV-positive IDU were enrolled, among whom the cumulative incidence of ED use was 63.7% (95% Confidence Interval [CI]: 59.1% – 68.3%) at 12 months after enrollment. Factors independently associated with time to first ED visit included: unstable housing (Hazard Ratio [HR] = 1.5, 95% CI: 1.1–2.0) and reporting being unable to obtain needed health care services (HR = 2.2, 95% CI: 1.2–4.1), whereas CD4 count and viral load were non-significant. Skin and soft tissue infections (SSTIs) accounted for the greatest proportion of ED visits (17%). Of the 2461 visits to the ED, 419 (17%) were admitted to hospital.
High rates of ED use were observed among HIV-positive IDU, a behavior that was predicted by unstable housing and limited access to primary care. Factors other than HIV infection appear to be driving ED use among this population in the post-HAART era.
Emergency Service; Injection Drug Use; HIV; Canada
Innovative health programs for injection drug users (IDUs), such as supervised injecting facilities (SIFs), are often preceded by evaluations of IDUs’ willingness to use the service. The validity of these surveys has not been fully evaluated. We sought to determine whether measures of willingness collected prior to the opening of a Canadian SIF accurately predicted subsequent use of the program.
Data were derived from a prospective cohort of IDUs. The sample size for this study was 640 IDUs. Using multivariate logistic regression, it was assessed if a history of reporting willingness to use the program, were it available, was associated with subsequent use. In sub-analysis restricted to individuals who had a history of reported willingness, we used multivariate longitudinal analysis to identify factors associated with not attending the SIF.
Among 442 IDUs, 72% of those who reported initial willingness to use a SIF later attended the program, and a prior willingness to use a SIF significantly predicted later attendance (adjusted odds ratio = 1.67). In sub-analyses restricted to those who had a history of reporting willingness to use the SIF, not using the program was predicted by not frequenting the neighborhood where the SIF was located.
Our findings indicate that reported willingness measures collected from IDUs regarding potential SIF program participation prior to its opening independently predicted later attendance even when variables that were likely determinants of willingness were adjusted for. These data suggest that willingness measures are reasonably valid tools for planning the delivery of health services among IDU populations.
injection drug use; supervised injection facilities; validity of willingness measures
Previous studies suggest that active drug use may compromise HIV treatment among HIV-positive injection drug users (IDU). However, little is known about the differential impacts of cocaine injection, heroin injection, and combined cocaine and heroin injection on plasma HIV-1 RNA suppression.
Data were derived from a longstanding open prospective cohort of HIV-positive IDU in Vancouver, Canada. Kaplan-Meier methods and Cox proportional hazards regression were used to examine the impacts of different drug use patterns on rates of plasma HIV-1 RNA suppression.
Between May 1996 and April 2008, 267 antiretroviral (ART) naïve participants were seen for a median follow-up duration of 50.6 months after initiating ART. The incidence density of HIV-1 RNA suppression was 65.2 (95%CI: 57.0–74.2) per 100 person-years. In Kaplan-Meier analyses, compared to those who abstained from injecting, individuals injecting heroin, cocaine, or combined heroin/cocaine at baseline were significantly less likely to achieve viral suppression (all p < 0.01). However, none of the drug use categories remained associated with a reduced rate of viral suppression when considered as time-updated variables (all p > 0.05).
Active injecting at the time of ART initiation was associated with lower plasma HIV-1 RNA suppression rates; however, there was no difference in suppression rates when drug use patterns were examined over time. These findings imply that adherence interventions for active injectors should optimally be applied at the time of ART initiation.
injection drug use; antiretroviral therapy; viral suppression