Using the aggregated data of all sentinel sero-surveys (1991 to 2007), this study aimed to report the HIV trend among Iranian prisoners.
Overall, we analysed the aggregated data from 397 HIV sero-surveys conducted in 72 prisons (included 155,771 prisoners) from 1991 through 2007.
The overall HIV prevalence was 2.8% (95% CI: 1.8%-4.3%). In 1998, HIV prevalence dramatically increased to 4.5% (95% CI: 1.1%-16.8%), which later became stable at level of 2.8%. Prisons were so heterogeneous regarding HIV prevalence (0% to 13.2%).
Since the outbreak, the ministry of health has acknowledged prisoners as one of the high-risk groups for HIV, increased the number of sentinel surveys and on-site harm reduction services to better monitor and response to the HIV epidemic. The downward trend of HIV prevalence after 2005 suggests the effectiveness of such interventions which need to be continued.
Sentinel sero-survey; Prevalence; HIV testing; Prisoners; Iran
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.
Crack cocaine; Sex work; Sexual risk; HIV; STI
Illicit use of methadone and buprenorphine has been described as a growing problem in Sweden in recent years, and has been associated with an increased drug-related mortality. Critics claim that the substances have become popular among adolescents and that they function as a gateway to heroin use. The aim of this study is to investigate, firstly, the extent to which illicit use of methadone and buprenorphine occurs among adolescents and young adults in Sweden, and secondly, at what stage in a user’s drug career these substances tend to appear.
The study is based on surveys and structured interviews on drug use among various populations of young people, in addition to qualitative interviews with 86 informants who, in their professional capacity, encounter adolescents or young adults who are using illicit drugs.
Illicit use of methadone and buprenorphine is rare among young people in Sweden. According to high school surveys, less than 0.1% have tried these substances. Among young drug users in general, few have tried the substances, and there is nothing to indicate that they act as gateway drugs. Among adolescents and young adults with severe drug problems, however, the illicit use of methadone and buprenorphine is more common (54% in a compulsory care sample). These substances normally enter the drug career late, and few use them as their main drug of choice. Other prescription drugs, like benzodiazepines and tramadol, are used by adolescents to a far greater extent. Diversion and illicit use of methadone and buprenorphine is not seen as a serious problem by the professionals interviewed. A general view is that the substances are mainly used by people with a heroin or polydrug addiction, often for “self-medication” purposes. However, several informants express concern that methadone and buprenorphine may cause fatalities among young drug users without an opioid tolerance.
Illicit use of methadone and buprenorphine among young drug users is not a widespread problem in Sweden. Harm-reduction measures should target drug users with more severe problems, among whom illicit use of methadone and buprenorphine is more common and pose a medical risk. Illicit use of other prescription drugs, which are less controlled and more widely used by young people, is an important issue for further research.
Methadone; Buprenorphine; Illicit use; Adolescents; Young adults; Drug career; Diversion
Areca (Betel Nut) is the fourth most commonly used psychoactive drug throughout the world and is legal in U.S. It is carcinogenic. Within a health program in the Federated States of Micronesia we surveyed use among adolescents.
One hundred 7th and 8th graders in Yap and Pohnpei were surveyed and clinical oral examinations conducted. The questionnaire included items on Areca: age first used Areca, whether peers or family members used Areca, frequency of use, whether tobacco was used, and source of Areca. Questions also assessed anxiety and depression. Two scales assessed getting along with other kids and adaptation to school.
61.5-71.4% of adolescents had ever used Areca and 54.7-68.6% used it at least once in the last month.
Most adolescents surveyed in Yap and Pohnpei used Areca, which may place these youth at increased risk for cancer and health disparities.
Areca; Betel; Adolescent; Oral mucosa; Micronesia; Substance-related disorders
'Non-compliant’ individuals in opioid maintenance treatment, OMT, are often met with tight control regimes to reduce the risk of 'diversion’, which may lead to harm or death among persons outside of OMT. This article explores reported practices of, and motivations for, diversion of methadone and buprenorphine, in a group of imprisoned individuals in OMT.
28 in-depths interviews were conducted among 12 OMT-enrolled, imprisoned individuals, most of whom were remand prisoners. All had experienced tight control regimes prior to imprisonment due to varying degrees of 'non-compliance’ and illicit drug use during treatment. Their acquired norm of sharing with others in a drug using community was maintained when entering OMT. Giving one’s prescription opioids to an individual in withdrawal was indeed seen as an act of helping, something that takes on particular significance for couples in which only one partner is included in OMT and the other is using illicit heroin. Individuals enrolled in OMT might thus be trapped between practicing norms of helping and sharing and adhering to treatment regulations. ’Diversion’, as this term is conventionally used, is not typically understood as practices of giving and helping, but may nevertheless be perceived as such by those who undertake them.
As we see it, the need to sustain oneself as a decent person in one’s own eyes and those of others through practices such as sharing and helping should be recognized. Treatment providers should consider including couples in which both individuals are motivated for starting OMT.
Diversion; Opioid maintenance treatment; Methadone; Buprenorphine; Reciprocity
To examine the predictors of continued drug- and sex-related HIV-risk behaviors among drug users in methadone maintenance therapy (MMT) programs in China.
We followed a sample of 5,035 drug users enrolled for the first time in MMT programs at baseline, 6 months, and 12 months utilizing a longitudinal prospective study design. Drug users’ HIV-risk behaviors, MMT characteristics, and drug use, were assessed at all three waves using a structured interview and HIV/HCV status was assessed at baseline and 12-month follow-up using biological specimens.
The point prevalence of HIV was 7.6% and 78.4% for HCV at baseline. Results of generalized linear mixed logistic regression models revealed that HIV-positive MMT clients were more likely to engage in drug injection (aOR = 1.70) and syringe sharing (aOR = 4.73). HCV-positive clients were more likely to inject drugs (aOR = 2.58), share syringes (aOR = 1.97), and have multiple sexual partners (aOR = 1.47). Adherence to MMT was the most significant predictor of reduced HIV-risk behaviors.
Our data confirmed the positive effects of MMT on HIV prevention and underscored the urgency for programs to reduce HIV risk in HIV- and HCV-positive clients. There is a pressing need to strengthen existing counseling services for HIV-positive drug users to reduce their drug-related risk behaviors and to provide counseling for HCV-positive drug users. Further studies are needed to explore interventions to address high dropout rates and low adherence among MMT clients.
Methadone maintenance therapy; HIV-risk behaviors; Longitudinal study; China
Blue lights are sometimes placed in public washrooms to discourage injection drug use. Their effectiveness has been questioned and concerns raised that they are harmful but formal research on the issue is limited to a single study. We gathered perceptions of people who use injection drugs on the effects of blue lights with the aim of informing harm reduction practice.
We interviewed 18 people in two Canadian cities who currently or previously used injection drugs to better understand their perceptions of the rationale for and consequences of blue lights in public washrooms.
Participants described a preference for private places to use injection drugs, but explained that the need for an immediate solution would often override other considerations. While public washrooms were in many cases not preferred, their accessibility and relative privacy appear to make them reasonable compromises in situations involving urgent injecting. Participants understood the aim of blue lights to be to deter drug use. The majority had attempted to inject in a blue-lit washroom. While there was general agreement that blue lights do make injecting more difficult, a small number of participants were entirely undeterred by them, and half would use a blue-lit washroom if they needed somewhere to inject urgently. Participants perceived that, by making veins less visible, blue lights make injecting more dangerous. By dispersing public injection drug use to places where it is more visible, they also make it more stigmatizing. Despite recognizing these harms, more than half of the participants were not opposed to the continued use of blue lights.
Blue lights are unlikely to deter injection drugs use in public washrooms, and may increase drug use-related harms. Despite recognizing these negative effects, people who use injection drugs may be reluctant to advocate against their use. We attempt to reconcile this apparent contradiction by interpreting blue lights as a form of symbolic violence and suggest a parallel with other emancipatory movements for inspiration in advocating against this and other oppressive interventions.
Harm reduction; Injection drug use; Public injection; Fluorescent blue lights; Internalized oppression
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
HIV infection among people who inject drugs (IDU) remains a major global public health challenge. However, among IDU, access to essential HIV-related services remains unacceptably low, especially in settings where stigma, discrimination, and criminalization exist. These ongoing problems account for a significant amount of preventable morbidity and mortality within this population, and indicate the need for novel approaches to HIV program delivery for IDU. Task shifting is a concept that has been applied successfully in African settings as a way to address health worker shortages. However, to date, this concept has not been applied as a means of addressing the social and structural barriers to HIV prevention and treatment experienced by IDU. Given the growing evidence demonstrating the effectiveness of IDU-run programs in increasing access to healthcare, the time has come to extend the notion of task shifting and apply it in settings where stigma, discrimination, and criminalization continue to pose significant barriers to HIV program access for IDU. By involving IDU more directly in the delivery of HIV programs, task shifting may serve to foster a new era in the response to HIV/AIDS among IDU.
Task shifting; People who inject drugs; Stigma and discrimination; HIV services
Smokers of any age can reap substantial health benefits by quitting. In fact, no other single public health effort is likely to achieve a benefit comparable to large-scale smoking cessation. Surveys document that most smokers would like to quit, and many have made repeated efforts to do so. However, conventional smoking cessation approaches require nicotine addicted smokers to abstain from tobacco and nicotine entirely. Many smokers are unable – or at least unwilling – to achieve this goal, and so they continue smoking in the face of impending adverse health consequences. In effect, the status quo in smoking cessation presents smokers with just two unpleasant alternatives: quit or suffer the harmful effects of continuing smoking. But, there is a third choice for smokers: tobacco harm reduction. It involves the use of alternative sources of nicotine, including modern smokeless tobacco products like snus and the electronic cigarette (E-cig), or even pharmaceutical nicotine products, as a replacement for smoking. E-cigs might be the most promising product for tobacco harm reduction to date, because, besides delivering nicotine vapour without the combustion products that are responsible for nearly all of smoking’s damaging effect, they also replace some of the rituals associated with smoking behaviour. Thus it is likely that smokers who switch to E-cigs will achieve large health gains. The focus of this article is on the health effects of using an E-cig, with consideration given to the acceptability, safety and effectiveness of this product as a long-term substitute for smoking.
Tobacco; Harm reduction; Snus; Electronic cigarettes
Harm reduction has been increasingly finding its way into public drug policies and healthcare practices worldwide, with successful intervention measures justifiably focussing on the highest-risk groups, such as injecting drug users. However, there are also other types of drug users in need for harm reduction, even though they pose less, low, or no public health risk. Occasionally, drug users may autonomously organise themselves into groups to provide advocacy, harm reduction, and peer-help services, sometimes online. The http://www.daath.hu website has been operated since 2001 by the “Hungarian Psychedelic Community”, an unorganised drug user group with a special interest in hallucinogenic and related substances. As of today, the website serves about 1200 visitors daily, and the online community comprises of more than 8000 registered members. The Daath community is driven by a strong commitment to the policy of harm reduction in the form of various peer-help activities that aim to expand harm reduction without promoting drug use. Our review comprehensively summarises Daath’s user-led harm reduction services and activities from the last ten years, firstly outlining the history and growth phases of Daath, along with its self-set guidelines and policies. Online services (such as a discussion board, and an Ecstasy pill database) and offline activities (such as Ecstasy pill field testing, and a documentary film about psychedelics) are described. In order to extend its harm reduction services and activities in the future, Daath has several social, commercial, and legislative challenges to face. Starting with a need to realign its focus, outlooks for the upcoming operation of Daath are pondered. Future trends in harm reduction, such as separating harm-decreasing from benefit-increasing, are also discussed. We aim to share these innovative harm reduction measures and good practices in order to be critically assessed, and – if found useful – adapted and applied elsewhere.
Community networks; Drug users; Harm reduction; Hungary; Self-help groups
Egypt has low HIV prevalence (below 0∙02%) among the general population, mostly attributed to the conservative culture. The 2010 second round biological/behavioral surveillance survey (Bio-BSS) conducted in some governorates revealed concentrated epidemic among male injecting drug users (IDUs).
The current study aimed at exploring the perspective of IDUs regarding the HIV preventive efforts targeting them to provide relevant evidence based policy recommendations. The study included desk review, in-depth interviews with service providers and focus group discussions with IDUs of both sexes.
The study described the current harm reduction interventions in Egypt and highlighted the insights of active IDUs and service providers interacting with them as regards their ability to address their needs and what they miss in these interventions and how IDUs perceive these interventions.
The epidemiological reality of HIV infection in Egypt favors prioritizing efforts to the high risk groups rather than the general population. Hence, harm reduction should be at the core of interventions targeting HIV. The current study revealed that there is still a long way to go to enhance the role of these interventions in influencing a significant behavior change among target group.
AIDS; IDUs; Harm reduction; Egypt
We utilized multiple recruitment approaches to recruit IDUs in a longitudinal cohort study to examine HIV incidence and behavior change pre- and post-introduction of comprehensive HIV prevention services.
IDUs were recruited through peer referral, targeted outreach by outreach workers (ORWs) and as walk-in clients at drop-in centers. Participants received monetary compensation for participation (USD 0.80). Participants were given recruitment coupons to recruit peers (regardless of recruitment method). For peer referral, participants received a food coupon, as secondary compensation, for each peer he/she successfully recruited. We report the profile of IDUs by recruitment method, based on the baseline behavioral survey and HIV test results. Cost per IDU recruited by recruitment method was also calculated.
A total of 3,818 IDUs were recruited between May 2011 and October 2011. More than half of the study participants were recruited through targeted outreach (ORW: 53.6%; peer-referral: 26.3%; walk-ins: 20.1%). Of the participants who were given recruitment coupons, 92.7% recruited no peers. Those who successfully recruited at least one peer were significantly more likely to be in a stable living accommodation compared to those who did not recruit any peers (51.1% versus 42.7%; p < 0.05). Only 45.9% of the food coupons were claimed for successful recruitment of peers. Peer-referred IDUs were more likely to be living with family or relatives (50.7% versus ORW: 40.1% and walk-in: 39.8%; p < 0.001) rather than on the street or shared housings compared to the other two recruitment modes. Walk-ins were more likely than peer-referred and ORW-referred IDUs to be HIV-positive (walk-ins: 26.1%; peer-referred: 19.1%; ORW: 19.9%; p < 0.01) and have risky injection practices (walk-ins: 62.2%; ORW: 57.0%; peer-referred: 58.6%; p < 0.05). The cost per IDU recruited through ORW referral method was the most costly at USD 16.30, followed by peer-referral at USD 8.40 and walk-in at USD 7.50.
When recruiting a large number of IDUs, using multiple recruitment modes is ideal with regard to diversification of IDU characteristics and risk profile. Although it was the most costly, ORW recruitment was more effective than the other two methods. Lack of monetary compensation for successful recruitment of peers may have hampered peer-referral.
Injection drug user; HIV prevention; Out-reach worker; Peer-referral; Harm-reduction
The majority of HIV-infected individuals requiring antiretroviral therapy (ART) in Russia are Injection Drug Users (IDU). Substitution therapy used as part of a comprehensive harm reduction program is unavailable in Russia. Past data shows that only 16% of IDU receiving substance abuse treatment completed the course without relapse, and only 40% of IDU on ART remained on treatment at 6 months. Our goal was to determine if it was feasible to improve these historic outcomes by adding intensive case management (ICM) to the substance abuse and ART treatment programs for IDU.
IDU starting ART and able to involve a “supporter” who would assist in their treatment plan were enrolled. ICM included opiate detoxification, bi-monthly contact and counseling with the case, weekly group sessions, monthly contact with the “supporter” and home visits as needed. Full follow- up (FFU) was 8 months. Stata v10 (College Station, TX) was used for all analysis. Descriptive statistics were calculated for all baseline demographic variables, baseline and follow-up CD4 count, and viral load. Median baseline and follow-up CD4 counts and RNA levels were compared using the Kruskal-Wallis test. The proportion of participants with RNA < 1000 copies mL at baseline and follow-up was compared using Fisher’s Exact test. McNemar’s test for paired proportions was used to compare the change in proportion of participants with RNA < 1000 copies mL from baseline to follow-up.
Between November 2007 and December 2008, 60 IDU were enrolled. 34 (56.7%) were male. 54/60 (90.0%) remained in FFU. Overall, 31/60 (52%) were active IDU at enrollment and 27 (45%) were active at their last follow-up visit. 40/60 (66.7%) attended all of their ART clinic visits, 13/60 (21.7%) missed one or more visit but remained on ART, and 7/60 (11.7%) stopped ART before the end of FFU. Overall, 39/53 (74%) had a final 6–8 month HIV RNA viral load (VL) < 1000 copies/mL.
Despite no substitution therapy to assist IDU in substance abuse and ART treatment programs, ICM was feasible, and the retention and adherence of IDU on ART in St. Petersburg could be greatly enhanced by adding ICM to the existing treatment programs.
Injection drug users; Russia; HIV/AIDS; Antiretroviral therapy; Case management
To determine relapse rates and associated factors among people who use drugs (PWUDs) attending abstinence-oriented drug treatment clinics in Dhaka, Bangladesh.
A cohort of male and female PWUDs admitted to the 3-month drug detoxification-rehabilitation treatment programmes of three non-governmental organisation-run drug treatment clinics in Dhaka, Bangladesh were interviewed on admission and over the following 5 months, which included the first 2 months after discharge. The study subjects comprised 150 male and 110 female PWUDs who had been taking opiates/opioids, cannabis or other drugs (including sedatives) before admission, had provided informed consent and were aged ≥16 years. Interviews were conducted using semi-structured questionnaires at four time points; on admission, at discharge and at 1 and 2 months after discharge. Relapse rates were assessed by the Kaplan–Meier method. Factors associated with relapse on enrolment and after discharge were determined using the Cox proportional hazards regression model.
A greater proportion of female than male subjects relapsed over the study period (71.9% versus 54.5%, p < 0.01). For men, baseline factors associated with relapse were living with other PWUDs (relative hazard ratio [RHR] = 2.27), living alone (RHR = 2.35) and not having sex with non-commercial partners (RHR = 2.27); whereas for women these were previous history of drug treatment (RHR = 1.94), unstable housing (RHR = 2.44), higher earnings (RHR = 1.89), preferring to smoke heroin (RHR = 3.62) and injecting buprenorphine/pethidine (RHR = 3.00). After discharge, relapse for men was associated with unstable housing (RHR = 2.78), living alone (RHR = 3.69), higher earnings (RHR = 2.48) and buying sex from sex workers (RHR = 2.29). Women’ relapses were associated with not having children to support (RHR = 3.24) and selling sex (RHR = 2.56).
The relapse rate was higher for female PWUDs. For both male and female subjects the findings highlight the importance of stable living conditions. Additionally, female PWUDs need gender-sensitive services and active efforts to refer them for opioid substitution therapy, which should not be restricted only to people who inject drugs.
Relapse; Gender; Drug detoxification-rehabilitation; People who use drugs; Bangladesh
About a third of the global HIV infections outside sub-Saharan Africa are related to injecting drug use (IDU), and this accounts for a growing proportion of persons living with HIV. This paper is a response to the need to monitor the state of the HIV epidemic as it relates to IDU and the availability of HIV treatment and harm reduction services in 21 high epidemic countries.
A data collection form was designed to cover questions on rates of IDU, prevalence and incidence of HIV and information on HIV treatment and harm reduction services available to people who inject drugs (PWID). National and regional data on HIV infection, IDU in the form of reports and journal articles were sought from key informants in conjunction with a systematic search of the literature.
Completed data collection forms were received for 11 countries. Additional country-specific information was sourced via the literature search. The overall proportion of HIV positive PWID in the selected countries ranged from 3% in Kazakhstan to 58% in Vietnam. While IDU is relatively rare in sub-Saharan Africa, it is the main driver of HIV in Mauritius and Kenya, with roughly 47% and 36% of PWID respectively being HIV positive. All countries had antiretroviral treatment (ART) available to PWID, but data on service coverage were mainly missing. By the end of 2010, uptake of needle and syringe programmes (NSP) in Bangladesh, India and Slovakia reached the internationally recommended target of 200 syringes per person, while uptake in Kazakhstan, Vietnam and Tajikistan reached between 100-200 syringes per person. The proportion of PWID receiving opioid substitution therapy (OST) ranged from 0.1% in Kazakhstan to 32.8% in Mauritius, with coverage of less than 3% for most countries.
In order to be able to monitor the impact of HIV treatment and harm reduction services for PWID on the epidemic, epidemiological data on IDU and harm reduction service provision to PWID needs to be regularly collected using standardised indicators.
Injecting drug use; People who inject drugs; Harm reduction; HIV prevention
In spite of the negative health effects of waterpipe tobacco smoking, its use is becoming more common. The objective of this study is to systematically review the medical literature for motives, beliefs and attitudes towards waterpipe tobacco smoking.
We electronically searched MEDLINE, EMBASE, and the ISI the Web of Science in January 2012. We included both quantitative and qualitative studies. We selected studies and abstracted data using standard systematic review methodology. We synthesized data qualitatively.
We included 58 papers reporting on 56 studies. The main motives for waterpipe tobacco smoking were socializing, relaxation, pleasure and entertainment. Peer pressure, fashion, and curiosity were additional motives for university and school students while expression of cultural identity was an additional motive for people in the Middle East and for people of Middle Eastern descent in Western countries. Awareness of the potential health hazards of waterpipe smoking was common across settings. Most but not all studies found that the majority of people perceived waterpipe smoking as less harmful than cigarette smoking. Waterpipe smoking was generally socially acceptable and more acceptable than cigarette smoking in general. In Middle Eastern societies, it was particularly more acceptable for women’s use compared to cigarette use. A majority perceived waterpipe smoking as less addictive than cigarette smoking. While users were confident in their ability to quit waterpipe smoking at any time, willingness to quit varied across settings.
Socializing, relaxation, pleasure and entertainment were the main motives for waterpipe use. While waterpipe users were aware of the health hazards of waterpipe smoking, they perceived it as less harmful, less addictive and more socially acceptable than cigarette smoking and were confident about their ability to quit.
Tobacco; Waterpipe; Addiction; Motives; Beliefs; Attitudes
Cohort studies provide an excellent opportunity to monitor changes in behaviour and disease transmission over time. In Australia, cohort studies of people who inject drugs (PWID) have generally focused on older, in-treatment injectors, with only limited outcome measure data collected. In this study we specifically sought to recruit a sample of younger, largely out-of-treatment PWID, in order to study the trajectories of their drug use over time.
Respondent driven sampling, traditional snowball sampling and street outreach methods were used to recruit heroin and amphetamine injectors from one outer-urban and two inner-urban regions of Melbourne, Australia. Information was collected on participants’ demographic and social characteristics, drug use characteristics, drug market access patterns, health and social functioning, and health service utilisation. Participants are followed-up on an annual basis.
688 PWID were recruited into the study. At baseline, the median age of participants was 27.6 years (IQR: 24.4 years – 29.6 years) and two-thirds (67%) were male. Participants reported injecting for a median of 10.2 years (range: 1.5 months – 21.2 years), with 11% having injected for three years or less. Limited education, unemployment and previous incarceration were common. The majority of participants (82%) reported recent heroin injection, and one third reported being enrolled in Opioid Substitution Therapy (OST) at recruitment. At 12 months follow-up 458 participants (71% of eligible participants) were retained in the study. There were few differences in demographic and drug-use characteristics of those lost to follow-up compared with those retained in the study, with attrition significantly associated with recruitment at an inner-urban location, male gender, and providing incomplete contact information at baseline.
Our efforts to recruit a sample of largely out-of-treatment PWID were limited by drug market characteristics at the time, where fluctuating heroin availability has led to large numbers of PWID accessing low-threshold OST. Nevertheless, this study of Australian injectors will provide valuable data on the natural history of drug use, along with risk and protective factors for adverse health outcomes associated with injecting drug use. Comprehensive follow-up procedures have led to good participant retention and limited attrition bias.
Injecting drug use; Cohort; Longitudinal studies; Australia
Illicit drug users have a high prevalence of HCV and represent the majority of newly infected persons in the U.S. Despite the availability of effective HCV treatment, few drug users have been evaluated or treated for HCV. Racial and ethnic minorities have a higher incidence and prevalence of HCV and higher HCV-related mortality. Factors contributing to poor engagement in care are incompletely understood.
Fourteen mixed-gender focus groups of either African American or Latino/a drug users (N = 95) discussed barriers to HCV testing and treatment. Themes were identified through content analysis of focus group discussions.
Many drug users were tested for HCV in settings where they were receiving care. Outside of these settings, most were unaware of voluntary test sites. After testing HCV positive, drug users reported not receiving clear messages regarding the meaning of a positive HCV test, the impact of HCV infection, or appropriate next steps including HCV clinical evaluations. Many drug users perceived treatment as unimportant because they lacked symptoms, healthcare providers minimized the severity of the diagnosis, or providers did not recommend treatment. Mistrust of the motivations of healthcare providers was cited as a barrier to pursuing treatment. Social networks or social interactions were a source of HCV-related information and were influential in shaping drug users perceptions of treatment and its utility.
Drug users perceived a paucity of settings for self-initiated HCV testing and poor provider-patient communication at test sites and during medical encounters. Notably, drug users reported having an unclear understanding about the meaning of a positive HCV test, the health implications of HCV infection, the importance of clinical evaluations and monitoring, and of treatment options for HCV. Efforts to improve the delivery of clinical messages about HCV infection for drug users at test settings and clinical encounters are needed.
Hepatitis C; Illicit drug use; Injection drug use; Health care access
Karachi is the largest metropolis of Pakistan and its economic hub attracting domestic migrants for economic opportunities. It is also the epicenter of HIV epidemic in the country. Since 2004, one pilot study and four behavioral and biological surveillance rounds have been conducted in Karachi. In addition many student research projects have also focused on key risk groups including injection drug users (IDUs). As a result of this extra ordinary exposure of same kind of questions, IDUs know how to respond to high value questions related to sharing of needles or unsafe sexual practices. The purpose of the study was to explore the element of research fatigue among IDUs in Karachi, Pakistan.
The study was conducted on 32 spots in Karachi, selected on the basis of estimate of IDUs at each spot. A trained field worker (recovered IDU) visited each spot; observed sharing behavior of IDUs and asked questions related to practices in January 2009. Verbal consent was obtained from each respondent before asking questions.
On average 14 IDUs were present at each spot and out of 32 selected spots, 81% were active while more than two groups were present at 69% spots. In each group three to four IDUs were present and everyone in the group was sharing. One dose of injecting narcotics was observed. Sharing of syringes, needles and distilled water was observed at 63% spots while professional injector/street doctor was present at 60% spots.
There is a need to check internal consistency in surveillance research. It is highly likely that IDUs and other risk groups know how to respond to key questions but their responses do not match with the practices.
HIV; IDUs; Research fatigue
Needle-syringe exchange programs (NSPs) have been substantially rolled-out in China since 2002. Limited studies reported effectiveness of NSPs in a Chinese setting. This study aimed to assess the association between accessibility to NSPs and drug-use risk behaviors of IDUs by investigating primary (self-reported) data of IDUs recruited from NSP sites, community settings and mandatory detoxification centers (MDCs) in Hunan province, China.
A cross-sectional survey was conducted in Hunan province in 2010. IDU recruits participated in a face-to-face interview to provide information related to their ability to access NSPs, demographic characteristics, and injecting behaviors in the past 30 days.
Of the total 402 participants, 35%, 14% and 51% participants indicated low, medium and high ability to access NSPs in the past 30 days, respectively. A significantly higher proportion of IDUs (77.3%) from the high-access group reported ≤2 injecting episodes per day compared with medium- (46.3%) and low-access (58.8%) groups. Only 29.0% of high-access IDUs re-used syringes before disposal in the past 30 days, significantly lower than those in the medium- (43.1%) and low-access (41.3%) groups. Reported levels of needle/syringe sharing decreased significantly as the ability to access NSPs increased (16.3%, 12.7% and 2.5% in the low, medium and high access groups, respectively). Ninety percent of IDUs recruited from MDCs had low ability to access NSPs.
Increased NSP accessibility is associated with decreased levels of injecting frequency, repetitive use and sharing of injecting equipment among Chinese IDUs. Mandatory detention of IDUs remains as a major barrier for IDUs to access NSPs in China.
Evidence documents successful hepatitis C virus (HCV) treatment outcomes for people who inject drugs (PWID) and interest in HCV treatment among this population. Maximising HCV treatment for PWID can be an effective HCV preventative measure. Yet HCV treatment among PWID remains suboptimal. This review seeks to map social factors mediating HCV treatment access.
We undertook a review of the social science and public health literature pertaining to HCV treatment for PWID, with a focus on barriers to treatment access, uptake and completion. Medline and Scopus databases were searched, supplemented by manual and grey literature searches. A two step search was taken, with the first step pertaining to literature on HCV treatment for PWID and the second focusing on social structural factors. In total, 596 references were screened, with 165 articles and reports selected to inform the review.
Clinical and individual level barriers to HCV treatment among PWID are well evidenced. These include patient and provider concerns regarding co-morbidities, adherence, and side effect management. Social factors affecting treatment access are less well evidenced. In attempting to map these, key barriers fall into the following domains: social stigma, housing, criminalisation, health care systems, and gender. Key facilitating factors to treatment access include: combination intervention approaches encompassing social as well as biomedical interventions, low threshold access to opiate substitution therapy, and integrated delivery of multidisciplinary care.
Combination intervention approaches need to encompass social interventions in relation to housing, stigma reduction and systemic changes in policy and health care delivery. Future research needs to better delineate social factors affecting treatment access.
Hepatitis C; Antiviral treatment; Treatment access; People who inject drugs; Social factors
Those working in the fields of harm reduction, healthcare, and human services must cope with a range of stresses, including post traumatic stress and vicarious trauma. Pain and loss are just a part of the job. So is dealing with premature death as a result of HIV, hypertension, and even overdose. Faced with a range of challenges, some workers in the field even turn to self-medication. For some, it is about pleasure; for others it is about alleviating suffering. In recent years, several leaders in the AIDS and harm reduction fields have died ahead of their time. Some stopped taking their medications; others overdosed. Rather than weakness or pathology, French sociologist Emile Durkheim saw self-destructive behavior as a byproduct of social disorganization and isolation, as a way of contending with a breakdown of social bonds and alienation. There are any number of reasons why such behavior becomes part of work for those involved with battling the dueling epidemics of Hepatitis C, HIV, and related concerns. Forms of stress related to this work include secondary trauma, compassion fatigue, organizational conflict, burnout, complications of direct services, and lack of funding. Faced with day-to- day struggles over poverty, punitive welfare systems, drug use, the war on drugs, high risk behavior, structural violence, and illness, many in the field are left to wonder how to strive for wellness when taking on so much pain. For some, self-injury and self-medication are ways of responding. Building on ethnographic methods, this reflective analysis considers the stories of those who have suffered, as well as a few of the ways those in the field cope with harm and pain. The work considers the moral questions we face when we see our friends and colleagues suffer. It asks how we as practitioners strive to create a culture of wellness and support in the fields of harm reduction, healthcare, and human services. Through a brief review of losses and literature thereof, the essay considers models of harm reduction practice that emphasize health, pleasure and sustainability for practitioners.
Suicide; Self injury; Secondary trauma; Vicarious trauma; Wellness; Overdose
The aims were to identify predictors of treatment retention in methadone maintenance treatment (MMT) clinics in Pearl River Delta, China.
Retrospective longitudinal study. Participants: 6 MMT clinics in rural and urban area were selected. Statistical analysis: Stratified random sampling was employed, and the data were analyzed using Kaplan-Meier survival curves and life table method. Protective or risk factors were explored using Cox’s proportional hazards model. Independent variables were enrolled in univariate analysis and among which significant variables were analyzed by multivariate analysis.
A total of 2728 patients were enrolled. The median of the retention duration was 13.63 months, and the cumulative retention rates at 1,2,3 years were 53.0%, 35.0%, 20.0%, respectively. Multivariate Cox analysis showed: age, relationship with family, live on support from family or friends, income, considering treatment cost suitable, considering treatment open time suitable, addiction severity (daily expense for drug), communication with former drug taking peer, living in rural area, daily treatment dosage, sharing needles, re-admission and history of being arrested were predictors for MMT retention.
MMT retention rate in Guangdong was low and treatment skills and quality should be improved. Meanwhile, participation of family and society should be encouraged.
Methadone maintenance treatment; Retention; Cox’s proportional hazards model
Unsafe injection practices play a major role in elevated rates of morbidity and mortality among people who inject drugs (IDU). There is growing interest in the direct involvement of IDU in interventions that seek to address unsafe injecting. This study describes a drug user-led safer injecting education campaign, and explores facilitators’ experiences delivering educational workshops.
We conducted semi-structured qualitative interviews with 8 members of the Injection Support (IS) Team who developed and facilitated a series of safer injecting education workshops. Interviews explored facilitator’s perceptions of the workshops, experiences being a facilitator, and perspectives on the educational campaign. Interviews were transcribed verbatim and a thematic analysis was conducted.
IS Team facilitators described how the workshop’s structure and content enabled effective communication of information about safer injecting practices, while targeting the unsafe practices of workshop participants. Facilitators’ identity as IDU enhanced their ability to relate to workshop participants and communicate educational messages in language accessible to workshop participants. Facilitators reported gaining knowledge and skills from their involvement in the campaign, as well as positive feelings about themselves from the realization that they were helping people to protect their health. Overall, facilitators felt that this campaign provided IDU with valuable information, although facilitators also critiqued the campaign and suggested improvements for future efforts.
This study demonstrates the feasibility of involving IDU in educational initiatives targeting unsafe injecting. Findings illustrate how IDU involvement in prevention activities improves relevance and cultural appropriateness of interventions while providing individual, social, and professional benefits to those IDU delivering education.
Injection drug use; Safer injecting education; User-led intervention