Narratives of people who inject drugs on factors contributing to opioid overdose

BackgroundIn recent years, there has been increasing national and global attention to opioid overdoses. In San Francisco, it is estimated that the population of people who inject drugs (PWID) has more than doubled in the past ten years. The risk factors for opioid overdose have been examined closely, but firsthand accounts of PWID who have experienced overdoses are less documented. In this paper, we use two theories - lay expertise and structural vulnerabilities - as frameworks to frame and qualitatively examine the narratives of PWID surrounding their recent overdose experiences.MethodsAudio-recorded semi-structured open-ended motivational interviewing counseling sessions were conducted with PWID in San Francisco who have experienced at least one non-fatal overdose event (N = 40). Participants discussed the context of recent opioid overdoses, either witnessed or personally experienced, focusing on their perceptions of unique contributing factors. Interview data were coded and analysed using ATLAS.ti. We used a thematic content analysis approach to qualitatively analyze data queries and generate themes. We used theories of structural vulnerability and lay expertise to frame the analysis.ResultsUsing quotes from the participants, we report four central themes that contributed to participants' overdose experiences: 1) Social Dynamics and Opioid Expertise; 2) Uncertain Supply, Composition, Source; 3) Balancing Polysubstance Use, and 4) Emotional Pain.ConclusionAs PWID described their overdose experiences, many factors that contributed to their overdoses were situated at the structural level. The everyday, lived experiences of PWID often competed or conflicted with public health messages and approaches. The accumulated expertise of PWID about everyday risk factors can be leveraged by public health practitioners to inform and improve overdose prevention interventions and messages.     

Effective use of naloxone among people who inject drugs in Kyrgyzstan and Tajikistan using pharmacy- and community-based distribution approaches

BackgroundOpioid overdose (OD) is a major cause of mortality among people who inject drugs (PWID) in Central Asia, and distribution of naloxone, an opioid antagonist, can effectively prevent these deaths. However, little is known about the use and wastage of distributed naloxone ampoules. Having reliable data on wastage rates is critical for accurately calculating the health impact of naloxone distribution projects targeting PWID.MethodsIn 2011, Population Services International (PSI) launched two pilot naloxone distribution programs in Kyrgyzstan (pharmacy-based approach) and Tajikistan (community-based approach). PWID were trained on OD prevention and naloxone use. Upon returning for more ampoules, the PWID completed a brief survey on their OD experience and naloxone use. 158 respondents in Kyrgyzstan and 59 in Tajikistan completed the questionnaire. Usage and wastage rates were calculated based on responses. A four-year model wastage rate that takes into account the shelf life of naloxone for both countries was then calculated.Results51.3% of respondents in Kyrgyzstan and 91.5% in Tajikistan reported having ever experienced an OD. 82.9% of respondents in Kyrgyzstan and all respondents in Tajikistan had ever witnessed an OD. Out of these PWID who experienced or witnessed OD, 81.5% in Kyrgyzstan and 59.3% in Tajikistan reported having been injected with naloxone, and 83.2% in Kyrgyzstan and 50.9% in Tajikistan reported injecting another individual with naloxone. Of ampoules received, 46.5% in Kyrgyzstan and 78.1% in Tajikistan were used. In both countries, 3.1% of these ampoules were wasted. The four-year model wastage rates for Kyrgyzstan and Tajikistan were found to be 13.8% and 3.9% respectively.ConclusionFindings indicate that a high proportion of naloxone distributed to PWID is used in actual OD incidents, with low wastage rates in both countries. Expanding these distribution models can potentially create more positive health outcomes for PWID in Central Asia.     

Factors associated with recent symptoms of an injection site infection or injury among people who inject drugs in three English cities

BackgroundPeople who inject drugs (PWID) are at risk of injection site infections and injuries. The factors associated with recent symptoms of these problems are examined.MethodPWID recruited using respondent driven sampling, underwent a computer-assisted interview and provided a dried-blood spot sample. Weight data were examined using logistic regression.ResultsThe mean age of the 855 participants was 32 years, and 25% were women. During the preceding 28 days, 94% had injected heroin and 50% crack-cocaine; with 41% injecting into their arms and 47% their groin. The passing on of used needles/syringes was reported by 9.7% and receiving by 8.0%. During the preceding 28 days, 21% reported having redness, swelling and tenderness, 6.1% an abscess, and 5.2% a sore/open wound at an injection site; with a quarter (24%) reporting one or more of these. A range of factors were associated with these symptoms; all three symptoms were associated with more frequent injection and the use of multiple injection sites; two of the symptoms were also associated with having recently overdosed and the use of particular injection sites.ConclusionsInjection site infections and injuries are common among PWID and targeted interventions are needed to reduce risk.     

Prevalence and correlates of carrying naloxone among a community-based sample of opioid-using people who inject drugs

BackgroundOverdose prevention programs are effective at reducing opioid overdose deaths through training people who inject drugs (PWID) how to respond to witnessed overdoses and use naloxone. This report examines prevalence and correlates of carrying naloxone among a community-based sample of PWID.MethodsUsing respondent driven sampling, PWID (n = 571) in Philadelphia, PA were recruited for the 2015 National HIV Behavioral Surveillance project. The impact of socio-demographics, social services, and law enforcement interaction on naloxone carrying were analyzed using multivariable logistic regression.ResultsOdds of carrying naloxone were higher among PWID who were: homeless (adjusted odds ratio [aOR] = 1.65, 95% confidence interval [CI]: 1.01, 2.83), reported a syringe exchange program as their primary source of syringes (aOR = 2.92, CI: 1.68, 5.09), and had been stopped by police ≥6 times (aOR = 2.16, CI: 1.12, 4.16) or arrested (aOR = 1.84, CI: 1.02, 3.30) in the past year.ConclusionsSyringe exchange access was associated with naloxone carrying and is likely a primary source for naloxone and overdose reversal training for PWID. Homelessness and law enforcement encounters are known barriers to harm reducing behaviors; however, both were positively associated with carrying naloxone in this sample. Larger studies are needed to explore these relationships in greater depth.     

The prevalence of non-fatal overdose among people who inject drugs: A multi-stage systematic review and meta-analysis

BackgroundPeople who inject drugs (PWID) are at an elevated risk of fatal overdose in the first year after experiencing a non-fatal event. Such non-fatal events may also result in overdose-related sequelae, ranging from physical injury to paralysis. Given variation in drug markets and treatment availability across countries and regions, we may see similar variations in non-fatal overdose prevalence. Monitoring non-fatal overdose prevalence among PWID is essential for informing treatment intervention efforts, and thus our review aims to estimate the global, regional, and national prevalence of non-fatal overdose, and determine characteristics associated with experiencing such an event.MethodsWe conducted a systematic review and meta-analyses to estimate country, regional, and global estimates of recent and lifetime non-fatal overdose prevalence among PWID. Using meta-regression analyses we also determined associations between sample characteristics and non-fatal overdose prevalence.ResultsAn estimated 3.2 (1.8–5.2) million PWID have experienced at least one overdose in the previous year. Among PWID, 20.5% (15.0–26.1%) and 41.5% (34.6–48.4%) had experienced a non-fatal event in the previous 12 months and lifetime respectively. Frequent injecting was strongly associated with PWID reporting recent and lifetime non-fatal overdose. Estimates of recent non-fatal overdose were particularly high in Asia and North America.ConclusionAround one in five PWID are at an elevated risk of fatally overdosing every year, however there is substantial geographical variation. In countries with higher rates of non-fatal overdose there is need to introduce or mainstream overdose prevention strategies such as opioid agonist treatment and naloxone administration training programs.     

Integrated models of care for people who inject drugs and live with hepatitis C virus: A systematic review

BackgroundDespite the key role that people who inject drugs (PWID) play in the hepatitis C virus (HCV) epidemic, HCV treatment rates among this population have been historically low. Integrated models of HCV and substance use care have the potential to overcome some barriers to access; however, the evidence base is uncertain. This systematic review assesses the impacts of integrated HCV and substance use services on engagement in HCV care among PWID.MethodsWe searched five databases up to December 2018 to identify original quantitative studies evaluating the impacts of co-location of HCV and substance use services on engagement in the HCV cascade of care among adult PWID. We conducted a narrative synthesis, categorizing models based on patient entry point (a: HCV facility, b: substance use disorder (SUD) facility, and c: other facilities), and levels of integrated services offered (a: HCV/substance use testing only, b: HCV/substance use treatment, and c: testing/treatment + other services).ResultsA total of 46 articles corresponding to 44 original studies were included. Almost all studies (n = 42) were conducted in high-income countries and only six studies in the Direct-Acting Antiviral (DAA) era. Twenty-six studies discussed the integration of services at SUD facilities, one at HCV facilities, and seventeen at other facilities. Analysis of included studies indicated that overall integrated care resulted in improved engagement in HCV care (e.g., testing, treatment uptake and cure). However, the quality of evidence was predominantly low to moderate.ConclusionsAvailable evidence suggests that integration of HCV and substance use services may improve engagement along the continuum of HCV care among PWID. Given limitations in data quality, and very few studies conducted in the DAA era and in low- and middle-income settings, further research is urgently needed to inform strategies to optimize HCV care access and outcomes among PWID globally.     

Divergent estimates of HIV incidence among people who inject drugs in Ukraine

BackgroundDivergent estimates of HIV incidence among people who inject drugs (PWID) in Ukraine have been reported in modeling studies, longitudinal cohort studies, and recent infection assays used in cross-sectional surveys. Estimates range from 0.65 to 24.8 infections per 100 person-years with substantial regional variation. In this paper, we study the sources of this discrepancy.MethodsWe compared baseline characteristics of study subjects recruited in the cross-sectional integrated bio-behavioral surveillance surveys (IBBS) in 2011 and 2013, with those from the longitudinal network intervention trial (network RCT) conducted between 2010 – 2013, the study that found a remarkably high incidence of HIV among PWID in Ukraine. The analysis was conducted for two cities: Mykolaiv and Odesa.ResultsSignificant differences were found in the characteristics of study subjects recruited in the IBBS surveys and the network RCT, in particular in Odesa, where the mismatch in the estimates of HIV incidence is greatest. In Odesa, recent syringe sharing was about three times as prevalent in the network RCT as in the IBBS; 39% of the network RCT and 16–18% of the IBBS participants indicated stimulants rather than opiates as their drug of choice; 97% of respondents in the network RCT and 45% in the IBBS-2013 reported injecting in a group over half of the time; and the average monthly number of injections in the network RCT was about twice that in the IBBS studies.ConclusionsDifferences in study designs and sampling methodologies may be responsible for the substantial differences in HIV incidence estimates among PWID in Ukraine. The potential sources of selection bias differed between the studies and likely resulted in the recruitment of lower risk individuals into the IBBS studies compared to the network RCT. Risk stratification in the population of PWID may have implications for future surveillance and intervention efforts.     

Increasing availability of benzodiazepines among people who inject drugs in a Canadian setting

ABSTRACT

Background: Benzodiazepine misuse is associated with mortality and is common among people who inject drugs (PWID). This study aimed to examine the temporal trends in the availability of benzodiazepines among PWID in a Canadian setting, and to identify factors associated with more immediate access to benzodiazepines. Methods: Data were derived from 3 prospective cohorts of PWID in Vancouver, Canada, between June 2012 and May 2015. The primary outcome was the perceived availability of benzodiazepines, measured in 3 levels: not available, delayed availability (available in ≥10 minutes), and immediate availability (available in <10 minutes). The authors used multivariable generalized estimating equations to identify factors associated with availability of benzodiazepines. Results: In total, 1641 individuals were included in these analyses. In multivariable analyses, factors associated with immediate benzodiazepine availability included incarceration (adjusted odds ratio [AOR]: 1.42, 95% confidence interval [CI]: 1.06, 1.89) and participation in methadone maintenance therapy (MMT) (AOR: 1.35, 95% CI: 1.14, 1.60). Factors associated with delayed benzodiazepine availability included incarceration (AOR: 1.45, 95% CI: 1.02, 2.07) and participation in MMT (AOR: 1.77, 95% CI: 1.48, 2.12). Benzodiazepine availability increased throughout the study period for both immediate (AOR: 1.14, 95% CI: 1.10, 1.18 per 6-month follow-up period) and delayed (AOR: 1.17, 95% CI: 1.12, 1.22 per 6-month follow-up period) availability. Conclusions: Among our sample of PWID, benzodiazepine availability is increasing and was associated with health and criminal justice system characteristics. Our findings indicate a need to examine prescribing practices and educate both PWID and health care providers about the risks associated with benzodiazepine use.     

Life projects: the transformative potential of direct-acting antiviral treatment for hepatitis C among people who inject drugs

Background and objectivesPeople who inject drugs (PWID) are disproportionately affected by chronic hepatitis C (HCV) in high-income countries. The advent of direct-acting antivirals (DAAs) makes treatment of this underserved population more possible than ever. The dearth of programs adapted to the needs of PWID and stigma associated with drug use and chronic HCV pose significant barriers to the effective uptake of treatment among this population. We employed “life projects” as a conceptual framework to examine the social incentives of PWID being treated for HCV. This study advances the existing literature on the transformative potential of HCV treatment among PWID, explores how these transformations may affect treatment success, and discusses implications for decisions around whether and when to treat PWID.MethodsWe conducted in-depth interviews with participants of a pilot clinical trial testing the effective delivery of DAA treatment to PWID within two healthcare for the homeless clinic settings – one group receiving opioid agonist therapy (OAT) and another group frequenting a needle and syringe exchange program (NSP). A purposive sample of 27 participants was selected based on place of care. Interviews were transcribed, coded, and analysed for patterns using a priori domains and emergent themes.ResultsParticipants in both treatment groups described significant life projects that motivated them to complete HCV treatment. These projects included social redemption, strengthening of relationships, pursuit of abstinence from substance use, and harm reduction. These themes were consistent between treatment groups, though more participants in the syringe exchange group relied on harm reduction than on pursuing abstinence to prevent reinfection after achieving virologic cure.ConclusionUnderstanding the incentives that propel PWID to complete HCV treatment could help to enhance treatment uptake and adherence through dedicated programs that address current barriers to care.     

Utilization of buprenorphine and methadone among opioid users who inject drugs

ABSTRACT

Background: There has been a rise in opioid abuse and related injection drug use in the United States, and treatment for opioid use disorders may be underutilized. The study aim was to describe utilization of opioid agonist therapy (OAT), and assess factors associated with utilization of OAT, among persons who inject drugs (PWID) in the Seattle metropolitan area. Methods: Data were obtained from the 2015 National HIV Behavioral Surveillance (NHBS) system among PWID in the Seattle area. Persons aged ≥18 years who injected drugs in the past year were recruited using respondent-driven sampling. Local supplemental questions assessed whether participants had received methadone or buprenorphine treatment in the past year. The analysis was restricted to participants who reported use of any opioids in the past year. Analyses compared the demographic, health insurance status, duration of injection drug use, prior history of overdose, prior receipt of hepatitis C virus/human immunodeficiency virus (HCV/HIV) testing (self-report), and screening positive for HCV/HIV via study testing between methadone- or buprenorphine-treated and untreated PWID. Multivariate logistic models were performed to assess adjusted associations with receipt of any OAT. Results: The sample included 487 PWID who used opioids in the past year, of whom 27.1% (95% confidence interval [CI]: 23.1–31.1) reported past-year treatment with methadone and 4.7% (95% CI: 2.8–6.6) reported treatment with buprenorphine. There were no significant differences in demographics among participants who did and did not report past-year OAT; however, participants who were treated with methadone were more likely to be insured and have hepatitis C. After adjustment for other covariates, having health insurance was strongly associated with receipt of OAT (adjusted odds ratio [aOR] = 18.6; 95% CI: 2.5–138.7). Conclusions: OAT, in particular buprenorphine, has been underutilized by opioid-using PWID in the Seattle area. Health insurance is a critical factor for enabling PWID to utilize OAT treatment for opioid use disorders.     

Interventions to prevent HIV and Hepatitis C in people who inject drugs: A review of reviews to assess evidence of effectiveness

BackgroundInjecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.MethodsA review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000–2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into ‘core’ or ‘supplementary’ using critical appraisal criteria, and the strength of review-level evidence was assessed.ResultsTwelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission.ConclusionReview-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.     

The extent of and factors associated with self-reported overdose and self-reported receipt of naloxone among people who inject drugs (PWID) in England,Wales and Northern Ireland

BackgroundOverdose is a major cause of death among PWID, and for opioid overdoses naloxone administration can reduce harm. However, globally there is limited national level data on the extent of non-fatal overdose and naloxone uptake. The first national level data on the extent of self-reported overdose and self-reported receipt of naloxone among UK PWID, providing a baseline to monitor the impact of the recent policy change regarding naloxone availability, is presented.MethodsData on self-reported overdose and receipt of naloxone during the preceding year for 2013–2014 from a national survey of PWID was analysed. Participants who reported injecting during the preceding year were included.ResultsParticipants (3850) were predominantly male (75%); mean age was 36 years. The most commonly injected drugs were: heroin (91%), crack (45%) and amphetamine (29%). 15% (591) reported overdosing during the preceding year. There were no differences in the proportion reporting overdose by age or gender, but overdose was more common among those who: injected multiple drugs; recently ceased addiction treatment; injected with used needles/syringes; ever had transactional sex; had used a sexual health clinic or emergency department and lived in Wales or Northern Ireland. Among those reporting an overdose during the preceding year, a third reported two to four overdoses and 7.5% five or more overdoses; half reported receiving naloxone. Those reporting naloxone receipt in the preceding year were more likely to: live in Wales or Northern Ireland; ever received used needles/syringes; ever been imprisoned; and less likely to have injected two drug types.ConclusionThese data provide a baseline for monitoring the impact of the 2015 UK policy change to improve take-home naloxone access. Interventions tackling overdose should promote naloxone awareness and access, and target those who; are poly-drug injectors, have ceased treatment, share needles/syringes and whose drug use links to sexual activity.     

Perceived discrimination among racial and ethnic minority drug users and the association with health care utilization

ABSTRACT

People who use drugs (PWUDs) are at increased risk for several medical conditions, yet they delay seeking medical care and utilize emergency departments (EDs) as their primary source of care. Limited research regarding perceived discrimination and PWUDs’ use of health care services exists. This study explores the association between interpersonal and institutional racial/ethnic and drug use discrimination in health care settings and health care utilization among respondents (N?=?192) recruited from methadone maintenance treatment programs (36%), HIV primary care clinics (35%), and syringe exchange programs (29%) in New York City (n?=?88) and San Francisco (n?=?104). The Kaiser Family Foundation Survey of Race, Ethnicity, and Medical Care questionnaire was utilized to assess perceived institutional racial/ethnic and drug use discrimination. Perceived institutional discrimination was examined across race/ethnicity and by regular use of ERs, having a regular doctor, and consistent health insurance. Perceived interpersonal discrimination was examined by race/ethnicity. Perceived interpersonal drug use discrimination was the most common type of discrimination experienced in health care settings. Perceptions of institutional discrimination related to race/ethnicity and drug use among non-Hispanic Whites did not significantly differ from those among non-Hispanic Blacks or Hispanics. A perception of less frequent institutional racial/ethnic and drug use discrimination in health care settings was associated with increased odds of having a regular doctor. Awareness of perceived interpersonal and institutional discrimination in certain populations and the effect on health care service utilization should inform future intervention development to help reduce discrimination and improve health care utilization among PWUDs.     

Prevalence of HIV,HCV and HBV infection and sociodemographic characteristics of people who inject drugs in China: A systematic review and meta-analysis

BackgroundGlobally, China is the largest country by population and contributes substantially to the burden of people who inject drugs (PWID). The aims of this study were to estimate the prevalence of HIV, hepatitis C virus (HCV) and hepatitis B virus (HBV) among PWID at the national and subnational level in China and examine characteristics of PWID.MethodsWe undertook a systematic review of studies published from 2008 to 2017 on HIV, HCV, and HBV seroprevalence among PWID, and characteristics of PWID in Mainland China, Hong Kong, Macao and Taiwan. Meta-analyses were conducted to generate pooled prevalence estimates by province, region, and nationally.ResultsEighty-five papers were included. The pooled HIV, HCV antibody and HBV prevalence among PWID in China was 10.5% (95% confidence interval [95%CI]: 8.6%–12.5%), 71.6% (65.7%–77.6%) and 19.6% (13.7%–25.5%), respectively. In Mainland China, HIV prevalence was highest in the Southwest (14.4%, 10.5%–18.4%) and lowest in the North (1.3%, 0.4%–3.4%). Xinjiang Province had the highest HIV prevalence (42.6%, 35.5%–49.8%). HCV antibody prevalence was highest in the Southwest (77.7%, 69.9%–85.4%), followed by South (76.2%, 65.9%–86.4%). Sichuan had the highest HCV antibody prevalence (91.7%, 86.6%–95.3%), followed by Guangxi (86.1%, 81.8%–90.4%). HBsAg prevalence among PWID was highest in South (25.3%, 14.6%–36.0%), followed by Central (20.8%, 17.4%–24.1%). HBsAg prevalence ranged from 2.4% (0.6–5.9%) in Guizhou to 40.0% (33.7%–46.6%) in Shannxi Province. In China, women and young people accounted for 21.3% and 23.1% of PWID, respectively. It was estimated that 96.1% of PWID injected opioids mainly, and recent injecting risk and sexual risk was reported by 28.5% and 36.7%.ConclusionThere is a large burden of HIV, HCV and HBV prevalence among PWID in China, with considerable geographic variation. The disease burden of viral hepatitis is particularly high, implying that effective management should be integrated into harm reduction interventions among PWID in China.     

Low HIV testing rate and its correlates among men who inject drugs in Iran

BackgroundIran has a concentrated HIV epidemic among people who inject drugs (PWID). Low HIV testing uptake could contribute to the significant number HIV-infected PWID, who go undiagnosed. This study aims to assess HIV testing uptake and its correlates among PWID in Iran.MethodsData were collected through a national cross-sectional bio-behavioral study in 2010. Adult male HIV-negative PWID were included in the current analysis. All estimates were adjusted for the clustering effect of the sampling sites. Multivariable logistic regression was used to examine the correlates of recent HIV testing and adjusted odds ratios (AOR) were reported.ResultsOut of the 2146 eligible PWID for this study, 49.8% reported having ever tested for HIV. However, only 24.9% had tested in the previous year and received their test results. Around 65.2% of PWID knew an HIV testing site. In the multivariable analysis, knowing an HIV testing site (AOR = 13.9; P-value < 0.001), ≥24 years of age (AOR = 3.30; P-value = 0.027), and multiple incarcerations (AOR = 1.71; P-value < 0.001) were positively, and a monthly income of ≥65 US dollar (AOR = 0.23; P-value = 0.009) was negatively associated with having been tested and received the results.ConclusionDespite the availability of free HIV counselling and testing for PWID in Iran, only one-fourth of adult male PWID had been tested for HIV and received their results. Implementing policies and strategies to normalize routine HIV testing among PWID are crucial steps to help curb the epidemic among Iranian PWID.     

Income inequality,drug-related arrests,and the health of people who inject drugs: Reflections on seventeen years of research

This paper reviews and then discusses selected findings from a seventeen year study about the population prevalence of people who inject drugs (PWID) and of HIV prevalence and mortality among PWID in 96 large US metropolitan areas. Unlike most research, this study was conducted with the metropolitan area as the level of analysis. It found that metropolitan area measures of income inequality and of structural racism predicted all of these outcomes, and that rates of arrest for heroin and/or cocaine predicted HIV prevalence and mortality but did not predict changes in PWID population prevalence. Income inequality and measures of structural racism were associated with hard drug arrests or other properties of policing. These findings, whose limitations and implications for further research are discussed, suggest that efforts to respond to HIV and to drug injection should include supra-individual efforts to reduce both income inequality and racism. At a time when major social movements in many countries are trying to reduce inequality, racism and oppression (including reforming drug laws), these macro-social issues in public health should be both addressable and a priority in both research and action.     

Changes in risk behaviours during and following treatment for hepatitis C virus infection among people who inject drugs: The ACTIVATE study

BackgroundThe risk of hepatitis C virus (HCV) reinfection due to continued injecting risk behaviours might remain a barrier to HCV treatment among people who inject drugs. We aimed to evaluate changes in risk behaviours during and following HCV treatment among people with ongoing injecting drug use or receiving opioid substitution treatment (OST).MethodsACTIVATE was an international multicentre clinical trial conducted between 2012 and 2014. Participants with HCV genotypes 2/3 infection were treated with peg-interferon/ribavirin for 12 or 24 weeks and completed a self-administered behavioural questionnaire at each study visit. The impact of time in treatment and follow-up on longitudinally measured recent (past month) behavioural outcomes was evaluated using generalized estimating equations.ResultsAmong 93 enrolled participants (83% male, median age 41 years), 55 (59%) had injected in the past month. Any injecting drug use decreased during HCV treatment and follow-up (OR 0.89 per incremental study visit; 95% CI 0.83–0.95). No significant changes were found in ≥daily injecting (OR 0.98; 95% CI 0.89–1.07), use of non-sterile needles (OR 0.94; 95% CI 0.79–1.12), sharing of injecting paraphernalia (OR 0.87; 95% CI 0.70–1.07) or non-injecting drug use (OR 1.01; 95% CI 0.92–1.10). Hazardous alcohol use decreased throughout (OR 0.56; 95% CI 0.40–0.77) and OST increased between enrolment and end of treatment (OR 1.48; 95% CI 1.07–2.04).ConclusionsRecent injecting drug use and hazardous alcohol use decreased, while OST increased during and following HCV treatment among participants with ongoing injecting drug use. These findings support further expansion of HCV care among PWID.