The role of community-based nurses in harm reduction for HIV prevention: a South East and South Asia case study

International studies have explored the use of community-based nurses for harm reduction programs and HIV prevention. However, none have explored this role within the countries of Nepal, Myanmar, and China where the legal and political environment may adversely affect uptake of services by people who use injection drugs. Based on experiences as a nurse and harm reduction technical adviser for the development of community-based nursing initiatives in Nepal, Myanmar and China, I review some of the strengths and challenges associated with harm reduction programs in these countries. Community-based nurses play an important role in increasing the access and uptake of public health services by people who inject drugs. Within the context of harm reduction programs, community-based nurses develop a unique trust with people who inject drugs by providing non-discriminatory health care. Nurses act as information bridges between communities of people who use injection drugs, law enforcement, political and health care stakeholders. In doing so, they facilitate timely policy and programmatic responses. However, community-based nurses are prone to burnout due to long working hours and a limited pool of human resources. Community-based nurses have proven essential to the effective implementation of harm reduction program for HIV prevention in Nepal, Myanmar and China. Increased attention and support to these health care professionals have the potential to strengthen existing programs targeting people who inject drugs.     

Alcohol supply,demand, and harm reduction: What is the strongest cocktail?

The concept of harm reduction emerged from the drug field in the 1980s in response to the urgent need to reduce the risk and spread of blood-borne viruses in people who continued to inject illicit drugs. The concept has since become increasingly influential in the alcohol and even tobacco fields. While there are many different applications of the term today, the distinction used by the International Harm Reduction Association (IHRA) between strategies relying on ‘use reduction’ and those that primarily strive for harm reduction without necessarily requiring reduction in consumption is used here. The evidence base for the effectiveness of harm reduction strategies on the one hand, and efforts that require a degree of use reduction via demand or supply reduction on the other hand, is summarised based on a comprehensive review funded by the Australian government. In the alcohol field, the concept of harm reduction has sometimes been proposed as an alternative to the view that alcohol-related harm will only be reduced via a reduction of the total population consumption of alcohol. This paper will present evidence to suggest that, in order to be most effective, a comprehensive policy to reduce alcohol-related harm needs also to include interventions to reduce the quantity of alcohol consumed per occasion. Furthermore, it is highly unlikely in most modern drinking societies that significant reductions in alcohol-related harm can occur without also a significant drop in total population consumption. Nonetheless, harm reduction is an important and influential principle in alcohol policy that can be incorporated alongside such effective strategies as controls on the physical and economic availability of alcohol and the routine delivery of brief interventions in primary health care settings.     

Living with addiction: The perspectives of drug using and non-using individuals about sharing space in a hospital setting

Hospitals seem to be places where harm reduction approaches could have great benefit but few have responded to the needs of people who use drugs. Drawing on recent theoretical contributions to harm reduction from health geography, we examine how the implementation of harm reduction is shaped by space and contested understandings of place and health. We examine how drug use and harm reduction approaches pose challenges and offer opportunities in hospital-based care using interview data from people living with HIV and who were or had recently been admitted to a hospital with an innovative harm reduction policy. Our data reveal the contested spatial arrangements (and the related practices and corporeal relations) that occur due to the discordance between harm reduction and hospital regulatory policy. Rather than de-stigmatising drug use at Casey House Hospital, the adoption of the harm reduction policy sparked inter-client conflict, reproduced dominant discourses about health and drug users, and highlights the challenges of sharing space when drug use is involved. The hospital setting produces particular ways of being for people who use and those who do not use drugs and the demarcation of space in a drug using context. Moving forward, harm reduction practice and research needs to consider more than just interactions between drug users and healthcare providers, or the role of administrative policies; it needs to position ethics at the forefront of understanding the collisions between people, drug use, place, and space. We raise questions about the relationship between subjectivity and spatial arrangements in mediating the success of harm reduction.     

Views of Iranian prison staff towards needle-exchange program in prison

Aims: Prison staff members have a core role in the provision of harm reduction strategies in prison. This study aimed to evaluate the attitudes of prison directors, managers and health staff toward Needle Exchange Program (NEP) among people who inject drugs in Iranian prisons. Methods: With a grounded theory design, this qualitative study was conducted in 2011 in Iran. The study population included directors of provincial prison organisations, prison managers, heads of health departments in prisons, prison health officers, physicians, counsellors and healthcare workers in prisons. Participants’ responses were collected via focus group discussions. Results: Attitudes of the participants could generally be categorised in three including: Health-related aspects; Behavioural and social aspects; and Legal, organisational and financial aspects. Those who were in line with the existence of NEP in prisons mentioned some pre-requisites for supporting this program in prisons. Conclusion: Positive and negative views of Iranian prison staff toward NEP in prisons suggest that there are many obstacles to the provision of harm reduction strategies in prison. Consideration of socio-cultural parameters of the target community as well as combination of NEP and other harm reduction strategies might help to improve the effectiveness of harm reduction in prisons.     

Learning from HIV epidemics among injecting drug users

HIV/AIDS was the defining issue for international harm reduction during its first twenty years. This issue was marked by strong contrasts: rapid HIV transmission in some populations of injecting drug users, and close to elimination of HIV in other populations; a formidable research base for designing effective HIV programmes and persistent political problems in implementing evidence-based programmes on a public health scale. Elevated rates of HIV infection among ethnic minority drug users have occurred in many different countries. We do not yet have systematic knowledge of how to reduce stigmatization of AIDS or people who use drugs. Nevertheless, international harm reduction for people who use drugs has moved beyond HIV/AIDS to a variety of other health and social problems, while retaining firm bases in science and human rights.     

“It Goes on Everywhere”: Injection Drug Use in Canadian Federal Prisons

Background: International and Canadian research on in-prison injection drug use has documented the frequency of its occurrence as well as some of the resulting consequences such as increased prevalence of HIV and hepatitis C virus. Access to prison-based harm reduction programing is thus important. Objectives: The aim of this study was to learn from former prisoner experiences and insights on in-prison injection drug use in order to advance and improve access to harm reduction options, in particular prison-based needle and syringe programs (PNSPs). Methods: The qualitative and community-based study was conducted in 2014/2015 and included former prisoners from Ontario, Canada (N = 30) who had recent experience of incarceration in a federal prison and knowledge of injection drug use. Data analysis followed the deductive approach, drawing on the expertise of the academic and community-based research team members. Results: Interview and focus group participants disclosed that drugs are readily available in Canadian federal prisons and that equipment used to inject is accessed in a variety of ways, sometimes gained through illicit means and sometimes made by prisoners themselves. Equipment sharing is a frequent occurrence, and disposal of such supplies is rare. Conclusions/Importance: While not yet available in Canada, PNSPs have led to positive outcomes in international contexts, including reductions in needle sharing and transmission of HIV and hepatitis C. Support for PNSPs among numerous Canadian organizations and associations, along with a recent change in government, could suggest a renewed opportunity for PNSP implementation.     

Implementing harm reduction in non-urban communities affected by opioids and polysubstance use: A qualitative study exploring challenges and mitigating strategies

BackgroundHarm reduction services, which typically provide overdose education and prevention with distribution of naloxone and other supplies related to safer drug use, help reduce opioid-related overdose and infectious disease transmission. However, structural stigma and the ongoing criminalization of drug use have limited the expansion of harm reduction services into many non-urban communities in the United States that have been increasingly affected by the health consequences of opioid and polysubstance use.MethodsWe conducted qualitative interviews with 22 professionals working with people who use drugs in cities and towns across Rhode Island and Massachusetts to understand challenges and strategies for engaging communities in accepting harm reduction perspectives and services.ResultsOur thematic analysis identified several interrelated challenges to implementing harm reduction services in non-urban communities, including: (1) limited understandings of harm reduction practice and preferential focus on substance use treatment and primary prevention, (2) community-level stigma against people who use drugs as well as the agencies supporting them, (3) data reporting and aggregating leading to inaccurate perceptions about local patterns of substance use and related health consequences, and (4) a “prosecutorial mindset” against drug use and harm reduction. From key informants’ narratives, we also identified specific strategies that communities could use to address these challenges, including: (1) identifying local champions to advocate for harm reduction strategies, (2) proactively educating communities about harm reduction approaches before they are implemented, (3) improving the visibility of harm reduction services within communities, and (4) obtaining “buy-in” from a wide range of local stakeholders including law enforcement and local government.ConclusionThese findings carry important implications for expanding harm reduction services, including syringe service programs and safe injection sites, into non-urban communities that have a demonstrated need for evidence-based interventions to reduce drug-related overdose and infectious disease transmission.     

“We get by with a little help from our friends”: Small-scale informal and large-scale formal peer distribution networks of sterile injecting equipment in Australia

BackgroundIn Australia, sterile needles and syringes are distributed to people who inject drugs (PWID) through formal services for the purposes of preventing blood borne viruses (BBV). Peer distribution involves people acquiring needles from formal services and redistributing them to others. This paper investigates the dynamics of the distribution of sterile injecting equipment among networks of people who inject drugs in four sites in New South Wales (NSW), Australia.MethodsQualitative data exploring the practice of peer distribution were collected through in-depth, semi-structured interviews and participatory social network mapping. These interviews explored injecting equipment demand, access to services, relationship pathways through which peer distribution occurred, an estimate of the size of the different peer distribution roles and participants’ understanding of the illegality of peer distribution in NSW.ResultsData were collected from 32 participants, and 31 (98%) reported participating in peer distribution in the months prior to interview. Of those 31 participants, five reported large-scale formal distribution, with an estimated volume of 34,970 needles and syringes annually. Twenty-two participated in reciprocal exchange, where equipment was distributed and received on an informal basis that appeared dependent on context and circumstance and four participants reported recipient peer distribution as their only access to sterile injecting equipment. Most (n = 27) were unaware that it was illegal to distribute injecting equipment to their peers.ConclusionPeer distribution was almost ubiquitous amongst the PWID participating in the study, and although five participants reported taking part in the highly organised, large-scale distribution of injecting equipment for altruistic reasons, peer distribution was more commonly reported to take place in small networks of friends and/or partners for reasons of convenience. The law regarding the illegality of peer distribution needs to change so that NSPs can capitalise on peer distribution to increase the options available to PWID and to acknowledge PWID as essential harm reduction agents in the prevention of BBVs.     

Peer networking for the reduction of drug-related harm

In recent decades, community organizing among people who use drugs has evolved within diverse social milieus. In order to explore issues surrounding peer networking for the reduction of drug-related harm, Canada's first National Harm Reduction Conference was preceded by a collaborative participatory research process involving people who use drugs and other stakeholders. Prior to the conference, an anonymous 40-item web-based questionnaire was completed by individuals recruited through advertising, the internet and word-of-mouth. Almost 900 stakeholders responded. Peer-based networks for the reduction of drug-related harm were seen as potentially effective, efficient health promoters. Respondents reflected that networks were timely, and that governments should take some responsibility to provide means of direct support. Current networks were identified as models for further development, and building upon existing networks were seen to allow for the consolidation and sharing of information, skills and understandings. Electronic communication infrastructure was singled out as highly useful given its ability to disseminate information and ideas across large geographic areas. Safety and anonymity of network members were identified as critical due to the stigma, discrimination and potential legal ramifications associated with drug use. Peer-based approaches to the reduction of drug-related harm were seen to promote a socially-inclusive community-based response to a growing public health issue. However, there was some skepticism regarding the feasibility of such networks given the currently criminalised status of many drugs in Canada. While the literature suggests networking for people who use drugs may be challenged by community context and social structure, findings suggest in Canada some harm minimising subcultural change has, and can continue to occur, as a result of peer networking activities.     

Qualitative accounts of needle and syringe cleaning techniques among people who inject drugs in Sydney,Australia

Introduction and Aims. Cleaning needles/syringes is an important second‐line harm reduction strategy, yet there is limited information on practices employed by people who inject drugs in Australia. This study attempts to identify and assess cleaning practices in terms of the techniques involved and the social contexts in which cleaning takes place. Design and Methods. As part of an exploratory qualitative study in south‐west Sydney, in‐depth interviews and simulated cleaning exercises were conducted with 12 people who inject drugs. Interviews were digitally recorded and transcribed verbatim. Open coding was used to inductively classify data into themes, and data were examined for patterns and variations in the relationships within and between themes. Results. Data indicate that cleaning and reuse of needles/syringes was common in this small sample. The most frequently utilised reagent was cool water. While all participants reported cleaning and reusing only their own equipment, none of the techniques demonstrated would have been sufficient to deactivate human immunodeficiency virus or hepatitis C virus. Discussion and Conclusions. Results suggest that even where cleaning of needles and syringes is widespread, people who inject drugs may not engage in efficacious cleaning. The combination of the complexity of current cleaning messages and a lack of accurate information about efficacious techniques are likely to contribute to poor cleaning practice. Australia could benefit from the development of a nationally consistent cleaning message; however, the evidence would suggest that this would need to be accompanied by strategies designed to simplify and disseminate this information in order to increase the uptake of efficacious cleaning methods by people who inject drugs [Nathani J, Iversen J, Shying K, Byrne J, Maher L. Qualitative accounts of needle and syringe cleaning techniques among people who inject drugs in Sydney, Australia. Drug Alcohol Rev 2010]     

An urgent impetus for action: safe inhalation interventions to reduce COVID-19 transmission and fatality risk among people who smoke crack cocaine in the United Kingdom

Crack cocaine use is rising in the United Kingdom (UK), with smoking the primary form of administration. Provision of safe inhalation equipment for crack cocaine is prohibited under UK law. Pipes used for crack cocaine smoking are often homemade and/or in short supply, exacerbating COVID-19 transmission and respiratory risk. This is of concern, given high prevalence of respiratory health harms such as chronic obstructive pulmonary disease (COPD) among people who smoke illegal drugs. This commentary draws on scoping review and mixed method empirical evidence to argue for provision of safe crack inhalation equipment in the UK, with commensurate legal reform. Review of crack inhalation interventions illustrates the health protective and service engagement benefits of smoking equipment supply. Survey data generated with 455 people who inject drugs in London illustrate high prevalence of current crack use (66%, n=299). Qualitative accounts illustrate perceptions of relative smoking safety – alongside accounts of severe respiratory-related health harms. To date, injecting drug use has been of primary concern in relation to harm reduction initiatives. It is crucial that people who smoke illegal drugs are considered a vulnerable population in regard to COVID 19 transmission and fatality risk, with innovative harm reduction measures scaled up in response.     

Public Health and the origins of the Mersey Model of Harm Reduction

In the mid-1980s in Liverpool, and the area surrounding it (Merseyside and Cheshire), harm reduction was adopted on a large scale for the first time in the UK. The harm reduction model was based on a population approach to achieve the public health goal of reducing the harm to health associated with drug use. The particular concern at that time was the risk of HIV infection, but there was also the issue of the health of a group of young people who were under-served by health services. To achieve the goal, services were developed that would attract the majority of those at risk within the community, not simply the few who wished to stop using drugs, and which would enable contact with the target group to be maintained so as to bring about the necessary changes in behaviour required to maintain health and reduce risk. This Commentary describes some of the background to the development of the Mersey Model of Harm Reduction from the memories and perspectives of two people who promoted harm reduction within the health service and the region.     

‘It's Fast,It's Quick,It Stops Me Being Sick’: How to influence preparation of opioid tablets for injection

Introduction and Aims. Injection of pharmaceutical opioids (PO) among people who inject drugs has increased in many countries. The common method for preparing PO tablets for injection uses heat, resulting in greater particulate matter and therefore increased risk of local infection risk and damage to veins and organs. A cold preparation process has fewer risks, but this preparation method is not commonly used. This study seeks to explore how people who inject PO learn to prepare injections and how health promotion efforts could influence practice. Design and Methods. Between March and December 2013, qualitative interviews were undertaken with 33 clients of Sydney's Medically Supervised Injecting Centre who inject PO tablets regarding sources of knowledge and current preparation methods for injection of POs. Results. Overwhelmingly, the most commonly reported source of knowledge around injection of tablets was others who inject. Most participants reported heating the solution as the quickest way to administer the drug. Attitudes to the use of wheel filters varied, with some participants reporting that they would use the filters if they were shown how, while others reported a number of barriers to using filters, including complexity of use. Discussion and Conclusions. Harnessing the power of social connections may provide avenues for education about safer injecting of tablets, including the use of wheel filters. Further work is required to debunk myths about the relative potencies of cold versus hot drug solution. Collaborations between harm reduction workers and peer workers would assist in knowledge dissemination regarding safer injecting practices.     

Drug scene,drug use and drug-related health consequences and responses in Kulob and Khorog,Tajikistan

BackgroundTajikistan and other Central Asian republics are facing intertwined epidemics of injecting drug use and HIV. This paper aims to examine drug scene, drug use, drug-related infectious diseases, drug treatment and other responses to health consequences of drug injecting in two Tajik cities of Kulob (Khatlon Region) and Khorog (Gorno-Badakhshan Autonomous Oblast).MethodsWe conducted 12 focus group discussions in Kulob and Khorog and analysed peer-reviewed literature, published and unpublished programme and country reports and other publications that focused on substance use and/or HIV/AIDS in Tajikistan and included the Khatlon and Gorno-Badakhshan regions.ResultsIn both Kulob and Khorog, heroin is used by the overwhelming majority of people who inject drugs (PWID), with one dose of heroin in Khorog costing less than a bottle of vodka. Opioid overdose among PWID in Tajikistan is a serious issue that appears to be substantially underestimated and inadequately addressed at the policy and practice levels. In integrated bio-behavioural surveys (IBBS), HIV and HCV prevalence in both Kulob and Khorog varied widely over a short period of time, raising questions over the quality and reliability of these data. Access to opioid substitution therapy (OST) and antiretroviral therapy (ART) by PWID is either lacking or inadequate. Very few women who inject drugs access needle and syringe programmes in Kulob and Khorog. HCV treatment cannot be afforded by the overwhelming majority of PWID due to high costs.ConclusionTajikistan IBBS data point to the potential problems in using composite national prevalence as an adequate reflection of the HIV epidemic among PWID in the country and highlight the importance of examining site-specific prevalence rates for better understanding of the dynamics of the epidemic over time as well as potential problems related to the reliability of data. Furthermore, our analysis highlights that in a country where almost all PWID inject opiates, agonist treatment should be an intervention of choice. Scaling-up both OST and ART coverage must be seen as the top priority for reducing HIV prevalence and incidence in Tajikistan. Naloxone distribution programmes need to be expanded and drug treatment, harm reduction and HIV services that meet the specific needs of female injecting drug users should be put in place.     

Polydrug use and polydrug markets amongst image and performance enhancing drug users: Implications for harm reduction interventions and drug policy

BackgroundOver the past two decades, the use of image and performance enhancing drugs (IPEDs) has increased significantly. Once largely confined to professional athletes, IPED use has transcended the elite sporting arena and is now predominantly found among non-elite, recreational gym users. This paper presents research findings from a qualitative study of IPED use and supply in a ‘hardcore’ bodybuilding gym in the north of England. This article makes an original contribution to the field by providing an in-depth account of the use and supply of IPEDs among this population, demonstrating the intersectionality that exists across IPEDs, diverted medication and both licit and illicit substance use and supply.MethodsThe findings are based on the research team’s privileged access to an independent, ‘hardcore’ body building gym in the north of England. Four fieldworkers undertook overt systematic observations, supplemented by 20 semi-structured interviews.ResultsAmongst this sample of bodybuilders, substance use transcended IPEDs to encompass a much broader cocktail of substances all who used IPEDs concomitantly used diverted medication as a means of negating anticipated side-effects, and over half used illegal psychoactive drugs. Furthermore, virtually all of these substances were available to buy via the gym, through fellow gym members and, at times, staff.ConclusionThis article draws three main conclusions. (1) We are witnessing a convergence of IPED use and supply with diverted medication and ‘traditional’ recreational substances. (2) The extensive poly-substance use reported by interviewees in this sample necessitates a review of existing harm reduction advice for IPED users that takes into consideration the full range of substances currently being used. (3) Punitive drug policy reform that aims to reduce IPED markets needs to consider the potential to displace social supply towards more commercially-driven dealing. Harsher drug laws may also risk criminalising and stigmatising IPED users.     

Moving from a project to programmatic response: Scaling up harm reduction in Asia

The response to the HIV epidemics among people who inject drugs in Asia began to emerge in the early to mid 1990s, with the rather hesitant implementation of small-scale needle syringe programmes and community care initiatives aiming to support those who were already living with the virus. Since then Asia has seen a significant scaling up of harm reduction, despite very limited resources and difficult policy and legislative environments. One of the major reasons this has happened, is the utilisation of programme based approaches and the firm entrenchment of harm reduction thinking within national HIV/AIDS programmes and strategic plans—in most cases aided by multilateral and bilateral donors. Several models of scale up have been noted in Asia. The transition away from project based approaches, while on the whole positive, can also have a negative impact if the involvement of civil society and a client focussed approach is not protected. Also there are implications for which models of capacity building can be systematised for ongoing scale up. Most crucially, the tensions between drug policy, human rights and public health policies need to be resolved if harm reduction services are to be made available to the millions in Asia who are still unable to access these services.     

Exploring the relationship between online buyers and sellers of image and performance enhancing drugs (IPEDs): Quality issues,trust and self-regulation

BackgroundOnline drug markets are expanding the boundaries of drug supply including the sale and purchase of image and performance enhancing drugs (IPEDs). However, the role of the internet in IPED markets, and in particular the ways in which these substances are supplied via the surface web, has rarely been considered. This article examines the online IPED market in order to inform drug policy and to provide a nuanced understanding of retailers involved, particularly exploring the relationship between buyers and sellers.MethodsThis paper is based on two extensive research projects conducted in the Netherlands and Belgium. The first project focuses on muscle drugs and is based on 64 IPED dealing cases, semi-structured interviews with authorities (N = 32), and dealers (N = 15), along with an analysis of 10 steroid-selling websites. The second research project primarily focuses on weight loss drugs and sexual enhancers in the Netherlands, and relies on interviews with authorities (N = 38), suppliers (N = 30), and consumers (N = 10), analysis of 69 criminal case files, and an online analysis.ResultsIn the literature, the illicit online sale of IPEDs is generally associated with illegal online pharmacies that try to mislead buyers. While confirmed in our research, we also illustrate that there are online suppliers who invest in customer relationships and services, and that users are aware of the illegal nature of their business. These e-vendors incorporate a ‘social supply business model’ by providing the best possible service to their customers and attempting to minimise risks in order to attract, satisfy and maintain customers.ConclusionAs it is likely that users will continue to make use of the internet to order IPEDs, regardless of closing down selling websites, it is first of all important to counteract these online sources by educating all types of consumers and providing harm reduction services.     

Positive effects of community attachment on internalised stigma and wellbeing among people who inject drugs

BackgroundInternalised stigma experienced by people who inject drugs (PWID) is known to have negative health consequences. Research has explored factors that may protect or buffer individuals from the negative consequences of internalised stigma. Community attachment, or perceived connection to a community of like people, can have numerous health-related benefits. However, this relationship may be complex for PWID; being part of a social network of PWID may provide opportunity for more frequent drug use and equipment sharing. This study investigated the relationships between community attachment, internalised stigma, and wellbeing among PWID, while also addressing potential health risks associated with PWID community attachment.MethodsPWID (n=603) were recruited through nine peer-based drug user organisations across Australia with assistance from the peak consumer organisation. Participants completed a survey measuring community attachment, internalised stigma, personal wellbeing, injecting frequency, and equipment sharing.ResultsGreater attachment to a PWID community was associated with lower internalised stigma, but also with sharing of injecting equipment and increased frequency of injecting behaviour. The relationship between community attachment and personal wellbeing was mediated by internalised stigma, however this was only the case for PWID who reported no sharing of injecting equipment.ConclusionsThis research highlights the significance of community attachment for PWID while also noting the complexity of this relationship and the potential negative consequences. It is important to view networks of PWID communities as sources of positive social capital, where norms about health behaviours and harm reduction can be promoted and which can buffer community members from the harms associated with stigma.     

People Who Inject Drugs and Have Mood Disorders—A Brief Assessment of Health Risk Behaviors

Background: People who inject drugs have a greater risk of infectious disease and mortality than other substance abusers and nondrug users. Variation in risk behavior among people who inject drugs is likely associated with comorbid mental health disorders. Objectives: Examine the association between a history of mood disorder and recent risk behavior among people who inject drugs. Methods: With baseline data from a behavioral HIV prevention clinical trial in a population of people who inject drugs, we used logistic regression models to compare the risk behaviors of people who report a past diagnosis of bipolar disorder (n = 113) or depression (n = 237) to a comparison group with no history of diagnosed mental illness (n = 446). We also assessed differences between groups before and after adjusting for demographic characteristics and current depressive symptoms. Results: While there were no differences between groups in frequency of drug use, people who inject drugs who report a history of mood disorders reported more injection risk behaviors, drug overdoses, sex exchanges, and multiple partners than those with no history of mental illness. Adjusting the comparison for demographic characteristics and current depressive symptoms had little impact on these findings. Variation in risk between depression and bipolar disorder groups was minimal. Conclusions/Importance: People who inject drugs and have mood disorders have unique and significant social, clinical, and risk reduction needs. Despite the limited validity of self-reported mental health history, simply asking about a history of mood disorder may be effective for identifying a particularly vulnerable population of people who inject drugs.