Effects of drug treatment for heroin sniffers: a protective factor against moving to injection?

We explore the relationship between contact with treatment and transition to injection for heroin sniffers. Our primary research question is, does contact with treatment delay onset of injection for heroin sniffers? A stratified network-based sample was recruited from multiple communities in South Florida which were known for high drug use. Three categories of respondents were recruited based on injection outcome: long-term injectors, short-term injectors, and sniffers (n = 900). We answer our research question in two steps. First, we investigate the prevalence of drug treatment for heroin sniffers and injectors using case-control methods. The preliminary findings indicate a positive relationship between contact with treatment and injection status outcome. Second, we further examine the relationship by attempting to identify the causal factors that delay initial injection for a subgroup of current injectors using survival regression procedures. Delaying or preventing transition to injection could significantly decrease risk of HIV transmission by reducing or eliminating risky injecting behaviors. We conclude with a discussion of policy implications and suggestions for future research.     

HIV/AIDS Patients Who Move to Urban Florida Counties Following a Diagnosis of HIV: Predictors and Implications for HIV Prevention

We characterized patients at publicly funded HIV/AIDS patient treatment sites who moved (“migrated”) post-diagnosis of HIV to five urban Florida counties, by geographic, demographic, socioeconomic and risk variables. Each patient who came for services at the sites in a 2–3 week sampling period was asked to complete a brief, self-administered questionnaire. We compared migrant with non-migrant patients to disclose characteristics predictive of migration and help plan for continuity of HIV care, future funding, and HIV prevention. Overall, 25% (range by site, 20%–38%) of the 1,286 patients in the study migrated to the counties from a non-contiguous Florida county, another state, or another country. In a multivariate model comparing interstate migrants with non-migrants, white and Hispanic race/ethnicity, age 9–29 years at first HIV diagnosis compared with older age, increasing education, highest current income and exposure category (men having sex with men and injection drug users) were independently associated with migration (all p < 0.05). In a similar model for international migrants, the independently associated variables included Hispanic ethnicity, education, and younger age at first HIV diagnosis. Although migrating can bring benefits to a patient such as improved access to health care or a new employment opportunity, it is stressful because it can result in changes in a person’s social network, employment, and health care providers. Thus, moving could create unique patient needs concerning medication adherence, risk-taking, and other psychosocial needs. Given the high percentage of migrants in these urban Florida county clinics, these needs should be further examined and addressed. Lieb is with the Florida Department of Health, Bureau of HIV/AIDS, Tallahassee, FL, USA; Trepka is with the Stempel School of Public Health, Florida International University, Miami, FL, USA; Liberti, Cohen, and Romero are with the Florida Department of Health, Tallahassee, FL, USA.     

The Effect of a Case Management Intervention on Drug Treatment Entry Among Treatment-Seeking Injection Drug Users With and Without Comorbid Antisocial Personality Disorder

We examined the effect of a case management intervention on drug treatment entry among injection drug users (IDUs) with and without comorbid antisocial personality disorder (ASPD). Injection drug users attending the Baltimore Needle Exchange Program who sought and were granted referrals to opioid agonist treatment were randomized to receive a strengths-based case management intervention or passive referral. Of 162 IDUs, 22.8% met the DSM-IV criteria for ASPD. Compared to those without ASPD, IDUs with comorbid ASPD who spent 25 or more minutes with their case manager prior to their treatment entry date were 3.51 times more likely to enter treatment than those receiving less than 5 min, adjusting for intervention status, race, and treatment site (95% confidence interval 1.04–11.89). Providing case management services to IDUs with comorbid ASPD may facilitate treatment entry and reduce the negative consequences of drug abuse. Havens is with the Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, USA; Cornelius is with the School of Social Work, University of Maryland, Baltimore, MD, USA; Ricketts, Huettner, and Strathdee are with the Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Latkin is with the Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Bishai is with the Department of Population and Family Health Sciences, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Lloyd is with the School of Social Administration, Temple University, Philadelphia, PA, USA; Strathdee is with the Division of International Health and Cross-cultural Medicine, Department of Family Health Sciences, University of California San Diego School of Medicine, San Diego, CA, USA.     

Effectiveness of Respondent-Driven Sampling for Recruiting Drug Users in New York City: Findings from a Pilot Study

A number of sampling methods are available to recruit drug users and collect HIV risk behavior data. Respondent-driven sampling (RDS) is a modified form of chain-referral sampling with a mathematical system for weighting the sample to compensate for its not having been drawn randomly. It is predicated on the recognition that peers are better able than outreach workers and researchers to locate and recruit other members of a “hidden” population. RDS provides a means of evaluating the reliability of the data obtained and also allows inferences about the characteristics of the population from which the sample is drawn. In this paper we present findings from a pilot study conducted to assess the effectiveness of RDS to recruit a large and diversified group of drug users in New York City. Beginning with eight seeds (i.e., initial recruits) we recruited 618 drug users (injecting and non-injecting) in 13 weeks. The data document both cross-gender and cross-race and -ethnic recruitment as well as recruitment across drug-use status. Sample characteristics are similar to the characteristics of the drug users recruited in other studies conducted in New York City. The findings indicate that RDS is an effective sampling method for recruiting diversified drug users to participate in HIV-related behavioral surveys. Abdul-Quader, Sabin, and Gallagher are with the Centers for Disease Control and Prevention, Atlanta, USA; Heckathorn is with the Department of Sociology, Cornell University, New York, USA; McKnight, Bramson, and Des Jarlais are with The Baron Edmond de Rothschild Chemical Dependency Institute, Beth Israel Medical Center, New York, USA; Nemeth is with the New York State Department of Health, Albany, USA. An erratum to this article can be found at     

Risk factors for HIV-1 seroconversion among injection drug users: a case-control study.

OBJECTIVES. A nested case-control study was conducted in Miami, Fla, to determine risk factors associated with human immunodeficiency virus type 1 (HIV-1) seroconversion among injection drug users. METHODS. The study identified 21 incident cases of HIV-1 infection and 76 unmatched controls from two longitudinal cohorts of injection drug users. One cohort consisted of individuals who originally had been recruited from treatment centers; a second cohort was recruited from the "street." Logistic regression analyses that adjusted for age, gender, and race were performed. RESULTS. The final model determined that the primary independent risk factor that best explained the risk for seroconversion was sharing injection equipment in the year prior to conversion; a marginal risk factor was presence of sexually transmitted disease during this same period. CONCLUSIONS. Both an injection component and a sexual component play a role in seroconversion among injection drug users, although the injection component is much stronger.     

Low-Frequency Heroin Injection among Out-of-Treatment, Street-Recruited Injection Drug Users

In this paper, we explore the understudied phenomenon of “low-frequency” heroin injection in a sample of street-recruited heroin injectors not in drug treatment. We conducted a cross-sectional study of 2,410 active injection drug users (IDUs) recruited in San Francisco, California from 2000 to 2005. We compare the sociodemographic characteristics and injection risk behaviors of low-frequency heroin injectors (low-FHI; one to 10 self-reported heroin injections in the past 30 days) to high-frequency heroin injectors (high-FHI; 30 or more self-reported heroin injections in the past 30 days). Fifteen percent of the sample met criteria for low-FHI. African American race, men who have sex with men (MSM) behavior, and injection and noninjection methamphetamine use were independently associated with low-FHI. Compared to high-FHI, low-FHI were less likely to report syringe sharing and nonfatal heroin overdose. A small but significant proportion of heroin injectors inject heroin 10 or less times per month. Additional research is needed to qualitatively examine low-frequency heroin injection and its relationship to drug use trajectories.     

Accelerated Transition to Injection Among Male Heroin Initiates in Hanoi,Vietnam: Implications for Early Harm Reduction Interventions

This paper examines changes in the interval between first heroin smoking and onset of injection in a large, out-treatment sample of male heroin users in Hanoi, Vietnam (n = 1,115). Mean age at initiation of heroin use (smoking) was 18.4 and mean age of onset of heroin injection was 20.9 years. Full multivariate analysis indicates that the interval between first heroin use (smoking) and first heroin injection has been significantly attenuated among more recent heroin initiates (P = 0.0043), suggesting that heroin users in Vietnam may be at increased risk for exposure to HIV relatively soon after onset of heroin use, highlighting the need for behavioral interventions that target heroin smokers. Critical intervention goals include delaying the onset of injection and improved education about safer drug sharing and drug injection practices.     

Met and unmet need for dental services among active drug users in Miami,Florida

This study considers both met and unmet need for dental services among chronic drug users in Miami, Florida, and compares them with non-drug users recruited from the same neighborhoods (N=1,479). Three primary findings emerged: (1) dental problems are among the most frequently reported health problems, (2) drug use is independently associated with need for dental services, and (3) injection drug use is independently associated with increased odds of unmet need for dental services. These findings suggest that policies that increase access to dental services for drug users and other disadvantaged groups are needed. These services could be integrated into existing behavioral health programs already targeting active drug users.     

Community activism relating to a cluster of breast cancer

In 1985, residents of a suburban community in South Florida became concerned when several young women were diagnosed with breast cancer. First as individuals, then through a community-based effort, they attempted to gain attention and action on what they believed to be a cluster of breast cancer. Through their efforts to find out whether some agent or toxic exposure existed in the community that might have caused breast cancer, the women formed a community-based organization. This paper describes the activism of the women to resolve the issue through an epidemiologic study of the breast cancer occurrence in their community. Furthermore, it substantiates the need and role of rational community response in resolving community threats and concerns.H. V. McCoy is an Assistant Professor of Public Health at Florida International University, N. Miami, Florida.Edward J. Trapido is an Associate Professor of Oncology; Clyde B. McCoy is Professor of Oncology; Nancy Strickman-Stein is a Research Associate; Inger Brown is a Research Assistant; all at the University of Miami School of Medicine, Miami, Florida.Acknowledgments: Dorothy Lockwood, University of Delaware. This study was partially funded by the State of Florida Contract #LCD-E7 and Papanicolaou Women's Corp. of the Sylvester Comprehensive Cancer Center, University of Miami School of Medicine.This paper is dedicated to the memory of Liviana Avello, a leader and motivator in the quest for knowledge of the breast cancer issue in Kendale Lakes, and to the Kendale Lakes Women Against Cancer.     

The Impact of Legalizing Syringe Exchange Programs on Arrests Among Injection Drug Users in California

Legislation passed in 2000 allowed syringe exchange programs (SEPs) in California to operate legally if local jurisdictions declare a local HIV public health emergency. Nonetheless, even in locales where SEPs are legal, the possession of drug paraphernalia, including syringes, remained illegal. The objective of this paper is to examine the association between the legal status of SEPs and individual arrest or citation for drug paraphernalia among injection drug users (IDUs) in California from 2001 to 2003. Using data from three annual cross-sections (2001-03) of IDUs attending 24 SEPs in 16 California counties (N = 1,578), we found that overall, 14% of IDUs in our sample reported arrest or citation for paraphernalia in the 6 months before the interview. Further analysis found that 17% of IDUs attending a legal SEP (defined at the county level) reported arrest or citation for drug paraphernalia compared to 10% of IDUs attending an illegal SEP (p = 0.001). In multivariate analysis, the adjusted odds ratio of arrest or citation for drug paraphernalia was 1.6 [95% confidence interval (CI) = 1.2, 2.3] for IDUs attending legal SEPs compared to IDUs attending illegal SEPs, after controlling for race/ethnicity, age, homelessness, illegal income, injection of amphetamines, years of injection drug use, frequency of SEP use, and number of needles received at last visit. IDUs attending SEPs with legal status may be more visible to police, and hence, more subject to arrest or citation for paraphernalia. These findings suggest that legislative efforts to decriminalize the operation of SEPs without concurrent decriminalization of syringe possession may result in higher odds of arrest among SEP clients, with potentially deleterious implications for the health and well-being of IDUs. More comprehensive approaches to removing barriers to accessing sterile syringes are needed if our public health goals for reducing new HIV/HCV infections are to be obtained. Martinez is with the Center for AIDS Prevention Studies, University of California, San Francisco, 50 Beale Street, Suite 1300, San Francisco, CA 94105, USA; Bluthenthal is with the Drug Policy Research Center, RAND, Santa Monica, CA, USA and the Urban Community Research Center, Department of Sociology, California State University Dominguez Hills, Carson, CA, USA; Lorvick is with the Urban Health Program, RTI International, San Francisco, CA, USA; Anderson is with the Sacramento Area Needle Exchange, Sacramento, CA, USA; Flynn is with the Department of Internal Medicine, University of California, Davis, CA, USA; Kral is with the Urban Health Program, RTI International, San Francisco, CA, USA and the Department of Family and Community Medicine, University of California, San Francisco, CA, USA.     

上海市嘉定区吸毒人员艾滋病流行病学调查分析

目的了解上海市嘉定区社区吸毒人员艾滋病、梅毒和丙肝感染情况,性病艾滋病知识知晓情况,以及吸毒、性行为状况,评估社区吸毒人员艾滋病防治效果。方法由镇（街道）禁毒社工对社区吸毒人员进行问卷调查,并采集血样进行血清学检测。结果2009年、2012年分别调查290人、283人,未检出HIV感染者;梅毒RPR阳性率分别为2．41％、3．18％：丙肝阳性率分别为27．93％、29．79％;艾滋病基本知识知晓率分别为83．79％、89．75％。2009年、2012年调查对象主要使用海洛因、冰毒和摇头丸等毒品,曾注射过毒品的比例分别为42．76％、43．82％,其中与别人共用过针具的比例分别为5．65％、6．90％。最近一个月发生性行为的比例分别为32．76％、43．82％;最后一次性行为使用安全套的比例分别为46.32％、50．81％：最近一年曾发生过商业性行为的比例分别为2．07％、5.30％。多元Logistic回归分析结果显示,年龄越大,知识得分越低,曾注射吸毒的比例越高;年龄越大,安全套使用率越低。结论嘉定区吸毒人员梅毒、丙肝感染率高,艾滋病知识知晓率有所提高,存在注射吸毒、共用注射器及不安全性行为等危险因素。应采取降低吸毒危害和经性传播的综合性干预措施。     

Sampling and Recruitment in Multilevel Studies among Marginalized Urban Populations: The IMPACT Studies

Illicit drug use in urban settings is a major public health problem. A range of individual level factors are known to influence drug use and its consequences, and a number of recent studies have suggested that the neighborhood in which an individual lives may also play a role. However, studies seeking to identify neighborhood-level determinants of drug use, particularly among marginalized urban populations, need to overcome significant challenges, particularly in the area of sampling and recruitment. One key issue is defining functional neighborhoods that are relevant to local residents. Another arises from the need to sample a representative or even a diverse population when studying marginalized groups such as illicit drug users. These are common problems that raise particular challenges when both need to be addressed in the same study. For example, many sampling approaches for neighborhood-level studies have included some form of random sample of households, but this may systematically overlook marginalized populations. On the other hand, the sampling approaches commonly used in studies of hidden populations such as chain referral, snow ball, and more recently, respondent-driven sampling, typically expand beyond a geographic “neighborhood.” We describe the organization and rationale for the IMPACT Studies in New York City as a case illustration on how such issues may be addressed. Ompad, Galea, Fuller, Weiss, Beard, Chan, Edwards, and Vlahov are with the Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY, USA; Galea is with the Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA; Marshall is with the RAND Corporation, Santa Monica, CA, USA; Fuller and Vlahov are with the Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.     

四川省西昌市吸毒人群首次静脉注射吸毒情况调查

目的了解四川省西昌市吸毒人群从首次口吸毒到首次静脉注射吸毒的发生情况。方法于2004-05／07从社区中招募吸毒人群，调查其社会人口学、首次吸毒前吸烟、饮酒情况、首次吸毒的时间和方式及种类、首次静脉注射吸毒情况。结果在调查的451名吸毒人员中，首次使用的毒品均为海洛因，其中，首次为口吸和静脉注射的分别为80．7％（364／451）和19．3％（87／451）。从首次口吸到首次静脉注射的发生率为21．82／100人年（95％ CI为19．60～24．05），多因素Cox比例风险模型分析结果显示，初中以下文化（HR=1．38；95％ CI为1．12～1．70）和15岁以前开始吸烟（HR=1．41；95％ CI为1．15～1．73）与首次口吸到首次静脉注射发生的关系有统计学意义。结论首次口吸到静脉注射毒品的时间与文化程度有关，这一转变的发生率也与吸毒人群吸烟早迟有关。但需进一步了解吸毒人群首次静脉注射吸毒的发生情况及其影响因素。     

The Relationship between Drug User Stigma and Depression among Inner-City Drug Users in Baltimore, MD

There is growing awareness of the role of stigma and discrimination in HIV prevention, testing, and medical care. Yet, few studies have examined the stigma associated with using illicit drugs. In the present study, we examined the relationship between social network characteristics, drug user stigma, and depression. Study participants were comprised of 340 individuals who reported cocaine, crack, and/or heroin use in the prior 6 months and were involved in an HIV prevention study. They were recruited through street outreach, referrals, and word of mouth in inner-city Baltimore, MD, USA. The stigma scale was comprised of eight items, such as “how much do you feel ashamed of using drugs?” Depression was assessed with the Center for Epidemiological Studies Depression Scale, using cutoffs of 16 and 20 or greater. In the bivariate analyses, gender, homelessness in the past 6 months, drug user stigma, larger size of drug network, and current use of heroin, cocaine, and crack were all significantly associated with high levels of depression, whereas in the multivariate analyses, only drug user stigma remained significantly associated with depression. The results of this study suggest that drug treatment providers and other professionals who provide services to drug users should consider developing trainings to address drug user stigma. These programs should focus on the attitudes and behaviors of health and service providers toward drug users, among drug users themselves, and among family members and others who provide social support to drug users.     

Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: A pilot intervention study

Fatal heroin overdose has become a leading cause of death among injection drug users (IDUs). Several recent feasibility studies have concluded that naloxone distribution programs for heroin injectors should be implemented to decrease heroin overdose deaths, but there have been no prospective trials of such programs in North America. This pilot study was undertaken to investigate the safety and feasibility of training injection drug using partners to perform cardiopulmonary resuscitation (CPR) and administer naloxone in the event of heroin overdose. During May and June 2001, 24 IDUs (12 pairs of injection partners) were recruited from street settings in San Francisco. Participants took part in 8-hour training in heroin overdose prevention, CPR, and the use of naloxone. Following the intervention, participants were prospectively followed for 6 months to determine the number and outcomes of witnessed heroin overdoses, outcomes of participant interventions, and changes in participants’ knowledge of overdose and drug use behavior. Study participants witnessed 20 heroin overdose events during 6 months follow-up. They performed CPR in 16 (80%) events, administered naloxone in 15 (75%) and did one or the other in 19 (95%). All overdose victims survived. Knowledge about heroin overdose management increased, whereas heroin use decreased. IDUs can be trained to respond to heroin overdose emergencies by performing CPR and administering naloxone. Future research is needed to evaluate the effectiveness of this peer intervention to prevent fatal heroin overdose.     

More free syringes, fewer drug injectors in the case of Spain

International policy on the prevention of HIV and other health problems among drug users should be guided by scientific evidence. However, it has frequently been argued that Needle Exchange Programs (NEPs) have negative effects such as facilitation of injection of illicit drugs, without providing evidence to support this hypothesis. Since the early 1980s Spain has experienced a severe HIV epidemic among drug injectors. A delayed but comprehensive implementation of harm reduction programs has taken place since the early 1990s. This paper assesses trends between 1991 and 2004, both in the number of sterile syringes exchanged or delivered by NEPs or other programs to improve injectors' access to sterile injection material, and in the number of injectors admitted to first treatment for heroin or cocaine dependence, as a proxy for trends in the number of new drug injectors in Spain. The results show increased access to sterile syringes and a sharp decrease in the number of new drug injectors, suggesting that NEPs have not promoted drug injection. A positive overall transition from injecting to smoking was also observed in the most frequent route of heroin or cocaine administration.     

Risk of Mortality during Four Years after Substance Detoxification in Urban Adults

The objective of this analysis was to assess the mortality rate and risk factors in adults, with substance dependence, who are not receiving primary medical care (PC). Date and cause of death were identified using the National Death Index data and death certificates for 470 adults without PC over a period of almost 4 years after detailed clinical assessment after detoxification. Factors associated with risk of mortality were determined using stepwise Cox proportional hazards models. Subjects were 76% male, 47% homeless, and 47% with chronic medical illness; 40% reported alcohol, 27% heroin, and 33% cocaine as substance of choice. Median age was 35. During a period of up to 4 years, 27 (6%) subjects died. Median age at death was 39. Causes included: poisoning by any substance (40.9% of deaths), trauma (13%), cardiovascular disease (13.6%), and exposure to cold (9.1%). The age adjusted mortality rate was 4.4 times that of the general population in the same city. Among these individuals without PC in a detoxification unit, risk factors associated with death were the following: drug of choice [heroin: hazard ratio (HR) 6.9 (95% confidence interval (CI) 1.6–31.1]; alcohol: HR 3.7 (95% CI 0.79–16.9) compared to cocaine); past suicide attempt (HR 2.1, 95% CI 0.96–4.5); persistent homelessness (HR 2.4, 95% CI 1.1–5.3); and history of any chronic medical illness (HR 2.1, 95% CI 0.93–4.7). Receipt of primary care was not significantly associated with death (HR 0.85, 95% CI 0.34–2.1). Risk of mortality is high in patients with addictions and risk factors identifiable when these patients seek help from the health care system (i.e., for detoxification) may help identify those at highest risk for whom interventions could be targeted. Saitz, Cheng, Richardson, and Samet are with the Clinical Addiction Research and Education Unit, Department of Medicine, Boston Medical Center, Boston, MA, USA; Saitz, Gaeta, Cheng, Richardson, and Samet are with the Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA; Saitz and Richardson are with the Youth Alcohol Prevention Center, Boston University School of Public Health, Boston, MA, USA; Gaeta is with the Boston Health Care for the Homeless Program, Boston, MA, USA; Cheng is with the Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA; Larson is with the New England Research Institutes, Watertown, MA, USA; Samet is with the Department of Social & Behavioral Sciences, Boston University School of Public Health, Boston, MA, USA.     

Risky sexual behaviors associated with recreational drug use among men who have sex with men in an international resort area: Challenges and opportunities

South Florida is home to a highly transient population of approximately 145,000 men who have sex with men (MSM) and annually hosts over 1.8 million gay and bisexual visitors. To develop more effective interventions for HIV/sexually transmitted infections (STI) prevention in this setting, we conducted a cross-sectional study of recreational drug use and risky sexual behaviors among MSM. A standardized, selfadministered questionnaire, reviewed and approved by a university Institutional Review Board, was offered to men 18 years of age and older who reported ever having sex with a man. Men were approached on weekends in five diverse locations in Miami-Dade County and five in Broward County in winter 2004. An honorarium of $10 was offered to those who completed and returned a questionnaire. Of 407 participants, 115 men (28%) lived in Miami-Dade, 147 (36%) lived in Broward, 46 (11%) lived in another county in south Florida, and 99 (24%) lived elsewhere. Overall, 32% reported using one or more “club drugs” in the past year. Club drug use was highly associated with unprotected anal intercourse (UAI) (P<.001). MSM residing outside of south Florida were more likely than local residents to report using cocaine and ketamine and engaging in unprotected receptive anal intercourse (URAI) in the past month (P=.03). Tourists may be even more likely than residents to engage in risky sexual behaviors and use certain recreational drugs. Interventions must be developed, implemented, and evaluated that take into account the unique characteristics of international resort areas. An earlier version was presented in Miami Beach on August 27, 2004, at the conference, “Opportunities, Challenges, and Successes of International Research,” cosponsored by the Drug Abuse and AIDS Research Center (DAARC) of the University of Miami and the National Institute on Drug Abuse (NIDA). Drs. Darrow, Biersteker, Geiss, Chevalier, Clark, Marrero, Mills, and Obiaja are with the Robert R. Stempel School of Public Health, Florida International University, Miami, Florida. Ana Adasme, Lenworth Anglin, Veronica Francis, Lynda Humaran, Maria Norasco-Warren, Lisa Quammie, and Nalinie Samlal also contributed to this report.     

Greater Drug Injecting Risk for HIV, HBV, and HCV Infection in a City Where Syringe Exchange and Pharmacy Syringe Distribution are Illegal

Comparing drug-injecting risk between cities that differ in the legality of sterile syringe distribution for injection drug use provides a natural experiment to assess the efficacy of legalizing sterile syringe distribution as a structural intervention to prevent human immunodeficiency virus (HIV) and other parenterally transmitted infections among injection drug users (IDUs). This study compares the parenteral risk for HIV and hepatitis B (HBV) and C (HCV) infection among IDUs in Newark, NJ, USA, where syringe distribution programs were illegal during the period when data were collected, and New York City (NYC) where they were legal. IDUs were nontreatment recruited, 2004–2006, serotested, and interviewed about syringe sources and injecting risk behaviors (prior 30 days). In multivariate logistic regression, adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) for city differences are estimated controlling for potential city confounders. IDUs in Newark (n = 214) vs. NYC (n = 312) were more likely to test seropositive for HIV (26% vs. 5%; AOR = 3.2; 95% CI = 1.6, 6.1), antibody to the HBV core antigen (70% vs. 27%; AOR = 4.4; 95% CI = 2.8, 6.9), and antibody to HCV (82% vs. 53%; AOR = 3.0; 95% CI = 1.8, 4.9), were less likely to obtain syringes from syringe exchange programs or pharmacies (AOR = 0.004; 95% CI = 0.001, 0.01), and were more likely to obtain syringes from street sellers (AOR = 74.0; 95% CI = 29.9, 183.2), to inject with another IDU’s used syringe (AOR = 2.3; 95% CI = 1.1, 5.0), to reuse syringes (AOR = 2.99; 95% CI = 1.63, 5.50), and to not always inject once only with a new, sterile syringe that had been sealed in a wrapper (AOR = 5.4; 95% CI = 2.9, 10.3). In localities where sterile syringe distribution is illegal, IDUs are more likely to obtain syringes from unsafe sources and to engage in injecting risk behaviors. Legalizing and rapidly implementing sterile syringe distribution programs are critical for reducing parenterally transmitted HIV, HBV, and HCV among IDUs. Neaigus, Zhao, Gyarmathy, and Cisek are with the Institute for International Research on Youth at Risk, National Development and Research Institutes, New York, NY, USA; Neaigus is with the Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA; Gyarmathy is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Friedman is with the Institute for AIDS Research, National Development and Research Institutes, New York, NY, USA; Friedman is with the Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Baxter is with the North Jersey Community Research Initiative, Newark, NJ, USA.     

Perceptions of risk and safety within injection settings: Injection drug users' reasons for attending a supervised injecting facility in Vancouver,Canada

The settings where drugs are injected represent a crucial dimension in the social structural production of drug-related harm. While the use of supervised injecting facilities has been associated with reductions in injection-related risk, few studies have examined the reasons why injection drug users utilise supervised injecting facilities. This study sought to explore injectors' motivations for injecting within the local supervised injecting facility (Insite) and how the supervised setting interacts with their situated risk perceptions. Fifty in-depth interviews were conducted with injection drug users who utilise Insite (Vancouver, Canada) in order to understand injectors' reasons for attending the supervised injecting facility and how the injection setting is perceived to influence risk. Participants were drawn from the Scientific Evaluation of Supervised Injecting cohort. Interviewees reported that Insite provides a suitable alternative to other injection settings (e.g. public injecting venues) and negates the need to observe social conventions deemed to be undesirable by some drug users. The facility mediates injection-related health risks by reducing the potential for blood-borne virus infection and overdose. The sanctioned and regulated environment of Insite is also perceived to provide refuge from important forms of ‘everyday risk', including encounters with police, street violence and loss of drugs, which characterise other injection settings. While public health perspectives have focused upon the potential of supervised injecting facilities to mediate injection-related harm, injection drug users perceive the supervised injection setting to provide protection from a broader range of hazards associated with injecting drugs in unregulated settings.