Hustlers and tricksters: Colonialism, the war on drugs, and survival strategies of people who inject drugs.

Hepatitis C Virus Serosorting in People Who Inject Drugs: Sorting Out the Details

Background Studies have examined how people who inject drugs (PWID) navigate public spaces for drug consumption, but little is known about consumption of drugs in private apartments. This study explores social, structural and physical environment factors influencing injecting practices and the rationalities shaping how PWID make decisions about where to consume drugs. Methods The study is based on qualitative data from 41 in-depth interviews conducted with both homeless and housed PWID recruited through snowball sampling in Uyo, Nigeria. Thematic analysis, framed by the theoretical constructs of structural and everyday violence, and situated rationality theories, was undertaken on transcripts. Results Analysis revealed different socio-spatial rationalities underlying decisions about where to use drugs: avoidance of police arrest, convenience and relaxation, avoidance of drug sharing, avoidance of drug-scene violence, and stigma and shame. These factors show the impacts of social, structural and physical environment factors on the lived experiences of PWID. Injecting in private apartments potentially offset the risk of stigma, police arrest and violence linked to public injecting, but increase the risk of overdose and sharing of drugs and needle-syringes based on social relations of trust. Conclusions Findings show that PWID chose between competing risks when deciding on where to inject drugs. Interventions should consider the situated contexts of risk, and adapt harm reduction measures to the risk profile of different populations of PWID.

BackgroundAn outbreak of HIV infections among people who inject drugs (PWID) started in 2014 in Luxembourg.ObjectivesWe conducted phylogenetic and epidemiological analyses among the PWID infected with HIV in Luxembourg or attending the supervised drug consumption facility (SDCF) to understand the main causes of the outbreak.MethodsBetween January 2013 and December 2017, analysis of medical files were performed from all PWID infected with HIV at the National Service of Infectious Diseases (NSID) providing clinical care nationwide. PWID were interviewed at NSID and SDCF using a standardized questionnaire focused on drug consumption and risk behaviours. The national drug monitoring system RELIS was consulted to determine the frequency of cocaine/heroin use. Transmission clusters were analysed by phylogenetic analyses using approximate maximum-likelihood. Univariate and multivariate logistic regression analyses were performed on epidemiological data collected at NSID and SDCF to determine risk factors associated with cocaine use.ResultsFrom January 2013 to December 2017, 68 new diagnosis of HIV infection reported injecting drug use as the main risk of transmission at NSID. The proportion of female cases enrolled between 2013–2017 was higher than the proportion among cases enrolled prior to 2013. (33% vs 21%, p < 0.05). Fifty six viral sequences were obtained from the 68 PWID newly diagnosed for HIV. Two main transmission clusters were revealed: one HIV-1 subtype B cluster and one CRF14_BG cluster including 37 and 9 patients diagnosed since 2013, respectively. Interviews from 32/68 (47%) newly diagnosed PWID revealed that 12/32 (37.5%) were homeless and 27/32 (84.4%) injected cocaine. Increased cocaine injection was indeed reported by the RELIS participants from 53 to 63% in drug users with services contacts between 2012 and 2015, and from 5 to 22% in SDCF users between 2012 and 2016. Compared with PWID who injected only heroin (n = 63), PWID injecting cocaine and heroin (n = 107) were younger (mean of 38 vs 44 years, p≤0.001), reported more frequent piercing (≤0.001), shared and injected drugs more often (p≤0.01), and were more frequently HIV positive (p<0.05) at SDCF using univariate logistic regression analysis. Finally, in the multivariate analysis, use of heroin and cocaine was independently associated with younger age, piercing, sharing of drugs, and regular consumption (p<0.05).ConclusionsInjecting cocaine is a new trend of drug use in Luxembourg associated with HIV infection in this recent outbreak among PWID.

BackgroundDrug use is a growing concern in Ghana. People who inject drugs (PWID) are highly vulnerable to HIV and other infectious diseases. Ghana’s National Strategic Plan for HIV/AIDS 2016–2020 identifies PWID as a key population, but efforts to address the needs of PWID have lagged behind those targeting sex workers and men who have sex with men. Lack of information about PWID is a critical barrier to implementing effective HIV prevention and treatment. We aimed to learn more about the vulnerability of the PWID population in order to inform much-needed harm reduction interventions.MethodsFrom April to July 2018, we conducted a mixed methods study in Kumasi, Ghana, to identify all major drug using locations, count the numbers of PWID to obtain rough population size estimations, and administer anonymous surveys to 221 PWID regarding drug use and sexual behavior. We also tested for HIV, HCV, and HBV from syringes used by survey participants.ResultsKey informants identified five major drug using locations and estimated the total PWID population size to be between 600 and 2000. Enumerators counted between 35 and 61 individuals present at each of the five bases. Sharing syringes and reusing discarded syringes are common practices. Over half of survey participants (59%) reported past-month syringe sharing (34% used a used syringe and 52% gave away a used syringe). Individuals with higher injection frequency (≥ 21 times weekly) and who injected with four or more people had higher odds of syringe sharing. Of the survey participants reporting sex in the last month (23%), most reported having one partner, but only 12% used condoms. Nearly all women (11/13) reported exchanging sex for drugs and 6/13 reported exchanging sex for money in the last six months. Fifteen percent of participants (all men) reported paying for sex using drugs or money. Of the used syringes, prevalence estimates were 3% (HIV), 2% (HCV), and 9% (HBV).ConclusionsOur findings confirm the urgent need to implement harm reduction interventions targeting PWID and to build a strong and enabling legal and policy environment in Ghana to support these efforts.

BackgroundThe number of people who inject drugs on the U.S.-Mexico border has been increasing over the last years and has become a public health concern due to their vulnerability to...

Fentanyl test strips as an opioid overdose prevention strategy: Findings from a syringe services program in the Southeastern United States

BackgroundIn 2009, Mexico reformed its health law to partially decriminalize drug possession considered for personal use and to increase mandatory referrals to certified drug rehabilitation centers in lieu of incarceration. Concurrently, news media reported violent attacks perpetrated by drug cartels against Mexican drug rehabilitation centers and instances of human rights violations by staff against people who inject drugs (PWID) in treatment. In many cases, these violent situations took place at “Peer Support” (Ayuda Mutua) drug rehabilitation centers that house a large number of drug-dependent PWID. In an effort to understand barriers to treatment uptake, we examined prevalence and correlates of perceived risk of violence at drug rehabilitation centers among PWID in Tijuana, Mexico.MethodsSecondary analysis of baseline data collected between March 2011 and May 2013 of PWID recruited into a prospective cohort study in Tijuana. Interviewer-administered surveys measured perceived risk of violence at drug rehabilitation centers by asking participants to indicate their level of agreement with the statement “going to rehabilitation puts me at risk of violence”. Logistic regression was used to examine factors associated with perceived risk of violence.ResultsOf 733 PWID, 34.5 % perceived risk of violence at drug rehabilitation centers. In multivariate analysis, reporting ever having used crystal methamphetamine and cocaine (separately), having a great or urgent need to get help for drug use, and ever receiving professional help for drug/alcohol use were negatively associated with perceived risk of violence at drug rehabilitation centers, while having been told by law enforcement that drug rehabilitation attendance is mandatory was positively associated with perceived risk of violence. All associations were significant at a 0.05 alpha level.ConclusionThe perception of violence at drug rehabilitation centers among PWID does not represent the lived experience of those PWID who attended professionalized services, reported a great or urgent need to get help for their drug use and had a history of using crystal and cocaine. Professionalizing service delivery and engaging law enforcement in their new role of decriminalization and service referral for PWID could address the perceptions of violence at drug rehabilitation centers. Similarly, health authorities should expand periodic inspections at drug rehabilitation centers to guarantee quality service provision and minimize PWIDs’ concerns about violence.Electronic supplementary materialThe online version of this article (doi:10.1186/s13011-015-0044-z) contains supplementary material, which is available to authorized users.

ABSTRACTAlthough previous research has focused on injection drug use behaviors in both urban and rural settings, few have drawn direct comparisons between adjacent rural and urban areas. Using data from the National HIV Behavioral Surveillance study as well as original data collected in a similar fashion, we compare the risk behaviors of people who inject drugs (PWID) in San Juan, Puerto Rico, with those of PWID in nearby rural areas. Specifically, we examine whether one’s own hepatitis C (HCV) infection status can be used to predict whether one asked their most recent co-injection partner about their HCV status. Acquiring such information allows injectors to seek out co-injection partners of concordant status as a way to minimize the risk of viral transmission. Results indicate that urban PWID with a known HCV+ status were more likely to know their last co-injector partner’s HCV status than were their peers with a negative or unknown HCV status. However, this relationship was not present in the rural data. These findings suggest that there are different risk norms in rural and urban PWID communities and that interventions successful in one type of community may not be so in others.

Internalized stigma and sterile syringe use among people who inject drugs in New York City, 2010–2012

ABSTRACTIntroduction: People who inject drugs (PWID) are highly exposed to drug-dealing networks. In Colombia, a recent dramatic increase in drug consumption has been reported. However, involvement of PWID in drug dealing, their demographics, and drug using behaviors has not been studied. Methods: A cross-sectional study involving 1,099 PWID recruited by Respondent Driven-Sampling in five Colombian cities was conducted in 2014. Correlates of demographic characteristics, drug dealing, and injection behaviors were examined by multivariate analysis, and a binary logistic regression model. Results: Drug-dealing PWID were predominantly male (86%) with a mean age of 26 years. 56% of participants—of whom 64% had low familial socioeconomic status—had been involved in drug dealing in the previous six months. Compared to non-drug-dealing PWID, drug-dealing PWID reported higher daily injection rate (AOR: 1.3), higher odds of injection equipment confiscation by the police (AOR: 1.4), and were less likely to pay for the drugs they injected (AOR: 0.6). Conclusions: Involvement of Colombian PWID in drug dealing was higher than previously reported, and drug-dealing PWID presented sociodemographic vulnerabilities and risky injection practices. Addressing these findings may lead to effective policy design and implementation, decreased drug-dealing involvement, harm reduction, and consumption prevention.

BackgroundA large proportion of people who inject drugs (PWID) living with hepatitis C virus (HCV) infection have not been treated. It is unknown whether inclusion of HCV diagnostics and treatment into integrated substance use disorder treatment and care clinics will improve uptake and outcome of HCV treatment in PWID. The aim is to assess the efficacy of integrating HCV treatment to PWID and this paper will present the protocol for an ongoing trial.MethodsINTRO-HCV is a multicentre, randomised controlled clinical trial that will compare the efficacy of integrated treatment of HCV in PWID with the current standard treatment. Integrated treatment includes testing for HCV, assessing liver fibrosis with transient elastography, counselling, treatment delivery, follow-up and evaluation provided by integrated substance use disorder treatment and care clinics. Most of these clinics for PWID provide opioid agonist therapy while some clinics provide low-threshold care without opioid agonist therapy. Standard care involves referral to further diagnostics, treatment and treatment follow-up given in a hospital outpatient clinic with equivalent medications. The differences between the delivery platforms in the two trial arms involve use of a drop-in approach rather than specific appointment times, no need for additional travelling, less blood samples taken during treatment, and treatment given from already known clinicians. The trial will recruit approximately 200 HCV infected individuals in Bergen and Stavanger, Norway. The primary outcomes are time to treatment initiation and sustained virologic response, defined as undetectable HCV RNA 12 weeks after end of treatment. Secondary outcomes are cost-effectiveness, treatment adherence, changes in quality of life, fatigue and psychological well-being, changes in drug use, infection related risk behaviour, and risk of reinfection. The target group is PWID with HCV diagnosed receiving treatment and care within clinics for PWID.DiscussionThis study will inform on the effects of an integrated treatment program for HCV in clinics for PWID compared to standard care aiming to increase access to treatment and improving treatment adherence. If the integrated treatment model is found to be safe and efficacious, it can be considered for further scale-up.Trial registrationClinicalTrials.gov.no. NCT03155906.

Objectives. To estimate the population size of people who inject drugs (PWID) in the United States in 2022. Methods. We constructed a hybrid estimator, which applied the ratio of nonfatal to fatal overdose among PWID to convert estimated injection-involved overdose deaths to the number of nonfatal overdoses. We divided the number of nonfatal overdose events by the prevalence of nonfatal overdose to generate PWID population size estimates. Results. There were an estimated 2 392 100 (95% confidence interval = 1 323 300, 4 648 100) PWID in 2022, which was 35% lower than the 2018 estimate. Most PWID were male and non-Hispanic White. The US South had the highest number of PWID. Conclusions. Reduced PWID population size may reflect improved data inputs or a true decline in the number of PWID because of high levels of overdose fatality or shifts in routes of drug consumption. These data are essential for determining needs for prevention services and rates of morbidity and mortality among PWID. (Am J Public Health. 2026;116(3):376-379. https://doi.org/10.2105/AJPH.2025.308310).

Hepatitis C is a blood borne virus affecting the liver. In the UK, approximately 214,000 people are infected with the hepatitis C virus. Hepatitis C disproportionally affects marginalised populations and in the UK sharing equipment used to inject drugs is the main risk factor for hepatitis C infection. Despite there being treatments for hepatitis C, many do not access it or indeed get tested, leading to deaths from complications of hepatitis C such as end stage liver disease or hepatocarcinoma. The World Health Organization’s target to eliminate viral hepatitis as a major public health threat by 2030, has led to calls for action to increase access to hepatitis C testing and treatment. To increase uptake of testing and treatment, an understanding of the current barriers to access is required. Historically, alcohol and injecting drug use have been barriers to receiving treatment. Alcohol is also regarded as problematic as it expedites the progression of hepatitis C. There is however a paucity of research on experiences of alcohol use in People Who Inject Drugs (PWID) who have hepatitis C. The aim of this research was to gain an understanding of the experiences, practices and meanings of alcohol for people living with hepatitis C and to understand their needs and support requirements. Being qualitative in nature, this research took an explorative, inductive approach, allowing emerging themes to lead the direction of the research. The starting point was observation of hepatitis C support groups and interviews with people who have/had hepatitis C (services users, n=21), leading onto interviews with professionals (n=12) working in drug, alcohol and hepatitis C services. A multi-methods approach was used. Service user interviews were life history interviews, using a calendar method, and for the interviews with professionals, vignettes about hypothetical services users and semi structured interviews were used. Data were analysed using a combination of approaches. For the interviews using the calendar method, the individual calendars were studied to ascertain the sequence of events in a participant’s life. More generally, an ongoing constant comparative approach occurred throughout the various stages of the research and interview transcripts were analysed using thematic analysis. This research has explored alcohol use in PWID who have hepatitis C, however the methods employed have afforded wider findings, giving an insight into barriers and challenges to hepatitis C support. Barriers/challenges were found at service user, service and strategic levels. For service users, barriers were to accessing support (incorporating, testing, treatment, advice, information and peer support) and for service providers and commissioners, challenges were to providing support services for people with the hepatitis C virus. Alcohol fits in to this picture as a barrier to support from the PWID community, due to the stigma of becoming ‘a drinker’ and as an exclusion to receiving hepatitis C treatment. There is a paucity of qualitative research on alcohol use and hepatitis C in PWID. To our knowledge this research is the first study exploring the lived experience of alcohol use for PWID who have hepatitis C in England. The findings from this study therefore contribute to the current limited body of knowledge on this topic. Although on completing this thesis some of the findings are out dated as hepatitis C treatment is now being provided out of the hospital setting, other barriers to providing and accessing hepatitis C support are still relevant. These findings will be of interest to those working both in practice and public health policy who are working towards the elimination of hepatitis C by 2030.

Aims: The way people who inject drugs (PWID) feel about drug policy may be profoundly shaped by lived experience of stigma and the subjectivities made available in policy and practice. Using a community-based participatory research approach, this study investigated why PWID hold particular views, and considered the complexities of how lived experience and opinions about drug policy intersect within this affected community. Methods: Three qualitative focus groups were undertaken. Participants were presented with survey results arising from a previous study, and asked to interpret and explain the possible rationales underlying the opinions expressed by their peers. Findings: A duality of opinion was identified, borne from lived experience of stigmatisation, which sometimes led PWID to qualify levels of support. By exploring the rationales underlying opinions, a tension emerged between what PWID theoretically know to be effective interventions, and experiences of how policies are delivered. A sense of “within-group” stigma emerged, with sub-groups of users and drug types denoted as more “dangerous” than others. Conclusions: This study illustrates how theoretical knowledge and lived experience intersect to inform opinions about drug policy. Through in-depth discussions with the affected community, we are reminded that public opinion research is always an interpretative and sensitive pursuit.

Syringe-sharing significantly increases the risk of HIV and viral hepatitis acquisition among people who inject drugs (PWID). Clearer understanding of the correlates of receptive syringe-sharing (RSS) is a critical step in preventing bloodborne infectious disease transmission among PWID in rural communities throughout the United States. This study aimed to measure the prevalence and correlates of RSS among PWID in a rural county in Appalachia. Observational, cross-sectional sample from a capture-recapture parent study. Cabell County, West Virginia (WV), USA, June-July 2018. The sample was restricted to people who reported injecting drugs in the past 6months (n=420). A total of 180 participants (43%) reported recent (past 6months) RSS. Participants reported high levels of homelessness (56.0%), food insecurity (64.8%) and unemployment (66.0%). The main outcome was recent re-use of syringes that participants knew someone else had used before them. Key explanatory variables of interest, selected from the risk environment framework, included: unemployment, arrest and receipt of sterile syringes from a syringe services program (SSP). Logistic regression was used to determine correlates of recent RSS. PWID reporting recent RSS also reported higher prevalence of homelessness, food insecurity and unemployment than their non-RSS-engaging counterparts. In adjusted analyses, correlates of RSS included: engagement in transactional sex work [adjusted odds ratio (aOR) =2.27, 95% confidence interval (CI)=1.26-4.09], unemployment (aOR=1.67, 95% CI=1.03-1.72), number of drug types injected (aOR=1.33, 95% CI=1.15-1.53) and injection in a public location (aOR=2.59, 95% CI=1.64-4.08). Having accessed sterile syringes at an SSP was protective against RSS (aOR=0.57, 95% CI=0.35-0.92). The prevalence of receptive syringe-sharing among people who inject drugs in a rural US county appears to be high and comparable to urban-based populations. Receptive syringe-sharing among people who inject drugs in a rural setting appears to be associated with several structural and substance use factors, including unemployment and engaging in public injection drug use. Having recently acquired sterile syringes at a syringe services program appears to be protective against receptive syringe sharing.