Overdose prevention behaviors among people who inject drugs in rural Appalachia: a qualitative study

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.

Injecting drug use is an important public health issue, causing significant morbidity and mortality worldwide. The contemporary drug market setting in Australia is defined by a lower prevalence and frequency of heroin injection among regular people who inject drugs (PWID) compared with in the past, and changing patterns of polydrug use, with some evidence of increasing use of pharmaceutical opioids. Our understanding of patterns of drug use and related risk behaviours among contemporary PWID is limited by the fact that much research has captured samples of predominantly older, long-term PWID, many of whom are on opioid substitution therapy (OST) and may use drugs only infrequently. The aim of the research presented in this thesis was to generate comprehensive information about patterns of drug use and associated risk behaviours among PWID who are active in contemporary settings, including understudied populations such as younger PWID, out-of-treatment PWID and PWID from culturally and linguistically diverse backgrounds. The Melbourne Injecting Drug User Cohort Study (MIX) is a prospective cohort of 688 community-recruited regular PWID. The median age of the cohort is 27.6 years and only 35% of participants were prescribed OST at baseline. Over 70% of the cohort completed a follow-up interview at 12 months post-baseline, demonstrating that it is possible to successfully retain a cohort of community-recruited PWID. Despite the uniqueness of this cohort, patterns of drug use by MIX participants were relatively similar to those displayed by sentinel samples of older, longer-term PWID. There were few differences in injecting initiation experiences between MIX participants who initiated injecting in contemporary settings and those who initiated in earlier settings and, although this had some ongoing impact, the relationship was not strongly related to current drug use patterns. Pharmaceutical opioid use was a key component of polydrug use among MIX participants, with 20% of the cohort reporting using illicitly-obtained pharmaceutical opioids in the month preceding baseline interview. Use of pharmaceutical opioids was however not sustained over time. The relationship between age and engagement in risk behaviours was examined using 10 years of data from the Australian Illicit Drug Reporting System, a national repeat cross-sectional survey of regular PWID recruited through needle and syringe programs, drug treatment and community settings. Older age was associated with decreased likelihood of engagement in a range of injecting-related and criminogenic risk behaviours. Injecting drug use among young people of African ethnicity was examined using MIX data and an additional qualitative study. Findings showed that injecting drug use (and substance use more broadly) and mental health are emerging issues among this community. Findings from this body of research inform the provision of harm reduction services which take into the account the key populations and patterns of drug use in the contemporary setting. Priority areas for future research include further research examining pharmaceutical opioid use among PWID, studies of substance use and mental health among resettled refugee youth, research into interventions to reduce injecting-related risk behaviours among younger PWID and additional longitudinal studies of PWID with a broader geographic focus.

Drug use stigma and its association with active hepatitis C virus infection and injection drug use behaviors among community-based people who inject drugs in India.

Short-term injection drug use changes following hepatitis C virus (HCV) assessment and treatment among persons who inject drugs with acute HCV infection

BackgroundA Cross-sectional Rapid Situational Assessment of People Who Inject Drug (PWIDs) applying Respondent Driven sampling techniques (RDS) was used to recruit subjects/participants in a study aimed at assessing HIV prevalence and risk behaviors among injecting drug users in Nairobi and Coastal regions of Kenya. There is paucity of data and information on injecting drug use in sub-Saharan Africa and there is sufficient evidence of existence of the environment for development and growth of injecting drug use. Past studies on PWID and its association to HIV and AIDS that have been conducted in Kenya do not provide sufficient information to support effective planning and comprehensive national response to the HIV and AIDS epidemic.MethodsA cross-sectional study design was adopted in which a set of initial subjects referred to as ‘seeds’ were first identified from which an expanding chain of referrals were obtained, with subjects from each wave referring subjects of subsequent waves. The seeds were drawn randomly from the population and interviewed to pick the one with the largest network and other unique characteristics. A maximum of twelve seeds were recruited. The second stage involved conducting assessment visits to the sites to identify potential collaborators that included non-governmental organizations (NGOs), drug treatment centres, health facilities, community based organizations (CBO’s) among others. Three NGOs located in the coast region and one in Nairobi region were identified to assist in identifying drug injection locations and potential participants. Key informant interviews (KIIs) and Focus Group Discussions (FGDs) were also conducted using interview guides.ResultsA total of 646 individuals (344 in Nairobi and 302 at the coast) were recruited for the study between January and March 2010. Of these 590 (91%) were male and 56 (9%) were female. Findings showed that most PWIDs initiated injecting drug use between the ages of 20–29 years, with the youngest age of initiation being 11 years and oldest age being 53 years. Most commonly injected drug was heroin (98%), with a small (2%) percentage injecting cocaine. Other non-injecting methods such as smoking or combining these two drugs with other drugs such as cannabis or Rohypnol were also common. Most PWIDs used other substances (cigarettes, alcohol, and cannabis) before initiating injecting drug use. The adjusted national HIV prevalence of PWIDs was 18.3% (19.62% unadjusted) with PWIDs in Nairobi region registering 18.33% (20.58% unadjusted) compared PWIDs for Coastal region indicating 18.27% (18.59% - unadjusted). The gender based HIV prevalence showed that women were more at risk of acquiring HIV (44.51%-adjusted) compared to men (15.97%-adjusted). The age specific HIV prevalence showed that PWIDs who initiated injecting at 11–19 years (44.7% adjusted) were most at risk in Nairobi compared to those who initiated injecting at age 20–24 years (23.2% - adjusted) in the coastal region. While all PWIDs continue to be at risk in the two regions, those from the Western parts of Nairobi, Kenya were at a relatively higher risk given their increased propensity for sharing injecting equipment and solutions.ConclusionsCompared to the national HIV prevalence of (4.9%), the results show that People Who Inject Drugs (PWIDs) are at particularly high risk of infection in Kenya and there is urgent need for intervention (KenPHIA, 2018). This study also showed clear evidence that 70% of PWIDs are primary school educated, engage in high risk injecting and sexual behaviors comprising sharing of injecting equipment, unprotected heterosexual and homosexual sex. Given that initiation of injecting drug use begins early and peaks after formal school years (20–29 years), prevention programmes should be targeted at primary and secondary school students, college and out of school youth. Further, to protect People who inject drugs (PWIDs) from HIV infection, the country should introduce free Needle Syringe Programs (NSP) with provision of condoms and Methadone Assisted Therapy (MAT) as a substitute for drug use.

Background: Fentanyl-associated overdose fatalities have increased dramatically throughout the United States. Fentanyl test strips (FTS) may be used by people who inject drugs (PWID) to lower overdose risks; however, virtually no research has been conducted to understand the perspectives of rural PWID in Appalachia on FTS utilization. Objectives: We aim to explore FTS awareness and potential use among PWID in two rural counties in West Virginia (WV). Methods: Semi-structured interviews with PWID (n = 48) in two rural counties in WV were conducted to explore FTS awareness, potential use, and possible behavioral changes following FTS utilization. Participants were recruited in areas where PWID congregate in each county. With participants’ permission, interviews were audio recorded and transcribed verbatim. Transcripts were analyzed using an iterative, constant comparative approach. Results: Very few participants had heard of FTS prior to the interview. Upon learning about FTS, PWID who reported frequently injecting heroin expressed high willingness to use FTS. Participants explained that learning their drugs contained fentanyl may make them more likely to engage in overdose risk reduction behaviors, such as: using less, doing tester shots, and not using the drugs entirely. Conclusion: Among our sample of rural PWID in Appalachia, most were unaware of FTS but expressed high willingness to utilize the technology. Participants described how receiving a positive FTS result may lead them to engage in overdose risk reduction behaviors. Augmenting existing overdose prevention initiatives in rural Appalachia such that rural PWID have access to FTS may result in reductions in overdose fatalities.

Potential impact of implementing and scaling up harm reduction and antiretroviral therapy on HIV prevalence and mortality and overdose deaths among people who inject drugs in two Russian cities: a modelling study

To demonstrate how we applied the capture-recapture method for population estimation directly in a rural Appalachian county (Cabell County, WV) to estimate the number of people who inject drugs (PWID). We conducted 2 separate 2-week periods of data collection in June ("capture") and July ("recapture") 2018. We recruited PWID from a syringe services program and in community locations where PWID were known to congregate. Participants completed a survey that included measures related to sociodemographics, substance use, and HIV and hepatitis C virus prevention. In total, 797 surveys were completed; of these surveys, 49.6% (n = 395) reflected PWID who reported injection drug use in the past 6 months and Cabell County residence. We estimated that there were 1857 (95% confidence interval = 1147, 2567) PWID in Cabell County. Among these individuals, most reported being White (83.4%), younger than 40 years (70.9%), and male (59.5%). The majority reported injecting heroin (82.0%), methamphetamine (71.0%), and fentanyl (56.3%) in the past 6 months. Capture-recapture methods can be applied in rural settings to estimate the size of PWID populations.

The new direct-acting antiretroviral drugs for treating hepatitis C have generated considerable momentum for treating HCV infection among people who inject drugs and perhaps ‘ending the HCV epidemic’. There are, however, important epidemiological and behavior research problems that need to be addressed before ‘ending the HCV epidemic’ will be possible. The development of direct-acting antivirals (DAAs) that cure HCV infection in more than 90% of patients with minimal side effects has led to calls for ‘eliminating HCV infection’ or ‘ending HCV epidemics’ among people who inject drugs (PWID) 1. Some of the calls for eliminating HCV infection have included substantial allocations of new funds, e.g. New York State 2. Grebely et al. 3 have estimated the number and prevalence of people with a recent history (within past year) of injecting drug use who are living with hepatitis C virus (HCV) viremia and the proportion of people with recent injecting drug use among all people living with HCV infection at the global, regional and national levels. A major value of this study is its potential contribution as a baseline for ‘eliminating HCV’. While DAAs and the lessons from successfully controlling HIV among PWID in many areas 4 should certainly be useful in controlling HCV among PWID, the data presented in Grebely et al. illustrate that there is still a major amount of epidemiological and behavioral science that will be needed before ‘eliminating’ (or even ‘controlling’) HCV among PWID can be accomplished. First, what would ‘elimination/ending the epidemic’ of HCV among PWID look like? From early in the HIV epidemic among PWID, we had multiple examples, e.g. Glasgow, Scotland, Lund, Sweden, Sydney, Australia and Tacoma, WA, USA, where large-scale implementation of syringe access programs have kept HIV prevalence stable at less than 5% 5. The Grebely et al. data do not provide many (if any) examples of areas where HCV viremia has been stabilized at ‘ending the epidemic’ levels. Would 5% viremia in the local PWID population be a realistic goal? What sort of HCV combined prevention and care programs would be needed to stabilize HCV at 5% or less in a PWID population? Such a system would need to detect and treat existing cases of HCV infection as rapidly as new infections were occurring. Secondly, how will we develop better estimates of the size of PWID populations and the percentage of PWID who are HCV viremic? The uncertainty intervals in the Grebely et al. estimates are rather large, typically almost as large as the estimates themselves. Uncertainty in the estimates of the PWID population size and the percentage of PWID who are HCV viremic would create difficult problems for local officials who would have the task of allocating resources and planning logistical operations for rapidly scaling-up treatment for HCV-infected PWID. Thirdly, what new interventions can be developed to reduce HCV transmission behavior among viremic PWID? One of the important factors in HIV prevention was that PWID who learned that they were HIV-seropositive greatly reduced transmission behavior (passing their used needles and syringes to others) well before antiretroviral therapy (ART) was available 6. We have not yet seen the equivalent reductions in transmission behaviors among PWID who know that they are HCV-seropositive 7. How do we successfully encourage HCV viremic PWID to reduce transmission behavior? Fourthly, what interventions can be developed and implemented to reduce the very high HCV incidence rates among people who have recently begun injecting drugs 8? Many new injectors typically do not identify as ‘drug injectors’, and thus do not utilize HIV/HCV safer injection programs 9. Fifthly, what interventions will be implemented to reduce the rates that drug users transition to injecting drug use? There have been calls for more research on this topic 10, and there are current research studies addressing this subject. However, the objective should be to develop an evidence base for reducing initiation into injecting drug use that is comparable to the evidence base for medication assisted treatment and for syringe access programs. The new DAAs certainly give us the capability of treating very large numbers of HCV infected people who use drugs and greatly reduce morbidity and mortality, and programs to provide access to HCV treatment should be scaled-up in high-, middle- and low-income countries as quickly as feasible, and the additional research needed to learn how to ‘end HCV epidemics’ among PWID should be funded. Finally, and perhaps most importantly, while the above may be considered scientific tasks, it is important to emphasize that the research should be conducted in full collaboration with PWID and drug-user organizations. Such collaboration should not only greatly improve the quality of the research, but also greatly improve the likelihood that the findings will be incorporated into public health programs that could ‘end the HCV epidemic’ among people who use drugs. None.

AimSafe consumption spaces (SCS) are indoor environments in which people can use drugs with trained personnel on site to provide overdose reversal and risk reduction services. SCS have been shown to reduce fatal overdoses, decrease public syringe disposal, and reduce public drug consumption. Existing SCS research in the USA has explored acceptability for the hypothetical use of SCS, but primarily among urban populations of people who inject drugs (PWID). Given the disproportionate impact of the opioid crisis in rural communities, this research examines hypothetical SCS acceptability among a rural sample of PWID in West Virginia.MethodsData were drawn from a 2018 cross-sectional survey of PWID (n = 373) who reported injection drug use in the previous 6 months and residence in Cabell County, West Virginia. Participants were asked about their hypothetical use of a SCS with responses dichotomized into two groups, likely and unlikely SCS users. Chi-square and t tests were conducted to identify differences between likely and unlikely SCS users across demographic, substance use, and health measures.ResultsSurvey participants were 59.5% male, 83.4% non-Hispanic White, and 79.1% reported likely hypothetical SCS use. Hypothetical SCS users were significantly (p < .05) more likely to have recently (past 6 months) injected cocaine (38.3% vs. 25.7%), speedball (41.0% vs. 24.3%), and to report preferring drugs containing fentanyl (32.5% vs. 20.3%). Additionally, likely SCS users were significantly more likely to have recently experienced an overdose (46.8% vs. 32.4%), witnessed an overdose (78.3% vs. 60.8%), and received naloxone (51.2% vs. 37.8%). Likely SCS users were less likely to have borrowed a syringe from a friend (34.6% vs. 48.7%).ConclusionsRural PWID engaging in high-risk behaviors perceive SCS as an acceptable harm reduction strategy. SCS may be a viable option to reduce overdose fatalities in rural communities.

BackgroundThe rise in injection drug use (IDU) has led to an increase in drug-related infections and hospitalizations. Harm reduction is an important strategy for preventing infections among people who inject drugs (PWID). We set out to evaluate how infectious disease physicians counsel PWID with serious injection-related infections on harm reduction practices.MethodsAn electronic survey was distributed to 1,510 physician members of the Emerging Infectious Network (EIN) to determine which harm reduction principles ID physicians recommend to PWID to reduce infection risks. EIN members who do not care for PWID were excluded. Two weekly reminders were sent to increase the response rate.ResultsThree hundred ninety-nine (26%, still in progress) ID physicians responded to the survey. Practice settings included: university (37%), community (27%), non-university teaching (23%), or other (14%) hospital settings. Of those, 279 (70%) reported routinely caring for PWID. 274 (98%) performed screening for HIV and hepatitis, and 239 (86%) discussed the risk of these viral infections. 65% prescribed immunization against hepatitis and 44% discussed HIV PrEP. 57% (n=159) reported not counseling patients on safer injection strategies. Common reasons for not counseling included limited time and a desire to emphasize antibiotic therapy/medical issues (33%, n=91), lack of training (30%, n=85), and believing that it would be better addressed by other services (27%, n=75). Among physicians who reported counseling PWID, they recommended abstinence from IDU (38%, n=105), handwashing & skin cleansing prior to injection (33%, n=92), avoiding injecting areas of skin breakdown (27%, n=76), and cleaning needles between use (26%, n= 73). Finally, 17% (N=47) reported no access to any addiction services.ConclusionAlmost all ID physicians screen PWID for HIV and viral hepatitis and discuss the risks of these infections. Despite frequently encountering PWID, less than half of ID physicians provide safer injection advice. Opportunities exist to standardize education of PWID on harm reduction, emphasizing safer injection practices in conjunction with other strategies (e.g. HIV PrEP, HAV/HBV vaccination) to prevent infections.DisclosuresAll Authors: No reported disclosures.

Background Considering most people who inject drugs (PWID) received help with the first injection, understanding the perspective of potential ‘initiators’ is a priority to inform harm reduction interventions. This paper examines how PWID narrate their experiences with injection initiation and assistance from the lens of their lived experience and perceptions of harm reduction. Methods In-depth interviews were conducted with individuals who reported injection drug use and recent (past 30 days) opioid use in Baltimore (N = 19) and Anne Arundel County (N = 4), Maryland and analyzed using a narrative approach. Results Respondents cast initiation events as meaningful transitions to a life characterized by predictable harms, including homelessness, infections, and social stigma. Respondents used examples from their personal experience to explain experiences with initiation and assistance by strategically attributing personal agency and predicting specific injection-related harms for initiates. In their narratives, respondents balanced notions of individual agency with harm reduction intentions by distinguishing between two forms of harm: perceived inevitable distal harm caused by long-term injection (e.g. socioeconomic decline) and potentially avoidable proximal harm caused by risky injection practices (e.g. overdose, HIV). Conclusions These findings highlight opportunities for interventions targeting injection initiation events and support the implementation of safer injection training in interventions. This identity of the ‘responsible drug user’ could be leveraged to support employing peers to help mitigate harm among inexperienced PWID either through peer outreach or formal venues, such as overdose prevention sites.

Harm reduction, when applied to drug use, prioritizes improving patient-centered health outcomes and reducing drug-related harm. In order for harm reduction strategies to be adopted by people who inject drugs (PWID), they need to be promoted, accessible, and accepted in that population and the community-at-large. While PWID face stigma at multiple levels, less is known about how stigma influences uptake and acceptance of harm reduction services and strategies among PWID. We aim to characterize the stigmatizing experiences PWID have had related to harm reduction and the role of stigma in influencing their acceptance and adoption of harm reduction services and strategies. A qualitative study using in-person, semi-structured interviews. We recruited hospitalized participants, age 18 and over, with a history of injection drug use. We developed an interview guide asking about various aspects of stigma and participants' experiences with naloxone, syringe service programs, fentanyl test strips, HIV and hepatitis C testing, and any other harm reduction strategies. Key themes were generated using a thematic analysis. We reached thematic saturation at 16 participants. PWID reported multi-level stigma related to harm reduction from themselves, the public, the healthcare system, and the legal and carceral systems. Themes were grouped into four main categories: internalized, interpersonal, intervention, and structural stigma. Stigma across all of these domains negatively impacted the ability of PWID to access harm reduction resources. Positive, non-stigmatizing experiences from others, such as syringe service programs and peer navigators, countered historically negative experiences and promoted greater education and comfort about using harm reduction resources among PWID. To expand the reach of harm reduction services, it is critical to develop interventions that can reduce the stigma against PWID and harm reduction.

BackgroundThe growing HIV epidemic in Eastern Europe and Central Asia has been driven by high rates of injection drug use. The Republic of Georgia has among the highest injection drug use rates globally, with a prevalence of 2.24%. The reach of evidence-based HIV prevention interventions like needle and syringe programs (NSP) among people who inject drugs (PWID) has remained below rates that could significantly impact the epidemic. Syringe vending machines (SVM) are an effective and cost-effective supplement to standard NSP; if acceptable to PWID, SVM could reach hard-to-reach PWID and cover geographic areas where fixed or mobile NSPs do not operate. The aim of this study was to assess the perceived acceptability of SVM among out-of-service (harm reduction or substance use treatment) PWID in Tbilisi, Georgia.MethodologyParticipants were recruited using respondent-driven sampling (RDS) to participate in cross-sectional, face-to-face interviews. We conducted individual interviews using a structured questionnaire that covered participants’ socio-demographics, drug use practices, and perceived acceptability of SVM. Uni-variate analyses were employed for data analysis.ResultsThe final sample (n = 149) was almost exclusively male with a mean age of 42.2 years and mean years of injection drug use of 14.4 years. Heroin, buprenorphine, and stimulants were the main drugs injected. Eighty-five percent of the sample had never received any harm reduction services, and 30% had never been tested for HIV. Fifteen percent of the sample reported sharing injection equipment with others during last month. All but one participant agreed that PWID would benefit from SVM and 145 (97%) said they would personally use SVM. Ninety percent of those sampled stated that they would use HIV self-tests if available from vending machines. The most highly endorsed features of SVM were provision of free injection equipment, no need to deal with pharmacies, uninterrupted 24/7 access, and availability of HIV self-testing kits.DiscussionPerceived acceptability of syringe vending machines was extremely high among PWID not currently receiving any harm reduction or treatment services, with strong support indicated for uninterrupted free access to sterile injection equipment, privacy, and anonymity. Introducing SVM in Georgia holds the potential to deliver significant public health benefits by attracting hard-to-reach PWID, reducing unsafe injection behavior, and contributing to HIV testing uptake and linkage to care.

HIV and people who use drugs in central Asia: Confronting the perfect storm