Policing Practices and HIV Risk Among People Who Inject Drugs - A Systematic Literature Review

Abstract

Background: Laws and their enforcement act as structural determinants of health. Among people who inject drugs (PWID) in numerous global settings, police encounters (e.g. syringe confiscation, physical assault) have been associated with health harms. However, these relationships have not yet been systematically assessed. We conducted a systematic literature review to quantify the contribution of policing to HIV risk among PWID. Methods: We screened MEDLINE, sociological databases and grey literature for studies conducted from 1981-November 2018 that included estimates of HIV infection/risk behaviors and policing practices adversely related to PWID health. Abstracts containing valid associations were selected for further review. We extracted and summarized quantitative findings from eligible studies. Findings: We screened 8,201 abstracts, reviewed 175 full-text articles and included 27 eligible analyses from nine countries (Russia, Mexico, USA, Canada, Ukraine, Thailand, Malaysia, China and India). Heterogeneity in variable and endpoint selection precluded meta-analyses. In 6 (22%)% studies, HIV infection among PWID was significantly associated with policing, including syringe confiscation, reluctance to buy or carry syringes for fear of police, rushed injection due to police presence, fear of arrest, being arrested for planted drugs, and physical abuse. Examining injection-related HIV risk behaviors as analytical endpoints, 16 (59)% studies identified policing practices to be independently associated with syringe sharing, shooting gallery utilization, and seeking informal injection assistance. In 9 (33%), policing was associated with PWID avoidance of harm reduction services, including syringe exchange, methadone maintenance, and safe consumption facilities. Most studies focused on high-income settings. Interpretation: Globally, evidence suggests that policing substantially shapes the HIV risk environment for PWID, but lower-income settings are underrepresented in research. Curbing injection-related HIV risk may necessitate additional structural interventions. Methodological harmonization could facilitate knowledge generation on the role of police as a determinant of population health. Funding: This work was supported by the National Institute on Drug Abuse [grant numbers R01DA039073, K01DA043421(JC)] and the UCSD Center for AIDS Research (CFAR) [International Pilot Grant NIAID 5P30AI036214]. Declaration of Interests: The authors declare that they have no conflicts of interest. Ethics Approval Statement: The authors conducted a systematic literature review in accordance with PRISMA guidelines that has been registered with PROSPERO, the international prospective register of systematic reviews (PROSPERO Registration #CRD42018105967).