Harm Reduction Programs Research Articles

“If He Looks Clean…”: Condom Use Decisions in Prostitution

ABSTRACTProstitutes engage in sex acts with multiple partners and have higher than average rates of intravenous drug use. For these reasons, unprotected sexual contact with a prostitute constitutes high-risk activity. The present study includes interviews with 34 indoor and outdoor sex workers that explore the factors involved in their condom use decisions. Three themes common to participants’ protective behavior decisions (interpersonal, situational, and personal factors) were elucidated and then analyzed within a rational choice framework. Policy implications include court-ordered sex education programs for women cited for prostitution and the expansion of harm reduction programs.

Piloting Hepatitis C Virus Treatment in People Who Inject Drugs (PWID) in Bangladesh

Background: Treatment of hepatitis C virus infection in people who inject drugs (PWID) is complicated by their lifestyle, lack of social and family support, adherence to treatment, and reinfections. This study assessed the feasibility of treating HCV infection with direct-acting antiviral (DAA) among PWID who were receiving services from one Drop-in-Centre (DIC) in Dhaka, Bangladesh. Methods: In this prospective study, 200 PWID were enrolled between May to July 2017. Blood was collected to conduct relevant laboratory tests. Face to face interviews were conducted to determine HCV related risk behaviours. All eligible PWID who were HCV RNA positive were provided daily daclatasvir (60 mg) and sofosbuvir (400 mg) for 12 weeks after which adherence level, SVR, and reinfections were assessed. Findings: Antibodies to HCV were positive for 79 (39·5%) and HCV RNA for 68 (34%). The risk of HCV infection was significantly higher among those who had been injecting drugs for more than seven years (AOR: 2·1; 95% CI: 1·0-4·2; p=0·05). Of 55 eligible PWID started on treatment, 48 were available for SVR assessment (Intention-to-treat SVR 87%). All achieved SVR except one reinfection (4·2 cases per 100 person¬-years). 75% (41 of 55) were at least 90% adherent to therapy. The new infection rate was 2·04 cases per 100 person-years (49 person years of follow-up). Interpretation: Our findings confirm that HCV treatment using sofosbuvir+daclatasvir for PWID enrolled in existing harm reduction programme in Bangladesh is feasible but requires additional interventions such as Opioid Substitution Therapy, intense follow-up, and counselling by study staffs. Funding Statement: World Health Organization. Declaration of Interests: All authors declare no competing interests. Ethics Approval Statement: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) has approved this study (PR-16033) after receiving the approval from institutional Research Review Committee (RRC) and Ethical Review Committee (ERC). The participants provided the written consent prior to enrollment.

More Than Malnutrition: A Review of the Relationship Between Food Insecurity and Tuberculosis.

Despite a significant reduction in tuberculosis (TB) mortality over the past decade, TB remains a leading cause of death worldwide. Food insecurity—through pathways such as malnutrition, mental health impact, and high-risk health behaviors—affects the risk of TB disease, treatment failure, and mortality. We searched the literature for studies reporting on the links between food insecurity and TB. In contrast to the well-documented interactions between food insecurity and HIV/AIDS, we found that the association between food insecurity and TB remains largely understudied—this is especially true with regard to non-nutritional correlations. Mental health and behavioral linkages between TB and food insecurity deserve further attention. An improved understanding of the pathways through which food insecurity impacts TB is crucial to inform evidence-based integration of interventions such as psychological counseling, psychiatric care, harm reduction programs, and efforts to address social determinants of disease within current TB programs.

The unintended consequences of emphasising blood-borne virus in research on, and services for, people who inject image and performance enhancing drugs: A commentary based on enhanced bodybuilder perspectives

Blood-borne viruses (BBVs) are an established focus of drug research and harm reduction. While a focus on BBVs has been applied to people who inject image and performance enhancing drugs (IPEDs), research has demonstrated that there are significant differences between this group and people who inject other drugs. Furthermore, the literature on BBVs and IPED use has been misrepresented by the media and harm reduction programs, with significant consequences for how some people who inject IPEDs view academic research and health services. It seems time to ask, is our current approach to the issue of BBV among people who inject IPEDs the most appropriate, and are there ways that it could be improved to ensure that there are no unintended consequences? In this commentary I suggest ways research and harm reduction efforts could tackle the issue of BBV without exacerbating existing divides between people who inject IPEDs and the health and academic communities. These suggestions are based on the views of the enhanced bodybuilders with whom I am privileged to work.

Establishing Sanctioned Safe Consumption Sites in the United States: Five Jurisdictions Moving the Policy Agenda Forward.

Safe consumption sites enable use of preobtained drugs in hygienic settings where trained staff are available to respond to overdoses and connect individuals with health and social services. This study examined efforts to advance policies to establish safe consumption sites in the United States, where no sanctioned sites exist. Between April and July 2018, the authors conducted 25 telephone interviews with a purposive sample of key informants in five communities considering safe consumption site implementation. Participants included organizers and advocates, government officials, and personnel with social service and health organizations. Interview notes were analyzed by using hybrid inductive-deductive coding. Key strategies for organizing support for safe consumption sites included involving people who use drugs, engaging diverse partners, supporting allies in related causes, and using various tactics to garner support from policy makers. Major barriers to adoption included identifying the right locations, uncertainty about the federal response, mistrust arising from racial injustice in drug policy, and financing. Participants identified facilitators of progress toward safe consumption site adoption, such as building on existing harm reduction programs, securing political champions, and exposing community officials to programs operating internationally. A window of opportunity may be opening to advance policy related to safe consumption sites; whether sanctioned sites become part of the broader policy strategy for addressing drug use and overdose in the United States will depend on the experiences of the first sites. Organizing around this issue may facilitate engagement among people who use drugs in broader conversations about drug policy.

Estimating the number of people who inject drugs and syringe coverage in Australia, 2005–2016

BackgroundEffective targeting of harm reduction programs for people who inject drugs (PWID) requires timely and robust estimates of the size of this population. This study estimated the number of people who inject drugs on a regular basis in Australia, calculated syringe coverage per person and the proportion of their injections covered by a sterile needle and syringe. MethodsWe used trends in indicators of injection drug use to extend the 2005 estimate of the population of people who regularly inject drugs from 2005 to 2016. Included indicators were lifetime/recent injection of illicit drugs, drug-related arrests, drug-related seizures, accidental deaths due to opioids, opioid-related hospital admissions/separations and new diagnoses of hepatitis C virus infection among those aged 15–24 years. Syringe distribution and frequency of injection data were used to assess syringe coverage per PWID and the proportion of their injections covered by a sterile syringe. ResultsThe estimated number of people who regularly inject drugs in Australia increased by 7%, from 72,000 in 2005 to 77,270 in 2016. The annual number of syringes distributed per person increased 34%, from 470 syringes in 2005 to 640 syringes in 2016. Syringe coverage per injection first exceeded 100% in Australia in 2013. ConclusionsDespite Australia’s high syringe coverage by international standards, the number of syringes distributed is likely to be only narrowly meeting demand. It is critical that needle syringe programs be provided with sufficient resources to continue their role as the key intervention required to prevent HIV and HCV transmission among PWID.

Hidden populations: discovering the differences between the known and the unknown drug using populations in the Republic of Georgia

BackgroundThe HIV epidemic in Georgia is increasing. Data shows that compared to previous years, Georgia has increasingly more HIV-infected individuals than previous assessments. Select client groups remain hard to reach by harm reduction programs. The need for innovative strategies to involve these individuals is imperative.MethodsThe following study examines demographics and risk factors of participants, previously known and not known to harm reduction services, for HIV and other infectious disease in towns across Georgia in 2015 and compares risk among different groups, while also assessing the rationale for implementing Peer-Driven Interventions in Georgian Harm Reduction activities. Important differences in demographics and risk profile are thought to exist between those exposed, and those unexposed, to harm reduction activity.ResultsImportant and striking differences between previously known and unknown participants, including demographic background and risk profile and behaviours exist in the drug using community. These differences can potentially explain some of the rise of HIV prevalence in Georgia.ConclusionSignificant differences exist between known and unknown drug users in Georgia, the differences between which are crucial for planning future and holistic harm reduction activities in Georgia, regionally and globally. The research advocates for smarter harm reduction activity, adds to the global evidence for the utility of Peer-Driven Intervention, and encourages sustained global effort for reduction of blood-borne disease burden globally.

A Perspective from the Field: Five Interventions to Combat the Opioid Epidemic and Ending the Dichotomy of Harm-reduction versus Abstinence-Based Programs

ABSTRACTIn this perspective article, the authors share our knowledge, expertise, and experiences in responding to the opioid epidemic in St. Joseph County (Indiana). The authors discuss five interventions we have used in the county to minimize the devastating effects of the opioid epidemic. Their hope is that the knowledge gained from this article will be transferred to other states and counties to further promote recovery and well-being for individuals who have opioid use disorders. The authors recommend that naltrexone (injectable extended-release) be offered in county jails, drug courts incorporate medication-assisted treatments (MATs) into their programming, recovery coaches be used in emergency rooms, harm-reduction recovery groups be accessible to individuals, and naloxone be readily available to communities. We also propose paradigm shifts in how some professionals approach treatment and conceptualize recovery. The authors challenge the agency-driven dichotomy of being either a harm-reduction or an abstinence-based program. Recovery is best understood on a spectrum and should be defined by the individuals we serve, not the projection of professional values or agency agendas of what they think ones recovery should look like.

Principles, practice, and policy vacuums: Policy actor views on provincial/territorial harm reduction policy in Canada

IntroductionCanada is experiencing a new era of harm reduction policymaking and investment. While many provinces and territories are expanding access to these services, harm reduction policy and policymaking varies across the country. The present study, part of the Canadian Harm Reduction Policy Project (CHARPP), described policy actors’ views on formal harm reduction policies in Canada’s 13 provinces and territories. MethodsAs part of CHARPP’s mixed-method, multiple case study, we conducted qualitative interviews with 75 policy actors, including government officials, health system leaders, senior staff at community organizations, and advocates with self-identified lived experience of using drugs. Interviews were conducted in English or French, and recorded and transcribed verbatim. We used latent content analysis to inductively code the data and generate main findings. NVivo 11 was used to organize the transcripts. ResultsParticipants expressed divergent views on formal provincial/territorial policies and their impact on availability of harm reduction programs and services. While some identified a need to develop new policies or improve existing ones, others resisted bureaucratization of harm reduction or felt the absence of formal policy was instead, advantageous. Instances where harm reduction was advanced outside of formal policymaking were also described. DiscussionPrevious CHARPP research documented wide variability in quantity and quality of formal harm reduction policies across Canada, and characterized official policy documents as serving largely rhetorical rather than instrumental functions. The present findings highlight diverse ways that actors used their discretion to navigate these weak policy contexts. Participants’ views and experiences sometimes referred to strengthening policy support, but institutionalization of harm reduction was also resisted or rejected. Results suggest that actors adopt a range of pragmatic strategies to advance harm reduction services in response to policy vacuums characteristic of morality policy domains, and challenge assumptions about the utility of formal policies for advancing harm reduction.

Standards for opioid use disorder care: An assessment of Nordic approaches.

Aims:Outcomes in opioid use disorder (OUD) in Nordic countries have improved with integrated treatment and harm-reduction programmes. Approaches and the standard of care are different across the region. Evidence of treatment needs and current approaches are defined from evidence to inform development of a common standard.Method:Evidence of population sizes and treatment approach collected. Common standards for care (harm reduction, pharmacotherapy, psychology/social therapy) defined for each country.Results:Evidence defines number in treatment; potential population needing treatment not defined for all countries. Populations sizes, treatment access (ratio in treatment programme compared to total country population) defined: Sweden 4,000 in OUD care (access ratio 40); Finland 3,000 (55); Norway 8,000 (154); Denmark 7,500 (132). Approach to treatment similar: integrated treatment programmes standard. Care provided by specialists in outpatient clinics/primary care; secondary care/inpatient services are available. Harm reduction is limited in Sweden but available and more accessible elsewhere. Treatment entry criteria: access relatively unlimited in Norway and Denmark, more limited in Finland and Sweden. Standards of care defined: easy access to high-quality services, individual planning, care not limited by time, management of relapse, education for patients, continuous engagement, holistic approach including management of comorbidities, needle equipment programmes without limit, treatment in prisons as community.Conclusion:There are opportunities to improve OUD care in the Nordics. Policy makers and clinicians can advance OUD care and share common success factors. Collaborative work across the Nordic countries is valuable. Further research in clinical practice development can yield important results for the benefit of patients with OUD.

Role of boyfriends and intimate sexual partners in the initiation and maintenance of injecting drug use among women in coastal Kenya

IntroductionGender dynamics and interpersonal relations within intimate partnerships are known to determine health behaviors, including substance use, within couples. In addition, influence from intimate partners may occur in the context of wider social ecological determinants of health behavior. The aim of this study was to document the role of intimate partners in influencing injecting drug use among women in Kenya, where injecting drug use is on the rise. MethodsWe performed secondary data analysis of an existing dataset from a 2015 qualitative study involving 45 women who inject drugs and 5 key stakeholders in coastal Kenya. Primary data had been collected via a combination of in-depth interviews and focus group discussions exploring sexual, reproductive, drug use, and other social contexts of women who inject drugs. The process by which intimate partners influenced women's initiation of drug use, transition to injecting practices, and maintenance of injecting drug use were identified using thematic analysis. ResultsBoyfriends and intimate either facilitated or restrained women's drug-injecting. On the one hand, young women's entry into drug use was prompted by relationship problems, or a need to acquiesce with their drug-using boyfriends. Once women started injecting, intimate partners facilitated ongoing drug-injecting by financing the acquisition of drugs, peddling drugs to their women, or sharing their drugs with their women. The social capital that peddlers held insulated women from police arrests, and encouraged women to seek and sustain intimate relations with well-connected peddlers. Men's influences over women were driven by an underlying patriarchal drug acquisition and economic power. On the other hand, boyfriends and intimate partners who were non-injectors or non-drug users sought to moderate women's injecting drug use by encouraging them to inject less, to smoke or snort instead of injecting, or to enroll into rehabilitation. These moderating influences were most prominent when couples were pregnant. Despite men being a source of practical and emotional support, women were frequently unable limit or alter their injecting drug use, due to its addictive nature. Men's disagreement with women's ongoing injecting strained relationships, and occasionally led to separation. ConclusionsSome boyfriends facilitated women's injecting drug use, while others moderated it, supporting assertions that intimate relationships can both be a site of injecting risks or protection. At the micro-level, these findings highlight an opportunity for couple-based interventions, leveraging on non-drug injecting males as a resource to support women adopt safer injecting practices. At a macro level, incorporating livelihood interventions into harm reduction programs is required in order to mitigate economic-based influence of male intimate partners on women's injecting drug use. At both levels, gender transformative approaches are essential. To gain a comprehensive understanding of women's injecting drug use, future studies drug use should explore women's contexts beyond micro influences and consider their wider macro-structural determinants.

HIV knowledge and risk behaviors among drug users in three Vietnamese mountainous provinces

BackgroundGlobally, people who inject drugs are highly vulnerable to HIV transmission. Methadone maintenance treatment (MMT) programs are one of the most cost-effective mechanisms to substitute opioid use and improve the quality of life of patients. Since the coverage of MMT is still limited and even for those patients who are treated, improving their knowledge on HIV and maintaining healthy behaviors are key to maximizing the outcomes of HIV harm reduction programs. This study examined the knowledge on HIV, perceived risk and HIV testing among drug users accessing methadone maintenance services in three Vietnamese mountainous areas.MethodsA cross-sectional study of 300 people enrolling for MMT services in three provinces in Vietnam was conducted. The factors associated with the knowledge, attitudes, and practices of respondents about HIV/AIDS were exploited using multivariable logistic model.ResultsOf the 300-people surveyed, 99% knew of HIV and 60.6% were identified as having good knowledge. While 75.2% identified that injecting drugs was a risk factor for HIV, 52.2% thought they were not at risk of HIV mainly as they did not share needles. 92.6% had undergone HIV testing with 17.4% being positive, a number which was significantly lower than Vietnam’s national average for people who inject drugs. Age, ethnicity and education were associated with knowledge of HIV while ART treatment was linked to self-assessed HIV status.ConclusionsThis study sheds new light on the knowledge attitudes and practices of people who inject drugs, particularly males in mountainous areas of Vietnam regarding HIV prevention. Overall, knowledge was good with most conducting safe practices towards transmission. Enhanced education and targeting of minority groups could help in increasing the numbers receiving MMT and HIV services.

Effectiveness of Methadone Maintenance Therapy (MMT) and Life Style Improvement Among Opiate Dependent Patients Registered

In Malaysia, drug addiction has been a big threat since 1983.As of by latest statistic by National Anti-Drug Agency in 2016, the number of drug abusers in Malaysia was 30846.Acknowledging the importance of drug abuse and relapse as a public health issue, Malaysian government had implemented Harm Reduction Programme .Under this programme, Methadone Maintenance Therapy (MMT) was launched in Oct 2005. This study was undertaken to evaluate the effectiveness of MMT programme among opiate dependent individuals in their daily life. In this study, 100 individuals from the Ministry of Health (MoH), Klinik Kesihatan Bayan Lepas (Bayan Lepas Health Clinic) and Agensi Anti-Dadah Kebangsaan (National Anti-Drug Agency) in Telok Bahang were involved. The subjects were interviewed with WHOQOL BREF questionnaires before joining the MMT programme and also after minimum 4 months of joining MMT. Results obtained were used for comparing life style implications among methadone patients before and after joining the MMT programme. Subjects were predominantly of Malay ethnicity (82%). Subjects were mostly aged between 51 to 60 years old (34%). Paired t-test was done on the WHOQOL scores at baseline (before MMT) and after minimum of 4 months enrolment for all four domains. Each domain showed significant improvement in QOL (P<0.05).The highest improvement was shown in the psychology domain with the mean value increment of 15.13±17.49. Physical domain showed the least improvement with the mean value of 9.39±16.21.This study has proven that MMT have highly contributed to improvement of quality of life among MMT clients in Klinik Kesihatan Bayan Lepas and AADK Telok Bahang. DOI : http://dx.doi.org./10.17576/JSKM-2019-1701-07

Predictors of Drug Injection in High-Risk Populations of Prisoners with a History of Tattooing: A Cross-Sectional Study.

Transmitting blood-borne diseases is alarming in places with high prevalence of people who inject drugs. This study aimed to determine the prevalence of drug injection and its related predictors among prisoners with a history of tattooing in Iran. Cross-sectional study. By using a census sampling, 5493 prisoners with a history of tattooing of 11988 prisoners participated for hepatitis B and C bio-behavioral surveillance surveys (BSS) in prisons of Iran, during 2015-2016 from 55 prisons in 19 provinces were assessed. The data for the BSS were collected using face-to-face checklist-based interviews. Weighted prevalence and the association between variables and history of drug injection were determined using Chi-square test and adjusted odds ratio (AOR) was estimated through multivariate logistic regression test using survey package. The mean age of participants was 33.9 ±8.3 yr. Most of them were male (96.4%) and had a history of drug use (85.4%). The prevalence of drug injection among drug users was 20.2%, of which 33.9% had a history of shared injection. The prevalence of drug injection among prisoners with a history of tattooing is associated with male gender (P=0.047), age ≥35 yr (P<0.001), being single (P=0.002), being divorced/widow (P=0.039), and a history of imprisonment (P<0.001). The prevalence of drug injection increases in the presence of other high-risk behaviors. It is necessary to initiate harm reduction programs and preventive interventions in groups with multiple high-risk behaviors.

HIV/tuberculosis/hepatitis C virus services for incarcerated populations in Azerbaijan and the Eastern Europe Central Asia region.

The tide of HIV, hepatitis C virus (HCV) and drug-resistant tuberculosis (TB) is a challenge for the penitentiary system in Eastern Europe Central Asia (EECA) region. We have analyzed the existing services for incarcerated individuals with HIV, HCV and TB to assess the current situation in the EECA region. Because of the current criminal-legal system, key risk population with strong linkage to the blood-borne and airborne infections has a high proportion among prisoners. Management of these diseases includes a set of services, such as early detection, counseling, testing and treatment, prevention, harm reduction programme, wide educational and information efforts, and organization of continuity care after release. WHO has developed a set of targets, the only precise achievement of which will reduce the burden of these infections and eliminate them as a public health problem. It is necessary to closely monitor the delivery of HIV, HCV and TB care services in penitentiary system of the EECA countries. The comprehensive operational research will help to develop the most effective practices allowing to achieve the care provision for the entire contingent of the penitentiary system and its continuity in the civil sector. Sustainable and sufficient funding is required as well as enough attention to ensure healthcare services at an appropriate level in the penitentiary system.

Assessment of Retrospective and Current Substance Use in Women Who Inject Drugs in Low-Income Urban Settings in Kenya

Women who inject drugs (WWIDs) continue to experience challenges that accumulate their risk to HIV transmission and other co-morbidities. However, data that conceptually link diverse substance use dimensions in WWIDs are lacking particularly in developing countries. We assessed retrospective and current substance use among 306 WWIDs in low-income urban settings in Kenya using mixed methods. Descriptive analyses were performed on quantitative data while qualitative narratives revealed insights from quantitative findings. The mean age of the study participants was 17 (range 11, 30) years. Out of the 306 WWIDs 57% commenced with substance use by combining both licit and illicit drugs. Intimate sexual partners including spouses and casual sex partners introduced seventy-four percent of WWIDs to substance use. Majority of the WWIDs (39.9%) commenced with 2- way substance combination with bhang and cigarette having the highest usage. However, 4-way substance combinations containing heroin, cigarette, bhang, valium, Rohypnol had the highest frequency (12.8%) at the time of the survey. Varied routes of heroin administration were mentioned including injection, smoking and sniffing as separate routes and as 2-way or 3-way mode combinations of these. To inform policies targeting the health and rights of girls and women in low income settings, this study recommends urgent upstream policies targeting the girl adolescent life in form of a multifunctional package composed of identifying girls at risk, substance use interventions, sexual health education, improved educational attainment, and progressive social policies that target low social economic status in the adolescent phase. Harm reduction programs in Kenya should target people who use heroin through both injection and non-injection modes of administration.

Seroprevalence of markers of hepatitis C virus exposure and associated factors in adults aged 18-39 years in the Arctic Russian city of Arkhangelsk: a cross-sectional study

ABSTRACT Hepatitis C, caused by the hepatitis C virus (HCV), is a major public health issue in Russia. The aim of our study was to assess the seroprevalence of markers of HCV exposure and factors associated with HCV seropositivity among the general population aged 18–39 years in the city of Arkhangelsk, Northwest Russia. A social research agency applied a quota sampling method to recruit study participants using cell phone numbers. All participants (n = 1243) completed a self-administered questionnaire and provided a blood sample. Sixty-five participants (5.2%, 95% confidence interval [CI] 4.9–5.5) tested positive for HCV IgM+G antibodies, and of these, 55 (84.6%) did not know that they were exposed to HCV. In multivariable logistic regression analysis, HCV seropositivity was significantly associated with older age, a history of injecting drug use, and having ever received a blood transfusion. To reach the goal of the World Health Organisation’s Global Health Sector Strategy on Viral Hepatitis, regional preventive programmes should include measures to reduce injecting drug use as well as scaling up harm-reduction and treatment programs for drug addicts.

Pattern of Substance Abuse and Prevalence of Risk Factors of HIV and Hepatitis among Addicted Women in Western Iran.

Background:Women are the first victims in most of social damages and corruptions. However, due to some social and cultural reasons, the most of the drug addiction studies in Iran target male population. Hence, this study aimed to investigate the pattern of substance abuse and prevalence of HIV and hepatitis risk factors among addicted women.Methods:This is a cross-sectional study conducted on women referred to methadone maintenance treatment centers of Western Iran (Kermanshah province). Data were collected through interview by a psychologist who is working full time in the centers.Results:A total of 138 addicted women were studied. Among whom, 50 individuals were aged >45 years old (36.2%), 135 individuals (97.8%) had a history of substance abuse in their family, and 66 individuals (40.5%) initiated drug use before age 20. The most common substances were opium and crack with a proportion of 76.8% and 9.4%, respectively. Prevalence of positive HIV and hepatitis B among addicted women were 18.8% (26 persons) and 5.0% (7persons), respectively. Three (2.1%) of addicted women with HIV also had HBV. The most commonly HIV transmission were drug injections (30.7%) and unprotected sex (11.5%).Conclusions:Although women do not constitute a significant part of substance abuse, increasing trend of women addiction, on one hand, and high prevalence of risk factors related to HIV or hepatitis in women, on the other hand; show that officials and experts are required to seriously consider prevention and harm reduction programs for women.

Evaluating the impact of global fund withdrawal on needle and syringe provision, cost and use among people who inject drugs in Tijuana, Mexico: a costing analysis

ObjectiveFrom 2011 to 2013, the Global Fund (GF) supported needle and syringe programmes in Mexico to prevent transmission of HIV among people who inject drugs. It remains unclear how GF...

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