Injecting Equipment Research Articles

Drug Injection-Related Norms and High-Risk Behaviors of People Who Inject Drugs in Athens, Greece

Drug use involves social interactions. Therefore, norms in the proximal environment of people who inject drugs (PWID) can favor behaviors that may result in HIV transmission. This work aimed at studying drug injection-related norms and their potential association with risky behaviors among PWID in Athens, Greece, in the context of economic recession and political activism that followed the fiscal crisis and soon after a recent HIV outbreak had leveled off. The Transmission Reduction Intervention Project (TRIP) was a social network-based approach (June 2013 to July 2015) that involved two groups of PWID seeds-with recent HIV infection and with long-term HIV infection and one control group of HIV-negative PWID. Network contacts of seeds were also enrolled. TRIP participants answered a questionnaire that included items on injection-related norms and behaviors. TRIP recruited 320 PWID (HIV positive, 44.4%). TRIP participants, especially those without HIV, often recalled or perceived as normative among their partners and in their networks some behaviors that can lead to HIV transmission. TRIP participants who recalled that they were encouraged by their regular drug partners to use an unclean syringe were almost twice as likely to report that they share syringes [odds ratio (OR) = 2.03; 95% confidence interval (CI) = 1.86-2.21], or give syringes to someone else (OR = 1.70; 95% CI = 1.42-2.04) as those who did not recall such an encouragement. Associations were modified by HIV status. HIV negatives, who were reportedly encouraged to share nonsyringe injecting equipment, were almost 4.5 times as likely to share that material as HIV-negative participants who were not encouraged (OR = 4.59, 95% CI = 4.12-5.11). Further research is needed on the multiple determinants (social, economic, and political) of norms in the social environments of PWID. Since peer norms are associated with risky behaviors, interventions should be developed to encourage norms and peer pressure against the sharing of injection equipment.

Distance matters: The association of proximity to syringe services programs with sharing of syringes and injecting equipment - 17 U.S. cities, 2015

BackgroundSyringe services programs (SSPs) have effectively limited the spread of HIV and hepatitis C (HCV) among people who inject drugs (PWID). Access to SSPs has been shown to reduce injection risk behaviors but the relationship between distance to an SSP and likelihood of sharing injection equipment is not well known. MethodsWe analyzed a sample of 8,392 PWID from 17 U.S. cities recruited through the National HIV Behavioral Surveillance (NHBS) system in 2015. Adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) were estimated from log-linked Poisson regression to explore associations between injecting equipment sharing in the past 12 months and distance to the nearest SSP. ResultsRegardless of SSP use, respondents who lived in zip codes further than the city-specific mean distance to nearest SSP were more likely to report sharing behavior. Among PWID who had not reported using an SSP in the previous 12 months, distributive sharing (aPR=1.13 95% CI=1.05, 1.21), receptive sharing (aPR=1.15, 95% CI=1.06, 1.24), and injection equipment sharing (aPR=1.08, 95% CI=1.03, 1.13) were more prevalent among residents who resided further than the average distance to the nearest SSP. ConclusionsGreater distance to an SSP was associated with increased sharing behaviors. Improved access to an SSP and subsequent decreases in sharing behaviors could reduce transmission of HIV and HCV among PWID. Accessibility should be taken into account when planning provision of SSPs.

Impact of Hepatitis C treatment on behavioural change in relation to drug use in people who inject drugs: A systematic review

Background: A systematic review was conducted to determine the impact of Hepatitis C (HCV) treatment on substance use behaviour in people who inject drugs (PWID).Methods: A search for peer reviewed journal articles from 1991 to present day was conducted using the following databases: PubMed, EMBASE, CINAHL and PsycINFO. Studies were appraised against the following inclusion criteria: recruitment of PWID for HCV treatment (either interferon alpha or direct acting antivirals based); measurement of behavioural change in relation to drug use; studies published in English.Results: Five studies investigating the impact of HCV treatment on behavioural change in relation to drug use amongst PWID were identified. Studies investigated the impact of HCV treatment on past month injecting drug use (four studies), injecting frequency (two studies), needle and syringe borrowing (two studies) and injecting equipment sharing (three studies). Three of the four studies assessing impact of treatment on past month injecting frequency found treatment significantly reduced the odds of participants reporting past month injecting at follow up. One study found that there was significant reduction in weekly injecting frequency between enrolment, treatment and follow up. No association was found between treatment engagement and needle and syringe borrowing. Two out of three studies reported a significant decrease in injecting equipment sharing between enrolment, treatment and follow up.Conclusions: Comparison and synthesis of results was challenging due to heterogeneity between studies. Moreover, four out of the five selected studies were conducted during the interferon era of treatment, possibly limiting the generalisability of the current review’s results to the new DAA treatment era. However, it is likely that engaging in treatment has a positive impact upon patients’ injecting drug use and injection equipment sharing behaviour. This raises the possibility that this may be an opportune time for further harm reduction measures.

Association between harm reduction intervention uptake and skin and soft tissue infections among people who inject drugs

BackgroundBacterial skin and soft tissue infections (SSTIs) are a health issue for people who inject drugs (PWID). There is a lack of evidence on the associations between harm reduction (HR) uptake and SSTIs. This paper examines the associations between the uptake of injecting equipment (IE) and opiate substitution treatment (OST) on SSTIs among PWID, and the injecting behaviours associated with having had an SSTI. This is the first large-scale, national study to examine the association between IE uptake and SSTIs. MethodsA cross-sectional, voluntary and anonymous survey was undertaken with PWID recruited from pharmacies/agencies providing IE across mainland Scotland during 2013–2014. Participants were asked: if they had an SSTI within the past year; about their uptake of HR within the past 6 months (including needle/syringes (N/S), paraphernalia and OST); and about their frequency of injecting, sharing of IE and re-use of own N/S. Data from 1876 PWID who had reported injecting within the past 6 months were analysed. FindingsIn multivariate logistic regression, those with high combined IE-OST uptake (adjusted odds ratio [AOR] 0.614, 95% CI 0.458–0.823, p=0.001) and medium combined IE-OST uptake (AOR 0.725, 95% CI 0.546–0.962, p=0.026) had lower odds of having had an SSTI compared to those with low combined IE-OST uptake. ConclusionsIE and OST uptake may reduce the level of SSTIs among PWID, suggesting increasing combined uptake may be beneficial. Nevertheless, a sizeable proportion of PWID with high HR uptake experienced SSTIs, suggesting the importance of other interventions.

Comparing profile of people who inject drugs (PWID) accessing different types of needle and syringe programs or secondary distribution in Kermanshah, Iran

Background: Needle and syringe programs (NSPs) have been developed and implemented since 2002 in Iran. NSPs are largely delivered through fixed site and outreach services. Characterizing people who inject drugs (PWID) primarily using different sources of injecting equipment can help service design.Objective: The objective of the present study was to characterize and compare the risk behaviors of PWID according to their primary sources of clean needles and syringes in Kermanshah, Iran.Methods: We used data from a cross-sectional study of 500 PWID in Kermanshah. Behavioral and program data were also assessed to identify their main source of injection equipment, demographic characteristics, and risk behaviors. The Cochran–Armitage trend test was used to test for trends in characteristics and risk behaviors among the three sources for clean needles. We also ran a multinomial logistic regression to assess the individual characteristics of those who have reported the outreach or other sources of NSP over fixed sites as their main sources of clean needles and syringe.Results: As reported by study participants, their three main sources were fixed sites (n = 230, 46%), (n = 180, 36%) and secondary distribution ((n = 90, 18%). The odds of reporting outreach versus fixed site as main source was significantly higher in those with unstable housing (AOR = 2.8, p = 0.01), who started injection under 25 years of age (AOR = 2.7, p = 0.03), and who have longer duration of injections (AOR = 2.3, p = 0.02). Similarly, the odds of reporting secondary distribution versus fixed site as main source of needles and syringes was significantly higher in those with unstable housing (AOR = 3.2, p = 0.01).Conclusions: We observed a trend toward more risky injection behaviors among the users of fixed sites to outreach program users and then those who have reported other alternates as main sources. This can be explained by insufficient coverage of injections.

Drug, sex and sociality: Factors associated with the recent sharing of injecting equipment among gay and bisexual men in Australia

• Gay and bisexual men's crystal methamphetamine injection is linked to sex. • Gay and bisexual crystal users often share injecting equipment. • Gay and bisexual men are at risk of hepatitis C from sharing injection equipment.

Una estrategia exitosa para la estimación del consumo de agujas y jeringas en usuarios de drogas inyectables en la República Checa

The objectives were to: (i) estimate the extent of the injecting equipment (IE) provided by needle exchange programs (NEPs) to injecting drug users (IDUs) in the Czech Republic in 2010; (ii) subsequently validate the recent methodology used for data collection by the Czech National Monitoring Centre for Drugs and Drug Addiction (CMC), and (iii) estimate the number of syringes provided to Czech IDUs. A simple document analysis was performed in order to collect data on the production, sale, and consumption of injecting equipment in the Czech Republic in combination with questionnaire screening in the NEPs and 21 brief interviews with key informants. Ten types of IE most commonly used for drug injecting by the Czech drug users were identified. Approximately 5,038,000 pieces of sterile IE were marketed in the Czech Republic in 2010. According to four manufacturers (with a market share of 96%) and with reference to the year 2010, 5,430,694 pieces of sterile IE were provided to Czech injecting drug users (487,694 pieces of IE were sold to IDUs in pharmacies and 5,038,000 pieces of IE were distributed by NEPs in 2010). We compared the amount of IE provided to IDUs as reported to the CMC National registry by NEPs (4,943,000) with that of IE distributed by manufacturers and distributors (5,038,000) in the country in 2010 and found a difference of less than two percent using two different methodologies. This study confirms the accuracy of the data on the amount of IE exchanged as collected by the CMC monitoring system. This study opens up important public health practice and policy-making issues. The methodology of this study may be used in regions where no data collection system is present or where confirmation of the data related to IE is needed.

Within-prison drug injection among HIV-infected Ukrainian prisoners: Prevalence and correlates of an extremely high-risk behaviour

BackgroundIn Ukraine, HIV-infection, injection drug use, and incarceration are syndemic; however, few services are available to incarcerated people who inject drugs (PWIDs). While data are limited internationally, within-prison drug injection (WP-DI) appears widespread and may pose significant challenges in countries like Ukraine, where PWIDs contribute heavily to HIV incidence. To date, WP-DI has not been specifically examined among HIV-infected prisoners, the only persons that can transmit HIV. MethodsA convenience sample of 97 HIV-infected adults recently released from prison within 1–12 months was recruited in two major Ukrainian cities. Post-release surveys inquired about WP-DI and injection equipment sharing, as well as current and prior drug use and injection, mental health, and access to within-prison treatment for HIV and other comorbidities. Logistic regression identified independent correlates of WP-DI. ResultsComplete data for WP-DI were available for 95 (97.9%) respondents. Overall, 54 (56.8%) reported WP-DI, among whom 40 (74.1%) shared injecting equipment with a mean of 4.4 (range 0–30) other injectors per needle/syringe. Independent correlates of WP-DI were recruitment in Kyiv (AOR 7.46, p=0.003), male gender (AOR 22.07, p=0.006), and active pre-incarceration opioid use (AOR 8.66, p=0.005). ConclusionsAmong these recently released HIV-infected prisoners, WP-DI and injection equipment sharing were frequent and involved many injecting partners per needle/syringe. The overwhelming majority of respondents reporting WP-DI used opioids both before and after incarceration, suggesting that implementation of evidence-based harm reduction practices, such as opioid substitution therapy and/or needle/syringe exchange programmes within prison, is crucial to addressing continuing HIV transmission among PWIDs within prison settings. The positive correlation between Kyiv site and WP-DI suggests that additional structural interventions may be useful.

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

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

Association between harm reduction intervention uptake and recent hepatitis C infection among people who inject drugs attending sites that provide sterile injecting equipment in Scotland

BackgroundPrevalence of the hepatitis C virus (HCV) among people who inject drugs (PWID) in Scotland is high. The Scottish Government has invested significantly in harm reduction interventions with the goal of reducing HCV transmission among PWID. In evaluating the effectiveness of interventions, estimates of HCV incidence are essential. MethodsDuring 2008–2009, PWID were recruited from services providing sterile injecting equipment across mainland Scotland, completed an interviewer-administered questionnaire and provided a dried blood spot for anonymous anti-HCV and HCV-RNA testing. Recent infections were defined as anti-HCV negative and HCV-RNA positive. Logistic regression was undertaken to examine associations between recent HCV infection and self-reported uptake of methadone maintenance therapy (MMT) and injection equipment. ResultsFifty-four percent (1367/2555) of participants were anti-HCV positive. We detected 24 recent HCV infections, yielding incidence rate estimates ranging from 10.8 to 21.9 per 100 person-years. After adjustment for confounders, those with high needle/syringe coverage had reduced odds of recent infection (adjusted odds ratio [AOR] 0.32, 95% CI 0.10–1.00, p=0.050). In the Greater Glasgow & Clyde region only, we observed a reduced odds of recent infection among those currently receiving MMT, relative to those on MMT in the last six months but not currently (AOR 0.04, 95% CI 0.001–1.07, p=0.055). The effect of combined uptake of MMT and high needle/syringe coverage was only significant in unadjusted analyses (OR 0.34, 95% CI 0.12–0.97, p=0.043; AOR 0.48, 95% CI 0.16–1.48, p=0.203). ConclusionWe report the first large-scale, national application of a novel method designed to determine incidence of HCV among PWID using a cross-sectional design. Subsequent sweeps of this survey will increase statistical power and allow us to gauge the impact of preventive interventions.

Distributive sharing among HIV–HCV co-infected injecting drug users: the preventive role of trust in one's physician

This study, based on data from the MANIF 2000 cohort study, investigates the relationship between the lending of injecting equipment, drug use, and experience with HIV care. The sample comprised 224 HIV–HCV co-infected patients who reported having injected drugs in the previous six months and their 538 visits to clinical services. Longitudinal data were collected for medical status, and self-reported risk behaviors. A logistic regression GEE model was used to identify correlates of distributive sharing. After multiple adjustment, patients who reported trust in physicians were significantly less likely to report lending injection equipment while cocaine users were at increased risk. Promoting dialog between physicians and injecting drug users (IDUs) may play an important role in HIV–HCV positive prevention.

Social inclusion and hepatitis C: exploring new possibilities for prevention

In Western countries, people who inject drugs experience a disproportionate burden of hepatitis C as a result of effective transmission of the virus via the sharing of used injection equipment. With a hepatitis C prevalence of 60% and higher in many areas, previous and current prevention efforts focusing on the availability of sterile injecting equipment along with education, have had only limited effect on incidence rate. Little attention has been paid to the broader social and political positions that drug use and people who use drugs hold in these societies. Insights from social research provide opportunities to broaden the possibilities for prevention efforts. We will review the social inclusion literature to provide some examples of how hepatitis C prevention may be approached in innovative ways.

Merseyside, the first harm reduction conferences, and the early history of harm reduction

In the mid 1980s, Liverpool implemented pioneering approaches to dealing with the problems caused by the use of drugs. The Mersey Harm Reduction Model concentrated on reducing the harms rather than, as previously was the case, trying to reduce drug use itself. This policy was given great impetus by the emergence of HIV and the danger of infection from using contaminated injection equipment. It became imperative to reduce this kind of risk behaviour by providing clean injecting equipment, prescribing methadone (and in a small percentage of cases, heroin) and by using outreach workers to go into the community and help people where they lived and to attract them into services. The police played a key role. Service uptake was rapid and included many who had never had previous contact with services. An HIV epidemic did not happen amongst injecting drug users in Mersey. In 1991, the approach was applied to the new phenomenon of the use of MDMA with the publication of the leaflet ‘Chill Out’. The First International Conference on the Reduction of Drug Related Harm took place in Liverpool in 1990 as a response to the interest shown in what was happening in the region and the International Harm Reduction Association was born out of these conferences.

Gender differences in injection risk behaviors at the first injection episode

Objectives To examine gender differences in drug injection equipment sharing at injecting initiation. Methods Young injecting drug users (IDUs) in New York City February 1999–2003 were surveyed about injection risk behaviors and circumstances at initiation. Analyses were gender-stratified and excluded participants who initiated alone. Multiple logistic regression estimated adjusted odds ratios. Results Participants ( n = 249) were 66% male and 82% White. Mean initiation age was 19.2; mean years since initiating was 3.0. Women were significantly more likely to cite social network influence as a reason for initiating, to have male and sex partner initiators, and to share injecting equipment than men. Among women, sharing any injection equipment was associated with initiation by a sex partner and having ≥2 people present. Among men, being injected by someone else predicted sharing any injection equipment, while using a legally obtained syringe was protective. Conclusions Social persuasion stemming from sexual and/or social relationships with IDUs may increase women's risk of sharing injection equipment at initiation, and consequently, their early parenteral risk of acquiring blood-borne infections. Interventions should focus on likely initiates, especially women in injecting-discordant sex partnerships, and IDUs (potential initiators).

Drug injecting and syringe use in the HIV risk environment of Russian penitentiary institutions: qualitative study

Evidence highlights the prison as a high risk environment in relation to human immunodeficiency virus (HIV) and hepatitis C virus (HCV) transmission associated with injecting drug use. We undertook qualitative studies among 209 injecting drug users (IDUs) in three Russian cities: Moscow (n = 56), Volgograd (n = 83) and Barnaul in western Siberia (n = 70). Over three-quarters (77%) reported experience of police arrest related to their drug use, and 35% (55% of men) a history of imprisonment or detention. Findings emphasize the critical role that penitentiary institutions may play as a structural factor in the diffusion of HIV associated with drug injection in the Russian Federation. While drugs were perceived to be generally available in penitentiary institutions, sterile injection equipment was scarce and as a consequence routinely shared, including within large groups. Attempts to clean borrowed needles or syringes were inadequate, and risk reduction was severely constrained by a combination of lack of injecting equipment availability and punishment for its possession. Perceptions of relative safety were also found to be associated with assumptions of HIV negativity, resulting from a perception that all prisoners are HIV tested upon entry with those found HIV positive segregated. This study shows an urgent need for HIV prevention interventions in the Russian penitentiary system.

Sterile syringe access and disposal among injection drug users newly enrolled in methadone maintenance treatment: a cross-sectional survey.

BackgroundWe sought to assess injection practices, means of acquiring and disposing of syringes, and utilization and knowledge of harm reduction resources among injection drug users (IDUs) entering methadone maintenance treatment (MMT).MethodsInterviews with 100 consecutive patients, including 35 IDUs, entering a MMT program in the Bronx, NY.ResultsUtilization of unsafe syringe sources was reported by 69% of IDUs in our sample. Most (80%) IDUs reused syringes, and syringe sharing was also common. Fewer than half knew that non-prescription pharmacy purchase of syringes was possible. The most common means of disposing of injecting equipment were the trash (63%) and syringe exchange programs (49%).ConclusionsThese findings indicate that drug users entering treatment under-utilize sanctioned venues to obtain sterile syringes or safely dispose of used injection equipment. Programs providing services to drug users should adopt a proactive stance to address the safety and health issues faced by injectors.

‘First steps’: using rapid assessment and response methods to develop research, intervention and advocacy capacity for addressing drug use in Rosario City, Argentina

During the last decade, injecting drug use (IDU) has increased in Rosario City, Argentina, and more than half of all reported HIV cases are thought to be related to the sharing of injection equipment. Despite this, valid and systematic data on the extent and nature of injecting drug use are rare, and only a limited number of HIV prevention interventions currently operate in the city. In response, the Universidad Nacional de Rosario have used the Spanish translation of the Rapid Assessment and Response Guide on Injecting Drug Use (IDU-RAR) developed by the World Health Organization (WHO. The Rapid Assessment and Response Guide on Injecting Drug Use (draft for field testing). Geneva: WHO, 1998) as a first step in producing more detailed research data, identifying urgently needed interventions, and designing a long-term harm reduction strategy for Rosario. This paper describes this process and the outcomes of the assessment where key findings indicate that: 65% of those sampled were HIV positive; 70% shared injecting equipment; the majority were not in contact with drug treatment services; 13% were under the age of 20; and 62% of those injecting drug users with HIV had neither medical care or treatment for their condition.

Injecting Equipment Provision in Australia: The State of Play

Injecting equipment provision measures in Australia can be judged reasonably successful as HIV prevention measures. In the capital cities of all Australian States and Territories, access to needles and syringes is easy, at least during the day in at least some areas. In conjunction with peer education and other activities, needle and syringe supply appears to have led to a change in norms away from the sharing of needles and other injecting equipment among at least older heroin injectors in large population centers. However, in many other areas, and in many subpopulations-particularly further marginalized groups such as Aboriginal and Vietnamese-Australian injectors-messages about HIV/AIDS risk are either not penetrating or are being ignored, and needle and other equipment sharing still appears to be common. The strategy of providing access to needles and syringes as a separate activity from peer education among injecting drug users (IDUs) needs to be reconsidered in the light of the widespread epidemic of hepatitis C among Australian IDUs. The level of supply of all injecting equipment also needs to be increased to assist all IDUs in learning and carrying out an aseptic injecting technique given the lack of an effective disinfection technique to prevent the spread of hepatitis C, and me problems surrounding both the promotion of disinfection and the promotion of noninjecting routes of administration.

"What We Want to Know About HIV/AIDS:" An Analysis of Questions Asked by Substance Abuse Clients Attending AIDS Education Classes in Puerto Rico

An analysis of the questions about human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) asked by intravenous drug users attending AIDS education classes at a public detoxification center in San Juan Puerto Rico provided guidelines for the design of future educational programs. Of the 13007 AIDS cases reported in Puerto Rico by April 1994 an estimated 57% were associated with contact with contaminated drug injecting equipment. The clinics mandatory AIDS education program is comprised of three loosely structured one-hour sessions in which active participation is encouraged. The present study analyzed 372 AIDS-related questions raised by 230 clients in the 50 one-hour sessions that occurred in June-October 1992. 62% of clients reported previous exposure to at least one AIDS education presentation. The questions fell into the following topic areas: HIV transmission and prevention 55.2%; natural history of HIV infection 24.5%; HIV testing 10.5%; treatment 7.0%; and other (e.g. epidemiology legal issues) 3.0%. Common were questions about modes of HIV transmission that while biologically plausible are highly unlikely (e.g. tears sweat saliva or urine). Also raised were questions about the likelihood of virus elimination during the process of heating drugs in a cooker and the use of bleach and alcohol for cleaning injection equipment. There was interest in why exposed individuals vary in their susceptibility to HIV as well as in the effect of illegal drug use on HIV progression. Clients pressured the educators to assign numerical ratings to different types of high-risk activities reflecting their need to pinpoint what constitutes an acceptable risk. As a result of this analysis AIDS educators at the center are now providing demonstrations with injecting equipment that illustrate the potential risk at different moments in the injecting process as well as procedures that eliminate or reduce this risk.

Frontloading

To determine whether frontloading (i.e., syringe-mediated drug-sharing) is a risk factor for HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) infection among injecting drug users (IDU). Cross-sectional study. Data on sociodemographic and behavioural characteristics were obtained by a standardized questionnaire. Serum samples were tested for seromarkers for HIV, HBV and HCV. IDU were recruited at 'low-threshold' storefront agencies (out-of-treatment sample), and at a centre for long-term drug use treatment (in-treatment sample). Individuals were included in the study if they had injected drugs within the previous 3 months. Serological evidence for HIV, HBV, HCV exposure. Of all IDU (n = 324), 84% had ever practised frontloading with non-sterile injecting equipment, and 46% had done so more than 100 times; 32% had front-loaded during the 6 months prior to the interview. The crude seroprevalence rates for HIV, HBV and HCV increased with the overall frequency of frontloading, and reached 22, 71 and 94%, respectively, among IDU who had frontloaded more than 100 times. After controlling for confounding effects by logistic regression, having practised frontloading more than 100 times was significantly associated with HIV infection [adjusted prevalence odds ratio (POR) 3.5; 95% confidence interval (CI), 1.4-9], and HCV infection (adjusted POR, 5.4; 95% CI, 2.3-12), but not with HBV infection. Another independent risk factor for all three virus infections was needle-sharing in prison. In communities where sterile injection equipment is readily available, and IDU have substantially reduced their overall levels of needle-sharing, the practice of frontloading appears to be a major risk factor for infections by blood-borne viruses among IDU. Prevention activities should specifically address this risk behaviour.