Injection Risk Behaviors Research Articles

A novel, multi-component contingency management intervention in the context of a syndemic of drug-related harms in Glasgow, Scotland: First year of the 'WAND' initiative.

To address high levels of drug-related harms among people who inject drugs (PWID) in Glasgow, a novel contingency management intervention was developed to engage high-risk PWID with four harm reduction measures (known as the WAND initiative: Wound care, Assessment of injecting, Naloxone, and Dried blood-spot test). Our aims were to assess if WAND engaged and re-engaged high-risk PWID. Baseline data of WAND participants (n=831) from 1st Sept-2020 to 30th Aug-2021 were analysed. For those who took part in the first six months, extent of re-engagement was determined and, among those re-engaged, intervention coverage was compared between baseline and final engagement. Among those who first engaged in WAND from Sept 2020-Feb 2021 (n=546), 40% re-engaged by Aug 2021. Compared to those who engaged once (n=321), those who re-engaged (n=215) within one year had higher baseline prevalence of injecting risk behaviours such as injecting daily (56% vs 64%, p=0.032), injecting away from home (42% vs 52%, p=0.0179), injecting cocaine (56% vs 75%, p<0.001), having an SSTI (40% vs 60%, p<0.001), and been prescribed naloxone (57% vs 72%, p<0.001). For those who re-engaged six months to one year after initial engagement (n=107), there was a significant increase in having a BBV test in the last six months (61% to 81%, p=0.003) and carrying naloxone (22% to 32%, p=0.011). WAND was able to engage and re-engage large numbers of high-risk PWID with multiple harm reduction initiatives. These findings suggest contingency management could be a useful tool for harm reduction services.

Interventions to reduce harms related to drug use among people who experience incarceration: systematic review and meta-analysis

Mortality, suicide, self-harm, and substance use are elevated among people who are incarcerated. There is a wide range of heterogeneous interventions aimed at reducing these harms in this population. Previous reviews have focused on specific interventions or limited their findings to drug use and recidivism and have not explored interventions delivered after release from prison. Our aim is to examine the effect of interventions delivered to people who use drugs during incarceration or after release from incarceration, on a wide range of outcomes. In this systematic review and meta-analysis, we searched Embase, MEDLINE, and PsycINFO databases up until Sept 12, 2023 for studies published from Jan 1, 1980 onwards. All studies evaluating the effectiveness of any intervention on drug use, recidivism outcomes, sexual or injecting risk behaviours, or mortality among people who use psychoactive drugs and who were currently or recently incarcerated were included. Studies without a comparator or measuring only alcohol use were excluded. Data extracted from each study included demographic characteristics, interventions, and comparisons. Pooled odds ratios and risk ratios were calculated using random-effects meta-analyses. We identified 126 eligible studies (47 randomised controlled trials and 79 observational studies) encompassing 18 interventions; receiving opioid-agonist treatment (OAT) in prison reduced the risk of death in prison (one study; hazard ratio 0·25; 95% CI 0·13-0·48), whereas receiving OAT in the first 4 weeks following release reduced risk of death in the community (two studies; relative risk 0·24; 95% CI 0·15-0·37). Therapeutic community interventions reduced re-arrest at 6-12 months (six studies; odds ratio [OR] 0·72; 95% CI 0·55-0·95) and reincarceration at 24 months (two studies; OR 0·66; 95% CI 0·48-0·96). There was scarce evidence that OAT and syringe service provision are effective in reducing injecting risk behaviours and needle and syringe sharing. There are effective interventions to reduce mortality and recidivism for people who use drugs who have been incarcerated. Nonetheless, there are also substantial gaps in the research examining the effect of interventions on risk behaviours and mortality during incarceration and a need for randomised designs examining outcomes for people who use drugs after release. Australian National Health and Medical Research Council.

Evaluating attitudes on health-seeking behavior among a network of people who inject drugs

People who inject drugs (PWID) are often members of HIV/AIDS risk networks, where individuals engage in sexual and injection risk behavior. Engagement in HIV care is important for this population. Low socioeconomic status, stigmatization, and lack of access to medical care often complicate successful engagement in the HIV cascade of care for PWID. This study investigates how individual's attitudes about how much control they have over HIV/AIDS risk in their life (i.e., locus of control and self-blame) affect health-seeking behavior in PWID participants and their community members. We applied causal inference methodology to PWID HIV risk networks ascertained from the Social Factors and HIV Risk Study (SFHR) conducted between 1991 and 1993 in Bushwick, Brooklyn, New York. We estimated protective disseminated effects of attitudes toward HIV/AIDS on the health-seeking behaviors of others in the PWID community. In other words, a positive attitude toward controlling HIV/AIDS can improve the health-seeking behavior of other members of the community who report a pessimistic attitude toward HIV/AIDS control. Given this finding, we also discuss potential network interventions to improve health-seeking behavior among both PWID individuals who receive the intervention and others in the PWID network informed by our analysis of disseminated effects.

Safe Injection Self-Efficacy is Associated with HCV and HIV Seropositivity Among People Who Inject Drugs in the San Diego-Tijuana Border Region.

Safe injection self-efficacy (SISE) is negatively associated with injection risk behaviors among people who inject drugs (PWID) but has not been examined in differing risk environments. We compared responses to a validated SISE scale between PWID in San Diego, California and Tijuana, Mexico, and examine correlates of SISE among PWID in Tijuana. PWID were recruited via street outreach for a longitudinal cohort study from October 2020-September 2021. We compared SISE scale items by city. Due to low variability in SISE scores among San Diego residents, we restricted analysis of factors associated with SISE to Tijuana residents and identified correlates of SISE score levels (low, medium, high) using ordinal logistic regression. Of 474 participants, most were male (74%), Latinx (78%) and Tijuana residents (73%). Mean age was 44. Mean SISE scores among San Diego residents were high (3.46 of 4 maximum) relative to Tijuana residents (mean: 1.93). Among Tijuana residents, White race and having previously resided in San Diego were associated with higher SISE scores. HCV and HIV seropositivity, homelessness, fentanyl use, polysubstance co-injection, and greater injection frequency were associated with lower SISE scores. We found profound inequalities between Tijuana and San Diego SISE, likely attributable to differential risk environments. Associations with fentanyl and polysubstance co-injection, injection frequency, and both HIV and HCV seropositivity suggest that SISE contribute to blood-borne infection transmission risks in Tijuana. SISE reflects an actionable intervention target to reduce injection risk behaviors, but structural interventions are required to change the risk environment.

A cross-sectional assessment of injection of "salts" and HIV transmission-related behaviours among a cohort of people who inject drugs in Kyrgyzstan.

Despite the increasing availability of new psychoactive substances (hereafter referred to as "salts") in Eastern Europe and Central Asia, there is a dearth of epidemiological data on the relationship between injecting "salts" and HIV risk behaviours. This is particularly relevant in settings where injection drug use accounts for a substantial proportion of the HIV burden, such as in Kyrgyzstan, a former Soviet Republic. This study assessed whether injecting "salts" is associated with sexual and injection-related HIV risk behaviours among people who inject drugs in Kyrgyzstan. The Kyrgyzstan InterSectional Stigma Study is a cohort of people who inject drugs in Kyrgyzstan's capital of Bishkek and the surrounding rural administrative division of Chuy Oblast. We conducted a cross-sectional analysis using survey data collected from cohort participants between July and November 2021, which included information on injection drug use (including "salts") and HIV risk behaviours. To minimize confounding by measured covariates, we used inverse-probability-weighted logistic and Poisson regression models to estimate associations between recent "salt" injection and HIV risk behaviours. Of 181 participants included in the analysis (80.7% men, 19.3% women), the mean age was 40.1 years (standard deviation [SD] = 8.8), and 22% (n = 39) reported that they had injected "salts" in the past 6 months. Among people who injected "salts," 72% (n = 28) were men, and most were ethnically Russian 59% (n = 23), with a mean age of 34.6 (SD = 9.6). Injecting "salts" was significantly associated with a greater number of injections per day (adjusted relative risk [aRR] = 1.59, 95% confidence interval [CI] = 1.30-1.95) but lower odds of using syringe service programmes in the past 6 months (adjusted odds ratio [aOR] = 0.20, 95% CI = 0.12-0.32). Injecting "salts" was also significantly associated with lower odds of condomless sex in the past 6 months (aOR = 0.42, 95% CI = 0.24-0.76) and greater odds of having ever heard of pre-exposure prophylaxis (aOR = 4.80, 95% CI = 2.61-8.83). (PWID) people who inject drugs who inject "salts" are a potentially emergent group with increased HIV acquisition risk in Kyrgyzstan. Targeted outreach bundled with comprehensive harm reduction and pre-exposure prophylaxis services are needed to prevent transmission of HIV and other blood-borne viruses.

Changes in risk behaviour following a network peer education intervention for HIV prevention among male Tajik migrants who inject drugs in Moscow: a cluster-randomized controlled trial.

The "Migrants' Approached Self-Learning Intervention in HIV/AIDS for Tajiks" (MASLIHAT) recruits and trains Tajik labour migrants who inject drugs as peer educators (PEs) in delivering HIV prevention information and encouragement to adopt risk-reduction norms and practices within their diaspora social networks while reducing their own HIV risk. The MASLIHAT intervention was tested in Moscow in a cluster-randomized controlled trial with 12 recruitment sites assigned to either the MASLIHAT intervention or an equal-time peer-educator training focused on other health conditions (TANSIHAT). From October 2021 to April 2022, 140 male Tajik migrants who inject drugs were recruited as PEs to attend the 5-session MASLIHAT training or the TANSIHAT non-HIV comparison condition. Each participant in both groups recruited two network members (NMs) who inject drugs with the intent to share with them the information and positive strategies for change they had learned (n = 280). All PEs and NMs (n = 420) participated in baseline and follow-up interviews at 3-month intervals for 1 year. All received HIV counselling and testing. Modified mixed effects Poisson regressions tested for group differences in injection practices, sexual risk behaviours and heavy alcohol use over time. At baseline, across both groups, 75% of participants reported receptive syringe sharing (RSS), 42% reported condomless sex and 20% reported binge drinking at least once a month. In contrast to TANSIHAT where HIV risk behaviours remained the same, significant intervention effects that were sustained over the 12 months were observed for receptive syringe and ancillary equipment sharing among both MASLIHAT PEs and NMs (p < 0.0001). Significant declines in the prevalence of sexual risk behaviours were also associated with the MASLIHAT intervention (p < 0.01), but not the comparison condition. Binge alcohol use was not affected in either condition; the MASLIHAT intervention had a transitory effect on drinking frequency that dissipated after 9 months. The MASLIHAT peer-education intervention proved highly effective in reducing HIV-related injection risk behaviour, and moderately effective in reducing sexual risk behaviour among both PEs and NMs. Network-based peer education is an important tool for HIV prevention among people who inject drugs, especially in environments that are not amenable to community-based harm reduction.

Safe Injection Self-Efficacy is associated with HCV and HIV seropositivity among people who inject drugs in the San Diego-Tijuana border region.

Safe injection self-efficacy (SISE) is negatively associated with injection risk behaviors among people who inject drugs (PWID) but has not been examined in differing risk environments. We compared responses to a validated SISE scale between PWID in San Diego, California and Tijuana, Mexico, and examine correlates of SISE among PWID in Tijuana. PWID were recruited via street outreach for a longitudinal cohort study from October 2020 - September 2021. We compared SISE scale items by city. Due to low variability in SISE scores among San Diego residents, we restricted analysis of factors associated with SISE to Tijuana residents and identified correlates of SISE scores (low, medium, high) using ordinal logistic regression. Of 474 participants, most were male (74%), Latinx (78%) and Tijuana residents (73%). Mean age was 44. Mean SISE scores among San Diego residents were high (3.46 of 4 maximum) relative to Tijuana residents (mean: 1.93). Among Tijuana residents, White race and having previously resided in San Diego were associated with higher SISE scores. HCV and HIV seropositivity, homelessness, fentanyl use, polysubstance co-injection, and greater injection frequency were associated with lower SISE scores. We found profound inequalities between Tijuana and San Diego SISE, likely attributable to differential risk environments. Associations with fentanyl and polysubstance co-injection, injection frequency, and both HIV and HCV seropositivity suggest that SISE contribute to blood-borne infection transmission risks in Tijuana. SISE reflects an actionable intervention target to reduce injection risk behaviors, but structural interventions are required to intervene upon the risk environment.

Changes in hepatitis C virus prevalence and incidence among people who inject drugs in the direct acting antiviral era

BackgroundThe World Health Organization (WHO) has set a goal to eliminate hepatitis C virus (HCV) infection by 2030, including a 90% reduction of HCV incidence. With the introduction of a needle syringe program (NSP) in Stockholm, Sweden, and unrestricted availability of direct acting antiviral (DAA) treatment, we investigate the change of prevalence and incidence of HCV infection among people who inject drugs (PWID) over time. MethodsAll persons attending the Stockholm NSP 2013-2021 (n=4,138) were included. The prevalence of viremic HCV infection was investigated yearly. For incidence analysis, PWID at risk with at least one follow-up test were included. Participants were divided into naive defined as anti-HCV negative (n=791), and exposed, defined as anti-HCV positive with a negative HCV RNA (n=1,030). Risk factors for HCV infection were analyzed using parametric exponential proportional hazards regression models. ResultsThe prevalence of viremic HCV infection decreased from 62% to 30% year 2013-2021 while the prevalence of cured after treatment increased from 0 to 22%, corresponding to 42% cured after treatment out of eligible in 2021. The overall incidence rate in naive was 16.9 (95% CI 15.0-19.0) and in exposed 12.8 (95% CI 11.6-14.2) per 100 person years (PY) and was not significantly reduced years 2013-2015 to 2020-2021 in either group. Risk factors for incident HCV infection in multivariable analysis were sharing needles/syringes, younger age, custody/prison past year, and homelessness, whereas opioid agonist treatment was protective. ConclusionThe prevalence of HCV was halved in PWID as unrestricted DAA treatment became available and NSP was established in Stockholm. However, overall incidence was not reduced. To meet the WHO incidence goal, targeting PWID with high injection risk behaviors for testing and treatment is essential, along with engagement in harm reduction services.

Integrated biobehavioral surveillance among people who inject drugs in Ukraine, 2007-2020

BackgroundRepeated integrated biobehavioral surveys (IBBS) have been implemented among people who inject drugs (PWID) in Ukraine to monitor the trends in key epidemiologic and programmatic indicators. MethodsThe study analyzed seven PWID IBBS rounds from 2007 to 2020 in seven Ukrainian cities. Participants were recruited using respondent-driven sampling, tested for HIV and anti-HCV antibodies, and completed a structured questionnaire. Composite weights (based on individual sampling probability and population size) were applied to generate point estimates and confidence intervals for HIV and HCV prevalence, injection risk behaviors, prevention service coverage, and HIV treatment cascade. Multi-level regression assessed temporal trends in these indicators in 2007-2020. ResultsThe samples consisted of 1587 participants in 2007, 1905 in 2008/9, 3066 in 2011, 2846 in 2013, 2699 in 2015, 2798 in 2017, and 3651 in the 2020 rounds. HIV prevalence decreased from 27% to 19% overall, and among PWID younger than 25 from 10.5% to 5.5%. Anti-HCV prevalence increased from 50% to 73% overall but decreased from 58% to 27% in the younger subgroup. Past-30-days injection risk behaviors consistently decreased, reaching a minimum of 38% for any risk in 2020. HIV treatment cascade indicators and coverage with opioid agonist treatment substantially improved in the last three rounds. Harm reduction services coverage fluctuated, declining from 52% to 33% in the last three rounds. ConclusionsThis analysis demonstrates the potential of repeated IBBS for monitoring the HIV epidemic and program coverage. We confirmed a sustained decline in overall HIV and HCV transmission, likely driven by reduced risky injection practices among PWID. The impact of harm reduction services requires further study. HIV status awareness and treatment coverage among PWID markedly increased, reaching the national average, possibly indicating the success of case-finding and linkage-to-care interventions. The upcoming IBBS round in Ukraine will also assess the impact of the war on service provision, risk behavior, and HIV transmission among PWID.

Changing the High-Risk Behaviors of Injecting Drug Users in Iran: Application Theory of Planned Behavior.

Injection risk behavior is a major predictor of HIV infection. The present study was conducted to survey the effect of educational intervention based on the theory of planned behavior on changing high-risk behaviors (the high-risk behaviors of injecting and behaviors of transmitting blood diseases to others) of injecting drug users under the coverage of addiction harm reduction centers. This study is an experimental research on 120 drug addicts in 2021-2022. Two addiction harm reduction centers in Fasa City, Iran, were chosen randomly (one as the test group and the other as the control group). The data collection tool is made up of two parts. The first part is a questionnaire on demographics. The second part is a questionnaire based on the theory of planned behavior, which was made using information from different sources and studies. The training program was set up based on the pretest results and the theory of planned behavior for the test group. Before and six months after the educational intervention, the experimental and control groups filled out the questionnaire. With a significance level of 0.05, the independent t, chi-square, and paired t statistical tests were used to examine the data using the SPSS 22 program. In the test group, the average age of addicts was 37.42 ± 10.55 years, while in the control group, the average age was 38.36 ± 10.09 years (p=0.244). Six months after the educational intervention, all TPB theory's constructs (knowledge, attitude, subjective norms and perceived behavioral control, behavioral intention, and behavior of injecting drug users) were higher in the test group than in the control group (p=0.001). The results show the effect of this educational intervention in reducing high-risk behaviors related to injection in injection drug addicts, so it is suggested as a useful method to reduce high-risk injection behaviors in these people.

Reduced injection risk behavior with co-located hepatitis C treatment at a syringe service program: The accessible care model.

The main mode of transmission of Hepatitis C in North America is through injection drug use. Availability of accessible care for people who inject drugs is crucial for achieving hepatitis C elimination. The objective of this analysis is to compare the changes in injection drug use frequency and high-risk injection behaviors in participants who were randomized to accessible hepatitis c care versus usual hepatitis c care. Participants who were hepatitis C virus RNA positive and had injected drugs in the last 90 days were enrolled and randomized 1:1 to an on-site, low threshold accessible care arm or a standard, referral-based usual care arm. Participants attended follow-up appointments at 3, 6, 9, and 12 months during which they answered questions regarding injection drug use frequency, behaviors, and treatment for opioid use disorder. The primary outcomes of this secondary analysis are the changes in the frequency of injection drug use, high-risk injection behaviors, and receiving medication for opioid use disorder in the last 30 days. A total of 165 participants were enrolled in the study, with 82 participants in the accessible care arm and 83 participants in the usual care arm. Participants in the accessible care arm were found to have a statistically significant higher likelihood of reporting a lower range of injection days (accessible care-by-time effect OR = 0.78, 95% CI = 0.62-0.98) and injection events (accessible care-by-time effect OR = 0.70, 95% CI = 0.56-0.88) in the last 30 days at a follow-up interview relative to those in the usual care arm. There were no statistically significant differences in the rates of decrease in receptive sharing of injection equipment or in the percentage of participants receiving treatment for opioid use disorders in the two arms. Hepatitis C treatment through an accessible care model resulted in statistically higher rates of decrease in injection drug use frequency in people who inject drugs.

Injection Behaviors and Use of Syringe Service Programs over Time among People Who Inject Drugs in Baltimore, Maryland

Introduction: People who inject drugs (PWID) are at increased risk for infectious disease transmission, including hepatitis C and HIV. Understanding trends in injection risk behaviors and syringe service program (SSP) use over time can help improve infectious disease prevention and other harm reduction services. Methods: Using National HIV Behavioral Surveillance System data from Baltimore, Maryland, we examined changes in receptive sharing of (1) syringes, (2) injection equipment, (3) syringes to divide drugs; and (4) receipt of syringes from SSPs among PWID from 2009 to 2018 (n = 518 in 2009, n = 638 in 2012, n = 586 in 2015, and n = 575 in 2018) using unadjusted and adjusted logistic models calculated across time for the total sample. Results: The conditional probability of receptive sharing of syringes and receipt of syringes from SSPs remained relatively stable, while receptive sharing of injection equipment and receptive sharing of syringes to divide drugs dropped substantially after 2009. White race and daily injection frequency were positively associated with sharing syringes and injection equipment and negatively associated with SSP use over time. In 2015, there was a notable shift such that women were twice as likely as men to receive syringes from SSPs and less likely than men to report the use of shared syringes or equipment. Conclusion: Findings indicate overall steady or decreasing trends in injection risk and steady trends in SSP usage over time, with some notable improvements among women and indications of shifting drug market patterns. Injection-related risk behaviors remain high among White PWID and may require targeted outreach and interventions.

The impact of border crossing and imprisonment on injection practices and risk of HIV and hepatitis C infection among men who inject drugs in Nepal.

In Nepal, personal drug use is criminalized and among people who inject drugs (PWID), the majority of whom are men, movement across the border with India for drug procurement and use is common. Using a risk environment approach, this study examined associations between border crossing and imprisonment with respect to HIV, HCV and injection risk behavior among men who inject drugs in Nepal. This cross-sectional study analyzed data from 1345 participants from 14 districts across Nepal. Explanatory variables were prior imprisonment and past-month border crossing to procure or use drugs. We used multivariable logistic regression to evaluate associations between these variables and HIV, HCV, HIV/HCV co-infection and past-month injection risk behavior among PWID. Over half of participants reported prior imprisonment (34.6% prior to past year, 21.6% within past year) and Indo-Nepal border crossing in the past year to use or buy drugs (31.2% sometimes, 20.8% often); over one quarter of participants (29.6%) reported both. Imprisonment prior to the past year was associated with higher odds of all outcome variables: HIV (adjusted odds ratio (aOR) 2.44, 95% confidence interval (CI) 1.29-4.59), HCV (aOR 1.51, 95% CI 1.08-2.09), HIV/HCV co-infection (aOR 3.12, 95% CI 1.58-6.14) and injection risk behavior (aOR 1.64, 95% CI 1.20-2.25). Past-year border crossing to procure or use drugs was associated with HCV (aOR 2.06, 95% CI 1.42-2.98) and injection risk behavior (aOR 1.47, 95% CI 1.04-2.10), with larger effect sizes among PWID who reported both border crossing as well as history of imprisonment. Imprisonment and border crossing were associated with injection risk behavior and disease outcomes. These findings indicate a need to implement cross-border disease surveillance and harm reduction initiatives in the Indo-Nepal border region and in Nepali prisons.

Alcohol use among people who inject drugs living with HIV in Kenya is associated with needle sharing, more new sex partners, and lower engagement in HIV care.

We assessed the prevalence and correlates of alcohol use among 870 people who inject drugs living with HIV in Kenya, with attention toward (1) sexual and injecting risk behaviors for HIV transmission and (2) HIV care engagement. We defined heavy alcohol use as > 14 drinks/week for men and > 7 drinks/week for women, moderate alcohol use as any lesser but non-zero amount, and any alcohol use as either moderate or heavy use. Approximately 39% of participants reported any alcohol use and 15% heavy use. In multivariate analysis, any alcohol use compared to no use was associated with needle sharing, > 3 new sex partners in the past 3 months, being unaware of HIV status, never enrolling in HIV care, and not being on ART (all p < 0.05). Heavy alcohol use as compared to no use was associated with needle sharing (aOR = 2.72; 95% CI 1.43,5.13), injection equipment sharing (aOR = 1.80; 95% CI 1.00,3.16), > 3 new sex partners in the past 3 months (aOR = 1.99; 95% CI 1.12,3.49), and being unaware of HIV status (aOR = 2.77; 95% CI 1.46,5.19). There was no association between any measure of alcohol use and unsuppressed viral load. Alcohol use among people who inject drugs living with HIV may carry elevated risk of HIV transmission mediated by sexual and injecting practices and is associated with lower engagement in multiple stages of the HIV care cascade.

COVID-19 vaccination and HIV transmission among persons who inject drugs during the first two years of the COVID-19 pandemic in New York City

BackgroundTo examine COVID-19 vaccination and HIV transmission among persons who inject drugs (PWID) during the COVID-19 pandemic (2020–2022) in New York City (NYC).MethodsTwo hundred and seventy five PWID were recruited from October 2021 to September 2022. A structured questionnaire was used to measure demographics, drug use behaviors, overdose experiences, substance use treatment history, COVID-19 infection, vaccination, and attitudes. Serum samples were collected for HIV, HCV, and SARS-CoV-2 (COVID-19) antibody testing.ResultsParticipants were: 71% male, the mean age was 49 (SD 11), 81% reported at least one COVID-19 immunization, 76% were fully vaccinated and 64% of the unvaccinated had antibodies for COVID-19. Self-reported injection risk behaviors were very low. HIV seroprevalence was 7%. Eighty-nine percent of the HIV seropositive respondents reported knowing they were HIV seropositive and being on antiretroviral therapy prior to the COVID-19 pandemic. There were two likely seroconversions in 518.83 person-years at risk from the March 2020 start of the pandemic to the times of interviews, for an estimated incidence rate of 0.39/100 person-years, 95% Poisson CI 0.05–1.39/100 person-years.ConclusionsThere is concern that the COVID-19 pandemic disruptions to HIV prevention services and the psychological stress of the pandemic may lead to increased risk behavior and increased HIV transmission. These data indicate adaptive/resilient behaviors in both obtaining COVID-19 vaccination and maintaining a low rate of HIV transmission among this sample of PWID during the first two years of the COVID-19 pandemic in NYC.

"The Drug Sellers Were Better Organized than the Government": A Qualitative Study of Participants' Views of Drug Markets during COVID-19 and Other Big Events.

"Big events", such as wars, economic crises, pandemics, or natural disasters, affect the risk environment in which people use drugs. While the impact of big events on injection risk behaviors and access to drug-treatment services is well documented, less is known about the effects of big events on drug markets. Based on self-reporting data on drug availability among people who use drugs (PWUD) in the aftermath of Hurricane Maria in Puerto Rico and during the COVID-19 lockdown in a Midwestern US state, this study aims to document the effects of big events on drug markets. Qualitative data on the effects of Hurricane Maria on drug markets are based on participants' self-reporting (N = 31). Data collection started after the hurricane and ended in 2020. Data on changes to the drug supply during the COVID-19 lockdown were collected based on semi-structured interviews with PWUD (N = 40) in a Midwestern US state. Findings show that while the drug markets might have initially been affected by big events, most effects were temporary. Drug availability, pricing, and quality might have suffered some initial fluctuations but stabilized as the drug markets absorbed the initial shocks caused by the hurricane and the lockdown measures. In preparation for increasingly more frequent and virulent pandemics and natural disasters, health infrastructures should be strengthened to prevent not only overdose episodes and deaths but also drug-related harms.

Sexual HIV transmission risk behaviors associated with stimulant drug injection among people who non-medically use gabapentin and opioids

ABSTRACT Background Recent research shows that co-use of stimulants and opioids appears to be increasing and injection of opioids and stimulants carries a risk for HIV transmission. This study examined stimulant injection and sexual HIV risk behaviors among individuals who reported nonmedical use of gabapentin and opioids (n = 62). Methods Comparisons of people who injected stimulants to those who did not were conducted using chi-square and t-tests. Results Compared to those who did not, people who injected stimulants, were less likely to be African American/Black (p < 0.05) and more likely to report sex with another person who injects drugs (p < 0.01), recent injections of prescription and/or illicit opioids (p < .000), and hepatitis C infection (p < 0.01). Condomless intercourse during group sex was more prevalent among stimulant injectors, significant at the trend level (p < 0.1). Conclusions Given the documented association between the use of opioids and nonmedical use of gabapentin and the growing trend of opioid-stimulant co-use, future research must examine whether nonmedical use of gabapentin is an indicator of substance use disorder severity and/or a risk factor for injection drug use. Education and intervention opportunities that address group sex and other sexual risk behaviors are warranted.

Substance use, injection risk behaviors, and fentanyl-related overdose risk among a sample of PWID post-Hurricane Maria

BackgroundWhile natural disasters like hurricanes are increasingly common, their long-term effects on people who inject drugs are not well understood. Although brief in duration, natural disasters can radically transform risk environments, increasing substance use and drug-related harms.MethodsBased on a study of people who inject drugs (PWID) and injection risk behaviors in rural Puerto Rico, the present study uses data from two different phases of the parent study. Data for 110 participants were collected from December 2015 to January 2017, soon before Hurricane Maria landed in September 2017; the 2019 phase, in the aftermath of the hurricane, included a total of 103 participants. The present study’s main analyses used data from 66 PWID who participated in both the pre-Maria and post-Maria interviews (66 individuals measured at two time points, for a total of 132 observations), using mixed-effects binomial logistic regression to examine recent overdose experiences pre- and post-Maria. A separate descriptive analysis included all 103 participants from the 2019 interview.ResultsAfter Hurricane Maria, some declines in injection frequency were observed (the percentage of people reporting injecting monthly or less increased from 3.0% before Hurricane Maria to 22.7% after Hurricane Maria). However, fewer PWID reported using a new needle for most or all injections. In the pre-Maria interview, 10.6% of participants indicated they had experienced an overdose during the year of the interview and/or the calendar year prior, and this figure increased to 24.2% in the post-Maria interview. In the regression analysis, the odds of reporting an overdose during the interview year and/or calendar year prior were three times as high post-Maria, relative to pre-Maria (odds ratio 3.25, 95% confidence interval 1.06–9.97).ConclusionSubstance use patterns, injection risk behaviors, and overdose episodes and deaths differed after Hurricane Maria, relative to before the hurricane, yet it is unclear to what extent these changes also reflect the simultaneous arrival of fentanyl. In preparation for future natural disasters, it is imperative to strengthen the health infrastructure by enhancing access and curbing barriers to syringe services programs and medications for opioid use disorder, particularly in rural or underserved locations.

Drug network identification predicts injecting risk behavior among people who inject drugs on hepatitis C virus treatment in Tayside, Scotland

The risk of Hepatitis C Virus (HCV) acquisition among People Who Inject Drugs (PWID) remains high when injecting risk behavior within networks endures. Several psychosocial factors influence such behavior. Following a drive within Tayside, a geographic region in Scotland, to achieve World Health Organization HCV elimination targets, addressing HCV re-infection risk as a barrier to elimination is critically important. This cross-sectional study seeks to address this barrier to elimination by investigating associations between group identification (one’s subjective sense of belonging and connectedness to a social group coupled with a sense of shared goals, beliefs and values with the other members of the group) and injecting risk behavior among PWID on HCV treatment at needle and syringe provision sites in Tayside. Participants completed psychosocial questionnaires between treatment weeks zero and three of treatment. Correlation analyses were undertaken, and significant factors included in multiple linear regression models for injecting risk behavior. Injecting frequency, drug network identification, and family identification, were correlated with injecting risk behavior, and drug network identification had a positive predictive on injecting risk behavior. Identification with a social group, conventionally associated with improved health, may pose health risks in specific contexts. Healthcare providers should consider stratifying individuals with higher group identification with PWID networks for enhanced harm reduction engagement to mitigate transmissible infection risk among PWID. Additionally, psychological interventions to strengthen group identification with networks which impact positively on health behavior should be explored.

Interventions to prevent HIV and Hepatitis C among people who inject drugs: Latest evidence of effectiveness from a systematic review (2011 to 2020).

Hepatitis C virus (HCV) and HIV remain prevalent among people who inject drugs (PWID) and transmission is usually associated with injecting risk behaviour (IRB). We update a 2011 review of reviews (RoR) to assess the latest evidence on the effectiveness of harm reduction interventions - drug treatment (including opioid agonist therapy [OAT]), needle and syringe programmes (NSP) and other interventions - in the prevention of HCV and HIV transmission, and related measures of infection risk (IRB and injecting frequency [IF]), among PWID. We undertook an initial search for systematic reviews (i.e. an Overview of Reviews [OoR]) and subsequent systematic searches for primary studies where required. Where there was sufficient evidence based on synthesis of multiple robust studies for an intervention effect in the 2011 RoR, new evidence was not sought. Medline, CINAHL, The Cochrane Library, EMBASE, PsycINFO and Web of Science were searched (2011-2020). Two reviewers screened papers, extracted data, and graded reviews/studies. We classified evidence as 'sufficient', 'tentative', 'insufficient', or 'no evidence'. We screened 8513 reviews and 7133 studies, with 27 and 61 identified as relevant, respectively. The level of evidence increased since the 2011 RoR and is now 'sufficient' for OAT (regarding all outcomes), NSP (for reducing HIV transmission and IRB), and combination OAT/NSP (for reducing HCV transmission). There is also now sufficient evidence for in-prison OAT, psychosocial interventions, pharmacy-based NSP and provision of sterile drug preparation equipment for reducing IRB. There is now a strong body of empirical evidence for the effectiveness of OAT and NSP, alone and in combination, in reducing IRB, and HCV and HIV transmission. However, there is still a relative lack of evidence for other interventions, including heroin-assisted treatment, pharmacological treatment for stimulant dependence, contingency management, technology-based interventions, low dead space syringes and drug consumption rooms on HCV or HIV risk.