Syringe Programs Research Articles

Improving implementation of needle and syringe programmes to expand, scale up, and sustain evidence-based prevention interventions for HIV and hepatitis C in prisons.

The 1990 resolution by the UN General Assembly committed member states to provide health-care equity for people in prison, who are included in the global goals to control HIV and eliminate hepatitis C virus (HCV) by 2030. WHO has set ambitious HCV elimination targets by including people who inject drugs (PWID), yet has not prioritised PWID who are incarcerated, a substantial population who have or are at risk for HCV infection. Human rights principles of health-care equity stipulate that "prisoners should enjoy the same standards of health care that are available in the community, without discrimination on the grounds of their legal status". Globally, only nine countries provide prison-based needle and syringe programmes (PNSPs), essential evidence-based interventions to holistically reduce the harms from drug use, of which only three countries extend reach to all prisons. Even where available, these services are accessed by few participants. PNSPs are recommended as an essential element of an effective HIV and HCV prevention strategy in prisons, and studies have shown that they are key to achieving HCV elimination in carceral settings. This Viewpoint, based primarily on unpublished data from key country-level stakeholders and expert opinion, highlights our perspective that implementation factors related to PNSP delivery in diverse settings likely contribute to low adoption and use of these services by PWID in prisons compared with in the community. However, successful expansion of these evidence-based interventions will depend on political commitment, national surveillance and monitoring programmes, and state-of-the-art implementation science methods, where inputs from multilevel stakeholders should guide improved implementation. Policy makers are urged to create and support opportunities to scale up PNSPs within countries where they exist and expand them to other countries where they are needed to solidify years of commitment towards the 2030 HCV elimination goals.

A Pilot Randomised Controlled Trial Involving Financial Incentives to Facilitate Hepatitis C Treatment Uptake Among People Who Inject Drugs: ETHOS Engage Study.

The primary aim of this study was to establish the feasibility of implementing a larger RCT designed to evaluate the effect of financial incentives on HCV treatment initiation among persons receiving opioid agonist therapy and/or who have injected drugs in the prior six months. ETHOS Engage is an observational cohort of participants recruited from drug treatment and needle and syringe programs in Australia. Among 11 drug and alcohol clinics, participants who were HCV RNA-positive were randomized (1:1) to receive standard of care or a AUD $60 gift card at treatment initiation. Regarding feasibility, 100% (57/57) of eligible participants enrolled to take part. Twenty-eight participants were randomised to the financial incentive arm (AUD $60 gift card) plus standard of care and 29 participants to the standard of care arm. In this pilot RCT (n = 57), median age was 42 years (IQR 37-49), 63% were male (n = 36), 35% Indigenous (n = 20) and 36% (n = 21) reported injecting drugs daily in the past month. Twelve weeks post-study enrolment, 11 (39%) participants in the financial incentive arm and 17 (59%) participants in the standard of care arm initiated HCV treatment. Findings indicate high feasibility among people who inject drugs to be randomised to receive financial incentives to initiate HCV treatment.

Depressive symptoms and determinants among people who inject drugs in Kaduna State, Nigeria

Background: People who inject drugs (PWID) are known to have higher rates of mental health disorders, particularly depression. Despite this, there is a lack of research on the prevalence of depression among PWID in Nigeria.Aim: This study aimed to determine the prevalence of depressive symptoms and their determinants among PWID.Setting: The study was conducted in Kaduna State, Northwest Nigeria where a needle and syringe programme (NSP) for PWID was recently initiated.Methods: A cross-sectional survey was conducted among PWID using a multi-stage sampling technique. Data were collected using structured interviews and digitalised questionnaires covering socio-demographics, depression symptoms (PHQ-9) and perceived social support (MSPSS).Results: A total of 525 participants were included in the study, with the majority being males (73.3%) aged 24–35 years (54.5%). The study revealed a high prevalence of depressive symptoms among PWID, with 47.4% reporting major symptoms. Predictors of depression identified among PWID included older age, female gender, divorce, unemployment, having primary education and moderate social support.Conclusion: The study underscored a concerning prevalence of depressive symptoms among PWID, notably linked to diverse sociodemographic factors, emphasising the need for holistic, context-specific mental healthcare approaches for this population.Contribution: This study contributes to the limited research on the mental health of PWID in Nigeria. It highlights the need for targeted mental health interventions that consider the unique sociodemographic characteristics of this population.

Achieving HIV epidemic control through accelerating efforts to expand access to pre-exposure prophylaxis for people who inject drugs.

The world is not on track to reach the majority of the UNAIDS 2025 targets, and people who inject drugs (PWID) continue to be left behind, hindered by counterproductive law enforcement practices, punitive laws, economic distress, and social stigma and discrimination. Poor access to HIV pre-exposure prophylaxis (PrEP) among PWID is nested within the limited access to broader harm reduction services, including needle and syringe programs, opioid overdose management, opioid agonist therapy (also known as medication-assisted treatment), and condoms. Among PWID, women who inject drugs are disproportionately affected and face additional gender-based barriers. Intersections between PWID and other key and priority population groups also exist. Although the prioritization of PWID for new PrEP products like the dapivirine vaginal ring and injectable cabotegravir has lagged in research, studies have shown that PWID find injectable and long-acting options acceptable and preferrable, including among women who inject drugs. While new PrEP products introduce new opportunities, equity in access must be assured for optimized impact toward achieving epidemic control. Programming for services must engage and empower PWID community leadership to address the structural barriers to services, implement community-led, differentiated, and integrated service modalities, and offer the choice of all harm reduction options to close the equity gaps in health outcomes. While waiting for necessary evidence and approvals, programs should work together with the PWID community to prioritize, expand, and facilitate efforts and investments toward increased access to and integration of PrEP and all recommended harm reduction services for PWID.

Experience and challenges delivering hepatitis C virus treatment for people who inject drugs in Kenya.

Despite having a higher risk of hepatitis C virus (HCV) infections, people who inject drugs (PWID) in sub-Saharan Africa (SSA) have limited access to HCV treatment. There is scarce literature on treatment delivery modalities that overcome logistical and financial barriers. We utilized different service delivery modalities to provide direct-acting antivirals (DAAs) to PWIDs infected with HCV through methadone clinics and needle and syringe program (NSP) sites in Kenya. In collaboration with Kenya's National AIDS and STI Control Programme (NASCOP), we enrolled individuals with active HCV infection confirmed by HCV RNA detection from methadone and NSP sites in Nairobi, Mombasa, and Kilifi counties. Liver function and hepatitis B virus (HBV) status were assessed at baseline. Those eligible for treatment were offered ledipasvir-sofosbuvir treatment provided by NASCOP through directly observed therapy (DOT). Participants completed a follow-up visit 12 weeks after completing treatment to measure sustained viral response (SVR-12). Challenges faced while delivering HCV treatment at participating sites included the limited availability and reliability of laboratory assays, and financial constraints faced by PWIDs to attend daily DOT. Based on our experience, strategies to deliver HCV treatment for PWID in Kenya should consider improving the availability of laboratory tests and prioritizing treatment through methadone centers to achieve good outcomes.

Widespread hepatitis C virus transmission network among people who inject drugs in Kenya

ObjectivesHepatitis C virus (HCV) disproportionately affects people who inject drugs (PWID) worldwide. Despite carrying a high HCV burden, little is known about transmission dynamics in low- and middle-income countries. MethodsWe recruited PWID from Nairobi and coastal cities and towns of Mombasa, Kilifi, and Malindi in Kenya at needle and syringe programs. Next-generation sequencing data from HCV hypervariable region 1 were analyzed using Global Hepatitis Outbreak and Surveillance Technology to identify transmission clusters. ResultsHCV strains belonged to genotype 1a (n = 64, 46.0%), 4a (n = 72, 51.8%) and mixed HCV/1a/4a (n = 3, 2.2%). HCV/1a was dominant (61.2%) in Nairobi, whereas HCV/4a was dominant in Malindi (85.7%) and Kilifi (60.9%), and both genotypes were evenly identified in Mombasa (45.3% for HCV/1a and 50.9% for HCV/4a). Global Hepatitis Outbreak and Surveillance Technology identified 11 transmission clusters involving 90 cases. Strains in the two largest clusters (n = 38 predominantly HCV/4a and n = 32 HCV/1a) were sampled from all four sites. ConclusionsTransmission clusters involving 64.7% of cases indicate an effective sampling of major HCV strains circulating among PWID. Large clusters involving 77.8% of clustered strains from Nairobi and Coast suggest successful introduction of two ancestral HCV/1a and HCV/4a strains to PWID and the existence of a widespread transmission network in the country. The disruption of this network is essential for HCV elimination.

Utilising integrated bio-behavioural surveillance (IBBS) to investigate declining hepatitis C antibody prevalence among people who inject drugs in the Australian Needle and Syringe Program Survey

BackgroundPrevalence of hepatitis C virus (HCV) antibody (Ab) on dried blood spot (DBS) samples in the Australian Needle and Syringe Program Survey (ANSPS) decreased nationally from 57 % in 2015 to 32 % in 2022. We aimed to investigate potential explanations for this decline. MethodsChanges in DBS HCV Ab prevalence were investigated by redefining positive cases as those with those with either a positive HCV Ab test result or a self-reported history of ever having HCV treatment (modified prevalence), examining HCV Ab prevalence by birth and age cohorts, and assessing trends in key risk behaviours. ResultsOverall prevalence of DBS HCV Ab declined rapidly and significantly from 57 % in 2015 to 32 % in 2022 (p < 0.001) however modified HCV Ab prevalence remained stable over time (85 % and 88 % in 2015 and 2022, respectively, p = 0.357). The proportion of participants with negative HCV Ab and self-reported HCV infection increased from 20 % in 1995 to 40 % in 2022 (p < 0.001) and the proportion with negative HCV Ab and lifetime HCV treatment increased from 3 % in 1999 to 67 % in 2022 (p < 0.001). We also observed a decreasing trend in DBS HCV Ab prevalence in all birth and age cohorts with a noticeable acceleration in the decline commensurate with the advent of HCV DAA treatment. A long-term decreasing trend was also observed for key risk behaviours (p < 0.001) however the short-term trend was not significant for recent receptive syringe sharing. ConclusionThe temporal decline in HCV Ab prevalence appears related to reduced sensitivity of DBS HCV Ab detection with viral clearance following treatment. Since 2016, HCV treatment uptake has increased markedly including among people who inject drugs. In this context, continuing to monitor HCV Ab prevalence by DBS testing is problematic, with a shift to surveillance of active infection the most relevant to guide policy and practice in this setting.

20 years on from the Dublin Declaration: European Committee for the Prevention of Torture and Inhuman or Degrading Treatment reporting on the provision of prison needle and syringe programmes in the Council of Europe region

BackgroundPrisons in Europe remain high-risk environments and conducive for infectious disease transmission, often related to injection drug use. Many infected people living in prison unaware of their infection status (HIV, hepatitis C). Despite all Council of Europe (CoE) member states providing community needle and syringe programmes (NSP), prison NSP are limited to seven countries. The study aim was to scrutinise the Committee for the Prevention of Torture and Inhuman or Degrading Treatment (CPT) reporting of periodic and ad hoc country mission visits to prisons, with an explicit focus on the extent to which member states are/were fulfilling obligations to protect prisoners from HIV/hepatitis C; and implementing prison NSP under the non-discriminatory equivalence of care principle. Study designSocio-legal review. MethodsA systematic search of the CPT database was conducted in 2024 with no date restriction. All CPT reports were screened in chronological order with the terms; “needle”, “syringe”, “harm reduction” and “NSP”. Relevant narrative content on prison NSP operations, including repeat CPT reminders and any official/publicly expressed reasons for not implementing is presented. ResultsCPT reporting reveals limited prison NSP provision in selected prisons visited on mission, with little change in status over time, despite documented evidence of prior observations around absent/insufficient harm reduction measures and explicit (often longstanding) recommendations to address deficits. Reasons for not implementing prison NSP include; existing availability of opioid substitute treatment, lack of evidence for injecting drug use, for security and maintenance of order, and contradiction with prison protocols sanctioning drug use. ConclusionsPrison health is public health. Regular research and evaluations of prison NSP in Europe are warranted. Future CPT visits should also continue to assess availability and standards of provision; recommend where appropriate including when opioid substitute treatment is already provided, and in line with broad availability of community NSP in Europe.

Publisher's Note

BackgroundPrevalence of hepatitis C virus (HCV) antibody (Ab) on dried blood spot (DBS) samples in the Australian Needle and Syringe Program Survey (ANSPS) decreased nationally from 57% in 2015 to 32% in 2022. We aimed to investigate potential explanations for this decline. MethodsChanges in DBS HCV Ab prevalence were investigated by redefining positive cases as those with those with either a positive HCV Ab test result or a self-reported history of ever having HCV treatment (modified prevalence), examining HCV Ab prevalence by birth and age cohorts, and assessing trends in key risk behaviours. ResultsOverall prevalence of DBS HCV Ab declined rapidly and significantly from 57% in 2015 to 32% in 2022 (p<0.001) however modified HCV Ab prevalence remained stable over time (85% and 88% in 2015 and 2022, respectively, p=0.357). The proportion of participants with negative HCV Ab and self-reported HCV infection increased from 20% in 1995 to 40% in 2022 (p<0.001) and the proportion with negative HCV Ab and lifetime HCV treatment increased from 3% in 1999 to 67% in 2022 (p<0.001). We also observed a decreasing trend in DBS HCV Ab prevalence in all birth and age cohorts with a noticeable acceleration in the decline commensurate with the advent of HCV DAA treatment. A long-term decreasing trend was also observed for key risk behaviours (p<0.001) however the short-term trend was not significant for recent receptive syringe sharing. ConclusionThe temporal decline in HCV Ab prevalence appears related to reduced sensitivity of DBS HCV Ab detection with viral clearance following treatment. Since 2016, HCV treatment uptake has increased markedly including among people who inject drugs. In this context, continuing to monitor HCV Ab prevalence by DBS testing is problematic, with a shift to surveillance of active infection the most relevant to guide policy and practice in this setting.

Polysubstance Use and Related Risk Behaviors among People Who Inject Drugs in Kenya Preparing for Hepatitis C Virus Treatment.

Polysubstance use (PSU), injection drug use (IDU), and equipment sharing are associated with bloodborne infection (BBI) transmission risk, particularly Hepatitis C Virus (HCV), yet data on PSU in low- and middle-income countries (LMICs) is limited. We report on baseline PSU, medication-assisted treatment (MAT) engagement, and motivation to reduce IDU among 95 people who inject drugs (PWID) who accessed needle and syringe programs (NSP) in Nairobi and Coastal Kenya prior to HCV treatment. Bivariate and multivariate logistic regression were used to examine the associations between PSU and behaviors that confer HCV transmission and acquisition risks. Most participants (70.5%) reported PSU in the last 30 days, and one-third (35.8%) reported PSU exclusive to just heroin and cannabis use. Common combinations were heroin and cannabis (49.3%), and heroin, cannabis, and bugizi (flunitrazepam) (29.9%). Participants at baseline were receiving MAT (69.5%), already stopped or reduced IDU (30.5%), and were HIV-positive (40%). PSU was significantly associated with IDU (p = 0.008) and the number of times (p = 0.016) and days (p = 0.007) injected in the last 30 days. Participants reported high PSU and equipment sharing, despite high MAT engagement. While co-locating BBI treatment within existing harm reduction services is necessary to promote uptake and curb re-infection, tailored services may be needed to address PSU, particularly in LMICs.

Correlates of stocking naloxone: a cross-sectional survey of community pharmacists

BackgroundProvision of take-home naloxone (THN) and overdose education reduces opioid-related mortality. In Australia, from July 2022, all Australian community pharmacies were eligible to supply naloxone for free through the national THN Program.AimThis study aimed to identify naloxone stocking rates and correlates of stocking naloxone across Australian pharmacies.MethodData were collected from a representative sample of Australian pharmacists in Victoria, New South Wales, Queensland and Western Australia via an online survey. Data collected included pharmacy and pharmacist characteristics and services offered within the pharmacy, including needle and syringe programs, opioid agonist treatment (OAT) and stocking naloxone. Binary probit regression analysis was used to identify correlates of stocking naloxone after controlling for key covariates.ResultsData from 530 pharmacists were analysed. In total, 321 pharmacies (60.6%) reported stocking naloxone. Chain pharmacies and pharmacies that provided OAT had a greater probability of stocking naloxone (B = 0.307, 95%CI: [0.057, 0.556], and B = 0.543, 95%CI: [0.308, 0.777] respectively). Most (61.7%) pharmacists felt comfortable discussing overdose prevention with patients who use prescription opioids, and this comfort was associated with a higher probability of stocking naloxone (B = 0.392, 95%CI: 0.128, 0.655). Comfort discussing overdose prevention with people who use illicit opioids was lower (49.4%) and was not associated with stocking naloxone.ConclusionThere is scope to increase stocking of naloxone and comfort with overdose prevention, particularly through addressing comfort working with higher risk groups such as people who use illicit opioids.

Analysis and mapping of harm reduction research in the context of injectable drug use: identifying research hotspots, gaps and future directions

BackgroundHarm reduction is a crucial approach in addressing the multifaceted challenges of injectable drug use. This paper presents an analysis and mapping of the existing literature on harm reduction research in the context of injectable drug use. By reviewing a comprehensive set of scholarly articles, this study identifies research hotspots, knowledge gaps, and future directions in the field. The findings provide valuable insights for researchers, policymakers, and practitioners to guide future research efforts and inform evidence-based harm reduction interventions.MethodsData for the study was obtained from the Scopus database, using keywords and phrases related to harm reduction and injectable drug use. Validation methods were employed to verify the accuracy and comprehensiveness of the search strategy. Data analysis involved identifying growth patterns, key contributors, mapping frequent terms, identifying research hotspots, and identifying emerging research directions.ResultsA total of 971 articles were found, with a notable increase from 2015 to 2022. The International Journal of Drug Policy (n = 172, 17.7%) and the Harm Reduction Journal (n = 104, 10.7%) were the most prolific journals, and the United States (n = 558, 57.5%) had the highest number of publications. The Johns Hopkins University (n = 80, 8.5%) was the most prolific institution. Mapping of frequent author keywords revealed the main keywords, including harm reduction, HIV, hepatitis C, and opioid overdose. The highly cited articles cover a broad time span and focus on topics like naloxone distribution, HIV and hepatitis C transmission, while recent articles concentrate on emerging issues such as the impact of the COVID-19 pandemic, fentanyl-related concerns, stigma reduction, and needle and syringe programs. Both sets of articles share a common focus on harm reduction strategies, but recent publications highlight current challenges and developments in the field.ConclusionsThis study provides insights into research landscape on harm reduction in injectable drug use. Research is concentrated in high-income countries, emphasizing the need for more research in low- and middle-income countries. Recent publications focus on emerging challenges like COVID-19 and fentanyl. Research gaps highlight the need for studies in diverse populations, social determinants, program evaluation, and implementation strategies to enhance harm reduction interventions.

Advancing Programme Science approaches to understand gaps in HIV prevention programme coverage for key populations in 12 Nigerian states: findings from the 2020 Integrated Biological and Behavioural Surveillance Survey.

Effective HIV prevention programme coverage is necessary to achieve Nigeria's goal of ending the epidemic by 2030. Recent evidence highlights gaps in service coverage and utilization across the country. The Effective Programme Coverage framework is a Programme Science tool to optimize a programme's population-level impact by examining gaps in programme coverage using data generated through programme-embedded research and learning. We apply the framework using Integrated Biological and Behavioural Surveillance Survey (IBBSS) data from Nigeria to examine coverage of four prevention interventions-condoms, HIV testing, and needle and syringe programmes (NSP)-among four key population groups-female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID) and transgender people. Data from Nigeria's 2020 IBBSS, implemented in 12 states, were analysed to examine HIV prevention programme coverage among key populations. For each key population group and prevention intervention of interest, weighted IBBSS data were used to retrospectively generate coverage cascades that identify and quantify coverage gaps. Required coverage targets were informed by targets articulated in Nigeria's National HIV/AIDS Strategic Framework or, in their absence, by guidelines from policy normative bodies. Availability-, outreach- and utilization coverage proxy indicators were defined using variables from IBBSS data collection tools. Sankey diagrams are presented to visualize pathways followed by participants between coverage cascade steps. Required coverage targets were missed for HIV testing and NSP among all key population groups. Condom availability coverage surpassed required coverage targets among FSW and MSM, while utilization coverage only among FSW exceeded the 90% required coverage target. Outreach coverage was low for all key population groups, falling below all required coverage targets. Our findings identify critical gaps in HIV prevention programme coverage for key populations in Nigeria and demonstrate non-linear movement across coverage cascades, signalling the need for innovative solutions to optimize coverage of prevention services. Programme-embedded research is required to better understand how key population groups in Nigeria access and use different HIV prevention services so that programmes, policies and resource allocation decisions can be optimized to achieve effective programme coverage and population-level impact.

Economic evaluation of the effect of needle and syringe programs on skin, soft tissue, and vascular infections in people who inject drugs: a microsimulation modelling approach

BackgroundNeedle and syringe programs (NSP) are effective harm-reduction strategies against HIV and hepatitis C. Although skin, soft tissue, and vascular infections (SSTVI) are the most common morbidities in people who inject drugs (PWID), the extent to which NSP are clinically and cost-effective in relation to SSTVI in PWID remains unclear. The objective of this study was to model the clinical- and cost-effectiveness of NSP with respect to treatment of SSTVI in PWID.MethodsWe performed a model-based, economic evaluation comparing a scenario with NSP to a scenario without NSP. We developed a microsimulation model to generate two cohorts of 100,000 individuals corresponding to each NSP scenario and estimated quality-adjusted life-years (QALY) and cost (in 2022 Canadian dollars) over a 5-year time horizon (1.5% per annum for costs and outcomes). To assess the clinical effectiveness of NSP, we conducted survival analysis that accounted for the recurrent use of health care services for treating SSTVI and SSTVI mortality in the presence of competing risks.ResultsThe incremental cost-effectiveness ratio associated with NSP was $70,278 per QALY, with incremental cost and QALY gains corresponding to $1207 and 0.017 QALY, respectively. Under the scenario with NSP, there were 788 fewer SSTVI deaths per 100,000 PWID, corresponding to 24% lower relative hazard of mortality from SSTVI (hazard ratio [HR] = 0.76; 95% confidence interval [CI] = 0.72–0.80). Health service utilization over the 5-year period remained lower under the scenario with NSP (outpatient: 66,511 vs. 86,879; emergency department: 9920 vs. 12,922; inpatient: 4282 vs. 5596). Relatedly, having NSP was associated with a modest reduction in the relative hazard of recurrent outpatient visits (HR = 0.96; 95% CI = 0.95–0.97) for purulent SSTVI as well as outpatient (HR = 0.88; 95% CI = 0.87–0.88) and emergency department visits (HR = 0.98; 95% CI = 0.97–0.99) for non-purulent SSTVI.ConclusionsBoth the individuals and the healthcare system benefit from NSP through lower risk of SSTVI mortality and prevention of recurrent outpatient and emergency department visits to treat SSTVI. The microsimulation framework provides insights into clinical and economic implications of NSP, which can serve as valuable evidence that can aid decision-making in expansion of NSP services.

Using an intersectionality lens to explore barriers and enablers to hepatitis C point-of-care testing: a qualitative study among people who inject drugs and service providers

BackgroundHepatitis C virus (HCV) infection is a significant global health burden, particularly among people who inject drugs. Rapid point-of-care HCV testing has emerged as a promising approach to improve HCV detection and linkage to care in harm reduction organizations such as needle and syringe programs. The objective of this study was to use an intersectionality lens to explore the barriers and enablers to point-of-care HCV testing in a needle and syringe program.MethodsA qualitative study was conducted using semi-structured interviews with clients (people who inject drugs) and service providers in a large community organization focused on the prevention of sexually transmitted and blood borne infections and harm reduction in Montreal, Canada. An intersectionality lens was used alongside the Theoretical Domains Framework to guide the formulation of research questions as well as data collection, analysis, and interpretation.ResultsWe interviewed 27 participants (15 clients, 12 providers). For clients, four themes emerged: (1) understanding and perceptions of HCV testing, (2) the role of an accessible and inclusive environment, (3) the interplay of emotions and motivations in decision-making, and (4) the impact of intersectional stigma related to HCV, behaviors, and identities. For providers, five themes emerged: (1) knowledge, skills, and confidence for HCV testing, (2) professional roles and their intersection with identity and lived experience, (3) resources and integration of services, (4) social and emotional factors, and (5) behavioral regulation and incentives for HCV testing. Intersectional stigma amplified access, emotional and informational barriers to HCV care for clients. In contrast, identity and lived experience acted as powerful enablers for providers in the provision of HCV care.ConclusionThe application of an intersectionality lens provides a nuanced understanding of multilevel barriers and enablers to point-of-care HCV testing. Findings underscore the need for tailored strategies that address stigma, improve provider roles and communication, and foster an inclusive environment for equitable HCV care. Using an intersectionality lens in implementation research can offer valuable insights, guiding the design of equity-focused implementation strategies.

Longitudinal trends in service utilisation of Alcohol and Other Drugs Services (AODS) during COVID-19: A Scoping Review

Background: COVID-19 has affected service delivery and utilization of AODS worldwide with a potential negative impact on service users and staff. Objectives: To understand the trends of service utilization of AODS, identify knowledge gaps, and provide directions for future research and planning. Methods: Medline, Embase, CINAHL, PubMed and PsycINFO were searched for original articles published in English since 2019, with quantitative analysis of service utilization of AODS. Of the 1546 initial search results, 938 were screened after de-duplication and 43 underwent full-text review. Data extracted from 30 studies informed this review. Results: Of the studies, 29 were from high-income countries and 15 focused on medication for opioid use disorders (MOUD). An initial reduction of service utilization followed by gradual improvement was seen in most treatment types, with most disruptions in residential programs, outreach services, home visits, group therapy and needle syringe programs and fewer disruptions in individual counselling and MOUD. Treatment initiations decreased, while treatment adherence improved during COVID-19. The use of telehealth and treatment-related policy changes were associated with improved service utilization. Telehealth was associated with catchment expansion and broadening of service-user profiles. An increased tendency to use the opioid long-acting injection was reported in Australia. Conclusions: The impact of COVID-19 on AODS changed over time and according to, the drug/treatment type and geographical remoteness. Main contributors to minimizing disruptions in service utilization included treatment-related policy changes, telehealth, and newer treatment modalities. Longitudinal studies beyond 2021 and studies on regional/rural AODS and AOD workforce are recommended.

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.

Needle and syringe sharing among people who have recently injected drugs in Australia: The ETHOS Engage Study.

Understanding needle/syringe sharing is crucial for reducing hepatitis C virus (HCV) infection and reinfection. This study aimed to assess the prevalence and factors associated with needle/syringe sharing among people who inject drugs in Australia, including those previously receiving HCV treatment. The ETHOS Engage study was an observational cohort study which collected self-reported survey data on demographic and drug use information from people who inject drugs attending drug treatment clinics and needle and syringe programs over two waves between May 2018 and June 2021. Logistic regression was used to identify factors associated with needle/syringe sharing. Overall, 1555/2395 people enrolled in ETHOS Engage (65%) injected drugs in the past month. Among these, 432 (28%) reported needle/syringe sharing in the past month and 276 (18%) reported receptive sharing. Factors associated with receptive sharing included younger age (adjusted odds ratio [aOR] 1.72; 95% confidence interval [CI] 1.28-2.30), recent incarceration (aOR 2.04; 95% CI 1.40-2.94), more frequent injecting (≥daily vs. less than weekly; aOR 2.59; 95% CI 1.75-3.84) and unstable housing (aOR 1.78; 95% CI 1.26-2.52). Among 560 participants with prior HCV treatment, 87 (16%) reported receptive sharing with younger age (aOR 2.42; 95% CI 1.45-4.05) and daily or greater injection frequency (aOR 2.51; 95% CI 1.31-4.83) associated with receptive sharing. Needle/syringe sharing was common among this population accessing harm reduction services. This study identifies high-risk populations with needle/syringe sharing. Research is needed to optimise HCV treatment to ensure people with ongoing risk behaviours receive adequate harm reduction following treatment to prevent reinfection.

Factors associated with hepatitis C testing, treatment, and current hepatitis C infection among men and women who inject drugs: The ETHOS engage study

BackgroundEvaluating gender-specific trends in hepatitis C virus (HCV) treatment uptake among men and women who inject drugs is crucial for ensuring equitable progress towards HCV elimination. This study aimed to quantify differences in testing, treatment, and current HCV infection between men and women who inject drugs. MethodETHOS Engage is an observational cohort study of people who inject drugs attending drug treatment clinics and needle and syringe programs in Australia recruited from May 2018-September 2019 (wave 1) and November 2019-April 2021 (wave 2). Participants completed a questionnaire including self-reported HCV testing and treatment history and underwent point-of-care HCV RNA testing (Xpert® HCV Viral Load Fingerstick). Logistic regression was used to compare the factors associated with self-reported HCV testing and treatment and current HCV infection for men and women who inject drugs. ResultsAmong 2,395 participants enrolled in ETHOS Engage, 66% (n = 1,591) were men, 33% (n = 786) women, and <1% (n = 18) did not identify as a man or woman. HCV testing history and current infection were similar among men and women. Among men or women ever eligible for HCV treatment (ever chronic HCV) (n = 1,242), women were less likely to report a history of HCV treatment compared to men (227/352, 64% vs. 631/890, 71%; p = 0.03). Among women, those aged <45 were less likely to report HCV testing (aOR: 0.57, 95%CI: 0.36, 0.90), treatment (aOR: 0.47, 95%CI: 0.29, 0.77), and more likely to have HCV infection (aOR: 1.48, 95%CI: 1.00, 2.20) ConclusionAmong women, those of childbearing age (<45) were less likely to report testing and treatment and were more likely to have current HCV infection. Women <45 years old should be a priority population for HCV care. Services that interface with these women should be optimised to enhance HCV testing and treatment.

Sex and gender differences in hepatitis C virus risk, prevention, and cascade of care in people who inject drugs: systematic review and meta-analysis

People who inject drugs (PWID) are a priority population in HCV elimination programming. Overcoming sex and gender disparities in HCV risk, prevention, and the cascade of care is likely to be important to achieving this goal, but these have not yet been comprehensively reviewed. Systematic review and meta-analysis. We searched Pubmed, EMBASE and the Cochrane Database of Systematic Reviews 1 January 2012-22 January 2024 for studies of any design reporting sex or gender differences among PWID in at least one of: sharing of needles and/or syringes, incarceration history, injection while incarcerated, participation in opioid agonist treatment or needle and syringe programs, HCV testing, spontaneous HCV clearance, direct-acting antiviral (DAA) treatment initiation or completion, and sustained virological response (SVR). Assessment of study quality was based on selected aspects of study design. Additional data were requested from study authors. Data were extracted in duplicate and meta-analysed using random effects models. PROSPERO registration CRD42022342806. 9533 studies were identified and 92 studies were included. Compared to men, women were at greater risk for receptive needle and syringe sharing (past 6-12 months: risk ratio (RR) 1.12; 95% confidence interval (CI) 1.01-1.23; <6 months: RR 1.38; 95% CI 1.09-1.76), less likely to be incarcerated (lifetime RR 0.64; 95% CI 0.57-0.73) more likely to be tested for HCV infection (lifetime RR 1.07; 95% CI 1.01, 1.14), more likely to spontaneously clear infection (RR1.58; 95% CI 1.40-1.79), less likely to initiate DAA treatment (0.84; 95% CI 0.78-0.90), and more likely to attain SVR after completing DAA treatment (RR 1.02; 95% CI 1.01-1.04). There are important differences in HCV risk and cascade of care indicators among people who inject drugs that may impact the effectiveness of prevention and treatment programming. Developing and assessing the effectiveness of gender-specific and gender-responsive HCV interventions should be a priority in elimination programming. Réseau SIDA-MI du Québec.