Search

Background: Studies investigating mortality risk associated with use of opioid analgesics, benzodiazepines, gabapentinoids, and opioid agonist treatment (OAT) among people with opioid dependence (PWOD) are lacking. This study addresses this gap using a cohort of 37,994 PWOD initiating opioid analgesics between July 2003 and July 2018 in New South Wales, Australia., Methods: Linked administrative records provided data on dispensings, sociodemographics, clinical characteristics, OAT, and mortality. Cox proportional hazards models assessed associations between time-varying measures of individual and concurrent medicine use and OAT with all-cause mortality, accidental opioid overdose, non-drug induced accidents, and non-drug-induced suicide. Opioid analgesic dose effects, expressed as oral morphine equivalents (OMEs) per day, were also examined., Outcomes: During the study period, 3167 individuals died. Compared with no use, all medicines of interest were associated with increased accidental opioid overdose risk; hazard ratios (HR) ranged from 1.33 (95 % CI: 1.05-1.68) for opioid analgesic use to 6.10 (95 % CI: 4.11-9.06) for opioid analgesic, benzodiazepine and gabapentinoid use. Benzodiazepine use was associated with increased non-drug-induced accidents and non-drug-induced suicides. For all-cause mortality, all combinations of benzodiazepines and gabapentinoids with opioid analgesics were associated with increased risk (aHRs ranged from 1.35 to 2.73). For most medicines/medicine combinations, all-cause mortality risk was reduced when in OAT compared to out of OAT. Higher opioid analgesic doses were associated with increased all-cause mortality (e.g., 90-199 mg vs 1-49 mg OME per day: HR 1.90 [95 % CI: 1.52-2.40])., Interpretation: The increased mortality risk associated with benzodiazepines and gabapentinoids among PWOD appear to be reduced when engaged in OAT. A greater focus on encouraging OAT engagement, providing overdose prevention education, and access and coverage of overdose antidotes is necessary to minimise the unintended consequences of medicines use in this population., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: S.L. has received untied education funding from Indivior. L.D. has received untied educational funding from Reckitt Benckiser, Indivior, Mundipharma Pty Ltd, and Seqirus. These untied grants are all unrelated to the current study. All other authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Barriers to HCV treatment initiation persisted after the introduction of direct-acting antivirals (DAAs) in Canada among people who inject drugs (PWID); whether DAA universal coverage lifted these barriers remain unknown. We assessed the evolution of HCV treatment initiation and associated factors among PWID in Montreal, Canada, comparing eras of IFN-based regimens (2011-2013), of DAA restricted access (2014-02/2018), and universal coverage (03/2018-03/2020)., Methods: We included chronically HCV-infected participants followed in a community-based PWID cohort in Montreal, Canada between 2011 and 03/2020 and collected data at 3-month intervals. Time-updated Cox regressions were conducted to examine 9 variables of interest associated with treatment initiation overall and for each of the three eras., Results: Of 276 participants, 126 initiated treatment during follow-up. Yearly initiation increased from 3% in 2011 to 19% in 2016, and 54% in 2018. PWID aged >40 (vs. ≤40) were twice as likely to initiate treatment in 2014-02/2018 (HR: 2.02 95%CI: [1.24-3.28]) but not in other periods (2011-2013: 0.55 [0.25-1.22]; 03/2018-03/2020: 1.14 [0.59-2.22])). Odds of initiation were lower for men than women in all periods, with women three times more likely to be treated under universal coverage (0.30 [0.11-0.77] vs 2011-2013: 0.67 [0.25-1.78] and 2014-02/2018: 0.75 [0.42-1.35]). Recent incarceration was negatively associated with initiation throughout all periods (2011-2013: 0.57 [0.13-2.43]; 2014-03/2018: 0.39 [0.17-0.91]; 03/2018-03/2020: 0.25 [0.07-0.83]). Barriers associated with high injection frequency appear to have diminished since DAA introduction (2014-02/2018: 0.71 [0.42-1.20]; 03/2018-03/2020: 1.05 [0.52-2.11] vs. 2011-2013: 0.26 [0.08-0.88]). Contact with a primary care physician and engagement in opioid agonist therapy were positively associated with treatment initiation, though estimates were attenuated under universal coverage relative to previous eras., Conclusion: Treatment initiation rates have increased since the introduction of universal DAA coverage, though barriers such as incarceration persist., Competing Interests: Declarations of Interest Julie Bruneau is reporting having received advisor fees from Gilead Sciences, AbbVie and Cepheid and a research grant from Gilead Sciences, outside of the current work. Sarah Larney is reporting having received advisor fees from Gilead Sciences. Valérie Martel-Laferrière is reporting having received advisor fees from AbbVie and research grants from Gilead Sciences and Merck, outside of the current work. The other authors declare they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: The COVID-19 pandemic has impacted supervised consumption site (SCS) operations in Montréal, Canada, potentially including changes in SCS visits, on-site emergency interventions, injection of specific drugs, and distribution of harm reduction materials., Method: We used administrative data from all four Montréal SCS from 1 March 2018 - 28 February 2021 to conduct an interrupted time series study with 13 March 2020 as the intervention point. We employed segmented regression using generalised least squares fit by maximum likelihood. We analysed monthly SCS visits and materials distributed as counts, and emergency interventions and drugs injected as proportions of visits., Results: SCS visits (level change = -1,286; 95% CI [-1,642, -931]) and the proportion of visits requiring emergency intervention (level = -0.27% [-0.47%, -0.06%]) decreased immediately in March 2020, followed by an increasing trend in emergency interventions (slope change = 0.12% [0.10%, 0.14%]) over the ensuing 12 months. Over the same period, the proportion of injections involving opioids increased (slope = 0.05% [0.03%, 0.07%]), driven by increasing pharmaceutical opioid and novel synthetic opioid injections. Novel synthetic opioids were the drugs most often injected prior to overdose. The proportion of injections involving unregulated amphetamines increased immediately (level = 7.83% [2.93%, 12.73%]), then decreased over the next 12 months (slope = -1.86% [-2.51%, -1.21%]). There was an immediate increase in needle/syringe distribution (level = 16,552.81 [2,373, 30,732]), followed by a decreasing trend (slope = -2,398 [-4,218, -578]). There were no changes in pre-existing increasing trends in naloxone or fentanyl test strip distribution., Conclusion: Reduced SCS use and increasing emergency interventions at SCS are cause for serious concern. Findings suggest increased availability of novel synthetic opioids in Montréal, heightening overdose risk., Competing Interests: Declarations of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier B.V.)

The World Health Organisation has established a goal of eliminating the hepatitis C virus (HCV) as a public health threat by 2030. Considerable effort is being directed towards research to support and enhance HCV treatment uptake among people who inject drugs, but there is a distinct lack of attention given to gender in this work. We argue that a gender lens is needed to make visible the limitations of current HCV elimination research, and support the development of innovative, inclusive approaches to HCV treatment. Partnerships between researchers and people who inject drugs are essential in this work, particularly in the development and evaluation of programs by and for women who inject drugs. Failure to acknowledge the gendered dimensions of HCV elimination risks entrenching gender disparities in access to treatment and cure., Competing Interests: Declarations of Interest SL has received an untied educational grant from Indivior unrelated to this work. NKM has received unrestricted research grants from Gilead and Merck unrelated to this work. CT has received speaker fees from Gilead and Abbvie and unrestricted research grants from Merck. AM and ADM have no conflicts of interest to report., (Copyright © 2022. Published by Elsevier B.V.)

Competing Interests: Declarations of Interest MS has received investigator-initiated funding from Gilead Sciences, AbbVie and Bristol Myers Squibb, and consultant fees from Gilead Sciences for activities unrelated to this work. SL has received untied investigator driven funding from Indivior unrelated to this work. The other authors have no disclosures.

Background: Take home naloxone (THN) programs have been rapidly upscaled in response to increasing opioid-related mortality. One often cited concern is that naloxone provision could be associated with increased opioid use, due to the availability of naloxone to reverse opioid overdose. We conducted a systematic review to determine whether THN provision is associated with changes in substance use by participants enrolled in THN programs., Methods: We conducted a systematic review of the literature to assess changes in heroin or other substance use by people who use opioids following THN provision., Results: Seven studies with 2578 participants were included. Of the seven studies, there were two quasi-experimental studies and five cohort studies. Based on the Joanna Briggs Institute quality assessment, four studies were of moderate quality and three studies were of high quality. Of the five studies that reported on the primary outcome of heroin use, no study found evidence of increased heroin use across the study population. Five studies reported on other substance use (benzodiazepines, alcohol, cocaine, amphetamine, cannabis, prescription opioids), none of which found evidence of an increase in other substance use associated with THN provision. Four studies reported on changes in overdose frequency following THN provision: three studies reporting no change, and one study of people prescribed opioids finding a reduction in opioid-related emergency department attendances for participants who received naloxone., Conclusion: We found no evidence that THN provision was associated with increased opioid use or overdose. Concerns that THN supply may lead to increased substance use were not supported by data from reviewed studies., Competing Interests: Declarations of Interest In the past 5 years, SN and SL have been investigators on untied education grants from Indivior, unrelated to the current work. SN has provided training to health care professionals on identifying and treating codeine dependence for which her institution has received payment from Indivior. SN and TL have been investigators on untied educational grants from Seqirus, unrelated to the current work. PD has received an investigator-driven grant from Gilead Sciences for unrelated work on Hepatitis C and an untied educational grant from Reckitt Benckiser for unrelated work on the introduction of buprenorphine-naloxone into Australia. PD and SN have served as unpaid members of an Advisory Board for an intranasal naloxone product., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Epidemiology is a core discipline generating evidence to inform and drive drug policy. In this essay, we speculate on what the future of drug epidemiology might become. We highlight for attention two areas shaping the future of drug epidemiology: nesting epidemiology within a 'syndemic' and 'relational' approach; and innovating in relation to causal inference in the face of complexity. We argue that shifts towards a more relational approach emphasise contingency, including in relation to how drugs might constitute benefit or harm. This leads us to speculate on a 'positive epidemiology'; one that is configured not merely in relation to harm but also in relation to the potential benefits of drugs in relation to well-being. In responding to the complex challenges of delineating contingent causalities, we emphasise the potential of carefully conducted observational study designs that go beyond statistical associations to test causal inference. We acknowledge that each of these developments we describe - a shift towards more relational approaches which emphasise contingent causation, and methodological innovations in relation to establishing causal inference - can be at odds with the other in how they imagine drug epidemiology futures., Competing Interests: Declarations of Interest MH has received unrestricted honoraria from Gilead, MSD, and AbbVie unrelated to this work. SL has received an untied educational grant from Indivior unrelated to this work., (Copyright © 2021. Published by Elsevier B.V.)

Background: "Big Events" are major disruptions to physical, political, and economic environments that can influence vulnerability to drug-related harms. We reviewed the impacts of Big Events with relevance to the COVID-19 pandemic on drug-related risk and harms and access to drug treatment and harm reduction services., Methods: We conducted a rapid review of quantitative, qualitative, and mixed methods literature relating to the following Big Events: respiratory infection pandemics, natural disasters, financial crises, and heroin shortages. Included studies reported data on changes to risks, harms, and/or service provisioning for people who use illicit drugs (other than cannabis) in the context of these Big Events. Searches were conducted in PubMed in May 2020, and two reviewers screened studies for inclusion. Peer-reviewed studies published in English or French were included. We used a narrative synthesis approach and mapped risk pathways identified in the literature., Results: No studies reporting on respiratory infection pandemics were identified. Twelve studies reporting on natural disaster outcomes noted marked disruption to drug markets, increased violence and risk of drug-related harm, and significant barriers to service provision caused by infrastructure damage. Five studies of the 2008 global financial crisis indicated increases in the frequency of drug use and associated harms as incomes and service funding declined. Finally, 17 studies of heroin shortages noted increases in heroin price and adulteration, potentiating drug substitutions and risk behaviors, as well as growing demand for drug treatment., Conclusion: Current evidence reveals numerous risk pathways and service impacts emanating from Big Events. Risk pathway maps derived from this literature provide groundwork for future research and policy analyses, including in the context of the COVID-19 pandemic. In light of the findings, we recommend responding to the pandemic with legislative and financial support for the flexible delivery of harm reduction services, opioid agonist treatment, and mental health care., Competing Interests: Declarations of Interest None., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Injecting risk behaviour, such as receptive sharing of injecting equipment and/or re-using one's equipment, is associated with bloodborne virus transmission and infections in people who inject drugs (PWID). We aimed to estimate prevalence and correlates of injecting risk behaviours amongst PWID., Methods: We conducted a systematic review and meta-analyses to estimate country, regional, and global prevalences of injecting risk behaviours (including sharing or re-using needle/syringe and sharing other injecting equipment). Using meta-regression analyses, we determined associations between study- and country-level characteristics and receptive needle/syringe sharing., Results: From 61,077 identified papers and reports and 61 studies from expert consutation, evidence on injecting risk behaviours was available for 464 studies from 88 countries. Globally, it is estimated that 17.9% (95%CI: 16.2-19.6%) of PWID engaged in receptive needle/syringe sharing at last injection, 23.9% (95%CI: 21.2-26.5%) in the past month, and 32.8% (95%CI: 28.6-37.0%) in the past 6-12 months. Receptive sharing of other injecting equipment was common. Higher prevalence of receptive needle/syringe sharing in the previous month was associated with samples of PWID with a lower proportion of females, shorter average injecting duration, a higher proportion with ≥daily injecting, and older studies. Countries with lower development index, higher gender inequality and lower NSP coverage had higher proportions reporting receptive needle/syringe sharing., Conclusions: High levels of injecting risk behaviours were observed amongst PWID globally, although estimates were only available for half of the countries with evidence of injecting drug use. There is a need for better capturing of injecting risk behaviours in these countries to inform implementation of harm reduction services and evaluate potential impacts of interventions to reduce risk., Competing Interests: Declaration of Competing Interest In the past three years, LD has received investigator-initiated untied educational grants for studies of opioid medications in Australia from Indivior and Seqirus. SL has received investigator-initiated untied educational grants from Indivior. AP and SM have received investigator-initiated untied educational grants from Seqirus. JG is a consultant/advisor and has received research grants from Abbvie, Cepheid, Gilead Sciences and Merck/MSD. JS reports non-financial support from Gilead Sciences, outside the submitted work. PV has received research support from Gilead Sciences and honoraria from AbbVie and Gilead Sciences, in relation to hepatitis C virus treatment for people who inject drugs. MH has received personal fees from Gilead Sciences, AbbVie, and Merck Sharp & Dohme.These companies/organisations had no knowledge of or role in the design, conduct, interpretation or publication of these findings., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: People who inject drugs (PWID) are at elevated risk of HIV infection. Data on population sizes of PWID living with HIV are needed to inform the implementation of prevention, treatment and care programs. We estimated national population sizes of people who recently (past 12 months) injected drugs living with HIV and evaluated ecological associations with HIV prevalence in PWID., Methods: We used national data on the prevalence of injecting drug use and of HIV among PWID, derived from systematic reviews, to estimate national population sizes of PWID living with HIV. Uncertainty was estimated using Monte Carlo simulation with 100,000 draws. We extracted data on sample characteristics from studies of HIV prevalence among PWID, and identified national indicators that have been observed or hypothesised to be associated with HIV prevalence in PWID. We used linear regression to evaluate associations between these variables and HIV prevalence in PWID., Results: Four countries comprised 55% of the estimated global population of PWID living with HIV: Russia (572,500; 95% uncertainty interval (UI) 235,500-1,036,500); Brazil (462,000; 95% UI 283,500-674,500); China (316,500; 95% UI 171,500-493,500), and the United States (195,500; 95% UI 80,000-343,000). Greater anti-HCV prevalence and national income inequality were associated with greater HIV prevalence in PWID., Conclusion: The countries with the largest populations of PWID living with HIV will need to dramatically scale up prevention, treatment and care interventions to prevent further increases in population size. The association between anti-HCV prevalence and HIV prevalence among PWID corroborates findings that settings with increasing HCV should implement effective interventions to prevent HIV outbreaks. The association between income inequality and HIV among PWID reinforces the need to implement structural interventions alongside targeted individual-level strategies., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: People who inject drugs (PWID) do so at varying frequencies. More frequent injecting is associated with skin and soft tissue infection, blood borne viruses, and overdose. The aims of this review are to estimate the prevalence of injecting frequency among PWID and compare these estimates to current needle-syringe distribution coverage estimates, and identify socio-demographic and risk characteristics, and harms associated with daily or more injecting., Methods: We conducted a systematic review of the peer-reviewed and grey literature from 2008 to 2018 and extracted needle-syringe distribution coverage data from a recent systematic review. We generated country-, region-, and global-level estimates of daily or more injecting. We also ran meta-regression analyses to determine associations between daily or more injecting and socio-demographic characteristics, injecting risk behaviour, non-fatal overdose, injection site skin infection, and blood borne virus prevalence., Results: Our search resulted in 61,077 sources, from which 198 studies were eligible for inclusion in this review. There were 74 countries with estimates for injecting frequency. Globally, we estimated that 68.1% (95%CI 64.5-71.6%) of PWID, equating to approximately 10.5 (95% UI 6.8-15.0) million people, inject daily or more frequently. There was a higher percentage of participants reporting daily or more injecting among samples with shorter injecting careers, more male participants and higher reporting of opioids as their main drug injected. Daily or more injecting was also associated with samples reporting a higher prevalence of HIV and hepatitis C antibody (anti-HCV), non-fatal overdose, and receptive needle sharing in the previous month., Implications: WHO recently recommended a needle-syringe distribution target of 300 needles per PWID per year which is unlikely to be sufficient for the majority of PWID injecting daily or more who are out of drug treatment., Funding: The Australian National Drug and Alcohol Research Centre, Australian National Health and Medical Research Council, University of New South Wales., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: People who inject drugs (PWID) are at an elevated risk of fatal overdose in the first year after experiencing a non-fatal event. Such non-fatal events may also result in overdose-related sequelae, ranging from physical injury to paralysis. Given variation in drug markets and treatment availability across countries and regions, we may see similar variations in non-fatal overdose prevalence. Monitoring non-fatal overdose prevalence among PWID is essential for informing treatment intervention efforts, and thus our review aims to estimate the global, regional, and national prevalence of non-fatal overdose, and determine characteristics associated with experiencing such an event., Methods: We conducted a systematic review and meta-analyses to estimate country, regional, and global estimates of recent and lifetime non-fatal overdose prevalence among PWID. Using meta-regression analyses we also determined associations between sample characteristics and non-fatal overdose prevalence., Results: An estimated 3.2 (1.8-5.2) million PWID have experienced at least one overdose in the previous year. Among PWID, 20.5% (15.0-26.1%) and 41.5% (34.6-48.4%) had experienced a non-fatal event in the previous 12 months and lifetime respectively. Frequent injecting was strongly associated with PWID reporting recent and lifetime non-fatal overdose. Estimates of recent non-fatal overdose were particularly high in Asia and North America., Conclusion: Around one in five PWID are at an elevated risk of fatally overdosing every year, however there is substantial geographical variation. In countries with higher rates of non-fatal overdose there is need to introduce or mainstream overdose prevention strategies such as opioid agonist treatment and naloxone administration training programs., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Globally, China is the largest country by population and contributes substantially to the burden of people who inject drugs (PWID). The aims of this study were to estimate the prevalence of HIV, hepatitis C virus (HCV) and hepatitis B virus (HBV) among PWID at the national and subnational level in China and examine characteristics of PWID., Methods: We undertook a systematic review of studies published from 2008 to 2017 on HIV, HCV, and HBV seroprevalence among PWID, and characteristics of PWID in Mainland China, Hong Kong, Macao and Taiwan. Meta-analyses were conducted to generate pooled prevalence estimates by province, region, and nationally., Results: Eighty-five papers were included. The pooled HIV, HCV antibody and HBV prevalence among PWID in China was 10.5% (95% confidence interval [95%CI]: 8.6%-12.5%), 71.6% (65.7%-77.6%) and 19.6% (13.7%-25.5%), respectively. In Mainland China, HIV prevalence was highest in the Southwest (14.4%, 10.5%-18.4%) and lowest in the North (1.3%, 0.4%-3.4%). Xinjiang Province had the highest HIV prevalence (42.6%, 35.5%-49.8%). HCV antibody prevalence was highest in the Southwest (77.7%, 69.9%-85.4%), followed by South (76.2%, 65.9%-86.4%). Sichuan had the highest HCV antibody prevalence (91.7%, 86.6%-95.3%), followed by Guangxi (86.1%, 81.8%-90.4%). HBsAg prevalence among PWID was highest in South (25.3%, 14.6%-36.0%), followed by Central (20.8%, 17.4%-24.1%). HBsAg prevalence ranged from 2.4% (0.6-5.9%) in Guizhou to 40.0% (33.7%-46.6%) in Shannxi Province. In China, women and young people accounted for 21.3% and 23.1% of PWID, respectively. It was estimated that 96.1% of PWID injected opioids mainly, and recent injecting risk and sexual risk was reported by 28.5% and 36.7%., Conclusion: There is a large burden of HIV, HCV and HBV prevalence among PWID in China, with considerable geographic variation. The disease burden of viral hepatitis is particularly high, implying that effective management should be integrated into harm reduction interventions among PWID in China., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: HCV transmission remains high in prisons globally. Understanding injecting risk behaviours in prisons is crucial to effectively develop and implement HCV prevention programs in this setting including treatment as prevention., Methods: HITS-p is a cohort study which enrolled people with a history of injecting drug use in prisons in NSW, Australia from 2005 to 2013. Participants completed an interview at enrolment and follow-up visits to determine injecting behaviours. Generalized estimating equation (GEE) and logistic regression methods were used to assess injecting risk behaviours prior to and following prison entry and to investigate injecting risk behaviours in prison., Results: Overall, 499 participants with a history of injecting drug use were included (median age, 26 years; 65% male). Participants were significantly less likely to inject drugs following incarceration. Among injectors, participants were less likely to inject ≥weekly but more likely to share a needle/syringe. At enrolment, the proportion reporting any injecting, ≥weekly injecting, and needle/syringe sharing in prison was highest among younger individuals. Younger age was associated with both re-initiation and continuation of injecting drug use following prison entry. Among those continuously imprisoned, younger age was associated with increased odds of any injecting, ≥weekly injecting, and sharing a needle/syringe., Conclusions: Upon entry to prison, injecting drug use decreased but syringe sharing increased among injectors. Younger individuals are most likely to exhibit high-risk injecting behaviours in prison. These data highlight the need for improved HCV prevention strategies (including improved needle/syringe access and scale up of HCV therapy) for those at increased risk of HCV transmission in prison, including younger individuals., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: People who inject drugs (PWID) often do not receive confirmatory RNA testing following positive HCV antibody testing. Expanding access to adequate testing and assessment will improve the progression of patients through the HCV care cascade with the potential to improve diagnosis as well as linkage to treatment. We aimed to determine current utilisation of general practitioners (GPs) by PWID in Australia compared to other settings for HCV testing and post-test discussions., Methods: A national sample (n=888) of people who had injected drugs regularly in the past 6 months was interviewed about HCV antibody, RNA testing, and post-test discussions, and the settings where these took place., Results: The majority of participants (n=735; 93%) reported antibody testing. Among participants who reported a positive result (n=435), 54% identified their regular GP as the setting where their most recent antibody test was conducted. Confirmatory RNA testing was reported by 60% (n=274) of those who reported being antibody positive. Among those who reported RNA testing (n=257), the most common setting reported was their regular GP (48%). There were no differences in the proportions who recalled post-test discussions at GPs compared to other settings., Conclusion: HCV testing was most frequently undertaken by participants' regular GP. GPs are currently providing testing and post-test discussions at similar proportions to other more specialised settings. However, RNA testing is incomplete for more than one-third of the antibody positive PWID interviewed. Our findings suggest that the general practice setting is a common and accessible setting for PWID to access HCV testing. Targeting GPs to improve follow-up of positive antibody tests may help to improve patient progression through the HCV care cascade., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Globally, it is estimated that 71.1 million people have chronic hepatitis C virus (HCV) infection, including an estimated 7.5 million people who have recently injected drugs (PWID). There is an additional large, but unquantified, burden among those PWID who have ceased injecting. The incidence of HCV infection among current PWID also remains high in many settings. Morbidity and mortality due to liver disease among PWID with HCV infection continues to increase, despite the advent of well-tolerated, simple interferon-free direct-acting antiviral (DAA) HCV regimens with cure rates >95%. As a result of this important clinical breakthrough, there is potential to reverse the rising burden of advanced liver disease with increased treatment and strive for HCV elimination among PWID. Unfortunately, there are many gaps in knowledge that represent barriers to effective prevention and management of HCV among PWID. The Kirby Institute, UNSW Sydney and the International Network on Hepatitis in Substance Users (INHSU) established an expert round table panel to assess current research gaps and establish future research priorities for the prevention and management of HCV among PWID. This round table consisted of a one-day workshop held on 6 September, 2016, in Oslo, Norway, prior to the International Symposium on Hepatitis in Substance Users (INHSU 2016). International experts in drug and alcohol, infectious diseases, and hepatology were brought together to discuss the available scientific evidence, gaps in research, and develop research priorities. Topics for discussion included the epidemiology of injecting drug use, HCV, and HIV among PWID, HCV prevention, HCV testing, linkage to HCV care and treatment, DAA treatment for HCV infection, and reinfection following successful treatment. This paper highlights the outcomes of the roundtable discussion focused on future research priorities for enhancing HCV prevention, testing, linkage to care and DAA treatment for PWID as we strive for global elimination of HCV infection., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: People released from correctional settings are at an elevated risk of opioid overdose death in the weeks immediately following release. However, it is not well understood how this population, as a particularly high-risk group, is included in, and benefits from take-home naloxone (THN) programs. The objective of this review is to map research into THN for people released from correctional settings in order to identify further research needs., Method: We searched electronic databases, grey literature, and conference abstracts for reports on THN for people in or released from correctional settings. Studies were categorised into themes defined by the study's aims and focus. Results from each study were summarised by theme., Results: We identified 19 studies reporting on THN programs for people released from correctional settings. Studies have examined attitudes towards naloxone among people in custody or recently released from custody (theme 1), and among non-prisoner stakeholders such as prison staff (theme 2). Evaluations and interventional studies (theme 3) have examined process indicators and approaches to naloxone training, including for contacts of prisoners, but there are challenges in assessing health outcomes of THN in the correctional context. Case reports suggest that training in correctional settings translates to action post-release (theme 4)., Conclusion: The feasibility of THN in the context of release from a correctional setting has been established, but there is a need for rigorous research into health outcomes and program implementation. This is an emerging field of study and ongoing assessment of the state of the literature and research needs is recommended., (Copyright © 2017 Elsevier B.V. All rights reserved.)

There is considerable interest in determining the impact that increased uptake of treatment for hepatitis C virus (HCV) infection will have on the burden of HCV among people who inject drugs (PWID). An understanding of the size of the population of PWID, rates of injecting cessation and HCV prevalence and incidence within the PWID population is essential for such exercises. However, these parameters are often uncertain. In this paper we review methods for estimating the size of the population of PWID and related parameters, taking into account the uncertainty that exists around data on the natural history of injecting drug use; consider issues in the estimation of HCV prevalence among PWID; and consider the importance of opioid substitution therapy and prisons as settings for the prevention and treatment of HCV infection among PWID. These latter two points are illustrated through examples of ongoing work in England, Scotland and Australia. We conclude that an improved understanding of the size of PWID populations, including current and former PWID and parameters related to injecting drug use and settings where PWID may be reached, is necessary to inform HCV prevention and treatment strategies., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background: Ukraine has the highest HIV burden of any European country with much of the current HIV epidemic concentrated among people who inject drugs (PWIDs) and their sexual partners. Opiate substitution therapy (OST) is limited in Ukraine and expansion of OST is urgently needed to help stem the tide of the HIV epidemic., Methods: We accessed publicly available data in Ukraine in order to explore geographic variability with respect to prevalence of HIV, PWIDs and OST programmes., Results: The regions of Ukraine with the largest number of opioid dependent persons (the south and eastern portions of the country) correspond to the regions with the highest HIV prevalence and HIV incidence. The number of opioid PWIDs per 100,000 population as well as the number of all OST treatment slots per 100,000 varied significantly across the three HIV prevalence categories. Overall, the proportion of individuals receiving either methadone maintenance therapy (MMT) or buprenorphine maintenance therapy (BMT) was quite low: average across categories: 7.3% and 0.4%, respectively. Additionally, less than half of OST patients receiving MMT or BMT were HIV positive patients., Conclusion: There is significant geographic variability in both numbers of HIV positive individuals and numbers of PWIDs across Ukraine, however, there may be a more concentrated epidemic among PWIDs in many regions of the country. Scale up of addiction treatment for PWID, especially OST, can have a significant impact on preventing injection related morbidity, such as HIV and HCV infection. Ukraine can learn from the mistakes other nations have made in denying critical treatment opportunities to PWID., (Copyright © 2014 Elsevier B.V. All rights reserved.)