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Influenced by a harm reduction philosophy, the then Victorian Labor Government announced the establishment of the state's first medically supervised injecting room (MSIR) in North Richmond in late 2017. But, public and political opinion remains sharply divided as to the merits of the MSIR. One influence on policy development appears to be media commentary on the MSIR and the wider illicit drugs policy debate. This paper compares the official editorials of the two daily Melbourne newspapers, the Herald Sun and The Age regarding the MSIR, from November 2017 until November 2022. Based on 33 articles (Herald Sun, N = 28; The Age, N = 5), our findings identify philosophical differences between the two newspapers as reflected in their sources of information, language and highlighted issues. The Age was mostly supportive of both the introduction of the North Richmond MSIR and proposals for a second site. The Herald Sun's position was more ambiguous, ranging from qualified support for the North Richmond MSIR to strong opposition to further sites. [ABSTRACT FROM AUTHOR]

Introduction: This paper aims to describe cocaine use, markets and harms in Australia from 2003 to 2019. Methods: Outcome indicators comprised prevalence of use from triennial household surveys; patterns of use from annual surveys of sentinel samples who use stimulants; and cocaine‐related seizures, arrests, hospitalisations, deaths and treatment episodes. Bayesian autoregressive time‐series analyses were conducted to estimate trend over time: Model 1, no change; Model 2, constant rate of change; and Model 3, change over time differing in rate after one change point. Results: Past‐year population prevalence of use increased over time. The percentage reporting recent use in sentinel samples increased by 6.1% (95% credible interval [CrI95%] 1.2%,16.9%; Model 3) per year from around 2017 (48%) until the end of the series (2019: 67%). There was a constant annual increase in number of seizures (count ratio: 1.1, CrI95% 1.1,1.2) and arrests (1.2, CrI95% 1.1,1.2), and percentage reporting cocaine as easy to obtain in the sentinel samples (percent increase 1.2%, CrI95% 0.5%,1.8%; Model 2). Cocaine‐related hospitalisation rate increased from 5.1 to 15.6 per 100 000 people from around 2011–2012 to 2017–2018: an annual increase of 1.3 per 100 000 people (CrI95% 0.8,1.8; Model 3). While the death rate was low (0.23 cocaine‐related deaths per 100 000 people in 2018; Model 2), treatment episodes increased from 3.2 to 5.9 per 100 000 people from around 2016–2017 to 2017–2018: an annual increase of 2.9 per 100 000 people (CrI95% 1.6,3.7; Model 3). Discussion and Conclusions: Cocaine use, availability and harm have increased, concentrated in recent years, and accompanied by increased treatment engagement. [ABSTRACT FROM AUTHOR]

Injecting use of image and performance-enhancing drugs ( IPED) in the general population is a public health concern. A wide and varied range of IPED are now easily accessible to all through the online market. A comprehensive literature review was undertaken according to Critical Appraisal Skills Programme ( CASP) guidelines for systematic review, to identify the relevant literature. No date restrictions were placed on the database search in the case of human growth hormone melanotan I and II, and oil and cosmetic injectables. In the case of anabolic androgenic steroids search dates were restricted to January 2014-2015. Publications not in English and with a lack of specificity to the topic were excluded. The review yielded 133 relevant quantitative and qualitative papers, clinical trials, clinical case presentations and editorials/reports. Findings were examined/reviewed under emergent themes which identified/measured extent of use, user profiling, sourcing, product endorsement, risk behaviours and health outcomes in users. Motivation for IPED use may be grounded in appearance, pursuit of health and youth, and body image disturbance. IPED users can practice moderated use, with pathological use linked to high-risk behaviours, which may be normalised within IPED communities. Many IPED trajectories and pathways of use are not scientifically documented. Much of this information may be available online in IPED specific discussion forums, an underutilised setting for research, where uncensored discourse takes place among users. This review underscores the need for future internet and clinical research to investigate prevalence and patterns of injecting use, and to map health outcomes in IPED users. This paper provides community-based clinical practice and health promotion services with a detailed examination and analysis of the injecting use of IPED, highlighting the patterns of this public health issue. It serves to disseminate updated publication information to health and social policy makers and those in health service practice who are involved in harm reduction intervention. [ABSTRACT FROM AUTHOR]

Background Intervention impact on reductions in hepatitis C virus (HCV) incidence among injecting drug users (IDUs) are modest. There is a need to explore how drug injectors' interpret HCV risk. Aims To review English-language qualitative empirical studies of HCV risk among IDUs. Methods Qualitative synthesis using a meta-ethnographic approach. Searching of eight electronic databases and reference lists identified manually papers in peer-reviewed journals since 2000. Only studies investigating IDU perspectives on HCV risk were included. Themes across studies were identified systematically and compared, leading to a synthesis of second- and third-order constructs. Findings We included 31 papers, representing 24 studies among over 1000 IDUs. Seven themes were generated: risk ubiquity; relative viral risk; knowledge uncertainty; hygiene and the body; trust and intimacy; risk environment; and the individualization of risk responsibility. Evidence supports a perception of HCV as a risk accepted rather than avoided. HCV was perceived largely as socially accommodated and expected, and in relative terms to human immunodeficiency virus (HIV) as the ‘master status’ of viral dangers. Symbolic knowledge systems, rather than biomedical risk calculus, and especially narratives of hygiene and trust, played a primary role in shaping interpretations of HCV risk. Critical factors in the risk environment included policing, homelessness and gendered risk. Conclusions Appealing to risk calculus alone is insufficient. Interventions should build upon the salience of hygiene and trust narratives in HCV risk rationality, and foster community changes towards the perceived preventability of HCV. Structural interventions in harm reduction should target policing, homelessness and gendered risk. [ABSTRACT FROM AUTHOR]

This paper uses data on the social context of drug-related harms in the Melbourne Aboriginal Community to inform an alternative model of harm minimisation, and discusses its potential application in programme development. The paper involves a secondary analysis of interviews and focus group discussions with 62 Community members who participated in a qualitative injecting drug use study conducted at the Victorian Aboriginal Health Service in Melbourne. Individuals and families within the Melbourne Aboriginal Community experience significant levels of harm associated with injecting drug use, and face restricted access to appropriate service options. This experience of drug use contributes to a broad range of values within the Community around harm minimisation approaches to programme delivery. We propose a fundamentally distinct harm minimisation model which explicitly acknowledges this range of conflicting values, and reflects the need for a breadth of services and programmes that address these tensions. Policies and funding must support Aboriginal Communities to negotiate through these conflicting Community values to actively create spaces in the service system for both using and non-using Community members. This includes the development of regional approaches which articulate an appropriate mix of services and the roles of Aboriginal and mainstream services in their delivery. [van der Sterren AE, Anderson IP, Thorpe LG. ‘Individual’ harms, Community ‘harms’: reconciling Indigenous values with drug harm minimisation . Drug Alcohol Rev 2006;25:219 – 225] [ABSTRACT FROM AUTHOR]

Introduction and Aims: Services provided by needle and syringe programs (NSP) within Australia are easily accessible by international standards. However, important variation in NSP policy remains across Australian jurisdictions. The potential impacts of these variations on program operation for clients have not been systematically analysed in Australia. In this paper we conduct a preliminary examination to compare individual-level syringe coverage between and within Australian capital cities.Design and Methods: Participants were 2498 people who inject drugs (PWID) recruited from all Australian capital cities as part of the annual Illicit Drug Reporting System PWID survey over the period 2014-2016. Insufficient coverage was defined when <100% of a participant's injecting episodes were 'covered' by sterile needles and syringes. We report the percentage of insufficient coverage for each capital city for each year, and present descriptive statistics for coverage parameters, and an alternative measure for insufficient coverage, as Supporting Information.Results: Differences in behaviours that have the potential to impact syringe coverage were highly variable over time and place leading to variations in levels of insufficient coverage between and within all cities. Overall, insufficient coverage was most evident in larger cities where insufficient coverage varied between 19% and 23% (Sydney) over time, compared to smaller cities with variation from 9% to 12% (Adelaide).Discussion and Conclusions: We found no consistent pattern of differences in individual-level needle and syringe coverage between and within Australian capital cities. Further work is needed to fully evaluate whether policy variation between Australian jurisdictions impacts on NSP coverage. [ABSTRACT FROM AUTHOR]

Injecting drug use is driving HIV epidemics in many countries around the world. There is evidence that such epidemics can be averted, halted and reversed if comprehensive HIV programmes targeting drug users are put into place. The term ‘harm reduction’ is used widely to describe the goals, policies and interventions of such programmes. However, despite its rapidly expanding use, the term has no universally accepted definition. This paper aims to describe the evolution and branding of the term ‘harm reduction’ and the adoption of the concept across a wide range of countries. It highlights a range of issues that remain controversial in the harm reduction discourse related to HIV and injecting drug use, including: the definition of ‘harm reduction’ and related terms; the scope of harm reduction; the promotion of a public health versus drug control dichotomy; the feasibility and appropriateness of harm reduction in low- and middle-income countries; and the strength of evidence on harm reduction interventions. The paper argues that harm reduction should be a core element of a public health response to HIV/AIDS where injecting drug use exists. The effectiveness of policies and programmes targeting drug users should be measured against public health outcomes. This requires the alignment of drug control measures with public health goals. A ‘model package’ for harm reduction is proposed, which provides guidance to countries on the selection of evidence-based policies and interventions, including: interventions for reducing HIV transmission; treatment of HIV/AIDS and associated comorbidities; appropriate models of service delivery; creation of supportive policy, legal and social environments; and strengthening of strategic information systems to better guide responses. [ABSTRACT FROM AUTHOR]

'Risk' and 'risk behaviour' have become keywords in discourses about AIDS. Notions of risk behaviour in the field of HIV prevention and the addictions largely derive from epidemiological categorisations which have had a key role in constructing lay and scientific understandings of the 'problems' of AIDS and injecting drug use. This has encouraged a restricted vision which inadequately captures risk as it is understood and experienced by drug users themselves. Drawing on case examples from qualitative research with illicit drug users, this paper explores the utility of current theories of risk behaviour in understanding how risk behaviour is socially organised. Two key developments in risk behaviour theory are examined. These are situated rationality and social action theories. Findings illustrate that situated rationality theories tend to be conceptually limited to an analysis of individual rationality which fails to capture the distribution and influence of power in negotiated actions and the habituated nature of risk behaviour. In contrast, social action theories aim to understand the interplay of social factors which give rise to individuals' situated risk perceptions and actions. Findings highlight the important role that qualitative research plays in questioning, as well as complementing, dominant scientific constructions of risk. Future theories of risk behaviour in the field of HIV prevention, as well as other health domains, need to consider risk as a socially organised rather than individual phenomenon. The paper concludes by asserting that understanding what risk actually means to participants themselves provides the necessary data for public health interventions to create the conditions where risk reduction becomes possible. [ABSTRACT FROM AUTHOR]

Introduction and Aims: Gay and other homosexually active men (hereafter 'gay men') are at elevated risk of becoming infected with hepatitis C virus (HCV) via injecting drug use and sexual risk practices. This paper aimed to measure HCV knowledge among gay men in Australia and whether knowledge differed according to HCV risk.Design and Methods: In 2013, a cross-sectional, online survey of 405 Australian gay men explored the social aspects of HCV. Bivariate and multivariate linear regressions were used to examine factors associated with higher HCV knowledge.Results: The mean age of respondents was 39.2 years (SD = 13.3), and most men (75.3%) were born in Australia. According to self-report, 32.1% were HIV-positive, 3.0% were HCV-positive and 8.9% were HIV/HCV co-infected. The mean number of correct HCV knowledge items was 8.2 (SD = 3.9; range 0-15). In a multivariate analysis, higher HCV knowledge was associated with higher educational attainment, being HCV-positive, being HIV-positive and injecting drug use.Discussion and Conclusions: HCV knowledge among gay men was moderately good, although knowledge of testing, treatment and natural history of HCV was generally quite poor. Encouragingly, higher knowledge was reported among men at highest HCV risk. Viral hepatitis and HIV organisations, together with general practitioners and other health services, should continue to target gay men at a high risk of acquiring HCV with education and health promotion. [Lea T, Hopwood M, Aggleton P. Hepatitis C knowledge among gay and other homosexually active men in Australia. Drug Alcohol Rev 2016;35:477-483]. [ABSTRACT FROM AUTHOR]

Introduction and Aims: The harms associated with non-medical use of pharmaceutical opioid analgesics are well established; however, less is known about the characteristics and drug-use patterns of the growing and hidden populations of people using pharmaceutical opioids illicitly, including the frequency of pharmaceutical opioid injection. This paper aimed to undertake a detailed examination of jurisdictional differences in patterns of opioid use among a cohort of people who regularly tamper with pharmaceutical opioids in Australia.Design and Methods: Data were drawn from the National Opioid Medications Abuse Deterrence study. The cohort was recruited from New South Wales (NSW; n = 303), South Australia (SA; n = 150) and Tasmania (TAS; n = 153) to participate in face-to-face structured interviews collecting data on use of pharmaceutical opioids, benzodiazepines, other sedative drugs and illicit substances, as well as the harms associated with substance use.Results: TAS participants reported greater use and injection of certain pharmaceutical opioids (particularly morphine and methadone tablets), and limited heroin use, with lower rates of engagement in opioid substitution treatment, compared with NSW participants. NSW participants were more socially disadvantaged and more likely to report risky injecting behaviours and injecting-related injuries and diseases compared with SA and TAS participants. SA participants reported greater rates of pain conditions, greater use of pain-based services, as well as broader use of pharmaceutical opioids in regards to forms and route of administration, compared with NSW participants.Discussion and Conclusions: Distinct jurisdictional profiles were evident for people who tamper with pharmaceutical opioids, potentially reflecting jurisdictional differences in prescribing regulatory mechanisms and addiction treatment models. [ABSTRACT FROM AUTHOR]

Introduction and Aims. In Australia, people who inject drugs (PWID) commonly report the use of benzodiazepines (BZDs). This paper explores the emerging use of alprazolam among PWID in Melbourne, Australia. Design and Methods. This study reports on 3 years of data collected through the Victorian Illicit Drug Reporting System (2008-2010). Structured interviews were conducted with 451 PWID and analysed using odds ratios and χ2-tests for trends over time. Results. While the proportion of PWID reporting recent BZD use remained stable over time, the proportion reporting alprazolam to be their most commonly used BZD fluctuated, peaking in 2009. Alprazolam users were significantly more likely to report using illicit BZDs and to report recent BZD injection compared with users of other BZDs. Alprazolam use was associated with the sale of drugs for cash, but not with other criminal activities. Discussion and Conclusion. The fluctuations in alprazolam use over time may be reflective of medical practitioners ceasing to prescribe alprazolam in response to reports of associated harms; however, this may in turn be driving the illicit alprazolam market. While the data do not indicate a clear association between alprazolam use and harms, considering the potential severity of associated harms and the association between alprazolam use and anterograde amnesia, patterns of alprazolam use among PWID should be closely monitored. Potential changes to prescribing practice should consider unintended consequences, such as replacement with other BZD types, or illicitly obtained BZDs.[Horyniak D, Reddel S, Quinn B, Dietze P. The use of alprazolam by people who inject drugs in Melbourne, Australia. Drug Alcohol Rev 2012;31:585-590] [ABSTRACT FROM AUTHOR]

Introduction and Aims. The number of illicit drug users incarcerated in Sri Lanka has been growing over the last decade. This paper presents drug-use characteristics and risk-taking behaviours among a group of male incarcerated drug users. Design and Methods. An interviewer-administered structured questionnaire was completed by 278 drug users in three prisons in Sri Lanka. Results. The majority (81.3%) of interviewees were aged 25–45 years. Most of them had received low levels of education, and experienced childhood delinquency and a deprived upbringing. Drug use was largely initiated during early adolescence, then continued to chronicity and the development of drug dependence. There was a high incidence (25–35%) of family history of drug abuse. Heroin (98%) and cannabis (54%) were the main drugs of abuse in the past 30 days. Polydrug use was common (75% in the past 12 months). Tobacco and alcohol use were widespread. The prevalence of intravenous drug use was higher than officially reported (15.8% vs. 1%). There was a high prevalence (53%) of risk-taking sexual behaviour. Discussion and Conclusion. The pattern of drug use was similar to those reported in nearby countries. However, the increasing prevalence of injecting drug use and risk-taking sexual behaviour is a concern. There is an urgent need to develop effective treatment strategies and to prevent the spread of HIV and hepatitis in Sri Lanka.[Dissabandara LO, Dias SR, Dodd PR, Stadlin A. Patterns of substance use in male incarcerated drug users in Sri Lanka. Drug Alcohol Rev 2009] [ABSTRACT FROM AUTHOR]

Introduction and aims. There has been considerable media attention recently upon possible increases in methamphetamine use in Australia. Much of this debate has focused upon extreme cases of problematic crystal methamphetamine use, without reference to the broader population context. This paper provides data on methamphetamine use in Australia, and documents trends in methamphetamine-related harms. Design and Methods. Data used were from: (1) Australian Customs Service drug detections; (2) Australian Crime Commission drug seizure, arrest and clandestine laboratory detections data; (3) National Drug Strategy Household Survey (NDSHS) and Australian Secondary Student Alcohol and Drug Survey (ASSADS); (4) data from the Illicit Drug Reporting System (IDRS) and Ecstasy and related Drug Reporting System (EDRS); and (5) data from NSW Emergency Department Information System, National Hospital Morbidity Database and Australian Bureau of Statistics causes of death databases. Results. There appears to have been an increase in both importation and local manufacture of meth/amphetamine. Population data show that meth/amphetamine use remains low and stable. However, clear increases in crystal methamphetamine use have occurred among sentinel groups of regular drug users. Frequent crystal use among regular injecting drug users is associated with earlier initiation to injecting, greater injection risk behaviours and more extensive criminal activity. In recent years, indicators of meth/amphetamine-related harm have stabilised, following steady increases in earlier years. Discussion and Conclusions. Some methamphetamine users experience significant problems related to their use; harms are particularly prevalent among regular IDU. Methamphetamine users, however, are a diverse group, and strategies need to be appropriately targeted towards different kinds of users. [Degenhardt L, Roxburgh A, Black E, Bruno R, Campbell G, Kinner S, Fetherston J. The epidemiology of methamphetamine use and harm in Australia. Drug Alcohol Rev 2008;27:243-252] [ABSTRACT FROM AUTHOR]

This paper explores differences between women's and men's first experience of injecting in relation to socio-demographic context, drug use, and the role of others. We collected cross-sectional retrospective data from 334 recently initiated (≤5 years) injecting drug users in New South Wales and Queensland, Australia using a structured questionnaire in face-to-face interviews. Logistic regression was used to estimate crude and adjusted odds ratios (OR). Findings from the adjusted analysis show that women had a shorter duration of illicit drug use prior to initiation (adjusted OR 0.84, 95%CI: 0.74 - 0.94), and were more likely to have their romantic-sexual partner facilitate the initiation by paying for the drugs (adjusted OR 4.64, 95%CI: 1.21 - 17.73). Women also reported a greater likelihood of being initiated in groups of other women (adjusted OR 2.87, 95%CI: 1.24 - 6.67), suggesting that some women play an active role in their initiation experience rather than relying on, or being lead by, a romantic-sexual partner. These findings demonstrate the crucial role that romantic-sexual partners play in women's initiation experience, but also provide evidence for the way that women can be active participants in their own initiation and in initiating other women. [Bryant J, Treloar C. The gendered context of initiation to injecting drug use: evidence for women as active initiates. Drug Alcohol Rev 2007;26:] [ABSTRACT FROM AUTHOR]

In industrialized countries, transmission of hepatitis C occurs primarily through injecting drug use. Transmission of hepatitis C in injecting drug users is mainly associated with the sharing of contaminated syringes/needles, although evidence for risk of hepatitis C infection through sharing of other injecting paraphernalia is increasing. In this paper, the independent effects of sharing paraphernalia other than syringes/needles have been estimated. The prevalence and force of infection were modelled using three serological data sets from drug users in three centres in Belgium as a function of the sharing behaviour. It was found that sharing of materials other than syringes/needles indeed seemed to contribute substantially to the spread of hepatitis C among injecting drug users. [ABSTRACT FROM AUTHOR]

The aim of this study was to provide an overview of the first year of the NSW Minimum Dataset for Alcohol and Other Drug Treatment Services data collection, including describing the patterns and correlates of people having received treatment in New South Wales. All closed treatment episodes for the 2000 - 2001 financial year were included for descriptive, univariate and multivariate analyses. There were 33 459 closed episodes of care in New South Wales in the 2000/2001 financial year. The majority of clients (69%) were male and the mean age was almost 34 years. The majority of treatment is sought for problems related to alcohol (37%) and heroin (33%) use. More than a third (40%) of clients were new to drug and alcohol treatment. Half the clients had a history of injecting drug use with 6.3% of those with heroin as their principal drug of concern, never having injected. The most common main service provided was in-patient withdrawal (26%). Multivariate logistic regression revealed that being older, not homeless, non-indigenous and having heroin as the principal drug of concern predicted receiving out-patient withdrawal management. Analyses of length of stay in residential treatments and number of service contacts in non-residential treatments are reported. The NSW MDS AODTS is a critical information source for policy development, service planning and surveillance. The results of this paper illustrate the utility of the data collection for identifying emerging issues in the patterns of drug use and service delivery for clients with alcohol and other drug problems. [Copeland J, Indig D. Patterns and correlates of treatment: findings of the 2000 - 2001 NSW minimum dataset of clients of alcohol and other drug treatment services. Drug Alcohol Rev 2004;23:185 - 194] [ABSTRACT FROM AUTHOR]

Recognizing the dearth of qualitative research on hepatitis C virus (HCV) infection associated with injecting drug use in the UK, this paper summarizes qualitative insights from a study exploring the social relations of HCV risk management among drug injectors in London. Adopting an inductive approach to data collection and analysis, 59 depth tape-recorded qualitative interviews were undertaken in 2001 with drug injectors recruited via drug user networks. While access to injecting equipment was reportedly good, needle and syringe sharing continued in exceptional circumstances and in the context of ‘trust relationships’. Analyses of drug injectors’ accounts of variations of ‘I never share’ showed that this construction denoted less a descriptor of actual risk behaviour than presentation of perceived risk status. Paraphernalia sharing, including spoons and filters, was common. There was much confusion and uncertainty concerning HCV knowledge, including its medical and transmission risks. Injectors were aware of the provisionality and partiality of their HCV knowledge. Confusion also surrounded the meaning of HCV antibody test results, with some feeling that their positive diagnosis had been ‘trivialized’ by their experiences of HCV testing. Injectors tended to make sense of HCV risk in relation to HIV. With most viewing HCV prevalence as high and HCV transmission as an inevitable consequence of injecting, HCV risk was perceived as ubiquitous and unavoidable. There is an urgent need to renew UK policies of harm reduction in order to support perceptions that HCV is avoidable and preventable. [ABSTRACT FROM AUTHOR]

ABSTRACT Aims As conceptualized by Robert Park in 1928, the ‘marginal man’ occupies simultaneously an intermediate point between two distinct cultures that embody some level of contradictory normative expectations, behaviors and beliefs. This paper explores the influence of ageing and social change on the creation of marginality among injection drug users over age 50 who have been chronic heroin users since their youth. Design Our data are drawn from in-depth interviews with 40 (28 male and 12 female) not-in-drug-treatment, active injecting drug users between the ages of 18 and 68. Setting Our sample was recruited using street outreach as part of a larger, community-based study conducted from a converted storefront in a high crime, economically depressed neighborhood on the west side of Chicago. Findings As they aged, and under the pressures of social change, the older users whom we studied moved from center positioning in the illicit drug culture of their youth to the margins of a differing drug culture of today where they participate largely unseen by others. Nostalgic for the ‘Old School’ mores of the past, and unable to transcend or assimilate fully into the cultural practices and norms of the ‘New’, they respond to their predicament by embracing ‘poise’ in the face of loneliness, stress and fear of victimization. Conclusions Our respondents’ experiences draw attention to the need to refine the field's theoretical and practical understandings of what it means to be marginal and its consequences for older drug users and people in general. The results also point to what happens when society changes but some of its members do not. [ABSTRACT FROM AUTHOR]

Issues: People who inject drugs are at risk of acute infections, such as skin and soft tissue infections, infective endocarditis, bone and joint infections and bloodstream infections. There has been an increase in these infections in people who inject drugs internationally over the past 10 years. However, the local data regarding acute infections in Australia has not been well described. Approach: We review the epidemiology of acute infections and associated morbidity and mortality amongst people who inject drugs in Australia. We summarise risk factors for these infections, including the concurrent social and psychological determinants of health. Key Findings: The proportion of people who report having injected drugs in the prior 12 months in Australia has decreased over the past 18 years. However, there has been an increase in the burden of acute infections in this population. This increase is driven largely by skin and soft tissue infections. People who inject drugs often have multiple conflicting priorities that can delay engagement in care. Implications: Acute infections in people who inject drugs are associated with significant morbidity and mortality. Acute infections contribute to significant bed days, surgical requirements and health‐care costs in Australia. The increase in these infections is likely due to a complex interplay of microbiological, individual, social and environmental factors. Conclusion: Acute infections in people who inject drugs in Australia represent a significant burden to both patients and health‐care systems. Flexible health‐care models, such as low‐threshold wound clinics, would help directly target, and address early interventions, for these infections. [ABSTRACT FROM AUTHOR]

Hepatitis C virus infection (HCV) is prevalent in prisons. Therefore, effective prison HCV services are critical for HCV elimination programmes. We aimed to evaluate the efficacy of a regional HCV prison testing and treatment programme. Between July 2017 and June 2022, data were collected prospectively on HCV test offer and uptake rates, HCV Antibody (HCV‐Ab) and HCV‐RNA positivity, treatment starts and outcomes for new inmates incarcerated in three prisons. Rates of HCV‐Ab and RNA positivity at reception, incidence of new HCV infections and reinfection following treatment were determined. From a total of 39,652 receptions, 33,028 (83.3%) were offered HCV testing and 20,394 (61.7%) completed testing. Including all receptions, 24.5% of tests (n = 4995) were HCV‐Ab positive and 8.4% of tests (n = 1713) were HCV‐RNA positive. When considering the first test for each individual (median age 34 years; 88.1% male), 14.8% (n = 1869) and 7.2% (n = 905) were HCV‐Ab and HCV‐RNA positive, respectively. The incidence of new HCV‐Ab and RNA positivity was 5.1 and 3.3 per 100 person‐years, respectively. Of 1145 HCV viraemic individuals, 18 died within 6 months and 150 were rapidly transferred out of area, leaving 977 individuals with outcomes. Of these, 835 (85.5%) received antivirals and 47 spontaneously cleared the infection, leaving 95 (9.7%) untreated. 607 (72.7%) achieved SVR. 95 patients had reinfection post‐treatment (rate 10.1 cases per 100 person‐years). Testing for HCV has increased in our prisons and the majority with viraemia are initiated on antiviral treatment. Reassuringly, a significant fall in frequency of HCV‐RNA positivity at prison reception was observed suggesting progress towards HCV elimination. [ABSTRACT FROM AUTHOR]

Background and aims: Injection drug use‐associated bacterial and fungal infections are increasingly common, and social contexts shape individuals' injecting practices and treatment experiences. We sought to synthesize qualitative studies of social–structural factors influencing incidence and treatment of injecting‐related infections. Methods: We searched PubMed, EMBASE, Scopus, CINAHL and PsycINFO from 1 January 2000 to 18 February 2021. Informed by Rhodes' 'risk environment' framework, we performed thematic synthesis in three stages: (1) line‐by‐line coding; (2) organizing codes into descriptive themes, reflecting interpretations of study authors; and (3) consolidating descriptive themes into conceptual categories to identify higher‐order analytical themes. Results: We screened 4841 abstracts and included 26 qualitative studies on experiences of injecting‐related bacterial and fungal infections. We identified six descriptive themes organized into two analytical themes. The first analytical theme, social production of risk, considered macro‐environmental influences. Four descriptive themes highlighted pathways through which this occurs: (1) unregulated drug supply, leading to poor drug quality and solubility; (2) unsafe spaces, influenced by policing practices and insecure housing; (3) health‐care policies and practices, leading to negative experiences that discourage access to care; and (4) restrictions on harm reduction programmes, including structural barriers to effective service provision. The second analytical theme, practices of care among people who use drugs, addressed protective strategies that people employ within infection risk environments. Associated descriptive themes were: (5) mutual care, including assisted‐injecting and sharing sterile equipment; and (6) self‐care, including vein health and self‐treatment. Within constraining risk environments, some protective strategies for bacterial infections precipitated other health risks (e.g. HIV transmission). Conclusions: Injecting‐related bacterial and fungal infections are shaped by modifiable social–structural factors, including poor quality unregulated drugs, criminalization and policing enforcement, insufficient housing, limited harm reduction services and harmful health‐care practices. People who inject drugs navigate these barriers while attempting to protect themselves and their community. [ABSTRACT FROM AUTHOR]

In this article the author discusses the study of M. J. Milloy and colleagues on the mortality rates of drug overdose among First Nation people in a Canadian setting. It notes that there are steps to be prioritized to turn around overdose-related mortality among the indigenous people in Canada. The author says that as there is minimal study on overdose mortality among indigenous people in developed nations, it is safe to assume an even greater dearth for indigenous people in developing nations.

Aims: To measure mortality rates and factors associated with mortality risk among participants in the SuperMIX study, a prospective cohort study of people who inject drugs. Design: A prospective observational study using self‐reported behavioural and linked mortality data. Setting: Melbourne, Australia. Participants/cases: A total of 1209 people who inject drugs (67% male) followed‐up between 2008 and 2019 for 6913 person‐years (PY). Measurements We linked participant identifiers from SuperMIX to the Australian National Death Index and estimated all‐cause and drug‐related mortality rates and standardized mortality ratios (SMRs). We used Cox regression to examine associations between mortality and fixed and time‐varying socio‐demographic, alcohol and other drug use and health service‐related exposures. Findings Between 2008 and 2019 there were 76 deaths in the SuperMIX cohort. Of those with a known cause of death (n = 68), 35 (51%) were drug‐related, yielding an all‐cause mortality rate of 1.1 per 100 PY [95% confidence interval (CI) = 0.88–1.37] with an estimated SMR of 16.64 (95% CI = 13.29–20.83) and overall accidental drug‐induced mortality rate of 0.5 per 100 PY (95% CI = 0.36–0.71). Reports of recent use of ambulance services [adjusted hazard ratio (aHR) = 3.77, 95% CI =1.78–7.97] and four or more incarcerations (aHR = 2.78, 95% CI = 1.55–4.99) were associated with increased mortality risk. Conclusions: In Melbourne, Australia, mortality among people who inject drugs appears to be positively associated with recent ambulance attendance and experience of incarceration. [ABSTRACT FROM AUTHOR]

Aims: To estimate incidence of post‐release injecting drug use (IDU) among men who injected drugs before imprisonment and determine factors associated with post‐release IDU frequency. Design, setting, participants: Prospective cohort study of men reporting monthly IDU before a period of sentenced imprisonment in Victoria, Australia, recruited between September 2014 and May 2016 (n = 195). Measurements: Any post‐release IDU and IDU frequency was measured via self‐report at 3‐month follow‐up interview. IDU frequency, measured over the preceding month, was categorised as no IDU, irregular IDU (1–4 days IDU) and regular IDU (≥5 days IDU). Incidence of any IDU was calculated at 3 months post‐release. Factors associated with IDU frequency were estimated using ordinal logistic regression. Findings Most (83%) participants reported post‐release IDU (265 per 100 person‐years, 95% CI, 227–309); with half (48%) reporting regular IDU, 23% irregular IDU and 29% no IDU in the month preceding follow‐up. Poorer psychological well‐being at follow‐up (General Health Questionnaire [GHQ‐12] score; adjusted odds ratio [AOR], 1.18; 95% CI, 1.07–1.29) and post‐release unemployment (AOR, 4.57; 95% CI, 1.67–12.49) were associated with increased IDU frequency. Retention in opioid agonist treatment (AOR, 0.49; 95% CI, 0.24–0.98) was associated with reduced IDU frequency. Non‐linear (inverted‐u) associations between IDU frequency and age (age: AOR, 1.51; 95% CI, 1.17–1.96; age‐squared: AOR, 0.99; 95% CI, 0.99–0.99) and pre‐imprisonment IDU frequency (pre‐imprisonment IDU frequency: AOR, 1.36; 95% CI, 1.15–1.61; pre‐imprisonment IDU frequency‐squared: AOR, 0.99; 95% CI, 0.99–0.99) were found, with odds peaking at age 39 and 19 days IDU, respectively. Longer baseline sentence length was associated with reduced odds of irregular and regular IDU (AOR, 0.99; 95% CI, 0.99–0.99). Conclusion: Among Australian men who inject drugs before imprisonment, resumption of injecting drug use after release from prison appears to be common, with imprisonment seeming to have little impact on reducing injecting drug use behaviour. [ABSTRACT FROM AUTHOR]

Introduction: People who inject drugs are at high risk of blood‐borne infections. We describe the epidemiology of HIV among people who inject drugs in England, Wales, and Northern Ireland (EW&NI) since 1981. Methods: National HIV surveillance data were used to describe trends in diagnoses (1981–2019), prevalence (1990–2019), and behaviours (1990–2019) among people who inject drugs aged ≥15 years in EW&NI. HIV care and treatment uptake were assessed among those attending in 2019. Results: Over the past four decades, the prevalence of HIV among people who inject drugs in EW&NI remained low (range: 0.64%–1.81%). Overall, 4978 people who inject drugs were diagnosed with HIV (3.2% of cases). Diagnoses peaked at 234 in 1987, decreasing to 78 in 2019; the majority were among white men born in the UK/Europe (90%), though the epidemic diversified over time. Late diagnosis (CD4 <350 cells/µl) was common (2010–2019: 52% [429/832]). Of those who last attended for HIV care in 2019, 97% (1503/1550) were receiving HIV treatment and 90% (1375/1520) had a suppressed viral load (<200 copies/ml). HIV testing uptake has steadily increased among people who inject drugs (32% since 1990). However, in 2019, 18% (246/1404) of those currently injecting reported never testing. The proportion of people currently injecting reporting sharing needles/syringes decreased from 1999 to 2012, before increasing to 20% (288/1426) in 2019, with sharing of any injecting equipment at 37% (523/1429). Conclusion: The HIV epidemic among people who inject drugs in EW&NI has remained relatively contained compared with in other countries, most likely because of the prompt implementation of an effective national harm reduction programme. However, risk behaviours and varied access to preventive interventions among people who inject drugs indicate the potential for HIV outbreaks. [ABSTRACT FROM AUTHOR]

Introduction and Aims: Opioid overdose prevention programs providing take-home naloxone have been expanding internationally. This paper summarises findings and lessons learnt from the Overdose Prevention and Emergency Naloxone Project which is the first take-home naloxone program in Australia implemented in a health care setting.Methods: The Project intervention provided education and take-home naloxone to opioid-using clients at Kirketon Road Centre and The Langton Centre in Sydney. The evaluation study examined uptake and acceptability of the intervention; participants' knowledge and attitudes regarding overdose and participants' experience in opioid overdose situations six months after the intervention. Participants completed baseline, post-training and follow-up questionnaires regarding overdose prevention and management which were analysed using repeated measures analysis of variance.Results: Eighty-three people participated in the intervention, with 35 (42%) completing follow-up interviews-51% reporting using naloxone with 30 overdoses successfully reversed. There were significant improvements in knowledge and attitudes immediately following training with much retained at follow-up, particularly regarding feeling informed enough (97%) and confident to inject naloxone (100%).Discussion: Take-home naloxone programs can be successfully implemented in Australian health settings. Barriers to uptake, such as lengthy processes and misperceptions around interest in overdose prevention, should be addressed in future program implementation. [ABSTRACT FROM AUTHOR]

Introduction: To describe trends in methamphetamine use, markets and harms in Australia from 2003 to 2019. Methods: Data comprised patterns of use and price from sentinel samples of people who inject drugs and who use MDMA/other illicit stimulants and population‐level amphetamine‐related police seizures, arrests, hospitalisations, treatment episodes and deaths from approximately 2003 to 2019. Bayesian autoregressive time‐series models were analysed for: no change; constant rate of change; and change over time differing in rate after one to three changepoints. Related indicators were analysed post hoc with identical changepoints. Results: The percentage of people who inject drugs reporting weekly use increased from 2010 to 2013 onwards, while use among samples of people who regularly use ecstasy and other illicit stimulants decreased. Seizures and arrests rose steeply from around 2009/10 to 2014/15 and subsequently plateaued. Price increased ($15.9 [95% credible interval, CrI $9.9, $28.9] per point of crystal per year) from around 2009 to 2011, plateauing and then declining from around 2017. Hospitalisation rates increased steeply from around 2009/10 until 2015/16, with a small subsequent decline. Treatment also increased (19.8 episodes [95% CrI 13.2, 27.6] with amphetamines as the principal drug of concern per 100 000 persons per year) from 2010/11 onwards. Deaths involving amphetamines increased (0.285 per 100 000 persons per year) from 2012 until 2016. Discussion and Conclusions: These findings suggest that problematic methamphetamine use and harms escalated from 2010 to 2012 onwards in Australia, with continued demand and a sustained market for methamphetamine. [Correction added on 30 May 2022, after first online publication: In the Abstract under 'Discussion and Conclusions' 'onwards' has been added after ... 2010 to 2012]. [ABSTRACT FROM AUTHOR]

Introduction and Aims: The effect of heroin administration route on speed of transition to regular use is unknown. This paper aims to determine whether the speed of transition from initiation of heroin use to daily heroin use differs by route of administration (injecting, chasing/inhaling or snorting).Design and Methods: Privileged access interviewer survey of purposively selected sample of 395 current people who use heroin (both in and not in treatment) in London, UK (historical sample from 1991). Data on age and year of initiation, time from initiation to daily use and routes of administration were collected by means of a structured questionnaire. Generalised ordered logistic models were used to test the relationship between route of initial administration of heroin and speed of transition to daily heroin use. Analyses were adjusted for gender, ethnicity, daily use of other drug(s) at time of initiation, year of initiation and treatment status at interview.Results: After adjustment, participants whose initial administration route was injecting had a 4.71 (95% confidence interval 1.34-16.5) increase in likelihood of progressing to daily use within 1-3 weeks of initiation, compared to those whose initial administration route was non-injecting.Discussion and Conclusions: The speed of transition from first use to daily heroin use is faster if the individual injects heroin at initiation of use. Those who initiate heroin use through injecting have a shorter time frame for intervention before drug use escalation. [Hines LA, Lynskey M, Morley KI, Griffiths P, Gossop M, Powis B, Strang J. The relationship between initial route of heroin administration and speed of transition to daily heroin use. Drug Alcohol Rev 2017;00:000-000]. [ABSTRACT FROM AUTHOR]

Whilst the testing and treatment of people who inject drugs (PWID) in Australia is a priority for local hepatitis C (HCV) elimination efforts, perceived stigma related to injecting drug use (IDU) has been identified as a major barrier for PWID engaging in health services. We used data from the EC Experience cohort study to explore associations between IDU‐related perceived stigma and the number of different health services accessed by PWID in Melbourne, Australia. Data from the baseline questionnaire were used. Primary outcome was self‐reported experience of stigma due to IDU (never, rarely, sometimes, often, always) in the previous 12 months. An ordinal logistic regression model assessed the association between stigma experienced and the number of different health services used (1–2, 3–4, 5–6, 7–10 different services) adjusted for recent IDU and key socio‐demographics. Between September 2018 and February 2020, 281 participants were recruited from four health services. Sixty‐nine per cent were male, median age was 42, 83% reported past‐month IDU, 34% had never tested/tested >12 months, 8% tested negative <12 months, 43% were HCV‐positive but not treated and 16% had been treated. Those accessing 5–6 services had 2.2 times greater odds of experiencing stigma (95% CI 0.86–6.65) compared with those using <5 services and those reporting 7–10 services had 2.43 times greater odds of experiencing stigma (95% CI 0.85–6.92) compared with those accessing <7 services. In conclusion, experiences of stigma may not necessarily be a barrier for PWID to access health services, but high rates of health service use may further expose, exacerbate or exaggerate stigma amongst PWID. Further examination of how stigma may be in/directly impact on hepatitis C treatment uptake is important and place‐based interventions aimed at reducing stigma experienced by PWID may be needed. [ABSTRACT FROM AUTHOR]

Summary: To achieve WHO hepatitis C virus (HCV) elimination targets by 2030, mathematical models suggest there needs to be significant scale‐up of treatment among people who inject drugs (PWID). We tested whether people who actively inject drugs can be recruited and treated successfully through a community needle and syringe programme (NSP), and assessed rates of re‐infection. 105 HCV RNA positive participants were enrolled prospectively. Participants were recruited from the largest NSP in Dundee over 42 months. 94/105 individuals commenced treatment. Genotype 1 (G1) individuals (n = 37) were treated with peg‐interferon+ribavirin+Simepravir/Telaprevir. Genotype 2/3 (G2/3) (n = 57) received peg‐interferon+ribavirin. Weekly study visits took place within the NSP. Mean age of participants was 34.0 years (SD 6.9), 71.3% (61/94) were male. One in five (20/94) participants were homeless. 68.1% (64/94) were on OST (opiate substitution therapy) at enrolment; participants injected median 6.5 times/wk. In terms of clinical outcomes, >80% treatment adherence was 71.3% (67/94). There was no difference in SVR‐12 rates by genotype: 81.0% (30/37) for G1 and 82.5% (47/55) for G2/3. At 18 months post‐treatment, 15/77 participants were reinfected, followed up over 69.8 person‐years, yielding a re‐infection rate of 21.5/100 person‐years (95% CI 13.00‐35.65). This trial demonstrates that HCV treatment can be delivered successfully to the target population of treatment as prevention strategies. We report higher rates of re‐infection than existing estimates among PWID. Scale‐up of HCV treatment should be pursued alongside a comprehensive programme of harm reduction interventions to help minimize re‐infection and reduce HCV transmission. [ABSTRACT FROM AUTHOR]

Background and Aims: People who have recently injected drugs are a priority population in efforts to achieve hepatitis C virus (HCV) elimination. This study estimated the prevalence and number of people with recent injecting drug use living with HCV, and the proportion of people with recent injecting drug use among all people living with HCV infection at global, regional and country‐levels. Methods: Data from a global systematic review of injecting drug use and HCV antibody prevalence among people with recent (previous year) injecting drug use were used to estimate the prevalence and number of people with recent injecting drug use living with HCV. These data were combined with a systematic review of global HCV prevalence to estimate the proportion of people with recent injecting drug use among all people living with HCV. Results: There are an estimated 6.1 million [95% uncertainty interval (UI) = 3.4–9.2] people with recent injecting drug use aged 15–64 years living with HCV globally (39.2% viraemic prevalence; UI = 31.6–47.0), with the greatest numbers in East and Southeast Asia (1.5 million, UI = 1.0–2.1), eastern Europe (1.5 million, UI = 0.7–2.4) and North America (1.0 million, UI = 0.4–1.7). People with recent injecting drug use comprise an estimated 8.5% (UI = 4.6–13.1) of all HCV infections globally, with the greatest proportions in North America (30.5%, UI = 11.7–56.7), Latin America (22.0%, UI = 15.3–30.4) and eastern Europe (17.9%, UI = 8.2–30.9). Conclusions: Although, globally, 39.2% of people with recent injecting drug use are living with hepatitis C virus (HCV) and 8.5% of all HCV infections occur globally among people with recent injecting drug use, there is wide variation among countries and regions. [ABSTRACT FROM AUTHOR]

Objectives: In persons with hepatitis C virus (HCV) infection, HIV coinfection leads to faster progression to advanced liver disease. The aim of our study was to estimate diagnosed HIV prevalence among people with evidence of current HCV infection (polymerase chain reaction positive) and examine predictors of coinfection. Methods: Adults (≥ 15 years old) with a current HCV infection reported to the Public Health England (PHE) sentinel surveillance of blood‐borne viruses were linked to the PHE national HIV database using a deterministic methodology. Descriptive and multivariate analyses were conducted. Results: Between 2008 and 2014, 5.0% (999/20 088) of adults with a current HCV infection were diagnosed with HIV coinfection. The majority acquired HIV through sex between men (441; 64.9%), followed by injecting drug use (153; 22.5%) and heterosexual contact (84; 12.4%). Of persons who were coinfected, 65.5% had been diagnosed with HIV infection > 6 months before their HCV diagnosis, 41.4% of whom had a negative anti‐HCV test between their HIV and HCV diagnoses. In a multivariable model among persons with current HCV infection, an HIV diagnosis was more likely among men [adjusted odds ratio (aOR) 3.29; 95% confidence interval (CI) 2.60–4.16] and persons of black ethnicity (aOR 3.19; 95% CI 1.36–7.46), and less likely among older adults (aOR 0.85 per 10‐year increase; 95% CI 0.79–0.92) and persons of Asian ethnicity (aOR 0.59; 95% CI 0.41–0.86). Conclusions: Our results indicate that the majority of diagnosed HIV and current HCV coinfections are among men who have sex with men. Safer sex campaigns should include awareness of transmission of HCV among MSM living with HIV. [ABSTRACT FROM AUTHOR]

Introduction and Aims: People who use performance and image enhancing drugs (PIED) are a growing population in needle syringe programs (NSP) in Australia. Previous international research has identified heterogeneity among the PIED-using population. This study investigated health behaviours among NSP attendees who had recently (last 12 months) injected PIEDs and examined differences among this group according to recent psychoactive drug use.Design and Methods: The Australian Needle and Syringe Program Survey is an annually repeated cross-sectional survey conducted at approximately 50 NSPs nationally. In 2015, respondents provided information on their demographic characteristics, health risk and health monitoring behaviours, and provided a capillary dried blood spot for HIV and hepatitis C virus antibody testing. Univariable and multivariable logistic regressions assessed factors associated with recent (last 12 months) use (all routes of administration) of psychoactive drugs.Results: Among recent PIED injectors (n = 156), 59% had recently used psychoactive substances. Those who had recently used psychoactive drugs were significantly younger, less educated and more likely to have experienced redness at an injection site in the previous 12 months but were more likely to report recent HIV/hepatitis C virus testing.Discussion and Conclusions: This study identified significant differences in demographic characteristics, risk and health seeking behaviour among PIED users who did and did not also use psychoactive substances. There is a need to enhance and tailor harm reduction efforts and to build the capacity of NSP staff to better meet the needs of this diverse group. [ABSTRACT FROM AUTHOR]

Background and aims In Scotland, hepatitis B virus (HBV) vaccination for all prisoners was introduced in 1999; here, we examine the impact of this programme among people who inject drugs (PWID) in the community. This study aimed to compare rates of HBV vaccine uptake before and after implementation of the prison programme and to estimate the determinants of vaccine uptake, the levels of ever/current HBV infection and the associations between vaccine uptake and ever/current HBV infection. Design Data collected via serial cross-sectional surveys were used to compare the proportion who reported being vaccinated over time. For the 2013-14 survey, rates of ever/current HBV infection were calculated and the associations between vaccine uptake and ever/current HBV infection were examined using logistic regression. Setting Services providing injecting equipment and drug treatment and street sites in Glasgow (1993-2002) and throughout Scotland (2008-14). Participants More than 10 000 PWID in total were recruited in the surveys. Measurements Participants completed a questionnaire (all years) to ascertain self-reported vaccine uptake and provided a blood spot (in 2013-14), tested for HBV core antibodies (anti-HBc) and surface antigen (HBsAg). Findings Among recent-onset PWID in Glasgow, vaccine uptake increased from 16% in 1993 to 59% in 2008-14 ( P < 0.001). Among all PWID in Scotland, uptake increased further from 71% in 2008-09 to 77% in 2013-14 ( P < 0.001) and was associated with incarceration [adjusted odds ratio (aOR) = 2.91, 95% confidence interval (CI) = 2.23-3.79]. The prevalence of anti-HBc and HBsAg in Scotland was 2.6 and 0.3%, respectively, among PWID who had commenced injecting in the decade since the programme's introduction. Vaccination was associated with reduced odds of ever (aOR = 0.60, CI = 0.37-0.97) and current (aOR = 0.40, CI = 0.16-0.97) HBV infection. Conclusions In Scotland, uptake of hepatitis B virus (HBV) vaccination among people who inject drugs (PWID) in the community has increased since the 1999 introduction of universal prison vaccination, and current levels of HBV infection among PWID are low compared with other European countries. [ABSTRACT FROM AUTHOR]

Introduction and Aims: To examine patterns of illicit drug use among Australian Indigenous young people, identify correlates of frequent use separately in urban, regional and remote settings and characterise those who inject.Design and Method: Cross-sectional design at 40 Indigenous events. Self-complete surveys were administered to Indigenous people aged 16-29 years using mobile devices.Results: 2,877 participants completed the survey. One in five reported using cannabis at least weekly in the previous year, but the use of other drugs was less prevalent. Patterns of drug use were largely similar across regions, although more participants in urban and regional areas reported using ecstasy (12% vs 11% vs 5%) and cocaine (6% vs 3% vs 1%) and more reported weekly cannabis use (18% vs 22% vs 14%). Injecting was rare (3%) but those who did inject reported a high incidence of needle sharing (37%). Methamphetamine (37%), heroin (36%) and methadone (26%) were the most commonly injected drugs, and injecting was related to prison experience (AOR 5.3 95% CI 2.8-10.0).Discussion and Conclusion: Attention is needed in relation to cannabis use, particularly among those Indigenous young people living in regional and urban settings. Also, although injecting is uncommon, it is associated with prison involvement. Priority must be given to reducing the numbers of Indigenous youth entering justice settings, delaying the age at first entry to justice settings, and reducing the risk of BBV acquisition while in custody through, for example, prison-based NSP, BBV education, and Indigenous-specific treatment that emphasises connection to country and culture. [Bryant J, Ward J, Wand H, Byron K, Bamblett A, Waples-Crowe P, Betts S, Coburn T, Delaney-Thiele D, Worth H, Kaldor J, Pitts M. Illicit and injecting drug use among Indigenous young people in urban, regional and remote Australia. Drug Alcohol Rev 2016;35:447-455]. [ABSTRACT FROM AUTHOR]

Aims To assess whether people who inject drugs (PWID) and who are treated for overdose by ambulance services have a greater mortality risk compared with other PWID, and to compare mortality risk within potentially critical time-periods (1 week, 1 month, 3 months, 6 months, 1 year, 5 years) after an overdose attendance with the mortality risk within potentially non-critical time-periods (time before and/or after critical periods). Design A prospective cohort study. Setting Oslo, Norway. Participants A total of 172 PWID street-recruited in 1997 and followed-up until the end of 2004. Measurements Interview data linked to data from ambulance records, Norwegian Correctional Services, Opioid Substitution Treatment records and National Cause of Death Registry. Separate Cox regression models (one for each critical time-period) were estimated. Findings Ambulance services treated 54% of the participants for an overdose during follow-up. The mortality rate was 2.8 per 100 person-years for those with an overdose and 3.3 for those without; the adjusted hazard ratio (HR) was 1.3 (95% CI = 0.6, 2.6, P = 0.482). Mortality risk was greater in all but the shortest critical time-period following ambulance attendance than in the non-critical periods. The mortality risk remained significantly elevated during critical periods, even when adjusted for total time spent in prison and substitution treatment. The HR ranged from 9.4 (95% CI = 3.5, 25.4) in the month after an overdose to 13.9 (95% CI = 6.4, 30.2) in the 5-year period. Conclusions Mortality risk among people who inject drugs is significantly greater in time-periods after an overdose attendance than outside these time-periods. [ABSTRACT FROM AUTHOR]

Aims To assess systematically the risk of HIV acquisition by type of drug injected across different settings. Methods A systematic review and meta-analysis were conducted. Databases were searched for studies of HIV incidence in people who inject different drugs (PWID). Pooled HIV incidence rate ratio (IRR) was used to compare HIV risk between injecting and not-injecting a given drug, when possible, or otherwise with those reported not to have injected the substance. Pooled estimates of crude IRR were derived using random-effects models. Variations in IRR were assessed in subgroup analyses, by drug and geographical region. Results Of 5779 studies screened, 15 were included. HIV incidence was reported for people injecting cocaine (eight: North America, Europe), amphetamine-type stimulants (ATS) (four: Western and Eastern Europe, Asia), heroin (11: all settings), opiate-stimulants (four: North America, Western and Eastern Europe) and opiates-sedatives (five: Europe, Asia). HIV risk in cocaine injectors was 3.6 times 95% confidence interval (CI) = 2.8-4.7, I2 = 0%; n = 4) that of non-injectors and 3.0 for ATS injectors (95% CI = 2.2-4.1, I2 = 0%; n = 2). Higher sexual risk was reported in cohorts injecting stimulants. Compared to not-injecting, HIV IRR was 2.8 (95% CI = 1.7-4.7, I2 = 77%; n=6) for all heroin injectors and 3.5 (95% CI = 2.3-5.2, I2 = 40%; n=5) for heroin injectors in Asia and Europe. Conclusion The risk of HIV acquisition in people who inject drugs appears to vary by drug type but differences are not statistically significant, precluding conclusive grading of risk. [ABSTRACT FROM AUTHOR]

While numerous studies have examined characteristics of young people who have recently initiated injecting, little attention has focused on young people who may be at high risk of transitioning to injecting. This study sought to examine the extent that socially disadvantaged young people were exposed to injecting, determine their level of hepatitis C ( HCV) knowledge and identify correlates of higher injecting exposure. A cross-sectional survey was administered to 210 young people in 2010-2011 who were exposed to injecting drug use, but had not transitioned to injecting. Respondents were primarily recruited from youth services in metropolitan Sydney. Exposure to injecting in the previous 12 months was assessed with four items that examined whether close friends, romantic/sexual partners or family members/acquaintances injected drugs, and whether they were offered an injection. Most respondents had at least a few close friends who injected drugs (65%) and almost half had been offered drugs to inject in the previous 12 months (48%). It was less common for respondents to report having a partner who injects (11%). Correlates of higher injecting exposure were examined with multivariate ordinal regression. In the multivariate model, higher exposure to injecting was independently associated with the experience of abuse or violent crime [adjusted odds ratio ( AOR) = 1.80] and reporting more favourable attitudes towards injecting ( AOR = 0.86). Higher exposure to injecting was not independently associated with patterns or history of drug use. HCV knowledge was low to moderate and was not associated with higher exposure to injecting. That drug use was not independently associated with higher injecting exposure may suggest that exposure is shaped more by social disadvantage than by drug use patterns. Additional research is required to investigate this, using an improved measure of exposure to injecting. [ABSTRACT FROM AUTHOR]

Introduction Adolescence is a time of physical, emotional and social transitions that have implications for health. In addition to being at high risk for HIV, young key populations (YKP) may experience other health problems attributable to high-risk behaviour or their developmental stage, or a combination of both. Discussion We reviewed the needs, barriers and gaps for other non-HIV health services for YKP. We searched PubMed and Google Scholar for articles that provided specific age-related data on sexual and reproductive health; mental health; violence; and substance use problems for adolescent, youth or young sex workers, men who have sex with men, transgender people, and people who inject drugs. Results YKP experience more unprotected sex, sexually transmitted infections including HIV, unintended pregnancy, violence, mental health disorders and substance use compared to older members of key populations and youth among the general population. YKP experience significant barriers to accessing care; coverage of services is low, largely because of stigma and discrimination experienced at both the health system and policy levels. Discussion YKP require comprehensive, integrated services that respond to their specific developmental needs, including health, educational and social services within the context of a human rights-based approach. The recent WHO Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations are an important first step for a more comprehensive approach to HIV programming for YKP, but there are limited data on the effective delivery of combined interventions for YKP. Significant investments in research and implementation will be required to ensure adequate provision and coverage of services for YKP. In addition, greater commitments to harm reduction and rights-based approaches are needed to address structural barriers to access to care. [ABSTRACT FROM AUTHOR]

Introduction Evidence suggests that people who inject drugs often begin their drug use and injecting practices in adolescence, yet there are limited data available on the HIV epidemic and the responses for this population. The comprehensive package of interventions for the prevention, treatment and care of HIV infection among people who inject drugs first laid out in 2009 (revised in 2012) by World Health Organization, United Nations Office of Drugs and Crime and Joint United Nations Programme on HIV/AIDS, does not consider the unique needs of adolescent and young people. In order to better understand the values and preferences of young people who inject drugs in accessing harm reduction services and support, we undertook a series of community consultations with young people with experience of injecting drugs during adolescence. Methods Community consultations (4-14 persons) were held in 14 countries. Participants were recruited using a combined criterion and maximum variation sampling strategy. Data were analyzed using collaborative qualitative data analysis. Frequency analysis of themes was conducted. Results Nineteen community consultations were organized with a total of 132 participants. All participants had experienced injecting drugs before the age of 18. They had the following age distribution: 18-20 (37%), 21-25 (48%) and 26-30 (15%). Of the participants, 73.5% were male while 25.7% were female, with one transgender participant. Barriers to accessing the comprehensive package included: lack of information and knowledge of services, age restrictions on services, belief that services were not needed, fear of law enforcement, fear of stigma, lack of concern, high cost, lack of outreach, lack of knowledge of HCV/TB and lack of youth friendly services. Conclusions The consultations provide a rare insight into the lived experiences of adolescents who inject drugs and highlight the dissonance between their reality and current policy and programmatic approaches. Findings suggest that harm reduction and HIV policies and programmes should adapt the comprehensive package to reach young people and explore linkages to other sectors such as education and employment to ensure they are fully supported and protected. Continued participation of the community of young people who inject drugs can help ensure policy and programmes respond to the social exclusion and denial of rights and prevent HIV infection among adolescents who inject drugs. [ABSTRACT FROM AUTHOR]

Introduction and Aims The medical complications of injecting preparations from crushed tablets can be severe, and most can be attributed to the injection of insoluble particles and micro-organisms. Previously we have shown that most of the particles can be removed by filtration, but it was not known whether bacteria could also be filtered in the presence of a high particle load. This study aims to determine the feasibility of filtration to remove bacteria from injections prepared from tablets. Design and Methods Injections were prepared from crushed slow-release morphine tablets, in mixed bacterial suspensions of S taphylococcus aureus, S treptococcus pyogenes and P seudomonas aeruginosa. The injection suspensions were passed through syringe filters of porosity 0.45 or 0.20 μm, or combined 0.8 then 0.2 μm, and the bacterial load was counted. Results Bacterial concentrations in unfiltered injections were 2.5-4.3 × 106 colony forming units mL −1. Both the 0.20 and 0.45 μm filters blocked unless a prefilter (cigarette filter) was used first. The 0.2 μm filter and the combined 0.8/0.2 μm filter reduced the bacteria to the limit of detection (10 colony forming units mL −1) or below. Filtration through a 0.45 μm filter was slightly less effective. Discussion and Conclusions Use of a 0.2 μm filter, together with other injection hygiene measures, offers the prospect of greatly reducing the medical complications of injecting crushed tablets and should be considered as a highly effective harm reduction method. It is very likely that these benefits would also apply to other illicit drug injections, although validation studies are needed. [Ng H, Patel RP, Latham R, Bruno R, Wanandy R, McLean S. Filtration of crushed tablet suspensions has potential to reduce infection incidence in people who inject drugs. Drug Alcohol Rev 2015;34:67-73] [ABSTRACT FROM AUTHOR]

Aims To examine changes in causes of death in a cohort treated for opioid dependence, across time and age; quantify years of potential life lost ( YPLL); and identify avoidable causes of death. Design People in New South Wales ( NSW) who registered for opioid substitution therapy ( OST), 1985-2005, were linked to a register of all deaths in Australia. Setting NSW, Australia. Measurements Crude mortality rates ( CMRs), age-sex-standardized mortality rates ( ASSRs) and standardized mortality ratios ( SMRs) across time, sex and age. Years of potential life lost ( YPLL) were calculated with reference to Australian life tables and by calculating years lost before the age of 65 years. Findings There were 43 789 people in the cohort, with 412 216 person-years of follow-up. The proportion of the cohort aged 40+ years increased from 1% in 1985 to 39% in 2005. Accidental opioid overdoses, suicides, transport accidents and violent deaths declined with age; deaths from cardiovascular disease, liver disease and cancer increased. Among men, 89% of deaths were potentially avoidable; among women, 86% of deaths were avoidable. There were an estimated 160 555 YPLL in the cohort, an average of 44 YPLL per decedent and an average of 29 YPLL before age 65 years. Conclusions Among a cohort of opioid-dependent people in New South Wales, 1985-2005, almost nine in 10 deaths in the cohort were avoidable. There is huge scope to improve mortality among opioid-dependent people. [ABSTRACT FROM AUTHOR]

Introduction and Aims. To estimate the contribution that people who inject drugs ( PWID) make to population-level use of prescription opioids in Australia. Design and Methods. Data on prescriptions of oxycodone, morphine and methadone tablets were obtained for New South Wales, Victoria, Tasmania and Queensland, and time series analyses used to characterise the trends from 2002 to 2010. Estimates of the number of PWID were combined with data on their levels, frequency and typical doses of morphine, methadone tablet (only prescribed in Australia for pain) and oxycodone from 2004 to 2010. Estimated consumption per 1000 PWID and per 1000 persons aged 20-69 years was contrasted and the proportion of total consumption accounted for by PWID estimated. Results. Morphine prescribing declined; oxycodone prescribing increased. PWID had far higher rates of prescription opioid consumption (defined daily doses per 1000) than the general population. Tasmania had highest use of prescribed opioids. PWID contribution to morphine consumption in Tasmania increased to 28% (range 22-37%) in 2010; elsewhere, PWID contribution was lower (midpoints of 2-12%, 2010). Methadone tablet use was less elevated compared with the general population. With the exception of Tasmania, PWID were estimated to consume less than 5% of oxycodone. Discussion and Conclusions. PWID use prescription opioids at high levels and can account for a significant proportion of consumption. Increased oxycodone prescribing in Australia has not been driven by PWID. Opioid substitution therapy and other effective treatments need to be more available and attractive to PWID. [Degenhardt L, Gilmour S, Shand F, Bruno R, Campbell G, Mattick RP, Larance B, Hall W. Estimating the proportion of prescription opioids that is consumed by people who inject drugs in Australia. Drug Alcohol Rev 2013;32:468-474] [ABSTRACT FROM AUTHOR]

Introduction and Aims While people who inject drugs are at high risk of hepatitis C virus ( HCV) infection and will be the target population for future HCV vaccine trials, little is known about clinical trial literacy ( CTL) in this group. We assessed the impact of a brief intervention ( BI) designed to improve HCV vaccine CTL among people who inject drugs in Sydney, Australia. Design and Methods People who inject drugs enrolled in a community-based prospective observational study between November 2008 and September 2010 ( n = 102) completed a CTL assessment followed immediately by the BI. Post-test assessment was conducted at 24 weeks. Results The median age of the sample was 27 years, 73% were male and 60% had 10 or less years of schooling. The median time since first injection was 5 years and 20% reported daily or more frequent injecting. The mean number of correct responses increased from 5.3 to 6.3/10 ( t = −4.2; 101df, P < 0.001) 24 weeks post-intervention. Statistically significant differences were observed for three knowledge items with higher proportions of participants correctly answering questions related to randomisation ( P = 0.002), blinding ( P = 0.005) and vaccine-induced seropositivity ( P = 0.003) post-intervention. Discussion and Conclusions A significant increase in HCV vaccine CTL was observed, suggesting that new and relatively novel concepts can be learned and recalled in this group. These findings support the feasibility of future trials among this population. [Correction added on 21 November 2012, after first online publication: T-score for mean number of correct responses was corrected to '−4.2' in the Results section.] [White B, Madden A, Hellard H, Kerr T, Prins M, Page K, Dore GJ, Maher L. Increased hepatitis C virus vaccine clinical trial literacy following a brief intervention among people who inject drugs. Drug Alcohol Rev 2013;32:419-425] [ABSTRACT FROM AUTHOR]

Introduction and Aims Targeted primary health-care services for injecting drug users have been established in several countries to reduce barriers to health care, subsequent poor health outcomes and the considerable costs of emergency treatment. The long-term sustainability of such services depends on the resources required and the coverage provided. This study assesses the additional cost required to operate a nurse-led primary health care in an existing needle syringe program setting, estimates the costs per occasion of service and identifies key factors influencing improved service utilisation. Design and Methods Using standard costing methods and the funder perspective, this study estimates costs using the 'ingredients' approach where the costs of inputs are based on quantities and unit prices (the ingredients). Results During the 2009-2010 fiscal year, the primary health-care clinic provided 1252 occasions of service to 220 individuals, who each made an average of 3.9 presentations. A total cost of AU$250 626 was incurred, 69% of which was for personnel and 22% for pathology. During the study period the average cost per occasion of service was AU$199.96, which could be as low as AU$93.32 if the clinic reached its full utilisation level. Discussion and Conclusions Although the average number of presentations per client was satisfactory, the clinic was underutilised during the study period. Proactive engagement of clients at the needle syringe program shopfront and an increased range of services offered by the clinic may help to attract more clients. [ABSTRACT FROM AUTHOR]

Aims To investigate the impact of scaling-up opiate substitution therapy ( OST) and high coverage needle and syringe programmes (100% NSP-obtaining more sterile syringes than you inject) on HCV prevalence among injecting drug users ( IDUs). Design Hepatitis C virus HCV transmission modelling using UK estimates for effect of OST and 100% NSP on individual risk of HCV infection. Setting Range of chronic HCV prevalent (20/40/60%) settings with no OST/100% NSP, and UK setting with 50% coverage of both OST and 100% NSP. Participants Injecting drug users. Measurements Decrease in HCV prevalence after 5-20 years due to scale-up of OST and 100% NSP to 20/40/60% coverage in no OST/100% NSP settings, or from 50% to 60/70/80% coverage in the UK setting. Findings For 40% chronic HCV prevalence, scaling-up OST and 100% NSP from 0% to 20% coverage reduces HCV prevalence by 13% after 10 years. This increases to a 24/33% relative reduction at 40/60% coverage. Marginally less impact occurs in higher prevalence settings over 10 years, but this becomes more pronounced over time. In the United Kingdom, without current coverage levels of OST and 100% NSP the chronic HCV prevalence could be 65% instead of 40%. However, increasing OST and 100% NSP coverage further is unlikely to reduce chronic prevalence to less than 30% over 10 years unless coverage becomes ≥80%. Conclusions Scaling-up opiate substitution therapy and high coverage needle and syringe programmes can reduce hepatitis C prevalence among injecting drug users, but reductions can be modest and require long-term sustained intervention coverage. In high coverage settings, other interventions are needed to further decrease hepatitis C prevalence. In low coverage settings, sustained scale-up of both interventions is needed. [ABSTRACT FROM AUTHOR]

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ABSTRACT Aims We conducted a systematic review of studies reporting seroincidence of hepatitis C infection (HCV) in relation to shared syringes and drug preparation equipment among injection drug users (IDUs). We identified published and unpublished studies that met inclusion criteria. Design We estimated the relative contributions of shared syringes and drug preparation equipment to HCV transmission using random-effects meta-analysis, and analyzed potential sources of heterogeneity of effects among studies. Findings Syringe sharing was associated with HCV seroconversion [pooled risk ratio (PRR) = 1.94, 95% confidence interval (CI) 1.53, 2.46], as was sharing drug preparation containers (PRR = 2.42, 95% CI 1.89, 3.10), filters (PRR = 2.61, 95% CI 1.91, 3.56), rinse water (PRR = 1.98, 95% CI 1.54, 2.56), combinations of this equipment (PRR = 2.24, 95% CI 1.28, 3.93) and 'backloading', a syringe-mediated form of sharing prepared drugs (PRR = 1.86, 95% CI 1.41, 2.44). Meta-regression results showed that the association between syringe sharing and seroconversion was modified by HCV seroprevalence in the IDU populations. Conclusions The risk of hepatitis C infection through shared syringes is dependent upon hepatitis C infection seroprevalence in the population. The risk of hepatitis C infection through shared drug preparation equipment is similar to that of shared syringes. Because the infection status of sharing partners is often unknown, it is important for injection drug users to consistently avoid sharing unsterile equipment used to prepare, divide or inject drugs and avoid backloading with an unsterile syringe. [ABSTRACT FROM AUTHOR]

ABSTRACT Aims The hepatitis C virus (HCV) disease burden among injecting drug users (IDUs) is determined by HCV incidence, the long latency period of HCV, competing mortality causes, presence of co-infection and HCV treatment uptake. We examined the effect of these factors and estimated the HCV disease burden in Amsterdam. Design A Markov model was developed, incorporating HCV and human immunodeficiency virus (HIV), and parameterized with data from the Amsterdam Cohort Studies, surveillance studies and literature. Setting IDU population of Amsterdam. Measurements HCV infection simulated from its acute phase to HCV-related liver disease (i.e. decompensated cirrhosis and hepatocellular carcinoma). Findings The HCV prevalence among IDUs in Amsterdam increased to approximately 80% in the 1980s. From 2011 to 2025, the HCV-related disease prevalence will accordingly rise by 36%, from 57 cases (95% range 33-94) to 78 (95% range 43-138), respectively. In total, 945 (95% range 617-1309) individuals will develop HCV-related liver disease. This burden would have been 33% higher in the absence of HIV, resulting in 1219 cases (95% range 796-1663). In Amsterdam, 25% of HIV-negative IDUs receive successful HCV treatment, reducing the cumulative disease burden by 14% to 810 (95% range 520-1120). Further reduction of 36% can be achieved by improving treatment, resulting in 603 cases (95% range 384-851). Conclusions The hepatitis C virus burden among injecting drug users in Amsterdam has been reduced by a high competing mortality rate, particularly caused by HIV infection, and to a smaller extent by hepatitis C virus treatment. Improved hepatitis C virus treatment is expected to contribute to reduce the future hepatitis C virus disease burden. [ABSTRACT FROM AUTHOR]