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Introduction: Methamphetamine use and methamphetamine-involved deaths have increased dramatically since 2015, and opioid-related deaths now frequently involve methamphetamine. Nevada and New Mexico are states with elevated rates of opioid and methamphetamine use. In this paper, we report results from a qualitative analysis that examined patterns of methamphetamine and opioid co-use over participants’ lifespan, factors that influence those patterns, and implications for health outcomes among users. Methods: Project AMPED was a multisite, mixed-methods study of methamphetamine use in Northern New Mexico and Northern Nevada. Between December 2019 and May 2020, qualitative interview participants were asked to describe their patterns of and reasons for co-administration of opioids and methamphetamine. Results: We interviewed 21 people who reported using methamphetamine in the past 3 months. Four primary patterns of methamphetamine and opioid co-use were identified: [1] using both methamphetamine and heroin, either simultaneously or sequentially (n = 12), [2] using methamphetamine along with methadone (n = 4), [3] using prescription opioids and methamphetamine (n = 1), and [4] using only methamphetamine (n = 4). Among those who used methamphetamine and heroin simultaneously or sequentially, motivations drew from a desire to enhance the effect of one drug or another, to feel the “up and down” of the “perfect ratio” of a goofball, or to mitigate unwanted effects of one or the other. Among those who used methamphetamine and methadone, motivations focused on alleviating the sedative effects of methadone. Conclusion: To address the emergent trend of increasing methamphetaminerelated deaths, researchers, health care professionals, and community health workers must acknowledge the decision-making processes behind co-use of opioids and methamphetamine, including the perceived benefits and harms of co-use. There is an urgent need to address underlying issues associated with drug use-related harms, and to design interventions and models of treatment that holistically address participants’ concerns. [ABSTRACT FROM AUTHOR]

Background: Dual substance dependence and psychiatric and psychological morbidities are overrepresented in prison populations and associated with reoffending. In the context of an increasing prison population in Australia, investigating the needs of vulnerable people in prison with a dual diagnosis can help inform in-prison screening and treatment and improve prison and community service integration and continuation of care. In this study we quantified psychiatric well-being in a sample of people in prison with a history of injecting drug use in Victoria, Australia, and identified factors associated with this outcome. Methods and Results: Data for this paper come from baseline interviews undertaken in the weeks prior to release as part of a prospective cohort study of incarcerated men who reported regular injecting drug use prior to their current sentence. Eligible participants completed a researcher-administered structured questionnaire that canvassed a range of issues. Psychiatric well-being was assessed using the 12-item General Health Questionnaire (GHQ-12) and potential correlates were included based on a review of the literature. Of the 317 men included for analyses, 139 were classified as experiencing current poor psychiatric well-being. In the multivariate model using modified logistic regression, history of suicide attempt (aOR = 1.36, 95%CI 1.03-1.78), two or more medical conditions (aOR = 1.87, 95%CI 1.30-2.67) and use of crystal methamphetamine in the week prior to their current sentence (aOR = 1.52, 95%CI 1.05-2.22) were statistically significantly associated with current poor psychiatric well-being. Conclusions: Comprehensively addressing the health-related needs for this vulnerable population will require a multidisciplinary approach and enhancing opportunities to screen and triage people in prison for mental health and other potential co-occurring health issues will provide opportunities to better address individual health needs and reoffending risk. [ABSTRACT FROM AUTHOR]

Background: About a third of the global HIV infections outside sub-Saharan Africa are related to injecting drug use (IDU), and this accounts for a growing proportion of persons living with HIV. This paper is a response to the need to monitor the state of the HIV epidemic as it relates to IDU and the availability of HIV treatment and harm reduction services in 21 high epidemic countries. Methods: A data collection form was designed to cover questions on rates of IDU, prevalence and incidence of HIV and information on HIV treatment and harm reduction services available to people who inject drugs (PWID). National and regional data on HIV infection, IDU in the form of reports and journal articles were sought from key informants in conjunction with a systematic search of the literature. Results: Completed data collection forms were received for 11 countries. Additional country-specific information was sourced via the literature search. The overall proportion of HIV positive PWID in the selected countries ranged from 3% in Kazakhstan to 58% in Vietnam. While IDU is relatively rare in sub-Saharan Africa, it is the main driver of HIV in Mauritius and Kenya, with roughly 47% and 36% of PWID respectively being HIV positive. All countries had antiretroviral treatment (ART) available to PWID, but data on service coverage were mainly missing. By the end of 2010, uptake of needle and syringe programmes (NSP) in Bangladesh, India and Slovakia reached the internationally recommended target of 200 syringes per person, while uptake in Kazakhstan, Vietnam and Tajikistan reached between 100-200 syringes per person. The proportion of PWID receiving opioid substitution therapy (OST) ranged from 0.1% in Kazakhstan to 32.8% in Mauritius, with coverage of less than 3% for most countries. Conclusions: In order to be able to monitor the impact of HIV treatment and harm reduction services for PWID on the epidemic, epidemiological data on IDU and harm reduction service provision to PWID needs to be regularly collected using standardised indicators [ABSTRACT FROM AUTHOR]

In the United States, HIV outbreaks are occurring in areas most affected by the opioid epidemic, including West Virginia (WV). Cultural Theory contends that multiple cultures co-exist within societies distinguished by their differing intensities of rules or norms of behavior ('grid') or degree of group allegiance/individual autonomy ('group'). Accordingly, we would expect that perceptions about HIV, including stigma, correspond with individuals' grid/group attributes. To explore this, we conducted qualitative interviews with people who inject drugs (PWID) recruited from a WV syringe service program. This paper focuses on our unexpected findings on stigma during a coinciding HIV outbreak. PWID living homeless identified as belonging to a 'street family'. Its members were mutually distrustful and constrained by poverty and drug dependence but despite their conflicts, reported openness between each other about HIV + status. Interviewees living with HIV perceived little enacted stigma from peers since the local outbreak. Contrasting stigmatizing attitudes were attributed to the town's mainstream society. The 'High Five' (Hi-V) Club, expressing defiance towards stigmatizing behavior outside the street family, epitomized the tensions between a desire for solidary and mutual support and a fatalistic tendency towards division and distrust. Fatalism may hinder cooperation, solidarity and HIV prevention but may explain perceived reductions in stigma.

Background: Coverage is used as one indicator of needle and syringe program (NSP) effectiveness. At the individual level, coverage is typically defined as an estimate of the proportion of a person who injects drugs' (PWID) injecting episodes that utilise a sterile syringe. In this paper, we explore levels of individual syringe coverage and its changes over time.Methods: Data were extracted from 1889 interviews involving 502 participants drawn from the Melbourne drug user cohort study (MIX). We asked questions relating to participants syringe acquisition, distribution and injecting frequency within the two weeks before interview. We created a dichotomous coverage variable that classified participants as sufficiently (≥100 %) covered if all their injecting episodes utilised at least one sterile syringe, and insufficiently (<100 %) covered if not. We categorised participants as "consistently covered" if they were sufficiently covered across interviews; as "consistently uncovered" if they were insufficiently covered across interviews; and "inconsistently covered" if they oscillated between coverage states. Chi-square statistics tested proportions of insufficient coverage across sub-groups using broad demographic, drug use and service utilisation domains. Logistic regression tested predictors of insufficient coverage and inconsistently covered categorisation.Results: Across the sample, levels of insufficient coverage were substantial (between 22-36 % at each interview wave). The majority (50 %) were consistently covered across interviews, though many (45 %) were inconsistently covered. We found strong statistical associations between insufficient coverage and current hepatitis C virus (HCV) infection (RNA+). Current prescription of opioid substitution therapy (OST) and using NSPs as the main source of syringe acquisition were protective against insufficient coverage.Conclusion: Insufficient coverage across the sample was substantial and mainly driven by those who oscillated between states of coverage, suggesting the presence of temporal factors. We recommend a general expansion of NSP services and OST prescription to encourage increases in syringe coverage. [ABSTRACT FROM AUTHOR]

Although civil society advocacy for health issues such as HIV transmission through injecting drug use is higher on the global health agenda than previously, its impact on national policy reform has been limited. In this paper we seek to understand why this is the case through an examination of civil society advocacy efforts to reform HIV/AIDS and drugs-related policies and their implementation in three former Soviet Union countries. In-depth semi-structured interviews were conducted in Georgia, Kyrgyzstan and Ukraine by national researchers with representatives from a sample of 49 civil society organizations (CSOs) and 22 national key informants. We found that Global Fund support resulted in the professionalization of CSOs, which increased confidence from government and increased CSO influence on policies relating to HIV/AIDS and illicit drugs. Interviewees also reported that the amount of funding for advocacy from the Global Fund was insufficient, indirect and often interrupted. CSOs were often in competition for Global Fund support, which caused resentment and limited collective action, further weakening capacity for effective advocacy. [ABSTRACT FROM AUTHOR]

A number of behavioural and clinical parameters influence the transmission of an infectious agent through direct contact between two individuals. The behavioural parameters encountered in such situations are also likely to exhibit an enormous amount of variability. With the spread of hepatitis C among injecting drug users, the parameters associated with injecting behaviour play an important role in the modelling of the transmission process. Computer simulation modelling is an ideal approach to deal with a large number of parameters as well as high levels of variability without excessive simplification. The simulation model presented in this paper is tested on data from a cohort of injecting drug users and the results obtained are very encouraging from a public health perspective. The model clearly indicates that the rate at which HCV spreads through a population of injecting drug users is extremely sensitive to the interaction rate and to the probability of infection through a single contact with an infective. At the same time it shows that rate of spread is not very sensitive to initial prevalence, which is very encouraging from a public health perspective. [ABSTRACT FROM AUTHOR]

Background: Several reports have described a growing prevalence of illicit drug use in Afghanistan, with recognition of a recent shift from traditional modes of consumption involving inhalation and oral ingestion to injecting drug use.Objective: Conduct a comprehensive review of existing literature to map the injecting drug use situation in Afghanistan. The review intends to describe risk factors and impacts of injecting drug use, drug use characteristics and risk behaviours among people who inject drugs (PWID), and access to harm reduction and treatment.Methods: We searched Embase, Global Health, Medline, PsycINFO, Web of Science, and grey literature to identify English language publications up to March 26th, 2022. Studies were eligible for inclusion if they explicitly targeted PWID or injecting drug use in Afghanistan and provided information relevant to the review questions. Two reviewers independently screened titles and abstracts for inclusion and extracted information based on the review objectives.Results: A total of 25 articles were identified representing 15 studies (11 quantitative, 2 qualitative, 2 mixed methods). All but one studies were cross-sectional. In majority of the studies, over 95% of the participants were male and most were conducted over a decade ago, in urban settings, mainly Kabul. Only one study examined risk factors of injecting drug use. Eleven studies described drug use characteristics and 9 reported risk behaviours among PWID. Health and social burden of injecting drug use were reported by 8 and 5 studies, respectively. Nine studies described access to harm reduction and treatment. Afghan PWID had high levels of injecting and sexual risk behaviours compared to global estimates. They reported high prevalence of incarceration and displacement. Access to harm reduction and treatment was very limited. This scoping review revealed important knowledge gaps including a gender gap in research with serious implications for drug policy and substance use care.Conclusions: Development of a national public health-oriented drug policy and substance use care programme is warranted along with efforts to develop health research capacity to address the need for epidemiological data. The current humanitarian crisis necessitates continued access to evidence-based harm reduction and treatment in Afghanistan. [ABSTRACT FROM AUTHOR]

IntroductionMethamphetamine use and methamphetamine-involved deaths have increased dramatically since 2015, and opioid-related deaths now frequently involve methamphetamine. Nevada and New Mexico are states with elevated rates of opioid and methamphetamine use. In this paper, we report results from a qualitative analysis that examined patterns of methamphetamine and opioid co-use over participants' lifespan, factors that influence those patterns, and implications for health outcomes among users.MethodsProject AMPED was a multisite, mixed-methods study of methamphetamine use in Northern New Mexico and Northern Nevada. Between December 2019 and May 2020, qualitative interview participants were asked to describe their patterns of and reasons for co-administration of opioids and methamphetamine.ResultsWe interviewed 21 people who reported using methamphetamine in the past 3 months. Four primary patterns of methamphetamine and opioid co-use were identified: [1] using both methamphetamine and heroin, either simultaneously or sequentially (n = 12), [2] using methamphetamine along with methadone (n = 4), [3] using prescription opioids and methamphetamine (n = 1), and [4] using only methamphetamine (n = 4). Among those who used methamphetamine and heroin simultaneously or sequentially, motivations drew from a desire to enhance the effect of one drug or another, to feel the “up and down” of the “perfect ratio” of a goofball, or to mitigate unwanted effects of one or the other. Among those who used methamphetamine and methadone, motivations focused on alleviating the sedative effects of methadone.ConclusionTo address the emergent trend of increasing methamphetamine-related deaths, researchers, health care professionals, and community health workers must acknowledge the decision-making processes behind co-use of opioids and methamphetamine, including the perceived benefits and harms of co-use. There is an urgent need to address underlying issues associated with drug use-related harms, and to design interventions and models of treatment that holistically address participants' concerns.

Abstract Background Within the UK, injecting in the femoral vein (FV), often called 'groin injecting', is a serious cause of risk and harm. This study aimed to use ultrasound scanning as a means to engage groin injectors (GIs), examine their femoral injecting sites and assess their venous health, with the intention of developing improved responses. Methods Between September 2006 and March 2009, GIs attending a network of community drug treatment centres in South East England were invited to attend an ultrasound 'health-check' clinic. This paper provides a narrative account of the scanning procedure and operation of the service, with descriptive statistical analysis of GIs who attended. The analysis uses a structured, specially-developed clinical data set that incorporates a categorisation for the severity of FV damage. Case studies using ultrasound images and a link to a video are provided to illustrate the range of presentations encountered and the categorisations used for severity. Results A total of 160 groin scans (76 bilateral and 8 unilateral) were performed in 84 GIs. The majority were men (69.0%) and the mean age of the sample was 36.8 years. The mean duration of drug use and injecting drug use was 19.7 years and 13.8 years, respectively. FV damage at the injecting site in the right groin was graded as minimal in 20 patients (25%), moderate in 27 (33.8%), severe in 16 (20.0%) and very-severe in 17 (21.3%). Corresponding figures for left FV were 24 (30.0%), 22 (27.5%), 18 (22.5%) and 16 (20.0%). Wide variation was observed in the time to the development of these grades of FV damage. Conclusions Modern, portable ultrasound scanners make it possible to examine the venous health of GIs in community treatment settings. Ultrasound scanning identified extensive FV damage, much hitherto-unrecognised in this population. These findings should further alert clinicians, policy-makers and patients to the urgent need for effective harm reduction responses to GI behaviour. Images of damaged FV in this paper might prove to be a useful resource for discussions about GI risks.

Background: Hepatitis C virus (HCV) transmission in the European Union, European Economic Area and United Kingdom is driven by injecting drug use (IDU), which contributes to the high burden of chronic infection among people in prisons. This study aimed to describe the context, epidemiology and response targeting HCV in prisons across the region.Methods: We retrieved and collated HCV-related data from the World Health Organization's Health in Prisons European Database and the European Centre for Disease Prevention and Control's hepatitis C prevalence database. Prisons population data were obtained from the Council of Europe Annual Penal Statistics on prison populations (SPACE I).Results: There were 12 to 93,266 people in prisons, with rates of 31·5 to 234·9 per 100,000 population. Median age was between 31 and 40 years, with up to 72% foreign nationals. Average detention time ranged from one to 31 months. Ministries of Health had sole authority over prisons health, budget administration and funding in 27, 31 and 8% of 26 reporting countries, respectively. Seroprevalence of HCV antibodies ranged from 2·3% to 82·6% while viraemic infections ranged from 5·7% to 8·2%, where reported. Up to 25·8 and 44% reported current and ever IDU, respectively. Eight countries routinely offered HCV screening on an opt-out basis. Needle and syringe programmes were available in three countries. Among the nine countries with data, the annual number of those who had completed HCV treatment ranged between one and 1215 people in prisons.Conclusions: HCV burden in prisons remains high, amidst suboptimal levels of interventions. Systematic monitoring at both local and regional levels is warranted, to advance progress towards the elimination of HCV in the region. [ABSTRACT FROM AUTHOR]

Abstract Background Dual substance dependence and psychiatric and psychological morbidities are overrepresented in prison populations and associated with reoffending. In the context of an increasing prison population in Australia, investigating the needs of vulnerable people in prison with a dual diagnosis can help inform in-prison screening and treatment and improve prison and community service integration and continuation of care. In this study we quantified psychiatric well-being in a sample of people in prison with a history of injecting drug use in Victoria, Australia, and identified factors associated with this outcome. Methods and Results Data for this paper come from baseline interviews undertaken in the weeks prior to release as part of a prospective cohort study of incarcerated men who reported regular injecting drug use prior to their current sentence. Eligible participants completed a researcher-administered structured questionnaire that canvassed a range of issues. Psychiatric well-being was assessed using the 12-item General Health Questionnaire (GHQ-12) and potential correlates were included based on a review of the literature. Of the 317 men included for analyses, 139 were classified as experiencing current poor psychiatric well-being. In the multivariate model using modified logistic regression, history of suicide attempt (aOR = 1.36, 95%CI 1.03–1.78), two or more medical conditions (aOR = 1.87, 95%CI 1.30–2.67) and use of crystal methamphetamine in the week prior to their current sentence (aOR = 1.52, 95%CI 1.05–2.22) were statistically significantly associated with current poor psychiatric well-being. Conclusions Comprehensively addressing the health-related needs for this vulnerable population will require a multidisciplinary approach and enhancing opportunities to screen and triage people in prison for mental health and other potential co-occurring health issues will provide opportunities to better address individual health needs and reoffending risk.

Aims: We report on motivations for crystal methamphetamine-opioid co-use/co-injection through narratives of people who inject drugs during a period of increased crystal methamphetamine use reporting in Australia. Methods: Fourteen in-depth interviews were undertaken with selected participants (12 male, 2 female) from the Melbourne Injecting Drug User Cohort Study, including those in and out of opioid substitution therapy (OST). Results: The main motivations for co-use reported by participants were as follows: (1) that heroin could be used to reduce the negative side effects of heavy crystal methamphetamine use, particularly during the 'comedown' phase; (2) that small quantities of crystal methamphetamine used with heroin could prolong the intoxication effect of heroin, and hence the time before opioid withdrawal; (3) that co-injection of crystal methamphetamine and heroin produced a more desirable intoxication effect than using either substance on its own and; (4) that crystal methamphetamine provided a substitute 'high' for heroin after commencing OST treatment. Conclusions: Co-use of methamphetamine and opioids has been used by people who inject drugs to facilitate intoxication, sometimes as the result of ineffective opioid substitution therapy (OST) treatment and perceived lack of pleasure after stabilisation on OST treatment. [ABSTRACT FROM AUTHOR]

People who inject drugs (PWID) are disproportionately represented among individuals who experience imprisonment and often have more complex physical and mental health needs than people in prison without injecting histories. The trajectories of PWID after prison release are poorly understood, hampering the development of effective strategies to address their distinct health needs. The Prison and Transition Health (PATH) Cohort Study is characterising the post-release trajectories of incarcerated male PWID in Victoria, Australia. We outline study methodology and baseline characteristics of participants prior to their release. Four hundred participants were recruited from three prisons and completed researcher-administered baseline interviews covering socio-demographics, social supports, physical health, mental health, alcohol and other drug use, and pre-release and transitional service utilisation. The median age among participants was 36 years (IQR 30-42), and they reported a median of five (IQR 3-9) previous adult incarcerations. Almost half (49%) were reliant on government payments prior to incarceration. One quarter (25%) of participants reported removal from their parents' care as children and 64% reported being a parent or primary caregiver to children. Most participants (81%) reported a previous mental health diagnosis and 44% reported three or more diagnoses. The most common drugs injected prior to incarceration were crystal methamphetamine (80%) and heroin (62%), and most (85%) reported being under the influence of drugs at the time of committing offences for which they were currently incarcerated. Injecting drug use during their current sentence was reported by 40% of participants, and 48% reported engaging with some form of drug treatment during their current sentence. Study participants are characterised by significant mental health and substance use morbidities, social disadvantage and criminogenic histories that present challenges for the provision of post-release support services. Data from the PATH Cohort Study will help inform strategies to improve the health and social outcomes of this population. [ABSTRACT FROM AUTHOR]

Background: Injecting drug users are at high risk of HIV infection globally. Research related to female drug users is rare in Kenya, yet it is required to inform the development of gender-sensitive HIV prevention and harm reduction services in East Africa, where injecting drug use is on the rise. Methods: This study aimed to document the nature of HIV risks encountered by women who inject drugs in the Mombasa and Kilifi, Kenya. Secondary data analysis was conducted on an existing dataset from a 2015 primary qualitative study involving 24 interviews and 3 focus group discussions with 45 women who inject drugs. These were complemented with five interviews with key stakeholders involved in the provision of services to women who inject drugs. Guided by the social ecology theory, a thematic analysis was conducted to identify the nature of HIV risks and their underlying determinants. Results: HIV risk behaviours fell into two broad categories: unsafe injecting and unprotected sex. These risks occurred in the form of sharing of needles, unprotected oral, anal, and vaginal sex, sexual assaults, injecting drug use during sex, sex work, and other types of transactional sex. The primary determinants underlying these risks were a low-risk perception, inequitable gender power, economic pressures, and poor availability of needles and condoms. These social-ecological determinants did not exist in isolation, but intersected with each other to create powerful influences which exposed women to HIV. Social-ecological determinants exerted constant influence and created a persistent 'HIV risk environment' that was involuntarily experienced by women. Conclusion: Individual, interpersonal, and societal-structural factors intersect to produce HIV risk behaviours. As a minimum, these risks will require a combination of multifaceted micro-level interventions including self-efficacy training, risk assessment skills, couple counselling, and universal access to the recommended harm reduction package. In addition, the current focus on micro-level interventions in Kenya needs to shift to incorporate macro-level interventions, including livelihood, employability, and gender norms-transforming interventions, to mitigate economic and gender-related drivers of HIV risks. In the Kenyan context, injecting drug use during sex work is emerging as an increasingly important HIV risk behaviour needing to be addressed. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to determine the effects of thermal processing and antioxidant formulation variables on the abuse deterrence performance of a high molecular weight poly(ethylene oxide) (PEO) polymer. Methods: A 24 factorial design with one categorical factor (antioxidant type) and three continuous factors (curing time, curing temperature, % antioxidant) was used. Abuse deterrence performance was evaluated using solution viscosity, surface melting temperature, and mechanical strength. Thermal degradation of PEO powders before compaction was also studied using DSC, FTIR spectroscopy, and viscosity analysis. Results: Our results showed that curing temperature and type of antioxidant can significantly affect the deterrence performance of PEO. The main effect plot for viscosity shows the most prominent factors affecting viscosity are curing temperature and type of antioxidant. However, curvature in the linear model obtained was not sufficient to completely describe the behavior. For surface melting temperature, butylated hydroxytoluene was associated with higher surface melting temperatures compared to ascorbic acid. Additionally, higher percent of antioxidant resulted in higher melting temperature. Particle size distribution to indicate mechanical strength showed no significant effects of tested factors. This suggests that comminution method has more prominent effect on tablet fragment size than the formulation and processing factors studied. Conclusion: While heat confers the mechanical strength to the polymer, it can diminish its physical stability and solution state viscosity. The experimental studies showed that prolonged exposure to high temperatures, even in the presence of antioxidants, can severely hamper polymer deterrence performance in both solid and solution states. [ABSTRACT FROM AUTHOR]

Background: Pharmacies are an important source of sterile syringes for people who inject drugs (PWID) in Tajikistan who are under high risk of HIV and hepatitis C virus. Accessibility of sterile syringes at pharmacies without prescription may depend on pharmacists' attitudes towards PWID. This qualitative inquiry examines meanings and processes of stigmatization of PWID among pharmacists and pharmacy students in Tajikistan. Methods: We conducted semi-structured interviews with 19 pharmacists and 9 students (N = 28) in the cities of Dushanbe and Kulob, Tajikistan. The interview topics included personal attitudes towards drug use and PWID, encounters with PWID, awareness and beliefs related to drug dependence and HIV, and attitudes and practices related to providing syringes to PWID. Interview transcripts were analysed using thematic analysis methods. Results: The main themes included the significance of religion in defining attitudes towards drug use, labelling of PWID, negative stereotypes (PWID are prone to crime, violence, and irrational aggression; inflict harm to families and society; are able to control drug use), emotions triggered by PWID (fear, sympathy) and discrimination against PWID (rejection, isolation, ostracism, limiting resources to PWID). The religious ban on drug use and pharmacists' moral and legal responsibility for the consequences of drug use were frequently mentioned as reasons for rejecting syringe sales. Still, many participants acknowledged the need for distributing syringes to PWID to prevent HIV. Conclusions: Stigma against PWID in Tajikistan plays an important role in shaping pharmacists' attitudes towards provision of services to this population. Local sociocultural context, in particular religious beliefs and social conservatism, may facilitate stigmatizing beliefs. [ABSTRACT FROM AUTHOR]

Background: Heroin injection is emerging as a significant dimension of the HIV epidemic in Kenya. Preventing transitions to injecting drug use from less harmful forms of use, such as smoking, is a potentially important focus for HIV prevention. There is, however, little evidence to support comprehensive programming in this area, linked to a shortage of analysis of the social and structural context for transitions, particularly in low-income settings. We explore accounts of transitions from smoking to injecting in Kenya to understand the role of individual, social and structural processes. Methods: We combine data from two separate studies conducted in Kenya: an in-depth qualitative study of HIV care access for people who inject drugs (study 1) and an ethnographic study of the political economy of the heroin trade in Kenya (study 2). In-depth interviews with PWID and community observation from study 1 are triangulated with accounts from stakeholders involved in the heroin trade and documentary data from study 2. Results: People who inject drugs link transitions to injecting from smoking to a range of social and behavioural factors, as well as particular aspects of the local drug supply and economy. We present these results in the form of two narratives that account for factors shaping transitions. A dominant narrative of 'managing markets and maintaining a high' results from a process of trying to manage poverty and a shifting heroin supply, in the context of deepening addiction to heroin. A secondary narrative focuses on people's curiosity for the 'feeling' of injecting, and the potential pleasure from it, with less emphasis on structural circumstances. Conclusions: The narratives we describe represent pathways through which structural and social factors interact with individual experiences of addiction to increase the risk of transitions to injecting. In response, HIV and harm reduction programmes need combinations of different strategies to respond to varied experiences of transitions. These strategies should include, alongside behaviour-oriented interventions, structural interventions to address economic vulnerability and the policing of the drug supply. [ABSTRACT FROM AUTHOR]

Aim: The potential for transmission of hepatitis C virus (HCV) in prison settings is well established and directly associated with sharing of injecting and tattooing equipment, as well as physical violence. This study is one of the first to examine the circumstances surrounding the acquisition of HCV in the prison setting via inmates' own accounts. Method: This is a sub-study of a cohort of prison inmates in New South Wales, Australia. Cohort participants were inmates who had reported ever injecting drugs and who had a negative HCV serological test within 12 months prior to enrolment. Cohort participants were monitored every 3 to 6 months for HCV antibodies and viraemia and via behavioural risk practices questionnaire. Participants with a documented HCV seroconversion were eligible to participate in in-depth interviews with a research nurse known to them. Results: Participants included six inmates (four men, two women) with documented within-prison HCV seroconversion. Participants reported few changes to their injecting practices or circumstances that they attributed to HCV acquisition. Participants believed that they were sharing syringes with others who were HCV negative and trusted that others would have declared their HCV status if positive. Some participants described cleaning equipment with water, but not with disinfectant. In a departure from usual routine, one participant suggested that he may have acquired HCV as a result of using a syringe pre-loaded with drugs that was given to him in return for lending a syringe to another inmate. Participants described regret at acquiring HCV and noted a number of pre- and post-release plans that this diagnosis impacted upon. Conclusions: Acquiring hepatitis C was not a neutral experience of participants but generated significant emotional reactions for some. Decisions to share injecting equipment were influenced by participants' assumptions of the HCV status of their injecting partners. The social organisation of injecting, in trusted networks, is a challenge for HCV prevention programs and requires additional research. [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]

Background: There is an HIV epidemic among people who inject drugs (PWID) in Manipur and Nagaland, Northeast India. Approximately one-third of PWID across these two states are aged below 25 years, yet until now there has been no systematic investigation of the differences between the younger and older PWID. We sought to profile differences in drug use and sexual practices across age groups and to examine whether age is associated with injecting and sexual risk behaviours. Methods: We used combined cross-sectional survey data collected in 2009 from two surveys involving a total of 3,362 (male) PWID in eight districts of Manipur and Nagaland. All data were collected using intervieweradministered questionnaires. Results: Compared to PWID aged 35 years or older, PWID aged 18 to 24 years were more likely share needles/ syringes in both Manipur (OR =1.8) and Nagaland (OR =1.6). Compared to PWID aged 35 years or older, PWID aged 18 to 24 years were almost two times as likely to draw up drug solution from a common container at their last injection in Manipur (OR =1.8). In Nagaland, PWID aged 18 to 24 years were more likely to use condoms consistently with both casual (OR =3.1) and paid (OR =17.7) female sexual partners compared to PWID aged 35 years or older. Conclusion: Risky injecting practices were more common among younger PWID in both Manipur and Nagaland, while unprotected sex was more common among older PWID in Nagaland. There is a clear need to focus public health messages across different age groups. [ABSTRACT FROM AUTHOR]

Background Injecting drug users are at increased risk for harmful effects compared to non-injecting drug users. Some studies have focused on differences in characteristics between these two groups (e.g., housing, overall health). However, no study has investigated the specific Dutch situation which in the last years has seen a decrease in homelessness among problematic hard-drug users and an increasing focus on physical health in low-threshold addiction care. The purpose of this study was to determine differences in sociodemographic, drug use and health characteristics between never-injecting (NIDUs), former-injecting (FIDUs) and current-injecting drug users (IDUs) and describe injecting practices. Methods A total of 202 problematic hard-drug users (NIDU = 64; FIDU = 76; IDU = 62) were recruited from 22 low-threshold care facilities, including drug consumption rooms, methadone maintenance treatment, heroin-assisted therapy, day shelter and/or night shelter, supported housing and day activity centres. Data were collected on-site through structured face-to-face interviews. Results Results indicate that IDUs represented a separate group of problematic hard-drug users, with distinct sociodemographic and drug use characteristics. Overall, IDUs appeared to be the group with least favourable characteristics (unstable housing/homelessness, illegal activities, polydrug use) and NIDUs appeared to have the most favourable characteristics (stable housing, help with debts, less polydrug use). The FIDU group lies somewhere in between. The three groups did not differ significantly in terms of health. Regarding injecting practices, results showed that majority of IDUs had injected drugs for over 10 years and IDUs injected heroin, cocaine, amphetamine and/or methadone in the past 6 months. Sharing syringes was not common. A quarter reported public injecting. Conclusions Unstable housing and homelessness are related to (former) injecting drug use, and stable housing is related to never-injecting drug use. Our study suggests that the number of 'new' IDUs is low. However, public injecting among IDUs is not uncommon and is associated with unstable housing. This emphasizes the potential of housing projects as a component of harm reduction measures. Therefore, prevention of (risks associated with) injecting drug use and supported housing programmes for problematic hard-drug users deserve the continuous attention of policymakers and professionals in low-threshold addiction care. [ABSTRACT FROM AUTHOR]

Background For the past two decades, there has been an enduring HIV epidemic among injecting drug users (IDUs) in India, and the Indian national AIDS control program (NACP) led by the National AIDS Control Organization (NACO) has kept IDUs at the forefront along with other key populations, in its efforts to prevent HIV. Given this, the objective of this study is to examine the association between IDUs' degree of exposure to peer-led education sessions (under NACP) and their needle sharing practices in Haryana, India. Methods The data for this study were drawn from a program monitoring system for the years 2009- 2010 and 2010-2011. The relationship between IDUs' background characteristics/injecting practices and degree of exposure to the program was assessed using chi-square and Student's t tests. Generalized estimating equations (GEE) were used to examine changes in needle sharing practices over time by degree of exposure to peer-led education sessions. Further, the analysis was stratified by frequency of injecting drug use. All statistical analyses were conducted using STATA version 11. Results The proportion of IDUs who shared needles substantially decreased from 2009 to 2011, particularly among those who attended three or more peer-led education sessions (49% vs 11%, p < 0.001) in a month. Further, subgroup analysis by frequency of injecting drugs demonstrates that this decline was significant among IDUs who injected frequently (adjusted odds ratio = 0.6, 95% confidence interval = 0.3-0.9, p = 0.043). Conclusion The study results indicate that repeated peer-led outreach sessions are more effective than exposure to a single education session. Hence, HIV prevention programs must promote repeated peer contacts with IDUs every month (at least two meetings) in order to promote safe injecting practices and behavior change. [ABSTRACT FROM AUTHOR]

Background: Cohort studies provide an excellent opportunity to monitor changes in behaviour and disease transmission over time. In Australia, cohort studies of people who inject drugs (PWID) have generally focused on older, in-treatment injectors, with only limited outcome measure data collected. In this study we specifically sought to recruit a sample of younger, largely out-of-treatment PWID, in order to study the trajectories of their drug use over time. Methods: Respondent driven sampling, traditional snowball sampling and street outreach methods were used to recruit heroin and amphetamine injectors from one outer-urban and two inner-urban regions of Melbourne, Australia. Information was collected on participants' demographic and social characteristics, drug use characteristics, drug market access patterns, health and social functioning, and health service utilisation. Participants are followedup on an annual basis. Results: 688 PWID were recruited into the study. At baseline, the median age of participants was 27.6 years (IQR: 24.4 years - 29.6 years) and two-thirds (67%) were male. Participants reported injecting for a median of 10.2 years (range: 1.5 months - 21.2 years), with 11% having injected for three years or less. Limited education, unemployment and previous incarceration were common. The majority of participants (82%) reported recent heroin injection, and one third reported being enrolled in Opioid Substitution Therapy (OST) at recruitment. At 12 months follow-up 458 participants (71% of eligible participants) were retained in the study. There were few differences in demographic and drug-use characteristics of those lost to follow-up compared with those retained in the study, with attrition significantly associated with recruitment at an inner-urban location, male gender, and providing incomplete contact information at baseline. Conclusions: Our efforts to recruit a sample of largely out-of-treatment PWID were limited by drug market characteristics at the time, where fluctuating heroin availability has led to large numbers of PWID accessing lowthreshold OST. Nevertheless, this study of Australian injectors will provide valuable data on the natural history of drug use, along with risk and protective factors for adverse health outcomes associated with injecting drug use. Comprehensive follow-up procedures have led to good participant retention and limited attrition bias. [ABSTRACT FROM AUTHOR]

Monitoring injecting drug users' (IDUs) health is challenging because IDUs form a difficult to reach population. We examined the impact of recruitment setting on hepatitis C prevalence. Individual datasets from 12 studies were merged. Predictors of HCV positivity were sought through a multilevel analysis using a mixed-effects logistic model, with study identifier as random intercept. HCV prevalence ranged from 21% to 86% across the studies. Overall, HCV prevalence was higher in IDUs recruited in drug treatment centres compared to those recruited in low-threshold settings (74% and 42%, respectively, P < 0·001). Recruitment setting remained significantly associated with HCV prevalence after adjustment for duration of injecting and recent injection (adjusted odds ratio 0·7, 95% confidence interval 0·6–0·8, P = 0·05). Recruitment setting may have an impact on HCV prevalence estimates of IDUs in Europe. Assessing the impact of mixed recruitment strategies, including respondent-driven sampling, on HCV prevalence estimates, would be valuable. [ABSTRACT FROM AUTHOR]

Background: Persons who inject drugs (PWID) are at an elevated risk for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection. In many high-income countries, needle and syringe exchange programs (NSP) have been associated with reductions in blood-borne infections. However, we do not have a good understanding of the effectiveness of NSP in low/middle-income and transitional-economy countries. Methods: A systematic literature review based on PRISMA guidelines was utilized to collect primary study data on coverage of NSP programs and changes in HIV and HCV infection over time among PWID in low-and middle-income and transitional countries (LMICs). Included studies reported laboratory measures of either HIV or HCV and at least 50% coverage of the local injecting population (through direct use or through secondary exchange). We also included national reports on newly reported HIV cases for countries that had national level data for PWID in conjunction with NSP scale-up and implementation. Results: Studies of 11 NSPs with high-coverage from Bangladesh, Brazil, China, Estonia, Iran, Lithuania, Taiwan, Thailand and Vietnam were included in the review. In five studies HIV prevalence decreased (range -3% to -15%) and in three studies HCV prevalence decreased (range -4.2% to -10.2%). In two studies HIV prevalence increased (range +5.6% to +14.8%). HCV incidence remained stable in one study. Of the four national reports of newly reported HIV cases, three reported decreases during NSP expansion, ranging from -30% to -93.3%, while one national report documented an increase in cases (+37.6%). Estimated incidence among new injectors decreased in three studies, with reductions ranging from -11/100 person years at risk to -16/100 person years at risk. Conclusions: While not fully consistent, the data generally support the effectiveness of NSP in reducing HIV and HCV infection in low/middle-income and transitional-economy countries. If high coverage is achieved, NSP appear to be as effective in LMICs as in high-income countries. Additional monitoring and evaluation research is needed for NSPs where reductions in HIV/HCV infection among PWID are not occurring in order to identify and correct contributing problems. [ABSTRACT FROM AUTHOR]