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Background: Internalised stigma experienced by people who inject drugs (PWID) is known to have negative health consequences. Research has explored factors that may protect or buffer individuals from the negative consequences of internalised stigma. Community attachment, or perceived connection to a community of like people, can have numerous health-related benefits. However, this relationship may be complex for PWID; being part of a social network of PWID may provide opportunity for more frequent drug use and equipment sharing. This study investigated the relationships between community attachment, internalised stigma, and wellbeing among PWID, while also addressing potential health risks associated with PWID community attachment., Methods: PWID (n=603) were recruited through nine peer-based drug user organisations across Australia with assistance from the peak consumer organisation. Participants completed a survey measuring community attachment, internalised stigma, personal wellbeing, injecting frequency, and equipment sharing., Results: Greater attachment to a PWID community was associated with lower internalised stigma, but also with sharing of injecting equipment and increased frequency of injecting behaviour. The relationship between community attachment and personal wellbeing was mediated by internalised stigma, however this was only the case for PWID who reported no sharing of injecting equipment., Conclusions: This research highlights the significance of community attachment for PWID while also noting the complexity of this relationship and the potential negative consequences. It is important to view networks of PWID communities as sources of positive social capital, where norms about health behaviours and harm reduction can be promoted and which can buffer community members from the harms associated with stigma., Competing Interests: Declarations of Interest The authors have no conflict of interest to declare., (Copyright © 2021 Elsevier B.V. All rights reserved.)

This paper explores the perceptions of 35 key informants (KIs) in a range of relevant health and community sectors regarding the stigmatisation of GBM's crystal methamphetamine use and sexual practice with view to informing stigma reduction efforts. A modified social ecological model was used to guide analysis and interpretation. At the individual level, KI participants indicated that crystal methamphetamine was used by some GBM to reduce the effects of internalised stigma. At the network level, KIs thought that some drugs and types of use could attract more stigma and that this could erode support from GBM networks for men who use crystal. KIs felt that few "mainstream" organisations could provide appropriate services for GBM who use crystal and furthermore, that there was significant work to "undo" misperceptions of the harms of crystal use. At the policy level, mass media anti-drug campaigns were seen to be a significant generator of stigma with irrelevant and patronising messages that lacked useful information. Efforts to reduce stigma about crystal methamphetamine use amongst GBM must address individual, network, organisation and policy issues and be underpinned by understandings of social power in relation to sex, sexuality, drug use, infectious status and sexual minorities., Competing Interests: Declarations of Interest Carla Treloar has received speakers’ fees from Abbive and Gilead and research funding from Merck. Max Hopwood has received research funding from Merck., (Copyright © 2021. Published by Elsevier B.V.)

Background and Aims: Interferon-free, direct-acting antivirals (DAAs) for hepatitis C virus (HCV) offer much promise to achieve World Health Organization targets by 2030. However, impediments at the practitioner and health-system level will continue to obstruct the scale-up of DAAs worldwide unless identified and acted upon. Applying a diffusion of innovations framework, the aim of this study was to identify structural factors impacting practitioner experiences of managing HCV treatment., Methods: In-depth, semi-structured, telephone interviews took place between September 2018 and April 2019 to investigate barriers and facilitators for engaging in HCV management and DAA therapy amongst general practitioners (GPs) who prescribe opioid agonist therapy and drug and alcohol specialists in Australia. Interviews were transcribed verbatim, de-identified, and coded, and data were analysed with iterative categorisation and thematic analysis using Everett Rogers's diffusion of innovation framework., Results: amongst 30 participants (12 GPs, 18 drug and alcohol specialists), several structural factors were reported to impede practitioner efforts to deliver optimal HCV care. Two primary themes were explored: contextual factors for the diffusion of DAA therapies, including attempts by participants to shift clinic culture and respond to siloed health structures, and adopter factors. Some participants chose to 'rock the boat' by circumventing clinic protocol and HCV guidelines to treat more clients, effectively shifting adopter categories to become greater advocates in HCV care. Also, while a role for GPs as the 'new adopters' in HCV management was discussed, many participants expressed uncertainty as to how much GPs should become involved in the diffusion of DAA therapies more widely., Conclusions: Reducing the global burden of HCV infection will not be possible without the widespread delivery of HCV treatment amongst practitioners. Practitioners and health workers require leadership and resources from health authorities so that the individual and population-level benefits of DAA therapy are realised., Competing Interests: Declarations of Interests ADM has nothing to declare. M Hopwood has received grant funding from Merck. JG has received research grants, speaker fees, and participated in advisory boards for Abbvie, Cepheid, Gilead Sciences, Hologic, Indivior, and Merck., (Copyright © 2020 Elsevier B.V. All rights reserved.)

In Australia, the crystalline form of methamphetamine ("crystal") is a commonly used illicit substance associated with sexual activity among gay and bisexual men. Attention to psychoactive substance use among this population is the subject of increasing global concern regarding the intentional and simultaneous combination of sex and drugs, often referred to as "chemsex". While not all gay and bisexual men who use psychoactive substances report problematic use, those who do often become representative of chemsex practices more generally, and the harms they experience become attributable to all men who use drugs for sex. The way in which these practices have been framed over the past few decades contributes to the rise of a narrow set of understandings of chemsex defined by the circumstances and behaviours presumed of drug-enhanced sexual activity. In effect, these understandings now align recognisable combinations of sexual and drug-using practices with assumed correlates of risk. The Crystal, Pleasures and Sex between Men study conducted 88 interviews with gay and bisexual men in four Australian cities between 2017 and 2018. Findings from the project revealed that men used crystal in a variety of settings and relations, which mediated their sexual practices and patterns of use. In looking at the wider context in which practices were associated with the combination of sex and drugs, we identified experiences that the contemporary discourse of chemsex-in its rhetorical proposition of at-risk behaviours and circumstances-may leave out of consideration. Our findings indicate that researchers should remain open to the variability and contingency of settings, relations and practices in gay and bisexual men's different networks when recommending public health responses to their engagement in drug-enhanced sexual activity. Accordingly, we seek to destabilise the definition of chemsex that precludes consideration of the influence of experiences beyond pre-determined risk parameters., Competing Interests: Declaration of Competing Interest Declarations of interest: This research was supported under National Health and Medical Research Council Project grant (project number APP1124378) and by a grant from the Western Australia Health Department (project number RG171390). The Centre for Social Research in Health and the Australian Research Centre in Sex, Health and Society also receive funding from the Australian Government Department of Health and Ageing., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Much research concerning drug use in the context of sexual activity among gay and bisexual men derives from public health scholarship. In this paper, we critically examine how the relationship between methamphetamine use and sexual risk practice is treated and understood in this body of research. While public health has made important contributions to establishing the link between methamphetamine use and sexual risk-taking, the precise nature of the relationship is not well defined. This creates space for ungrounded assumptions about methamphetamine use to take hold. We outline what appear to be two dominant interpretations of the methamphetamine/sexual practice relationship: the first proposes that methamphetamine has specific pharmacological properties which lead to sexual disinhibition, risky behaviour and poor health outcomes; the second proposes that methamphetamine attracts men who are already inclined toward highly sexualised interactions and risky practice, and that such men are likely to engage in these practices with or without drugs. We suggest that both interpretations are problematic in that they individualise and cast drug and sex practices as inherently risky and biopsychologically determined. We outline a more historically, socially and politically engaged way to understand methamphetamine use in the context of sexual activity by drawing on the concept of sex-based sociality and the ways in which gay and bisexual men may use methamphetamine and sex as social resources around which to build identities, establish relationships, participate in gay communities, and maximise pleasure while protecting themselves and others from harm., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Gay and bisexual men typically report high rates of illicit drug use, including methamphetamine use. This paper aimed to analyse trends in crystal methamphetamine ('crystal') and powder methamphetamine ('speed') use among gay and bisexual men in Australia, and characterise the sociodemographic, drug use, and sexual risk practices of men who reported crystal use., Methods: The Gay Community Periodic Surveys, routinely conducted behavioural surveillance surveys of gay men in Australia, were analysed to examine trends in recent crystal and speed use during 2005-14 (any use in the previous 6 months), and trends in regular crystal and speed use during 2007-14 (at least monthly use in the previous 6 months). Covariates of recent and regular crystal use were analysed using 2014 data., Results: Speed use declined from 25.0% to 10.2% during 2005-14 (p-trend <.001), while regular speed use declined from 7.0% to 2.3% during 2007-14 (p-trend <.001). Any crystal use declined from 15.6% to 11.4% during 2005-14 (p-trend <.001) and increased during 2010-14 (from 9.6% in 2010; p-trend <.001). Regular crystal use declined from 6.1% to 4.0% during 2007-14 (p-trend <.001) and remained stable during 2010-14 (3.9% in 2010; p-trend=.64). Participants who reported regular crystal use were more likely than men who used crystal less frequently to have used gamma-hydroxybutyrate, used party drugs for sex, and to have injected drugs in the previous 6 months. High rates of crystal use and injecting were reported among HIV-positive participants., Conclusion: Rates of both crystal and speed use, despite fluctuations, were consistently high throughout the study period. The high rates of crystal use and associations with potentially risky sexual practices indicate that gay and bisexual men should be a particular focus for targeted harm reduction and combined harm reduction and sexual health services., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Background: Assessment and uptake of treatment for hepatitis C among people who inject drugs (PWID) is low and strategies to enhance hepatitis C care in this group are needed. Knowledge of hepatitis C and its treatment is one precursor to decisions about treatment., Methods: We conducted a cross-section study designed to evaluate treatment considerations in participants with self-reported hepatitis C infection in New South Wales, Australia. Participants were recruited from needle and syringe programs, opiate substitution clinics, pharmacies that dispensed opiate substitution treatment and from the mailing list of a community-based hepatitis C organisation and completed a self-administered survey. Knowledge of hepatitis C was assessed by a 48-item scale addressing the natural history and treatment of hepatitis C. Factors associated with knowledge were assessed by ordinal regression., Results: Among the 997 participants recruited, 407 self-reported acquiring hepatitis C through injecting drug use and had never received hepatitis C treatment. Knowledge about hepatitis C was overall poor and the effects of the long term consequences of hepatitis C were over-estimated. Higher knowledge scores were associated with recruitment site, higher education levels and recent contact with a general practitioner. One-third of participants indicated that they did not intend to have treatment and one-fifth did not answer this question., Conclusion: Knowledge is a precursor to informed decisions about hepatitis C treatment. These results indicate that efforts to support those less engaged with hepatitis C care (and specifically those on opiate substitution treatment) and those with lower literacy are required., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: In Australia, sterile needles are distributed to people who inject drugs through formal services for the purposes of limiting the transmission of blood borne viruses (BBV). Secondary exchange (SE) involves people acquiring needles from formal services and redistributing them to others. This paper describes the extent, patterns and contexts of SE in south east Sydney, Australia and examines whether SE is independently associated with BBV risk practices., Methods: Quantitative and qualitative data were collected through a cross-sectional study using surveys and in-depth interviews. Respondents were people using community-based pharmacies to obtain sterile needles and syringes., Results: Data were collected from 229 survey respondents, over half of whom (54%) reported SE in the previous month. Of these, 40% engaged in distribution only, 25% in receipt only and 36% in both. Respondents reported passing on 21.7% of their needles to others in the last month, most commonly to friends (51.6%) and partners (27.4%). Recipients of SE were four times more likely than non-secondary exchangers to report borrowing used syringes in the last month. Respondents reported supplying sterile equipment to others to prevent reuse and to reduce risks associated with unplanned drug use., Conclusion: SE is a common activity in south east Sydney but does not appear to be highly organised, usually taking place in small networks of friends and/or partners for altruistic reasons. Harm reduction programs could capitalise on the prevalence of SE to reach injecting drug users who do not use formal distribution services.

Exploration of patients' illicit drug use during treatment for hepatitis C virus (HCV) infection is largely absent from the clinical literature. This paper explores injecting and other illicit drug use among people receiving interferon-based treatment for HCV infection, from the perspective of one group of health professionals. Data are presented from a qualitative study of six health professionals responsible for managing HCV treatment regimens at three major metropolitan hospitals across Sydney, Australia. During semi-structured in-depth interviews, participants discussed patients' use of injected and non-injected illicit drugs while coping with a demanding therapeutic regimen. Health professionals highlighted the socially conservative environment of healthcare and its negative perceptions of illicit drug users. Also discussed are the management of people who inject during treatment and the efficacy of cannabis to reduce side effects. The findings of this study indicate that while the health professionals adopted a harm reduction approach to patients' illicit drug use during HCV treatment, information regarding the risks and benefits of illicit drug use is silenced in this context. While ever prohibition remains Australia's illicit drug policy this situation appears unlikely to change. Research which investigates the extent of illicit drug use during HCV treatment, the risks and benefits associated with their use in this context, and the harms of perpetuating a duplicitous healthcare system is required.

Objective: To describe methadone injectors and the risk practices associated with injecting methadone in New South Wales, Australia. To assess the impact on injecting drug use and risk behaviour of the withdrawal of methadone injecting equipment from government-funded needle and syringe programs., Method: Cross-sectional survey, conducted in 1999, of 206 people who had injected methadone at least once in the previous month. Participants were from Central Sydney, West Sydney and rural New South Wales., Results: Of participants who had injected both methadone and other drugs in the previous month (n=162), significantly more reused their methadone injecting equipment compared with those who reused their other drug injecting equipment (60% vs. 28%, p<0.01). There was no significant difference in terms of sharing injecting equipment, with 19% reporting sharing methadone injecting equipment and 14% sharing other drug injecting equipment. However, women were more likely than men to share methadone injecting equipment. Over half of the participants had accessed diverted methadone and a substantial minority reported the use of public spaces for injecting methadone., Conclusions: Our results suggest that the current policy has led to increased reuse of equipment for injecting methadone., Implications: A range of other possible policy options, such as closer monitoring and dilution of take-home doses, increasing oral doses and implementing trials of injected methadone, may assist to reduce the prevalence of methadone syrup injection and related harms.